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

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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).

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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

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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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