Health Home HML Rate For Adults
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Health Home High, Medium, Low (HML) Billing For Adults
Health Home Rates: High, Medium, and Low (HML) Rates with Clinical and Functional Adjustments Effective December 1, 2016
- Effective 12/1/16, the monthly HML Assessment questionnaire is used to determine the rate code a member should be billed under for a that month.
- HML Assessment created and approved by the HH/MCO Workgroup and uses clinical/functional questions to determine a member´s HML status for each month based on real time member attributes.
- Providers should skip any questions that don´t apply to a member or any questions that they cannot answer.
- Each answered question qualifies as either High, Medium, or Low (see following slides).
- Does the member have at least one response in the "High" category?
- Yes – bill for member using the "High" rate code
- No – see # 2
- Does the member have at least one response in the "Medium" category?
- Yes – bill for member using the "Medium" rate code
- Bill for member using the "low" rate code
HML Rate Determination - Examples
| **Responses for 12/1/16 Service Date**** | ||||||
|---|---|---|---|---|---|---|
| Clinical & Functional Adjustments | Jane | Juan | Maria | |||
| Response | HML | Response | HAL | Response | HML | |
| Base Acuity (unadjusted) | unknown | 2.1 | L | 1.9 | L | |
| Predictive Risk | unknown | 10% | L | 47% | M | |
| HIV Viral Load | 100 | L | 150 | L | 260 | M |
| HIV T-Cell Count | 250 | M | 400 | L | unknown | |
| Homelessness | HUD 1 | H | NA | HUD 2 | M | |
| Incarceration Release Date | NA | NA | 11/24/2014 | M | ||
| IP Stay for Mental Illness Discharge Date | NA | NA | NA | |||
| IP Stay for SUD Treatment Discharge Date | 9/4/2014 | M | NA | 12/15/2014 | M | |
| SUD Active Use/Functional Impairment | NA | NA | NA | |||
| HML Rate for August 2015 Service Date | High | Low | Medium | |||
MAPP HML Monthly Billing Assessment Questions
| See Billing Support section of MAPP HHTS Specifications Document for the complete listing of HML fields (questions regarding ACT, AOT, and Adult Home members not listed here) | ||||
|---|---|---|---|---|
| Quest. # | Question in MAPP | COMMENT | Field # upload | Field # download |
| 1. | Does the member meet the HARP criteria based on claims and encounters? | This will be auto populated within MAPP by DOH | NA | 31 |
| 2. | Base Acuity | This will be auto populated within MAPP by DOH | NA | 27 |
| 3. | Risk | This will be auto populated within MAPP by DOH | NA | 30 |
| Clinical Adjustments | ||||
| 4. | What is the member´s Diagnosis code (primary reason for Health Home eligibility)? | This field will not be edited at go live and is optional. | 4 | 9 |
| 5. | Is the member HIV positive? | Questions 5a and 5b appear when the response to Q5 is "Yes" | 7 | 32 |
| 5a. | What is the member´s viral load? | Questions 5a and 5b appear when the response to Q5 is "Yes" | 8 | 33 |
| 5b. | What is the member´s T-Cell count? | Questions 5a and 5b appear when the response to Q5 is "Yes" | 9 | 34 |
| Functional Adjustments | ||||
| 6. | Is the member homeless? | Question 6a appears when the response to 6 is "Yes". | 10 | 35 |
| 6a. | Does the member meet the HUD Category 1 or HUD Category 2 level of homelessness? | Drop down box with two options: HUD Category 1 and HUD Category 2 | 11 | 36 |
| 7. | Was the member incarcerated within the past year? | Question 7a appears when the response to 7 is "Yes". | 12 | 37 |
| 7a. | When was the member released? | must enter a valid date. Date must be in the past | 13 | 38 |
| 8. | Did the member have a recent Inpatient stay due to mental illness? | Question 8a appears when the response to 8 is "Yes". | 14 | 39 |
| 8a. | When was the member discharged from the mental illness inpatient stay? | must enter a valid date. Date must be in the past | 15 | 40 |
| 9. | Did the member have a recent inpatient stay for substance abuse? | Question 9a appears when the response to 9 is "Yes". | 16 | 41 |
| 9a. | When was the member discharged from the substance abuse inpatient stay? | Question 9a appears when the response to 9 is Yes. | 17 | 42 |
| 10a. | Did the member have a Positive Lab test OR other documentation of substance use? | Each question must have response: Y/N. Must have at least 1 Y to 10a-10c AND at least one Y in 11a-11b | 18 | 43 |
| 10b. | Did the member have an LDSS positive screening for referral to SUD service? | |||
| 10c. | Was member referredfor SUD service from parole/probation within last 30 days? | |||
| 11a. | Is there documentation from family and/or criminal courts that indicates member involvement in a domestic violence and/or child welfare incident within the last 60 days? | |||
| 11b. | Is there documentation from Drug court OR a police report alleging member´s SUD including, but not limited to, operating a vehicle under the influence, harassment, disorderly conduct, and/or public lewdness within the last 60 days. | |||
| 12 | Was a Health Home core service provided this month? | Y/N | 19 | 44 |
| Attribute | Low | Medium | High |
|---|---|---|---|
| Base Acuity (unadjusted) | ≤ 2.5 | Between 2.5 and 5.0 | ≥ 5.00 |
| Clinical Adjustments | |||
| Predictive Risk | < 30% | between 30% and 50% | > 50% |
| HIV Viral Load | < 200 | between 200 and 400 | > 400 |
| HIV T-cell Counts | > 350 | between 200 and 350 | < 200 |
| Functional Adjustments | ||
|---|---|---|
| Homelessness | Medium | High |
| Meets HUD Category 2: Imminent Risk of Homelessness definition | Meets HUD Category 1: Literally Homeless definition | |
| Incarceration | Recent Incarceration between seven and twelve months | Recent Incarceration within six months |
| IP Stay for Mental Illness | IP Stay for Mental Illness within seven and twelve months | IP Stay for Mental Illness within six months |
| Functional Adjustments | ||
|---|---|---|
| IP Stay for SUD Treatment | Medium | High |
| IP Stay for SUD Treatment within 7 and 12 months | IP Stay for SUD Treatment within six months | |
| SUD Active Use/ Functional Impairment | Positive Lab test OR other documentation of substance use OR LDSS positive screening for referral to SUD service OR referral for SUD service from parole/probation within last 30 days AND documentation from family and/or criminal courts that indicates domestic violence and/or child welfare within the last 60 days OR documentation from Drug court within the last 60 days OR police report alleging SUD involvement including, but not limited to, operating a vehicle under the influence, harassment, disorderly conduct, and/or public lewdness within the last 60 days. | |
Health Home Rates: High Medium and Low Rates with Clinical and Functional Adjustments Effective December 1, 2016 For Adults
| Health Home Rates - High, Medium and Low | ||||
|---|---|---|---|---|
| Population | Region | Low | Medium | High |
| HARP | Downstate | $125.00 | $311.00 | $479.00 |
| non -HARP | Downstate | $62.00 | $249.00 | $383.00 |
| HARP | Upstate | $117.00 | $293.00 | $450.00 |
| non -HARP | Upstate | $58.00 | $234.00 | $360.00 |
| Other Health Home Rates | Rate | |||
| Health Home Plus * | Downstate | $800.00 | ||
| Health Home Plus * | Upstate | $700.00 | ||
| Adult Home ** | Downstate | $700.00 | ||
| Outreach | Statewide | $135.00 | ||
| * Limited to AOT members that are not receiving ACT services. ** Limited to Impacted Adult Home members assessed for transition to the community. If an impacted Adult Home member transitions to the upstate region, the rate is $563. |
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