New York State Health Home

Implementation Update

February 10, 2012

Presented byThe New York

State Department of Health

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Ready Set Go-State Plan Approval

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New York's Medicaid State Plan Amendment (SPA) for Phase I Health Homes for Medicaid Members with Behavioral Health and Chronic Conditions was approved with an effective date of January 1, 2012

• Final version of the SPA posted to the Health Home website

• A detailed Medicaid Update Article will be published

• Another Statewide webinar will be held on February 28

• Guidance will be provided on TCM transition

Final Phase I countiesBronxBrooklynNassauSchenectadyWashington

Note: Albany, Rennselaer and Saratoga have been moved from Phase II to Phase III to allow more time for network development

HamiltonClintonFranklinWarrenEssex

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Health Home Readiness

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Readiness Report Card

DEAA’s: 8 out of 13 Provider-led Health Homes have their lead DEAA approved (Note: the DEAA between each Health Home lead and the Department must be approved before lists can be shared; sub-agreements must be approved for Health Home lead to share member information with Health Home partners)

HCS Accounts: 10 out of 13 Health Homes have active HCS accounts (Passwords must be changed every 90 days)

Contingency Letters: All 13 Health Homes have returned signed designation letters

Health Home Readiness

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Lead Health Homes do all billing under one NPI number (with the exception of old and new TCM slots which will continue to be billed to eMedNY directly by case management agencies)

Provider Enrollment and NPI’s

• Health Homes may use an existing NPI number, enroll any newly structured organization once it is organized, obtain a new NPI for that organization, then bill under the NPI of the new organization

• Detailed Medicaid provider enrollment information is available on the Health Homes website

Health Home Readiness

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• Health Homes and Plans must maintain current contact information (updates to hh2011@health.state.ny.us)

Communication

• Health Homes and Plans must identify a contact number for Health Home participants to be directed for assistance and information

• Health Homes and Plans as appropriate must handle consent, enrollment and disenrollment correspondence with participants, using templates provided by the Department, and use consistent terminology

Health Home Readiness

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• Health Homes must prepare to meet quality measures and reporting responsibilities

Thinking Ahead

• Health Homes must develop systems to reimburse partners, commensurate with the level of Health Home services delivered

• Health Homes should think through their capacity, i.e., how many participants can they serve

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•Managed Care Plans are working on contracts with Provider-led Health Homes to allow Plans to assign their members into Health Homes as appropriate

•DOH is working on model contract language which will be shared with Health Homes for comment

•Managed Care member assignment into Phase 1 Provider-led health homes will likely commence in March

Working with Managed Care PlansProvider-led Health Homes must work closely with Managed Care Plans to:

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• Coordinate care and services

• Utilize the plan network, for in-plan benefits

• Respect prior authorization requirements

Working with Managed Care PlansManaged Care Plans must: • Contract with provider-led Health Homes

• Assign members using the State algorithm and their own data (e.g., PCP assignment) to appropriate Health Homes

• Reimburse Health Homes commensurate with the Health Home services being provided

• Act as State’s partners in monitoring the quality of Health Homes

• Work with Health Homes that are not achieving quality goals and/or meeting the member’s needs, to help them improve

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Health Home Assignment-FFS

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• Lists will be used to populate member tracking sheets, which Health Homes will access through the Health Commerce System (HCS)

•Updated network partner lists were received from all Health Homes to finalize the algorithm for identifying and assigning candidates based on loyalty

• Lists of potential participants will be created, with individuals scoring higher (based on risk for adverse events and lack of engagement in care) being identified for assignment first

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• Provider-led designated Health Homes will get access to member tracking sheets for their assigned members in February to begin outreach and engagement

• Outreach and engagement (or enrollment if applicable) commencing in February should be billed in March, using new rates and a February 1 date of service

Health Home Assignment-MC

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• Managed Care Plans have access to their member tracking sheets via the HCS, for individuals identified by DOH as potential Health Home candidates (based on risk and engagement, loyalty, PCP assignment)

• Managed Care Plans will evaluate potential candidates and assign them to Health Homes that best serve their needs

Health Home Assignment-TCM

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• TCMs will identify the Health Homes that best meet their member’s needs

• Managed Care Plans and Health Homes will receive member tracking sheets that reflect these assignments

• DOH will make assignments to Health Homes based on these recommendations

Assignment-New Referrals

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• New referrals (via HRA, county, SPOA or LGU, care management agency, practitioners, hospital, prisons, BHO, etc) meeting Health Home criteria must be assigned to Health Homes to ensure access to care management

• For Managed Care Members, the referring entity will contact the Plan to actuate the Health Home assignment

• For FFS members, the referring entity will contact DOH (contact information to be provided shortly) to actuate an appropriate Health Home assignment. Process will include collaboration with OMH, AIDS Institute, and OASAS to ensure these assignments best serve the needs of their populations

Member Tracking Sheet Elements • Patient Demographic information• Assigned Health Home • Health Home Direct Care Management Provider

• TCM, MATS, CIDP• MCO, CBO

• Enrollment/Disenrollment Status• Various Dates

• Consent• Enrollment/disenrollment

• Patient Profile (e.g., Risk Score, Acuity Score, Ambulatory Connectivity and Loyalty)

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The information on the member tracking sheet supports the claim…more on this in the Billing and Payment section

Outreach and Engagement

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• Outreach and engagement-three consecutive months to find and engage candidate and secure consent. If not successful, outreach and engagement can continue but three months must elapse before another three months of outreach and engagement can be billed

• If a Health Home candidate opts-out, at least three months must elapse before the candidate can be reassigned and no outreach can occur during this period

Enrollment and Consent

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• Enrollment starts when the candidate has signed the consent form and becomes a Health Home participant

• Care managers are expected to help potential Health Home participants understand that signing includes consent for Health Home Services as well as allowing health information to be shared with other Health Home providers and the RHIO

• A fillable PDF version of the consent form is available on the Health Home website (currently only in English, translations into other languages will be available)

Enrollment and Consent

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• Personal health information on Health Home members cannot be shared with network partners until consent is signed - the date of consent is considered the enrollment date

• Entry of an enrollment date on the member tracking sheet and submission of the sheet via HCS will support claiming through eMedNY for the enrollment rate, instead of the outreach and engagement rate

Billing and Payment-Eligibility

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Note: Billing and payment, including rates, were covered in detail at the December 9, 2011 Statewide Webinar (presentation is on the Health Homes website)

• Two options to populate the member tracking sheets will be available initially: manual data entry at the member level or file transfer for all Health Home candidates and participants. System changes are in progress to allow additional functions, e.g., look-up of Health Home status

• Eligibility will initially be controlled through sharing of member tracking sheets. Key elements of the tracking sheet (outreach dates, enrollment dates) will be loaded to member eligibility files to support claims and appropriate payment edits

Billing and Payment-Rates

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• CSC will notify managed care plans and Provider-led Health Homes when they are able to bill new Health Home rate codes.

• Payment rates will be set based on region and case mix (e.g. clinical acuity).

• Eventually rates will be further adjusted by member functional status (e.g. impairment in physical and/or behavioral functioning, housing status, self management abilities, etc).

• Except for TCMs, outreach and engagement will pay at 80% of the rate, once the candidate is enrolled the rate will be 100%

Health Home Rate Code Definitions

1386: Health Home Services (Plans and FFS)1387: Health Home Outreach (Plans and FFS)

1851: Health Home/OMH TCM1852: Health Home Outreach /OMH TCM

1880: Health Home/AIDS/HIV Case Management1881: Health Home Outreach/ AIDS/HIV Case Management

1882: Health Home/ MATS1883: Health Home Outreach/MATS 1885: Health Home/CIDP Case Management

Billing and Payment-Rates

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Billing and Payment-Claims

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• Claims are submitted by, and monthly payments made to, health plans (MC ) Provider-led Health Homes (FFS) and converting TCM programs (for both MC and FFS) through eMedNY

• Claims can only be submitted once per month and must be dated the first of the month; these are institutional claim types using the electronic 8371 format

Billing and Payment-TCMs

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TCM’s have unique billing rules:

• Existing case management slots, OMH-TCMs, HIV COBRA, CIDP and the MATS programs will convert to Health Home rates retroactive to January 1

• TCM’s will bill at 100% of the Per Member Per Month (PMPM) for outreach and engagement and for enrollment

Billing and Payment-TCMs

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TCM’s have unique billing rules:

• TCM programs billing under their existing NPI must bill eMedNY directly for both MC and FFS participants, including their legacy TCM capacity and new Health Home capacity

• Health Homes can negotiate with TCM programs for upstream payments for administrative services and other support

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• Guidance is under development for case management (i.e. TCM, COBRA) programs to bill new rates retroactively to January 1, 2012, for patients they are already serving (may have option to automatically reprocess these claims)

• No changes to billing until this guidance is released. TCMs should continue to bill as they are doing now. Once TCMs have transitioned to new codes, can use the active enrollment code for continuing care management services, but health information cannot be shared until Health Home consent is obtained

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Health Homes must provide at least one of the six core Health Home services per quarter. There will be no requirement for minimum face-to-face contacts, however, there must be evidence of activities that support billing, including:

• Contacts (face-to-face, mail, electronic, telephone)

• Patient assessment

• Development of a care management plan

• Active progress towards achieving goals

Metrics

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• Care management process metrics will be collected to assess the level of care management services provided and the degree to which the six core Health Home services have been delivered

• Initially, quality metrics will be derived for the most part from encounter and claims data. State outcome metrics are included in the SPA, guidance still pending from CMS (expected Summer 2012) on core measures and metrics

Metrics

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• Currently the State is exploring aligning Health Home care management metric reporting with CMART, a case management reporting utility used by Managed Care Plans

• For Managed Care Plan members, the Health Home will be required to send member-level metrics to the Managed Care Plan. Member-level metrics on FFS participants will be reported to the State. These metrics (e.g., frequency of contacts, dates) could be collected monthly, as part of the process of sharing tracking forms

• Goal is to have a uniform platform for reporting that would satisfy requirements of both Managed Care Plans and the State and to begin collecting process metrics as of April 2012

Assessment

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• This validated tool would be administered face-to-face upon enrollment, annually thereafter and at discharge and results reported to the State

• Results of functional assessments will be used to adjust initial rates, which were based on calculated acuity and risk scores

•The State is evaluating a functional self-assessment tool based on the FACIT-GP which would be used to evaluate each Health Home participant on a range of measures

Open Issues

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• Provider and Plan portals for reporting metrics, quality and assessment data

• Transitions from the shelter and criminal justice systems

• Frequency of reporting, for metrics, and quality data

Questions?

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Visit the Health Home Website at: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes

Send an email to the Health Homes Bureau Mail Log at hh2011@health.state.ny.us.