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Medicaid Health HomesWebinar #2
Tim McNeill, RN, MPH
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Health Homes in the ACA
Who can be a Health Home provider
Health Home services and hospitals
Conclusion
1
2
3
4 Collaboration Models
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What is a Health Home?
3
• A Health Home is a optional Medicaid benefit created
by Section 2703 of the Affordable Care Act
• Person-Centered care coordination model that
integrates primary, acute, behavioral health and LTSS
to treat the whole person
• Health Home is not a physical home
• It is also not synonymous with a Patient-Centered
Medical Home (PCMH)
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Are Health Homes and Medical
Homes the same
4
• Health Homes provide care coordination for a target population
• Health Homes do not provide medical management or medical
interventions for the population
• Disease self-management is a key component of Health Home
services
• Medical Homes focus on the implementation of medical
interventions to address the health needs of the population
• Health Homes will provide support for the consumer to comply
with the medical interventions prescribed by the Medical Home
– Transportation
– CDSME
– Social Supports
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Do all States Offer Health
Homes?
5
• Health Homes is an optional Medicaid benefit.
• States that wish to participate must submit a State Plan
Amendment (SPA) to establish the Health Homes
benefit in their State
• There ae Twenty (20) approved State Plan
Amendments for Health Homes
• Additional States are in the process of submitting their
SPA to establish Health Homes
– California Assembly Bill 361, authorized California to
submit a Section 2703 application
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States with an approved Health
Home amendment
6
Alabama Idaho
Iowa Kansas
Maryland Maine
Michigan Missouri
New Jersey New York
North Carolina Ohio
Oklahoma Rhode Island
South Dakota Vermont
Washington West Virginia
Wisconsin District of Columbia
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Matrix of Approved SPAs
7
• The following link will provide a summary matrix of each of
the currently approved State Plan Amendments for Health
Homes.
– https://www.medicaid.gov/state-resource-center/medicaid-state-
technical-assistance/health-homes-technical-
assistance/downloads/hh-spa-at-a-glance-3-19-14.pdf
• The categories in the Matrix are as follows:
– State
– Target Population
– HH Providers
– Enrollment (Opt-In vs Opt-Out)
– Payment
– Geographic area (defined region vs Statewide)
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How is the Health Home benefit
paid for
8
• States have great flexibility in how they set up the
reimbursement model for health homes.
• Most of the States and the District of Columbia have
set up Per Member Per Month (PMPM)
reimbursement models
• States receive a 90% enhanced Federal Medical
Assistance Percentage (FMAP) for the first eight
quarters (2 years)
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What are Health Home Services
9
• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Care Transitions
• Patient and Family Support
• Referral to community & social support services
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Who is eligible for a Health
Home
10
• States have great flexibility in defining the target
population to participate in the Health Home benefit
• A beneficiary must have Medicaid to be eligible to
participate
• General requirements include one or more of the
following criteria:
– Beneficiaries that have two (2) or more chronic conditions
– Beneficiaries with one (1) chronic condition and is at-risk
for second chronic condition
– Have one serious and persistent mental health condition
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Are Duals Included
11
• States can not exclude people with both Medicaid and
Medicare from Health Home Services
• If a Dual Eligible, meets the clinical criteria set by the
State, then they are eligible to receive the Health
Home benefit.
• Alignment of financial incentives
– Health Home Services for Duals with chronic depression
• Duals with 2 or more chronic conditions
• Duals in an ACO
• Duals in Bundled Payment
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Evaluation Measures
12
Measure
Adult Body Mass Index (BMI) Assessment
Screening for Clinical Depression and Follow-up Plan
Plan All-Cause Readmission Rate
Follow-up After Hospitalization for Mental Illness
Controlling High Blood Pressure
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Evaluation Measures (cont.)
13
Measure
Care Transition
Initiation and Engagement of Alcohol and Other Drug
dependence Treatment
Prevention Quality Indicator for Chronic Conditions
Ambulatory Care – Emergency Dept. Visits
Inpatient Utilization
Nursing Facility Utilization
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What if we have Medicaid
Managed Care
14
• If a State has implemented Medicaid Managed Care,
beneficiaries that are enrolled with a MCO are eligible to
receive the Health Home benefit
• Beneficiaries receiving LTSS are eligible for Health Home
services
• Duals in a Medicaid MLTSS plan are eligible
• Duals in a Medicaid wavier program are eligible
• Medicaid beneficiaries receiving OAA services are eligible
• Duals receiving OAA services are eligible
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Will the State Have Increased
Cost for Health Homes
15
• States will receive a enhanced 90% FMAP for the first
8 quarters of implementation of Health Homes
• The evaluation measures closely monitor expenditures
for the population during the 90% FMAP period
• If evaluation measures are achieved, the State will
receive more in cost savings than the cost of the
program, when it reverts to the standard FMAP
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Where are the Savings?
16
• Multiple groups are in search of creating savings under the
transforming healthcare landscape
• Two Medicaid groups have the highest expenditures:
– Dual Eligibles
– Aged, Blind, and Disabled
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Reform impacting Duals
17
• Value-Based Payment Reform
– ACOs
– Bundled Payment (BPCI)
– CJR
• Medicaid Managed Care
• MLTSS
• Health Homes
• Duals Demonstrations (high opt-out rates)
• D-SNP/C-SNP/I-SNP plans
• PACE programs
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Which Population has the most
chronic disease?
18
• Most chronic conditions were more prevalent for dual-eligible
beneficiaries
– 72% of dual-eligible beneficiaries had two or more conditions
– Dual eligible beneficiaries were 1.7 times as likely to have 6 or more
chronic conditions
– 1.7 times more likely to have COPD
– 1.6 times more likely to have heart failure
– 1.4 times more likely to have diabetes
• 98% of readmissions, in 2010, were for Medicare beneficiaries
with two or more chronic conditions– CMS Chronic Conditions Among Medicare Beneficiaries, Chartbook – 2012 Edition.
Available Online: https://www.cms.gov/research-statistics-data-and-systems/statistics-
trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf
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What are the characteristics of
Duals?
19
• According to the CBO, in 2009, there were 9 million
dual eligibles and they cost Federal and State
governments more than $250 billion in healthcare
benefits.
• Medicaid provides health care coverage to low-income
people who meet requirements for income and assets
• All Duals qualify for full Medicare benefits, but they
differ on the Medicaid benefits they qualify for
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Duals and Chronic Disease
20
• Full duals are twice as likely as non-dual Medicare
beneficiaries to have at least three chronic conditions
• Duals are nearly three times as likely to have been
diagnosed with a mental illness, including chronic
depression
– Many more have undiagnosed or untreated chronic
depression
• In 2009, total average healthcare spending:
– Nonduals - $8,300 per year
– Full Duals - $33,400 per year
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LTSS for Duals
21
• Less than 0.5% of partial duals are institutionalized
• 15% of full duals are institutionalized
• Partial duals often transition to a full dual after
completing the spend down period after a SNF/nursing
home admission.
• Full duals are five times as likely to use LTSS as non-
duals
• Full duals are twice as likely to use LTSS as the non-
dual ABD population
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Health Homes and Mental Health
Populations
22
• Many States have targeted their Health Homes efforts to
beneficiaries with a mental illness
– Eligibility requires a mental illness and one other chronic
physical health condition
• What are some of the diagnoses that are included in the
Health Homes Mental Health diagnostic criteria
– Chronic Depression
– Bipolar Disease
– Psychizophrenia
– Schizoaffective Disorder
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Experience with populations affected
by Mental Illness?
23
• Many Community-Based Organizations state that they have no
experience working with populations that have mental illnesses
so they could not serve a Health Home population
– Dual Eligible Beneficiaries are more than twice as likely to
have depression
– Persons with two or more chronic conditions are more likely
to have a depression co-morbidity
– Depression is the most common mental health problem
among older adults
– If you are working with Older Adults and persons with
disabilities and/or dual eligibles then you are likely also
working with persons with mental illness
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Alignment of Incentives
24
• Goal: Reduce per capita costs
– Readmissions, Inpatient utilization, ER utilization
• MACRA
– Physician Participation in APMs for Medicare beneficiaries
to include Duals
• Hospital Readmissions Penalty
• ACO Shared Savings
• Bundled Payment for Care Improvement (BPCI)
• Comprehensive Joint Replacement (CJR)
• Health Homes
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Operationalizing the concept
25
• District of Columbia
– Health Homes started January 1, 2016
– Population must have a Mental Illness and one or more
chronic physical health conditions
– Payment rate based on acuity
• High Acuity $481 PMPM
• Low Acuity $350 PMPM
– Must have Medicaid
– Dual Eligibles are included
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Hospital Collaboration Model
26
• Hospital begins screening for depression for admitted patients
with one or more chronic diseases
• Medicaid patients that screen positive for depression are
referred for Health home enrollment
• Care transitions team completes enrollment and provides a 30-
day care transitions intervention
• Consumers are linked with all relevant evidence-based
programs:
– CDSME
– Fall prevention program
– PEARLS
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DC Health Home Example
27
• George Washington University Medical Center
– Hospital is closely tracking their readmission rates
– Physicians are participating in the BPCI bundled payment
program
– Dual eligibles and consumers that face social determinants
of health are of particular concern
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Goals Align
28
• Case managers are screening consumers with a physical health
condition for social determinants of health and chronic
depression or other SMI
– Focused on Duals and the Medicaid ABD Population
• Consumers hat screen positive are referred to the Health Homes
program
• A care transitions intervention is initiated
• Post transition, the consumers can be referred to community-
based evidence-based programs:
– CDSME
– Fall Prevention
– HCBS
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Who is Paying for the Service
29
• Medicaid is the Payer for Health Home services
• GWU is the benefactor by partnering with the community
provider to serve Duals
• Both are incentivized to reduced readmissions, reduce inpatient
admissions, and improve health outcomes for a target
population of Duals
– GWU limits their risk for bundled payment and readmission
penalties for high-risk duals
– CBO receives an ongoing PMPM payment to provide care
coordination to the target population
– Community-Base Organization executes an agreement to expand
Health Home services to all admitted consumers that meet the
criteria.
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Are Health Homes coming to my
State?
30
• States that intend to implement Health Homes must submit a
State Plan Amendment to CMS.
• The State Plan amendment is submitted by the Division of
Medicaid
• The Division of Medicaid must obtain stakeholder input
• Notice of submission of the SPA and the content must be made
available to the public
– Generally available on the State Division of Medicaid
website
– Monitor for notices of intent and make sure you attend the
planning meetings
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Health Homes are in my State
31
• If you are in a State that has an approved State Plan
Amendment for Health Homes you should:
– Review the State Plan amendment from the Division of
Medicaid
– Read closely to determine the population that the State
included in the benefit
– Analyze the requirements to become an approved Health
Home provider
– Review the list of currently approved Health Home
providers
– Complete a GAP analysis to determine if you can be a
Health Home provider or partner with an existing provider
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Key components of the Health Home
provider RFQ?
32
• What types of organizations can provide Health Home
Services?
• What is the application process to become a Health Home
provider?
• What are the staffing requirements to become a health home?
• What are the target populations for health home services?
• Are health homes limited to a defined geographic region in the
State?
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What if I am not Eligible to be a
Health Home provider
33
• Identify an eligible population that you are currently serving
• Develop a scope of services you would expand under Health
Homes
• Define the cost to deliver the program
• Develop a pricing plan based on the market rate in comparison
to the Health Home rate
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Health Home Collaboration Model
34
• Implement a service delivery model targeted to the population
you serve
• Develop a model to jointly deliver services to the target
population
• Propose a pricing/reimbursement model where costs are
allocated first.