Interim Guidance Addressing Outreach Modifications

October 18, 2017

  • Guidance also available in Portable Document Format (PDF)

Purpose:

To provide additional guidance to Health Homes, Managed Care Organizations and Care Management Agencies implementing Outreach changes effective October 1, 2017.

The following information will replace section 6.4 Outreach and Engagement in the current Health Home Billing and Policy Manual. This guidance is intended to supplement guidance issued on September 25, 2017

  • All outreach services effective on or after October 1, 2017 will not exceed two (2) consecutive months whereas the second consecutive month must be a face to face.
  • Face to face contact is defined as an in-person meeting with the member and/or parent, guardian or legally authorized representative who has the authority to consent and enroll.
  • The outreach rate will be reduced from $135 to $110.
  • Health Homes and Care Management Agencies may enter into agreements to withhold partial payment of outreach dollars in anticipation of the retroactive rate adjustment back to October 1, 2017.
  • Outreach billable months cannot exceed 4 months in a rolling twelve (12) month period.
  • Billable outreach is connected to the individual not the Health Home or Care Management Agency.
  • Health Home enrollment will be determined by the individual´s choice to enroll, The DOH 5055 consent must be obtained to complete the enrollment process. Health Home consent confirms the member´s choice to enroll/continue enrollment and supports the member´s approval to access/share PHI with those entities approved by the member. Without consent, enrollment cannot occur.
  • Consent must contain at a minimum the Health Home and Care Management Agency, the member´s Medicaid Managed Care Plan, and the member´s health providers such as the primary care physician or other health provider (e.g, Behavioral Health) from which the majority of healthcare services are received. This will allow the CMA to access important information needed to document eligibility and provide care management core services, establish a care team, and build a plan of care (e.g., Comprehensive Assessment).

For outreach segments beginning prior to October 1, 2017, Care Management Agencies may elect to continue the outreach segment for three consecutive months. In doing so the care management agency must be cognizant that the rolling 12-month period begins for outreach services provided on/after October 1, 2017. Therefore, paid outreach claims for October 2017 and November 2017 will be counted as billable outreach months in the 4-month maximum outreach claims within the rolling twelve-month period.

The following grid has been developed to address specific questions related to acceptable outreach scenarios.

Example Month Outreach Segment Face to Face Billable
1. October 1-31 New No Yes
  November 1-30 Second consecutive month No No (HH should end the outreach segment as of 10/31/17)
2. October 1-31 New No - no progress Yes - end segment 10/31/17
  January 1-31 New information No-contact and appt scheduled Yes
Member is reached and appointment scheduled February 1-28 Second consecutive month Yes, member consents to enroll - Outreach ended 1-31-18 Yes, consented to enroll second month billed as enrolled effective 2/1/18. Enrollment segment created with a 2/1/18 begin date.
3. October 1-31 New No but phone contact Yes
Scheduled face to face November 1-30 Second consecutive month Yes - declined consent to enroll Yes, outreach month two no further outreach allowable
Member contacts CMA and is seeking to enroll January 1-31 No Yes, member consents to enroll Yes, consent and bill enrollment. Enrollment segment created with a 1/1/18 begin date
4. October 1-31 New Yes Yes
Member is undecided about Health Homes but agrees to meet again November 1-30 Second Consecutive Month No - member no show No (HH should end the outreach segment as of 10/31/17)
5. Prior Outreach History - with no new information October 1-31 No No No - MCO pend assignment until in receipt of new information
6. Grand fathered outreach segment 9/1/17 - 11/30/17; community referral 12/20 December 1-31 Yes - No - community referral resource to connect to member Yes
  January 1-31 Second Consecutive Month Yes - will not consent to enroll Yes - outreach end date 1/31/18 no additional outreach allowable
Member contacts CMA consents to enroll with additional information and support February 1-28 No Yes - consent to enroll Yes - bill as enrollment. Enrollment segment created with 2/1/18 begin date.
7. October 1-31 New No - no progress Yes - end segment 10/31/17
Example Month Outreach Segment Face to Face Billable
  January 1-31 New information No - contact and appt scheduled Yes
Member is reached and appointment scheduled February 1-28 Second consecutive month No show to scheduled appointment; unable to reach No
8. Previous outreach segment ended October 31, 2017. HH received Hospital ED alert. November 1-30 No, Although ED alert received there was no new information to reach member and alert arrived post discharge No No
9. Previous outreach segment ended October 31, 2017. HH received Hospital ED alert. November 1-30 New, ED alert received post discharge, however member was discharged to shelter - new information CMA reaching out to intake shelter for additional information No Yes
  December 1-31 No contact made with shelter or member No No. Outreach segment should be ended as of 11/30/17.
10. Previous grandfathered outreach ended November 30, 2017 December 1-31 No, ED Alert no new information No No
11. September 1-30 New No Yes
  October 1-31 No contact from previous month of outreach. Attempted a home visit No Yes
  November 1-30 No contact in second month. Home visit was not successful in September. Address is no longer accurate No Yes, technically since this example would fit under prior outreach policy; however, based on information and the unlikelihood of contact it would be in the members best interest to end the outreach segment as of 10/31/17 until new information is available.

Interim MAPP-HHTS Guidance for Determining a Member´s Previous Outreach Activity

Managed Care Member appears on MCP assignment file in an active assignment status

Scenario: This member is active on your assignment file, indicating that the member was associated with your MCP in the past (you have not newly accepted this member from a pending assignment). Since the member was associated with your MCP previously it is appropriate to use the Enrollment Download File to determine recent outreach.
Note: If the member is newly enrolled with your MCP you should use the Member CIN search file detailed below.

Limitation: Should this member have been recently enrolled in your MCP, it is possible that they had outreach activities when the member was not associated with your MCP, these outreach activities would not display on the enrollment file.

Steps:

  1. Download the MCP Assignment File
    1. Filter Field #76: Managed Care Plan Assignment Status to ‘Active"
    2. Filter Field #77: Health Home Assignment Status to "blank"
    3. Filter Field #81: CMA Assignment Status to "blank"
  2. Download the Enrollment File
    1. Filter Field #4: Outreach/Enrollment Code to "O"
    2. Filter Field #16: Status to "Closed" and "Pending Closed"
    3. Insert a column to the left of Field #1: Member ID
      1. In this cell (A2) type the following formula =B2&COUNTIF ($B$2: B2, B2)
      2. Drag this formula down the entire column
      3. Since it is possible that a member has more than one closed outreach segment in the last year, we are identifying them with their CIN number and the instance number – XX12345X1 (first outreach segment), XX12345X2 (second outreach segment) etc.
      4. To the right of this column insert another column.
      5. Enter the formula =RIGHT (A2, 1)
      6. Drag this formula down
      7. Filter this column (column B) to "1"
        1. This identifies the first instance of each member´s outreach
  3. Return to the MCP Assignment File
    1. Add a column to the right of Field #1: Member ID
    2. In cell B2 enter the following formula =vlookup (A2, ED info*, 3, false)
    3. Add a column to the right of column B
    4. In cell C2 enter the following formula =vlookup (A2, ED info*, 4, false)
      *where ED info is all values in columns C through F (click and drag mouse)
  4. Return to the Enrollment File. Filter column B to "2". Repeat step 3 (adding additional columns to the right). Continue to do this if there are additional instances (i.e. 3, 4, etc in column B of the enrollment file).
  5. Review the information in the MCP Assignment File to determine if the member is appropriate for outreach.
    1. If the member has 2 or more months of outreach within the last 12 months the member should NOT BE ASSIGNED DOWNSTREAM.

Member appears on the HH Assignment file in a pending (or active) status

Scenario: A member appears on your HH assignment file in either a pending status (or active but you don´t have/can´t remember recent information about the member). You aren´t sure if you have provided recent outreach to the member or if the member received recent outreach from a different organization. You use the Member CIN Search to see if the member has had any recent care management activity.
Note: If you believe the member was enrolled with your organization, you could use the steps detailed above to find out outreach information during the time the member was associated with your organization.

Limitation: CIN Search Download File only includes care management activity in the last six months that have been billed for. The CIN Search Download does not give specific information regarding outreach dates.

Steps:

  1. Filter the HH Assignment File to those members that you are considering assigning downstream (HH) or accepting (CMA)
    1. Typically, this would look like:
      1. FFS members with a pending HH assignment (recently received from DOH assignment file/community referral)
        1. Field #10: Managed Care Plan Name = "Blank"
        2. Field #74: Health Home Assignment Status = "Pending"
        3. Field #78: CMA Assignment Status = "Blank"
      2. Members with a pending CMA assignment (recently assigned downstream from HH)
        1. Field #78: CMA Assignment Status = "Pending"
      3. Members with an active HH assignment
        1. Field #74: Health Home Assignment Status = "Active"
        2. Field #78: CMA Assignment Status = "Blank"
        3. Note: Field #8: HH Assignment Create Date can give the HH more information as to when the assignment was created (i.e. a recent date and no CMA assignment may mean that a segment just ended with an end HH assignment response of "No")
  2. Copy CINs of those members in question
  3. Navigate to the Member CIN Search page from the quicklinks menu
  4. Paste the CINs into the CIN# box
  5. Click Download Search Results
  6. Click Yes when asked if you want to navigate to the download files page
  7. Open processed CIN Search Download
  8. Review any information that is returned in the Recent Care Management Activities (Fields #67-84)
    1. If any information is populated in these fields it is the responsibility of the user to review the member´s recent segments to determine if the member is eligible for outreach.
      1. This can be done by searching for the member on the Member CIN Search screen.
      2. Click on the hyperlink of the member´s name.
      3. Review the Health Home History section.

Potential/Recommended Fields be considered for additions to the Assignment Files:

  • Member´s most recent segment type
  • End date of the member´s most recent segment
  • HH MMIS ID and Name associated with the most recent segment
  • Segment end date reason of the most recent segment
  • # of outreach months within the past 12 months as of the file download
  • Y/N field to indicate whether a member is currently eligible for Outreach