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) |

Population Assignment/ Eligibility (Patient Tracking System)

  1. What requirements/systems will be in place for notification to Health Homes when clients present in emergency rooms and inpatient settings, especially in situations where the emergency room/inpatient setting is not part of the Health Home?
  2. Will there be a unique patient identifier to inform providers about a patient´s Health Home?
  3. What happens to behavioral health consumers who opt out of a health home?
  4. How does Health Home assignment take place?
  5. Who will be assigning individuals to Health Homes?
  6. How will consumers be notified of their assignment?
  7. How were adults with a serious and persistent mental illness (SPMI) transitioned to Health Homes? There are over 408,000 adults with SPMI.
  8. Will Health Homes be assigned members they have no previous relationship with?
  9. Will Managed Care Plans that assign Health Home eligible enrollees to Health Homes be following the same NYSDOH algorithm used for the fee–for–service population assignment?
  10. Will there be a mechanism to cap the number of members assigned to an organization?
  11. In the future, will all HIV+ Medicaid recipients be assigned a Health Home or is a second diagnosis and high cost claims necessary for eligibility?
  12. How will the State make Health Home services available to the homeless Medicaid population?
  13. Can you provide a brief definition for ´Risk Score´?
  14. How is it determined whether a substance use disorder is "chronic" enough to qualify a Medicaid member for Health Home services?
  15. How does an entity refer a Medicaid member for Health Home services?
  16. May individuals of all ages be served by a Health Home?
  17. Are Detention/Correctional facilities and Housing Agencies included under Health Homes?
  18. If a Health Home eligible individual is incarcerated when located during Outreach and Engagement, is it possible to enroll the client?
  19. How long can Health Home care management services be provided to an active Health Home member who is incarcerated?
  20. Will Medicaid Spenddown, Buy–in and individuals in the Special Needs Trust be eligible for Health Home services?
  21. Can individuals in a waiver program with care coordination, like the Long Term Home Health Care Program, enroll in a Health Home without jeopardizing their LTHHCP services?
  22. In the new Health Home Member Patient Tracking System Guide (06/2013) on Pg. 25; Outreach / Enrollment Code. If both outreach and enrollment occurred in the same month, only the enrollment event should be submitted. Please clarify as we understand this is to be an ´opt–out´ program and that members are automatically enrolled. DOH has not described an ´enrollment event´.
  23. Please clarify the following with regard to Outreach:
  24. Can a Health Home member also be in a Managed Long Term Care plan?
  25. Are we able to close Health Home cases in the event that the client has moved and cannot be located? If so, how do you close a Health Home case?
  26. Are the volume of assignments to lead Health Homes dependent on the NPI numbers (providers) enrolled in the Health Home network?
   Archived Questions
1. What requirements/systems will be in place for notification to Health Homes when clients present in emergency rooms and inpatient settings, especially in situations where the emergency room/inpatient setting is not part of the Health Home?

The process that will be used to assure notification will be defined by each Health Home. Hospitals are required under the federal ACA requirement to make referrals to Health Homes. A project is underway to display RE codes A1 and A2 in ePaces; the A1 and A2 RE codes will identify a member´s Health Home and Care Management Agency if the member is in outreach or enrollment status.

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2. Will there be a unique patient identifier to inform providers about a patient´s Health Home?

The State has not developed a patient identifier but a project is underway to display RE codes A1 and A2 in ePaces; the A1 and A2 RE codes will identify a member´s Health Home and Care Management Agency if the member is in outreach or enrollment status. In addition, Health Homes and Managed Care Plans have access to the MAPP Health Home Member Tracking System (HHTS)to look up members.

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3. What happens to behavioral health consumers who opt out of a health home?

It is imperative that the Health Home engage potential members assigned or referred to them. Health Homes and care management agencies should work with individuals so they understand the importance of the Health Home program in assisting them with accessing needed care and services. However, because the Health Home program is voluntary, individuals are given the choice to opt–out of the Health Home program.

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4. How does Health Home assignment take place?

The State uses a combination of 3M™ Clinical Risk Groups (CRG), which are a 3M product, an algorithm that predicts hospitalizations, and behavioral health indicators to select Medicaid enrollees for Health Homes. Medicaid enrollees, ages 21 and older, will be assigned, to the extent possible, to a Health Home provider based on existing relationships with health care providers or health care system relationships, geography, and/or qualifying condition.

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5. Who will be assigning individuals to Health Homes?

The State, and the managed care plans for managed care members, will be assigning patients to Health Homes based on loyalty and attribution data. The initial population group that was assigned was individuals who lacked any care management or meaningful primary care connection. The State will release lists of members to Health Home providers through the Health Home Tracking System assigned members current demographic information to facilitate outreach and engagement.

OMH Single Point of Access (SPOA) will continue to play a role in assigning patients to former TCM programs.

The State has also developed a process for accepting referrals from community providers. This process is described in the Health Homes Provider Manual within the Health Home Policy and Standards webpage

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6. How will consumers be notified of their assignment?

Potential Health Home members will be notified of their assignment to the Health Home or Managed Care Plan through a welcome letter provided by the Health Home (fee–for–service Medicaid recipients) or Managed Care Organization. The welcome letter will inform the potential member about the Health Home program, how enrollment can benefit him/her, reason for receiving the letter, the care management agency who will be contacting him/her, and options to Opt Out or request another Health Home, if available. It will also include the Medicaid Helpline number for any questions they may have.

As part of this process, the care management agency for the Health Home will send a welcome letter to further engage the potential member in the outreach and engagement process. This letter will reference the Health Home welcome letter, reason for receiving the letter, request contact for further discussion about the benefits of enrollment, and options to Opt Out or request another care management agency. It will also include the Medicaid Helpline number for any questions they may have.

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7. How were adults with a serious and persistent mental illness (SPMI) transitioned to Health Homes? There are over 408,000 adults with SPMI.

At the time of Health Home implementation, there were approximately 100,000 Medicaid members with SPMI only; the remaining members identified in the behavioral health group are members with a SPMI and a co–occurring diagnosis.

Members who were receiving care management services from an OMH TCM provider were assigned to Health Homes that included their TCM provider. The goal was not to disrupt existing care management relationships with the exception of TCMs, where these special arrangements were made, Medicaid members enrolled with plans will be assigned into Health Homes by the plan utilizing loyalty and attribution data and a suggested Health Home assignment provided by the State.

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8. Will Health Homes be assigned members they have no previous relationship with?

It is possible that some of the assigned members will not have a relationship with the Health Home they are assigned to, however, every effort is made to match recipients to Health Homes based on a loyalty analysis that takes into account the member´s utilization of health and behavioral health care services within a Health Home´s provider network.

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9. Will Managed Care Plans that assign Health Home eligible enrollees to Health Homes be following the same NYSDOH algorithm used for the Fee–for–Service population assignment?

The State will share its suggested Health Home assignment with managed care plans and encourage plans to assign their members to the suggested Health Home. However, managed care plans may have additional data on members. With the exception of managed care enrollees already in TCM programs, managed care plans will be responsible for making their own assignments to Health Homes and may assign additional members based on their own analytics.

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10. Will there be a mechanism to cap the number of members assigned to an organization?

At this time, the Department is not able to assign fee for service members based on a Health Home´s capacity. However, Managed Care Plans may keep a Health Home´s capacity in mind while assigning their plan members to a Health Home.

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11. In the future, will all HIV+ Medicaid recipients be assigned a Health Home or is a second diagnosis and high cost claims necessary for eligibility?

All HIV+ individuals are eligible for Health Home services because this diagnosis is a single qualifying condition for Health Homes. They do not need a second diagnosis to qualify.

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12. How will the State make Health Home services available to the homeless Medicaid population?

The State will assign a Health Home to homeless Medicaid enrollees that meet Health Home eligibility requirements using provider loyalty information, available information regarding their homeless status, and the enrollee´s last known address. In addition the Health Home program is supporting a variety of efforts to assist Health Homes in engaging with the homeless population, more information can be found by clicking here.

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13. Can you provide a brief definition for ´Risk Score´?

Risk scores predict the probability that recipients will experience a negative outcome (e.g. inpatient admission, long term care, death) in the following year. The predictive model used to calculate the risk scores is based on prior year service utilization. Negative outcomes are less likely for recipients with lower risk scores (0) and are more likely for recipients with higher risk scores (100).

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14. How is it determined whether a substance use disorder is "chronic" enough to qualify a Medicaid member for Health Home services?

Substance use disorder alone does not qualify a member for Health Home services. In order to be eligible for Health Home services, the member would need to have two chronic conditions, or one single qualifying condition (HIV/AIDS or a serious mental illness). Substance use disorder can qualify as one of the chronic conditions. In order to be considered chronic it needs to have had a significant impact on the member´s ability to function.

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15. How does an entity refer a Medicaid member for Health Home services?

Guidance for community referrals can be found in the Health Homes Provider Manual within the Health Home Policy and Standards webpage and was also included in the April 2012 Health Home Special Edition of the Medicaid Update. Health Homes can add Fee–for–Service (FFS) members meeting Health Home criteria to their tracking file as outlined in the Health Home Member Tracking System Specifications. If the member is in Managed Care then the Managed Care Plan should be contacted to make the referral.

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16. May individuals of all ages be served by a Health Home?

Health Homes should be mindful of their designation to serve children and/or adults and their approved network providers. However, the member´s choice should be paramount. If a member chooses to be served in a Health Home that is not designated to serve them (a child in a adult´s Health Home), then it is imperative that the Health Home Care Manager must share with the member and/or parent / guardian what population they are designated to serve and that their network and connection to service providers may not meet the member´s need. Additionally, it must be explained to the member and/or parent / guardian that there is a potential that the member may not be able access services that they are eligible for (i.e. HARP/HCBS).

In these circumstances, the Health Home CMA would have to bill under the appropriate billing mechanism based upon the Health Home designation to serve children or adults (i.e. a child in an adult Health Home would bill the adult HML and would not complete the CANS–NY). For more information click here.

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17. Are Detention/Correctional facilities and Housing Agencies included under Health Homes?

These entities are encouraged to partner with Health Homes and should reach out to Health Homes they would like to work with. Mechanisms are being explored to provide priority access to Health Homes for homeless individuals and those being released from detention and correctional facilities. Housing providers are being encouraged to network with one or all of the Health Homes in their area.

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18. If a Health Home eligible individual is incarcerated when located during Outreach and Engagement, is it possible to enroll the client?

Individuals who are incarcerated have their Medicaid suspended after 30 days and will not qualify for Health Home services until they are no longer incarcerated. However, the Health Home that is assigned that individual may work with county or local jails, prisons, and/or Department of Corrections (DOC)´s transitional services unit to make sure they are aware of the Health Home that will be willing to provide services after the individual´s term as the individual may have Medicaid in suspended status until released. This will hopefully lead to a smooth transition to Health Home services (outreach/enrollment) upon discharge.

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19. How long can Health Home care management services be provided to an active Health Home member who is incarcerated?

As a rule, Medicaid remains active for the first 30 days of incarceration and is then suspended until release. Upon release, Medicaid is restored back to the first day of the month of release so that services can be provided and billed. Depending on the anticipated length of incarceration (e.g., jail or prison), the member can remain enrolled in the Health Home program in an "inactive" status. However, during the period of incarceration when Medicaid is suspended, Health Home care management services cannot be billed.

The Department has developed a "Pended" status code as part of the move of the Health Home Member Tracking System (HHTS) to the Medicaid Analytics Performance Portal (MAPP) and be working in conjunction with other State agencies on guidance for Health Homes on the length of time an individual can remain in "Pended" status while incarcerated. At this time, there is no limit on the length of time a Health Home member can remain in "Pended" status while incarcerated in jail or prison.

It is imperative that Health Homes establish relationships with the criminal justice system to support timely and safe enrollment into the Health Home program upon release of an active Health Home member, or potential member. Health Homes should inform jails and prisons of a member´s enrollment in a Health Home and encourage communication to support the Health Homes ability to connect and serve individuals immediately upon release so they can assist in transitioning the individual back into the community.

Guidance on Health Home care coordination for incarcerated members can be found in the Health Home Policy and Standards page.

For more information on the State´s progress on Health Homes and the Criminal Justice Population click here.

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20. Will Medicaid Spenddown, Buy–in and individuals in the Special Needs Trust be eligible for Health Home services?

Medicaid spend down individuals can be included in the Health Home program for chronic behavioral and medical conditions. Services can be provided when they are Medicaid eligible. LDSS and OMH regional offices can work with members to ensure they meet any spend down requirements, pursuant to published ADMs. Person´s Living with HIV/AIDS (PLWHA) who have Medicaid spend down can contact ADAP for assistance with their spend–down requirements. Individuals participating in the Medicaid Buy–In program for Working People with Disabilities and those with an Exception Trust (a Supplemental Needs Trust that provides for Medicaid reimbursement upon the death of the recipient) who are fully eligible for Medicaid are eligible for Health Homes. Medicaid cannot reimburse for Health Home services provided to a spend–down member if the member does not meet their spend–down requirement in a given month. PLWHA can be served in a grant–funded program if they become ineligible for Medicaid or can not meet their spend down.

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21. Can individuals in a waiver program with care coordination, like the Long Term Home Health Care Program, enroll in a Health Home without jeopardizing their LTHHCP services?

No, Individuals receiving care management through this or other waivers cannot also receive care management from a Health Home. The care manager needs to work with the member to decide which program provides the best supports and services. Visit the Health Home website for more information about programs that are/are not compatible with the Health Home program. To see "Guide to Restriction Exception (RE) Codes and Health Home Services" click here.

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22. In the new Health Home Member Patient Tracking System Guide (06/2013) on Pg. 25; Outreach / Enrollment Code. If both outreach and enrollment occurred in the same month, only the enrollment event should be submitted. Please clarify as we understand this is to be an ´opt–out´ program and that members are automatically enrolled. DOH has not described an ´enrollment event´.

Health Home Program services are voluntary and an individual has to consent to Health Home services. An "enrollment event" is when the individual is changed from Outreach to Enrollment and is now considered to be in active care management the segment

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23. Please clarify the following with regard to Outreach:
  1. Minimum activity needed in a month to report on tracking sheet/bill
  2. Documentation needed to support
  3. Is the combination of using data to match list and sending letters to members sufficient to claim Outreach for month one for any member, assuming Outreach continues to be active and progressive going forward?
  4. Is documentation required in the clients care management record required to support billing for Outreach and Engagement?

All client contact and contact on behalf of the client must be recorded in the case management record in the Electronic Health Record (EHR). The Health Home monthly PMPM may be billed as long as active outreach is occurring each month and at least one of the five core services (excluding HIT) described on page 13 of the April 2012 Medicaid Update are provided in each billed month.

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24. Can a Health Home member also be in a Managed Long Term Care plan?

MLTC plans are for individuals needing more than 120 days of long term care services. If a Health Home member requires more than 120 days of these services, they may be auto–enrolled in a MLTC if available or receive services from a fee–for–service long term care provider if managed long term care plans are not available in their area. In their region a member can be enrolled in both a Health Home and a MLTC but the Health Home and MLTC must enter into an administrative services agreement using a standard template that is under development, so as not to duplicate services.

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25. Are we able to close Health Home cases in the event that the client has moved and cannot be located? If so, how do you close a Health Home case?

When sending a tracking file to the Health Home Member Tracking System there is a code that can be used to close a Health Home case for a member who is lost to follow–up. Details of the Health Home Member Tracking System Specifications Document can be reviewed by clicking here.

Further guidance on members who are lost to follow–up can be found in the Health Homes Provider Manual found on the Policy and Standards page.

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26. Are the volume of assignments to lead Health Homes dependent on the NPI numbers (providers) enrolled in the Health Home network?

Yes. The Department is comparing the claims and encounters for eligible Medicaid members to each of the Health Home network providers´ NPI numbers. Eligible members will match to a specific Health Home network based on that comparison, so it is possible that a Health Home with more NPI numbers might receive more eligible numbers.

For more information please click here.

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