Draft Preliminary Health Home Rate Chart
August 23, 2011
The table below contains a DRAFT listing of preliminary Health Home rates. The Department will monitor these rates to assure that they strike the right balance between Health Homes program needs while operating under efficient costs. The average health home payment for the members in the given groups are for illustration purposes only. Actual payments will be based on a blend of all of the provider's assigned health home patients. Payments will eventually be recalculated (and any changes will be paid prospectively) based on service intensity and functional status data.
Projected Average Health Home Payments by Base Health Status and Severity of Illness - (Excludes LTC and OPWDD populations)
Note: Draft for review and input only - these rates and projections are not final.
| Base Health Status1 | Severity of Illness | Recipients2 | Average Monthly Payment3 | Patient to Case Manager Ratio Range4 | SFY 11/12 Percent Enrolled in HH5 | SFY 11/12 HH Enrolled Recips6 |
|---|---|---|---|---|---|---|
| Single Serious Mental Illness (SMI)/ Seriously Emotionally Disturbed (SED) | Low | 75,528 | $122 | From 51 to 107 | 25% | 18,882 |
| Mid | 28,562 | $155 | From 34 to 71 | 35% | 9,997 | |
| High | 320 | $319 | From 12 to 47 | 50% | 160 | |
| Single SMI/SED Total / Avg | 104,410 | $132 | From 12 to 107 | 28% | 29,039 | |
| Pairs Chronic | Low | 365,718 | $60 | From 51 to 150 | 5% | 18,286 |
| Mid | 140,714 | $121 | From 34 to 115 | 10% | 14,071 | |
| High | 24,200 | $207 | From 11 to 63 | 20% | 4,840 | |
| Pairs Chronic Total / Avg | 530,632 | $83 | From 11 to 150 | 7% | 37,197 | |
| Triples Chronic | Low | 20,748 | $97 | From 51 to 149 | 20% | 4,150 |
| Mid | 29,167 | $153 | From 34 to 104 | 30% | 8,750 | |
| High | 10,136 | $279 | From 11 to 45 | 50% | 5,068 | |
| Triples Chronic Total / Avg | 60,051 | $154 | From 11 to 149 | 30% | 17,968 | |
| HIV/AIDS | Low | 20,353 | $49 | From 103 to 143 | 30% | 6,106 |
| Mid | 21,372 | $166 | From 51 to 108 | 40% | 8,549 | |
| High | 2,316 | $324 | From 11 to 22 | 50% | 1,158 | |
| HIV/AIDS Total / Avg | 44,041 | $122 | From 11 to 143 | 36% | 15,813 | |
| Grand Total | 739,134 | $98 | From 11 to 150 | 14% | 100,016 | |
Footnotes
- 1. Mutually exclusive categories based on Clinical Risk Grouping. SED and OASAS Children are included in price model but will be excluded from initial assignment.
- 2. Includes members that may currently be enrolled in care management programs (OMH TCM, COBRA, MATS and CIDP).
- 3. Average health home payment for the members in the given rate/severity group - these groups are for illustration purposes - actual payments to health home provider will be based on a blend of a given provider's health home patients from across all applicable rate/severity cells. Actual payments are calculated at the patient level based on the predicted service intensity (staff to patient ratio) required for each patient and rolled up to a blended amount (1 rate per provider for a given timeframe) for the entire group of patients assigned to the health home provider. These payments will eventually be recalculated (and any changes will be paid prospectively) based on service intensity and functional status data. DOH will closely review payment adequecy during health home implementation.
- 4. Range of staff to patient ratio variation for the selected group of patients - (for example high severity SMI/SED rate would support a range of staff to patient ratios from 1:12 to 1:47).
- 5. Possible percentage of patients in a given rate/severity group assigned to Health Home services. This percentage is for planning and illustration purposes only - actual number of patients will be based on predictive modeling, ambulatory connectivity and regional Health Home capacity analyses.
- 6. Total HH recipients times the percent enrolled for SFY 11/12 - this includes individuals currently in care management programs (OMH TCM, COBRA, MATS and CIDP) that may not be paid at the Health Home rate level during the first year. This is a draft planning and illustration number only.
