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New York State Health Homes Phase I Implementation UpdateStatewide Webinar
Presented by:
New York State Department of HealthDecember 9, 2011
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Health Homes Phase I Applications reviewed for:
Meeting Provider Qualifications and Standards and providing adequate choice within Health Home partnerships
Care Management “Bandwidth” ability to meet needs of all facets of complex populations (e.g., Mental Health, Housing, Substance Use Disorder, etc.)
Promoting the State vision to minimize silos and concentrate volume over a few rather than many Health Home networks/systems thereby assuring a more limited accountability structure and more financially viable Health Homes.
Creating choices where applicable between institutional lead and community based lead Health Homes
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Final Phase I countiesBronxBrooklynNassauSchenectadyWashington
Monroe and Saratoga moved to Phase IISt. Lawrence moved to Phase III
HamiltonClintonFranklinWarrenEssex
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Contingently Approved Designated Provider-led Phase I Health Homes
Bronx Brooklyn Nassau Schenectady
Adirondack Counties
Bronx Accountable Health Network(Joint Venture)
Maimonides Medical Center
North Shore-LIJHealth System
Visiting Nurse Service of Schenectady Co.
Adirondack Health Institute (AHI)
NYC Health and Hospitals Corporation
NYC Health and Hospitals Corporation
FEGS Health & Human Services System (CBC)
Glens Falls Hospital
Visiting Nurse Service of NY Home Care
Community Health Care Network
Bronx Lebanon (Joint Venture with CBC, I-Health and others)
Institute for Community Living (ICL/CBC) 4
Managed Care Plans Health Homes-Phase I Bronx Brooklyn Nassau Schenecta
dyAdirondack Counties
Fidelis Care New York
Fidelis Care New York
EmblemHealth
Fidelis Care New York
Fidelis Care New York
UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
Health First PHSP, Inc.
Health First PHSP, Inc.
Health First PHSP, Inc.
Affinity Health Plan Inc.
Affinity Health Plan Inc.
Affinity Health Plan Inc.
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Managed Care Plans Health Homes – Phase I
Bronx (cont) Brooklyn (cont) Nassau (cont)
Health Plus PHSP Health Plus PHSP Health Plus PHSP
Amerigroup New York, Inc
Amerigroup New York, Inc
NewYork-Presbyterian System SelectHealth, LLC
NewYork-Presbyterian System SelectHealth, LLC
Amida Care Amida Care
EmblemHealth
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Health Plans and Health Home ContractingDOH will approve health plan health home applications
so plans may assist with arranging for health home services. This approval is contingent on the following:Contracting with State Designated Provider-led Health
Homes is required in areas with sufficient approved State Designated Provider-led Health Homes capacity.
In instances where the plan is contracting with State Designated Provider Based Health Homes the plan may: choose which State Designated Provider Based Health home(s)
to contract with. assist with the provision of certain health home services (e.g.,
data management) as contractually agreed to by the State Designated Provider-led Health Home and the Health Plan - in this any case dollars retained by the plan shall be proportional to effort.
Plans should only directly provide health home services in areas where such approved capacity is insufficient as agreed upon by the State and the Health Plan.
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Continued Opportunities for PartnershipsThe Contingent Designated Provider-led
Health Homes are still finalizing joint governance arrangements and contracts
The State is still suggesting additional providers and provider types to designated Health Homes to include in their partnership – some of this is necessary to address approval contingencies.
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What if my application was not designated as a Health Home?Many high-quality providers submitted
Health Home applicationsThe State could not approve all of the
applicants as Health HomesApplicants who were not designated as
Health Homes and are not currently partnering with an approved Health Home provider should reach out to designated provider-led Health Homes and discuss possible partnerships
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HH Rosters and Sharing of listsState has started to share lists with Plans
about their members who qualify for Health Home services
Lead Health Homes will be required to submit a Data Exchange Agreement Application (DEAA) to share lists with their health home network providers
Lead Health Homes are responsible for securing member consent at enrollment to allow full access to member data.
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Monthly Roster Elements Patient Demographic informationHealth PlanAssigned Health Home Health Home Direct Care Management Provider
TCM, MATS, CIDPMCO, CBO
Enrollment/Disenrollment StatusVarious Dates
ConsentEnrollment/disenrollment
Patient Profile (e.g., Risk Score, Acuity Score, Ambulatory Connectivity and Loyalty)
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Updated Rates on Website
12
Projected Health Home PaymentsProjected Average Health Home Payments - Sample Populations
Previous
Patient #Base Health
Status Dx DescriptionSeverity of Illness
Acuity Score
Downstate Monthly Payment
Upstate Monthly Payment
Acuity Score
Downstate Monthly Payment
Upstate Monthly Payment
1 Pairs Chronic Diabetes and Hypertension Low 1.6947 $39 $32 0.8114 $17 $132 Pairs Chronic Diabetes and Asthma Low 4.6947 $109 $88 4.0729 $83 $673 Triples Chronic Diabetes - Hypertension - Other
Dominant Chronic DiseaseLow 5.7894 $135 $108 5.3524 $110 $88
4 Triples Chronic Congestive Heart Failure - Diabetes - Cerebrovascular Disease
Mid 6.0001 $140 $112 7.4909 $153 $123
5 Single SMI/SED Conduct, Impulse Control, and Other Disruptive Behavior Disorders
Low 6.3574 $148 $119 5.6522 $116 $93
6 Pairs Chronic Schizophrenia and Other Chronic Disease
Mid 7.1434 $166 $134 6.9474 $142 $114
7 Pairs Chronic Asthma and Other Moderate Chronic Disease
Mid 7.1434 $166 $134 8.3686 $171 $138
8 Single SMI/SED Schizophrenia Mid 7.9093 $184 $148 7.9318 $163 $1319 Pairs Chronic Diabetes and Advanced Coronary
Artery DiseaseHigh 8.818 $205 $165 7.0289 $144 $116
10 HIV/AIDS HIV Disease Mid 10.0992 $235 $189 10.0992 $207 $16611 Triples Chronic Cystic Fibrosis Low 10.1255 $236 $189 5.6337 $115 $9312 Triples Chronic Diabetes - 2 or More Other Dominant
Chronic DiseasesHigh 10.8664 $253 $203 12.3349 $253 $203
13 Triples Chronic Brain and Central Nervous System Malignancies
High 11.1186 $259 $208 21.1181 $433 $348
14 Triples Chronic Non-Hodgkin's Lymphoma High 11.1186 $259 $208 11.7499 $241 $19415 Single SMI/SED Schizophrenia High 16.6197 $387 $311 16.6288 $341 $27416 HIV/AIDS HIV Disease High 17.7378 $413 $332 17.7378 $363 $292
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Billing PrinciplesPrior to billing, the HH roster must be completed
including identification of each member’s: Designated health home (MCO/FFS provider)Contracted provider Care management agency MCO/FFS HH Lead Care Manager/TCM
MCO can only bill for non-TCM members
The roster supports the claim path.
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Assignment and BillingFor Fee-for-Service MembersState will assign members into Health HomesState Designated Health Homes will bill
eMedNY PMPM Rate Codes: 1386- Health Home Services1387- Outreach & Engagement – for up to 3
months initially, additional 3 months allowed, 3 months after last claim
Subcontractors bill the State Designated Health Home
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Assignments and Billing (cont’d.)For Managed Care Members, Managed Care
Plans:Assign members to State Designated Provider-
led Health Homes based on the information provided by the State and information the Plan has such as Primary Care Provider assignment
State Designated Provider-led Health Homes bill Managed Care Plans for delivering Health Home services to the Plans’ members (not including members assigned to TCM programs).
16
Assignments and Billing (cont’d.)For Plans that are NOT State Designated
Health Homes:
Plans will receive a ‘kick’ payment to pay the Health Homes the plan assigned members
Plans will bill the state the Rate Codes:1386- Health Home Services1387- Outreach & Engagement
17
Assignments and Billing (cont’d.)For Plans that ARE Health HomesPlans need to register for a NPI number and
enroll in the Medicaid program as a case management provider
Plans that are Health Homes will bill the state the Rate Codes: 1386- Health Home Services1387- Outreach & Engagement
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Billing for Existing Case Management ProvidersBill eMedNY for BOTH their current slots and
additional members assigned to them through Health Homes
Current slots –working on consolidating rates for average PMPM
New rate codes: COBRA–1880 MATS- 1386 OMH- (still working on OMH billing and rate
code consolidation)CIDP- receive current PMPM – new rate code-
1885 19
Billing for Existing Case Management Providers (cont’d.)
Case Management programs that add slots through Health HomesBill eMedNY for the additional slots the
average PMPM using: Health Home Rate codes 1386 & 1387
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Plans and Health Homes-Roles and ResponsibilitiesPlans: State’s partners in assigning members and monitoring the quality
of Health Homes
Assign members using the state algorithm and their own data to appropriate Health Homes
Contract with provider-led Health Homes in areas with sufficient provider-led Health Home capacity
Reimburse health homes commensurate with the Health Home services being provided
Monitor quality, assist Health Homes with Health Home care management network development/maintenance and move members out of Health Homes that are not achieving quality goals and/or meeting the member’s needs.
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Plans and Health Homes-Roles and Responsibilities (cont’d.)
Provider – Lead Health HomesContinually meet provider qualification standards Meet Quality Measures and reporting
responsibilitiesDevelop their Health Information PlansUtilize all of their partners appropriately in the
delivering of Health Home servicesReimburse partners commensurate with level of
Health Home services deliveredWork closely with health plans to coordinate care
management and service access22
Expected “Wave One” HH Enrollment Health Home Enrollment Phasing Phase Tier
Phase 1 Phase 2 Phase 3 Total State Fiscal
YearState Quarter FFY & Qrt High Cost Mid Cost Low Cost High Cost Mid Cost Low Cost High Cost Mid Cost Low Cost
SFY '11-'12 Qrt 1 FFY '10-'11 Qrt 3 - - - - - - - - - -
Qrt 2 FFY '10-'11 Qrt 4 - - - - - - - - - -
Qrt 3 FFY '11-'12 Qrt 1 - - - - - - - - - -
Qrt 4 FFY '11-'12 Qrt 2 3,715 10,661 16,401 - - - - - - 30,778
SFY '11-'12 Total 3,715 10,661 16,401 - - - - - - 30,778
SFY '12-'13 Qrt 1 FFY '11-'12 Qrt 3 9,289 26,652 41,003 3,663 10,510 16,168 - - - 107,285
Qrt 2 FFY '11-'12 Qrt 4 - - - 9,157 26,274 40,421 807 2,314 3,560 82,533
Qrt 3 FFY '12-'13 Qrt 1 5,573 15,991 24,602 - - - 2,016 5,785 8,901 62,869
Qrt 4 FFY '12-'13 Qrt 2 3,715 10,661 16,401 5,494 15,764 24,253 - - - 76,289
SFY '12-'13 Total 18,577 53,305 82,007 18,313 52,548 80,842 2,823 8,100 12,461 328,976
SFY '13-'14 Qrt 1 FFY '12-'13 Qrt 3 1,858 5,330 8,201 3,663 10,510 16,168 1,210 3,471 5,340 55,751
Qrt 2 FFY '12-'13 Qrt 4 - - - 1,831 5,255 8,084 807 2,314 3,560 21,851
Qrt 3 FFY '13-'14 Qrt 1 1,858 5,330 8,201 - - - 403 1,157 1,780 18,729
Qrt 4 FFY '13-'14 Qrt 2 1,858 5,330 8,201 1,831 5,255 8,084 - - - 30,559
SFY '13-'14 Total 5,573 15,991 24,602 7,325 21,019 32,337 2,420 6,943 10,681 126,891
SFY '14-'15 Qrt 1 FFY '13-'14 Qrt 3 - - - 1,831 5,255 8,084 403 1,157 1,780 18,511
Qrt 2 FFY '13-'14 Qrt 4 - - - - - - 403 1,157 1,780 3,340
Qrt 3 FFY '14-'15 Qrt 1 - - - - - - - - - -
Qrt 4 FFY '14-'15 Qrt 2 - - - - - - - - - -
SFY '14-'15 Total - - - 1,831 5,255 8,084 807 2,314 3,560 21,851
Total 27,866 79,957 123,010 27,470 78,822 121,263 6,049 17,356 26,702 508,496
* Low Cost Members are not slated for Health Home enrollment under the current plan but this could change as the project progresses and as high and mid- cost members are assigned in a given region.
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Average Amount Paid per Claim/Prescription for Top Ten Categories of Service that Contribute to Overall Spend by Countyfor Dates of Service 7/1/10 to 6/1/11
Phase 1 County Drugs Inpatient D&TCHospital
Outpatient
OMH Rehabilitative
Services
Case Management
Services
Skilled Nursing Facility
Physician Services Transportation
Home Health Agency
Professional Services
BRONX 5,474$ 6,743$ 125$ 140$ 990$ 160$ 1,599$ 27$ 60$ 107$
BROOKLYN 4,464$ 6,081$ 112$ 155$ 867$ 175$ 1,494$ 19$ 60$ 124$
CLINTON 3,462$ 4,098$ 135$ 118$ 495$ 519$ 1,208$ 28$ 69$ 83$
ESSEX 3,771$ 4,229$ 120$ 120$ 556$ 485$ 370$ 34$ 45$ 87$
FRANKLIN 3,876$ 5,116$ 151$ 141$ 910$ 391$ 1,359$ 34$ 65$ 115$
HAMILTON 3,451$ 8,793$ 69$ 86$ 756$ NA 1,925$ 25$ 117$ 140$
NASSAU 3,405$ 5,253$ 128$ 126$ 1,051$ 276$ 1,363$ 19$ 91$ 107$
SAINT LAWRENCE 3,621$ 4,787$ 117$ 354$ 881$ 246$ 892$ 33$ 100$ 96$
SARATOGA 3,367$ 2,950$ 112$ 88$ 1,085$ 309$ 476$ 21$ 53$ 65$
SCHENECTADY 3,512$ 3,149$ 86$ 122$ 926$ 170$ 1,072$ 27$ 41$ 65$
WARREN 2,779$ 4,571$ 81$ 104$ 938$ 336$ 1,287$ 31$ 53$ 86$
WASHINGTON 3,356$ 3,844$ 84$ 85$ 1,144$ 424$ 1,226$ 25$ 37$ 117$
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* Updated HH Attribution from June 1, 2010 through May 31, 2011 – County as of last date of Medicaid Eligibility. Saratoga and St. Lawrence have been moved out of phase one.
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Type Name Bronx Brooklyn Clinton Essex Franklin Hamilton Nassau Saint
Lawrence Saratoga
Schenect
ady Warren
Washingt
on Grand
Total AMIDA CARE SN 1,025 1,557 2,582 METPLUS SN 1,570 1,517 3,087 NY PRESB SYS SELECT HEALTH SN2,136 1,322 3,458
AIDS SNP Total 4,731 4,396 9,127 AFFINITY HEALTH PLAN 11,230 4,254 1,618 17,102 AMERIGROUP NY 600 3,652 4,252 CDPHP 1 1,606 1,594 4 334 3,539 EXCELLUS 1 1 313 315 FIDELIS HC NY 8,567 13,954 826 376 150 44 2,304 1 908 1,213 479 539 29,361 GHI HMO SELECT 1 1 2 GHI PPO 2 1 3 HEALTHFIRST 19,488 16,607 2,279 38,374 HEALTHPLUS 4,096 13,139 1,122 18,357 HIP 5,136 9,199 3,400 17,735 METROPLUS 13,465 13,090 26,555 NEIGHBORHOOD 3,297 6,604 1 9,902 UNITED HEALTHCARE COMM PLAN796 17,660 2,735 21,191 WELLCARE 1,757 3,031 4,788
HMO/PHSP Total 68,433 101,190 827 376 153 44 13,460 315 2,514 2,808 483 873 191,476 AFFINITY PROVIDER 22 4 26 FIDELIS PROVIDER 80 169 11 260 GHI HMO SELECT 8 9 1 18 HIP ADVANTAGE 124 230 86 440 LIBERTY HEALTH ADVANTAGE 14 14 1 29 MANAGED HEALTH INC PROVIDER13 17 30 METROPLUS PROVIDER 17 16 33 SENIOR WHOLE HEALTH OF NY 15 37 17 2 71 TOUCHSTONE/PRESTIGE 27 51 78 UNITED HEALTHCARE COMM PLAN 1 1
MEDICAID ADVANTAGE Total 305 511 88 15 48 17 2 986 FFS Total 24,934 41,462 2,091 464 1,281 32 7,631 3,269 1,313 1,677 1,070 664 85,888 Grand Total 98,403 147,559 2,918 840 1,434 76 21,179 3,584 3,842 4,533 1,570 1,539 287,477
AIDS SNP
HMO / PHSP
MEDICAID ADVANTA
GE
* Updated HH Attribution from June 1, 2010 through May 31, 2011 – Plan enrollment as of last date of Medicaid Eligibility Saratoga and St. Lawrence have been moved out of phase one.
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Health Home – Open IssuesWMS Flag to identify Health HomeCare Management Metrics Functional Status ToolTiming of State Plan and Start DateOMH TCM Rate CollapsingMATS RatesNext Webinar Date and Time TBD-Focus on Billing
Health Home Website: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/
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