Questions and Answers

Q & A Topics

General | Billing and Payment | Chronic Illness Demonstration Project (CIDP) | Health Home Design | Health Home Development Funds | Health Home Letter of Intent/Applications/Provider Enrollment/Application Form | Health Home Network | Health Information Technology | Managed Care | Member Forms | Population Assignment/ Eligibility (Patient Tracking System) | Quality Metrics and Evaluation (CMART) | Spend Down | Targeted Case Management (TCM) |


Billing and Payment

  1. Will the State provide real– time access to EMEDNY/MMIS for tracking purposes?
  2. What will be the reimbursement for Health Home services?
  3. Will TCMs that convert to Health Homes be paid the same for their TCM patients?
  4. How will Managed Care Plans pay subcontractors for conducting Health Home care management services?
  5. What HCPCS code should be used by Health Homes?
  6. Currently there are limits to providing billable services for clients who are either impatient or incarcerated. In what instances can Health Home services be provided, and billed for, if someone is receiving impatient services or is incarcerated.
  7. How much of the Health Home PMPM may be retained for administrative services such as HIT?
  8. Is the current Upstate PMPM rate final and does this rate differ between Health Homes within the same county?
  9. What is the current average monthly rate for current upstate Health Homes?
  10. What is the status of quality withholds and shared savings?
  11. How were former TCM and MATS providers converted to Health Home billing?
  12. Will the administrative fees of individual Health Homes be shared?
  13. Are there any issues with continuing to serve current clients who are dual eligible?
  14. Billing rates are going to be retroactive for former TCM providers. Will the billing rules also be retroactive? For example if Medicaid eligible client did not meet the standards for number of visits under the previous standards for billing, will they be included in the retroactive adjustment?
  15. What will be the methodology for care management partners in the Health Home to bill for care management services and will contracts need to be developed between Health Home and partners or subcontractors?
1. Will the State provide real– time access to EMEDNY/MMIS for tracking purposes?

At this time, Health Home enrollment information is not available in eMedNY. Health Homes , Care Management Agencies and Managed Care Plans have access to the Health Home Member Tracking System through the Health Commerce System (HCS) portal. A web– based portal that will expand access to member tracking system is being developed.

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2. What will be the reimbursement for Health Home services?

Information regarding Health Home reimbursement can be found here.

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3. Will TCMs that convert to Health Homes be paid the same for their TCM patients?

Yes. TCMs that converted to Health Homes were initially allowed to continue to be paid their TCM rate for up to one year following Health Home implementation based on the SPA approval date; this was subsequently extended to two years. The Department has submitted a State Plan Amendment to CMS to request approval to further extend the TCM rates until December 31, 2014.

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4. How will Managed Care Plans pay subcontractors for conducting Health Home care management services?

For non– TCM managed care enrollees, the Managed Care Plan will pay their Health Home providers the Health Home PMPM less a negotiated amount for administrative costs. See also question 10 in this section.

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5. What HCPCS code should be used by Health Homes?

HCPCS codes are not required on Health Home claims. In general, Health Homes are responsible for making decision on coding; The Department cannot make billing or coding recommendations.

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6. Currently there are limits to providing billable services for clients who are either impatient or incarcerated. In what instances can Health Home services be provided, and billed for, if someone is receiving impatient services or is incarcerated.

Health Homes cannot bill for Health Home services when members are either admitted to an Institute for Mental Disease (IMD) inpatient facility or incarcerated. Inpatient facilities should have discharge planners to assist with transition to a Health Home. Incarcerated individuals will have case management provided through the NYS Department of Corrections. There may be some situations in which care management can be provided. For further guidance refer to the Health Home Provider Manual and the Health Home Criminal Justice web page. |top of page|


7. How much of the Health Home PMPM may be retained for administrative services such as HIT?

The state has provided guidance that no more than 6% of the Health Home payment should be retained for administrative purposes, 3% for Managed Care Plans and 3% for the lead Health Home. Health Homes may also be investing in HIT and have other infrastructure costs and the State has not restricted the amount the Health Home may retain but have encouraged as much of the PMPM as possible should be used for direct Health Home services.

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8. Is the current Upstate PMPM rate final and does this rate differ between Health Homes within the same county?

The current base rates for Upstate and Downstate have been posted on Health Home website. The base rates are adjusted by member acuity and thus will differ depending on the member.

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9. What is the current average monthly rate for current upstate Health Homes?

There is no calculated average monthly rate. The current base rates for Upstate and Downstate for the period of 1/1/12– 11/30/16 can be found on the following excel Health Home Base Rates (XLS)

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10. What is the status of quality withholds and shared savings?

Quality withholds are no longer included in the current Health Home model. An amendment to the Health Home State Plan to characterize a shared savings model has been submitted to the federal Centers for Medicare and Medicaid Services (CMS). The Department is developing a shared savings model based on guidance distributed by CMS.

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11. How were former TCM and MATS providers converted to Health Home billing?

Once the State Plan Amendment (SPA) was approved for each phase converting OMH TCM providers were authorized to bill retroactive to the effective date of the SPA. For COBRA TCM programs, all unit billing was to be reconciled back to the effective date of each SPA once all phases were implemented.

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12. Will the administrative fees of individual Health Homes be shared?

Sharing of information about administrative fees for individual Health Homes is not a State requirement. If a Health Home wants to share that information they may do so.

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13. Are there any issues with continuing to serve current clients who are dual eligible?

You may continue to serve current members who are dual eligible. The Department now includes duals on assignment lists.

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14. Billing rates are going to be retroactive for former TCM providers. Will the billing rules also be retroactive? For example if a Medicaid eligible client did not meet the standards for number of visits under the previous standards for billing, will they be included in the retroactive adjustment?

No, reprocessing of claims will only be for those claims that were submitted to the system. Providers cannot go back and submit claims for Health Home services that did not met TCM rules at that time.

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15. What will be the methodology for care management partners in the Health Home to bill for care management services and will contracts need to be developed between Health Home and partners or subcontractors?

Prior to billing, the Health Home must submit member information to the Health Home Tracking System Portal containing each member´s begin date, status, Health Home, and care management agency. The appropriate Health Home biller will bill eMedNY per member, per month (PMPM.) Health Homes must have contracts with any care management partners they will be paying for the delivery of Health Home services.

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