Health Home Chronic Conditions Eligibility

  • Eligibility is also available in Portable Document Format (PDF)

Eligibility Requirements: Identifying Potential Members for Health Home Services

Individuals previously receiving TCM services through a COBRA HIV or OMH TCM program, receiving substance use case management services through Managed Addiction Treatment Services (MATS) programs, or those formerly receiving services in the Chronic Illness Demonstration Project (CIDP) have been transitioned to Health Home care management. For adults who may be eligible for Health Home services, the State identifies individuals through an analysis of claims and encounter data and provides lists of these individuals to Health Homes for outreach and engagement. Interested individuals are assessed and, if found eligible, assigned to a care manager. These are known as "list assigned members". For Children (ages 0–21 years old) who may be eligible for Health Home services, the State has developed the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) Referral Portal. The Portal requires the referral source, "Indicate the chronic conditions which, in your best informed judgement, you believe make the child you are referring eligible for Health Home." Currently, Managed Care Plans, Health Homes, Care Management Agencies, Local Government Units (LGU), Single Point of Access (SPOAs) and Local Department of Social Services (LDSS) (In NYC, VFCA that contract with ACS will make Referrals on behalf of ACS) have access to the MAPP HHTS Referral Portal. Individuals may also be referred to Health Homes from other providers or entities, including physicians, emergency departments, and community based providers, supportive housing providers, shelters, and family members. These referrals are known as community referrals. Whether a recipient has been list assigned by the State or comes to the Health Home through a community referral, the eligibility of the individual must be verified.

Determining Eligibility for Health Home Services

Step One

Step One is to determine Medicaid eligibility. Medicaid reimbursement for Health Home services can only be provided to individuals who are enrolled in Medicaid. While every effort is made to ensure that Medicaid is active for list assigned members, it is up to the provider to not only verify eligibility but to assure that Medicaid is active for both assigned members and for community referrals in order to ensure Medicaid reimbursement for Health Home services. It is also important to note that a client's Medicaid eligibility may change frequently. The care manager should continually verify Medicaid eligibility and work with eligible members to assist them in enrolling or renewing members for Medicaid benefits as required. It is important to note that Medicaid coverage may be granted retroactively. Currently, policies for Medicaid enrollment and determination for retroactive coverage vary by county although as enrollment moves to the New York State of Health Marketplace the process for enrolling individuals will be standardized.

Step Two

Step Two is to determine if the member is eligible for Health Home services. To be eligible for Health Home services, an individual must have two chronic conditions or one single qualifying condition. New York State has chosen HIV, Serious Mental Illness (SMI), and for children Serious Emotional Disturbance (SED) and Complex Trauma as single qualifying conditions. Having one chronic condition and being at risk of developing another condition does not qualify an individual as Health Home eligible in New York State. In summary, New York State's Health Home eligibility definition is as follows:

  • The individual must be enrolled in Medicaid
  • Medicaid members eligible to be enroll in a Health Home must have:
    • Two or more chronic conditions
    • One single qualifying chronic condition:
      • ✓ HIV/AIDS or
      • ✓ Serious Mental Illness (SMI) (Adults) or
      • ✓ Serious Emotional Disturbance (SED) or Complex Trauma (Children)

Substance use disorders (SUDS) are considered chronic conditions, but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition (as described below) to qualify.

Note that the diagnostic eligibility criteria must be verified for both list assigned recipients, MAPP HHTS Referral Portal referrals and for community referrals. The State identifies and list assigns potential members for Health Home services based on diagnosis codes used on claims and encounter data which may not be complete or which may not accurately assess the individual's current condition. Other sources such as medical records or assessments must be used to document diagnostic eligibility. Qualifying chronic conditions are any of those included in the "Major" categories of the 3MTM Clinical Risk Groups (CRGs) as described in the list below.

Major Category: Alcohol and Substance Use Disorder

  • Alcohol and Liver Disease
  • Chronic Alcohol Abuse
  • Cocaine Abuse
  • Drug Abuse – Cannabis/NOS/NEC
  • Substance Abuse
  • Opioid Abuse
  • Other Significant Drug Abuse

Major Category: Mental Health

  • Bi–Polar Disorder
  • Conduct, Impulse Control, and Other Disruptive Behavior Disorders
  • Dementing Disease
  • Depressive and Other Psychoses
  • Eating Disorder
  • Major Personality Disorders
  • Psychiatric Disease (Except Schizophrenia)
  • Schizophrenia

Major Category: Cardiovascular Disease

  • Advanced Coronary Artery Disease
  • Cerebrovascular Disease
  • Congestive Heart Failure
  • Hypertension
  • Peripheral Vascular Disease

Major Category: Metabolic Disease

  • Chronic Renal Failure
  • Diabetes

Major Category: Respiratory Disease

  • Asthma
  • Chronic Obstructive Pulmonary Disease Major Category: Other

Step Three

Step three is to determine appropriateness for Health Home services. Individuals who are Medicaid eligible and have active Medicaid and meet diagnostic eligibility criteria are not necessarily appropriate for Health Home care management. An individual can have two chronic conditions and be managing their own care effectively. An individual must be assessed and found to have significant behavioral, medical, or social risk factors to deem them appropriate for Health Home services. Appropriateness for Health Home services must be determined for list assigned members, MAPP HHTS Referral Portal referrals, as well as community referrals. While list assigned members have a risk score established by the State (and some community referrals may be on State lists and have a pre– assigned risk score) this score is based on claims and encounter data which may not be current. An assessment must be performed for all presumptively eligible individuals to evaluate whether the person has significant risk factors.

Determinants of medical, behavioral, and/or social risk can include:

  • Probable risk for adverse events (e.g., death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement);
  • Lack of or inadequate social/family/housing support, or serious disruptions in family relationships;
  • Lack of or inadequate connectivity with healthcare system;
  • Non–adherence to treatments or medication(s) or difficulty managing medications;
  • Recent release from incarceration, detention, psychiatric hospitalization or placement;
  • Deficits in activities of daily living, learning or cognition issues; OR
  • Is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home

The November 2012 Medicaid Update Health Home Special Edition requires providers who accept community referrals to establish Medicaid and diagnostic eligibility as well as assess the risk level of clients to determine appropriateness of Health Home services for these referrals. In a Health Home Implementation webinar on March 2014 it was clarified that list assigned members must also be assessed for eligibility and appropriateness in the same way as community referrals and evidence of this assessment will be required to support billing for Health Home services.

Health Homes, Managed Care Organizations, and network care management partners should have policies and procedures that document the responsibilities for establishing and verifying diagnostic eligibility and need criteria, but the Medicaid biller remains ultimately responsible. As described in the New York State Plan Amendment (SPA) recent claims and/or encounter data or other clinical data should be used to verify medical and psychiatric diagnoses. It is expected that documentation of Medicaid eligibility, diagnostic eligibility, and risk assessment be maintained as defined by agreements between the Managed Care Organization, the Health Home, and the network care management agency.

Generally, it is the care management agency that determines eligibility for Health Home services. For managed care members, the Managed Care Plans and other providers often have more detailed information on a member's diagnosis and care utilization. Managed Care Plans also review list assigned candidates provided by the State and make the final assignment for Health Home services, thus they are well–positioned to determine or assist in determining eligibility.

Note that the Health Home Outreach and Engagement rate can be billed until eligibility criteria have been established and documented, for up to three months. If an individual is determined not to meet diagnostic and risk eligibility criteria, billing for outreach should cease or the member should be dis–enrolled from the Health Home if the member is no longer eligible and the care manager should make a referral to a more appropriate level of care.

For more information about Health Home eligibility and members with Intellectual and Developmental Disabilities please click here.

Health Home Chronic Conditions
Acquired Hemiplegia and Diplegia
Acquired Paraplegia
Acquired Quadriplegia
Acute Lymphoid Leukemia w/wo Remission
Acute Non–Lymphoid Leukemia w/wo Remission
Alcoholic Liver Disease
Alcoholic Polyneuropathy
Alzheimer´s Disease and Other Dementias
Angina and Ischemic Heart Disease
Anomalies of Kidney or Urinary Tract
Apert´s Syndrome
Aplastic Anemia/Red Blood Cell Aplasia
Ascites and Portal Hypertension
Atrial Fibrillation
Attention Deficit / Hyperactivity Disorder
Benign Prostatic Hyperplasia
Bi–Polar Disorder
Blind Loop and Short Bowel Syndrome
Blindness or Vision Loss
Bone Malignancy
Bone Transplant Status
Brain and Central Nervous System Malignancies
Breast Malignancy
Burns – Extreme
Cardiac Device Status
Cardiac Dysrhythmia and Conduction Disorders
Cardiovascular Diagnoses requiring ongoing evaluation and treatment
Cerebrovascular Disease w or w/o Infarction or Intracranial Hemorrhage
Chromosomal Anomalies
Chronic Alcohol Abuse and Dependency
Chronic Bronchitis
Chronic Disorders of Arteries and Veins
Chronic Ear Diagnoses except Hearing Loss
Chronic Endocrine, Nutritional, Fluid, Electrolyte and Immune Diagnoses
Chronic Eye Diagnoses
Chronic Gastrointestinal Diagnoses
Chronic Genitourinary Diagnoses
Chronic Gynecological Diagnoses
Chronic Hearing Loss
Chronic Hematological and Immune Diagnoses
Chronic Infections Except Tuberculosis
Chronic Joint and Musculoskeletal Diagnoses
Chronic Lymphoid Leukemia w/wo Remission
Chronic Metabolic and Endocrine Diagnoses
Chronic Neuromuscular and Other Neurological Diagnoses
Chronic Neuromuscular and Other Neurological Diagnoses
Chronic Non–Lymphoid Leukemia w/wo Remission
Chronic Obstructive Pulmonary Disease and Bronchiectasis
Chronic Pain
Chronic Pancreatic and/or Liver Disorders (Including Chronic Viral Hepatitis)
Chronic Pulmonary Diagnoses
Chronic Renal Failure
Chronic Skin Ulcer
Chronic Stress and Anxiety Diagnoses
Chronic Thyroid Disease
Chronic Ulcers
Cirrhosis of the Liver
Cleft Lip and/or Palate
Coagulation Disorders
Cocaine Abuse
Colon Malignancy
Complex Cyanotic and Major Cardiac Septal Anomalies
Conduct, Impulse Control, and Other Disruptive Behavior Disorders
Congestive Heart Failure
Connective Tissue Disease and Vasculitis
Coronary Atherosclerosis
Coronary Graft Atherosclerosis
Crystal Arthropathy
Curvature or Anomaly of the Spine
Cystic Fibrosis
Defibrillator Status
Dementing Disease
Depressive and Other Psychoses
Diabetes w/wo Complications
Digestive Malignancy
Disc Disease and Other Chronic Back Diagnoses w/wo Myelopathy
Drug Abuse Related Diagnoses
Ear, Nose, and Throat Malignancies
Eating Disorder
Endometriosis and Other Significant Chronic Gynecological Diagnoses
Enterostomy Status
Esophageal Malignancy
Extrapyramidal Diagnoses
Extreme Prematurity – Birthweight NOS
Fitting Artificial Arm or Leg
Gait Abnormalities
Gallbladder Disease
Gastrointestinal Anomalies
Gastrostomy Status
Genitourinary Malignancy
Genitourinary Stoma Status
Gynecological Malignancies
Hemophilia Factor VIII/IX
History of Coronary Artery Bypass Graft
History of Hip Fracture Age > 64 Years
History of Major Spinal Procedure
History of Transient Ischemic Attack
HIV Disease
Hodgkin´s Lymphoma
Hydrocephalus, Encephalopathy, and Other Brain Anomalies
Hyperthyroid Disease
Immune and Leukocyte Disorders
Inflammatory Bowel Disease
Intestinal Stoma Status
Joint Replacement
Kaposi´s Sarcoma
Kidney Malignancy
Leg Varicosities with Ulcers or Inflammation
Liver Malignancy
Lung Malignancy
Macular Degeneration
Major Anomalies of the Kidney and Urinary Tract
Major Congenital Bone, Cartilage, and Muscle Diagnoses
Major Congenital Heart Diagnoses Except Valvular
Major Liver Disease except Alcoholic
Major Organ Transplant Status
Major Personality Disorders
Major Respiratory Anomalies
Malfunction Coronary Bypass Graft
Malignancy NOS/NEC
Mechanical Complication of Cardiac Devices, Implants and Grafts
Multiple Myeloma w/wo Remission
Multiple Sclerosis and Other Progressive Neurological Diagnoses
Neoplasm of Uncertain Behavior
Neurodegenerative Diagnoses Except Multiple Sclerosis and Parkinson´s
Neurogenic Bladder
Neurologic Neglect Syndrome
Neutropenia and Agranulocytosis
Non–Hodgkin´s Lymphoma
Obesity (BMI at or above 25 for adults and BMI at or above the 85 th percentile for children)
Opioid Abuse
Other Chronic Ear, Nose, and Throat Diagnoses
Other Malignancies
Pancreatic Malignancy
Pelvis, Hip, and Femur Deformities
Peripheral Nerve Diagnoses
Peripheral Vascular Disease
Persistent Vegetative State
Pituitary and Metabolic Diagnoses
Plasma Protein Malignancy
Post–Traumatic Stress Disorder
Postural and Other Major Spinal Anomalies
Prematurity – Birthweight < 1000 Grams
Progressive Muscular Dystrophy and Spinal Muscular Atrophy
Prostate Disease and Benign Neoplasms – Male
Prostate Malignancy
Psychiatric Disease (except Schizophrenia)
Pulmonary Hypertension
Recurrent Urinary Tract Infections
Reduction and Other Major Brain Anomalies
Rheumatoid Arthritis
Secondary Malignancy
Secondary Tuberculosis
Sickle Cell Anemia
Significant Amputation w/wo Bone Disease
Significant Skin and Subcutaneous Tissue Diagnoses
Spina Bifida w/wo Hydrocephalus
Spinal Stenosis
Spondyloarthropathy and Other Inflammatory Arthropathies
Stomach Malignancy
Tracheostomy Status
Valvular Disorders
Ventricular Shunt Status
Vesicostomy Status
Vesicoureteral Reflux