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Michigan’s Health Homes
MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES
P a y m e n t P r o c e s s
P u t t i n g p e o p l e f i r s t , w i t h t h e g o a l o f h e l p i n g a l l M i c h i g a n d e r s l e a d h e a l t h i e r a n d m o r e p r o d u c t i v e l i v e s , n o m a t t e r t h e i r s t a g e i n l i f e .
AgendaMichigan Behavioral and Opioid Health Homes
•Encounter Codes
•Diagnostic Codes
•Payment
•NMRE Billing and Encounter Code Description
Encounter Codes
Service Description
HCPCS & Revenue Codes
Reporting Code Description from HCPCS and CPT Manuals
Reporting Units/Duplicate Threshold“DT”
Reporting Technique & Claim Format
Coverage Reporting and Costing Considerations
Health Home-Opioid Health Home and Behavioral Health Home
S0280
S0280 HG
S0280-Behavioral Health Home
S0280 HG-Opioid Health Home
Monthly Case Rate
Professional Healthy Michigan Plan, State Plan, 1115
-Use HG modifier for Opioid Health Home-Use TS modifier for non-face-to-face encounters after the initial face-to-face encounter.
Encounter CodesBehavioral Health Home
HCPCS & Revenue Codes
S0280
Opioid Health Home
HCPCS & Revenue Codes
S0280 HG
*HG Modifier is only used for OHH
TS modifier must be used for non-face to face encounters after the initial face to face encounter for both BHH and OHH
OHH Qualifying ICD-10 Codes Medicaid Beneficiaries with the Specific ICD-10 Codes for Opioid Realated Disorders:
• F11.1 Opioid abuse
• F11.2 Opioid dependence
• F11.9 Opiod Use, Unspecified
Full list of ICD-10 Codes can be found in the OHH Handbook and ICD-10 Codes
BHH Qualifying ICD-10 CodesMedicaid beneficiaries with a specific ICD-10 Code for Serious Mental Illness or Serious Emotional Disturbance are eligible:
•F06 Other mental disorders due to known physiological condition
•F20 Schizophrenia
•F25 Schizoaffective disorders
•F31 Bipolar disorder
•F32 Major depressive disorder, single episode
•F33 Major depressive disorder, recurrent
•F43 Reaction to severe stress, and adjustment disorders
•F41 Other anxiety disorders
•F90 Attention-deficit hyperactivity disorders
A full list of Qualifying ICD-10 Codes will be in the BHH Handbook
Health Homes Diagnostic Z- Codes•Applicable ICD-10 Z diagnosis codes to be used with the S0280 with HG Modifier code include the following groups:
• Z55-Z65 (Socio-Economic Conditions) Persons with potential health hazards related to socioeconomic and psychosocial circumstances
• Z77-Z99 (EnvironmentalConditions)
• Z780-Z99 (Persons with potential health hazards related to family and personal history and certain conditions influencing health status)
* HG Modifier for OHH
(Please note that the Z-code should NOT be used as the primary diagnosis code)
Payment
PMPM PMPM with P4P$364.48 $382.70
OHH Case Rates to LE
Per Member Per Month (PMPM) PMPM with P4P
$389.97 $410.49
BHH Case Rates to LE
OHH Pay-for-Performance (P4P)MDHHS will afford P4P via a 5% performance incentive to the additional per member per month case rate. The LE must distribute P4P monies to HHPs that meet the quality improvement benchmarks in accordance with the approved SPA, plicy, and OHH Handbook.
Performance Measures
• Initiation and engagement of alcohol and other drug dependence treatment
•Follow-up after Emergency Department Visit for Alcohol or Other Drug Dependence
•Emergency Department Utilization for SUD per 1,000 Medicaid Beneficiaries
Timelines◦ Measurement Year: 10/1/2020 through 9/30/2021
◦ Performance Year 1: 10/1/2021 through 9/30/2022
◦ Performance Year 2: 10/1/2021 through 9/30/2022
BHH Pay-for-Performance (P4P)MDHHS will afford P4P via a 5% performance withhold. The LE must distribute P4P monies to HHPs that meet the quality improvement benchmarks in accordance with the with the approved SPA, policy, and the BHH Handbook.
▪ Performance measures include:
▪ Reduction in Ambulatory Care
▪ Increase in Controlling High Blood Pressure
▪ Access to Preventative/Ambulatory Health Services
▪ The metrics and specifications will be maintained in the BHH Handbook and on the MDHHS website.
▪ Timeline
▪ Measurement Year: 10/1/2020 through 9/30/2021
▪ Performance Year 1: 10/1/2021 through 9/30/2022
▪ Performance Year 2: 10/1/2021 through 9/30/2022
Michigan’s Health Home – Payment ScheduleThe enrollment file for the month with be sent to CHAMPS on the 26th of the month.
For example: ▪ Payment for newly enrolled beneficiaries added to BHH from July 1 though July 25.
▪ Retroactive payment for beneficiaries enrolled from June 26 to June 30.
▪ Prospective payment for the month of August (for all enrolled beneficiaries, as of July 26).
▪ Payment will be made on the second pay cycle (the Thursday after the 2nd Wednesday of the month).
▪ The payment will be included with any other scheduled payments associated with the LE’s tax identification number.
Michigan’s Health Home – RecoupmentThe payment for OHH services is subject to recoupment from the PIHP if the beneficiary does not receive an OHH service during the calendar month.
• The recoupment look back will occur six months after the monthly payment is made.
• Ex: in January the State would look back at the month of July’s payment
• CHAMPS will conduct an automatic recoupment process that will look for an
approved encounter code.• The recoupment process will run automatically on the 2nd of the month
• The LE must submit encounters by the end of the month before the scheduled recoupment.
Questions?Jon Villasurda, Jr., MPH
State Assistant Administrator
Michigan Department of Health and Human Services
Kelsey Schell, MPH (OHH Contact)
Opioid Health Home Analyst
Michigan Department of Health and Human Services
Lindsey Naeyaert, MPH (BHH Contact)
Behavioral Health Innovation Specialist
Michigan Department of Health and Human Services
NMRE
Brandon Rhue | Chief Information Officer
HIPAA Security Officer
Northern Michigan Regional Entity
1999 Walden Drive Gaylord, MI 49735
