Session 9 – January 17, 2013

1

2

Working Together HIT Requirements and Funding Opportunities Sharing Member Information Member Eligibility for Health Home Services Outreach and Engagement Work Health Home Services Acuity Scores Billing and Rates

The State’s decision to pursue the Health Home (HH) model in a transformative way was predicated on the successes and lessons learned in OMH Targeted Case Management (TCM), HIV COBRA TCM, OASAS Managed Addiction Treatment Services (MATS), and DOH Chronic Illness Demonstration Project (CIDP)

HH providers integrate and coordinate all primary, acute, behavioral health, and community support services; treating the whole person with the goal to improve care and reduce costs.

3

The HH model expands concepts from both converting case management programs and Patient Centered Medical Home model by building additional linkages and enhancing coordination and integration of medical and behavioral health care to better meet the needs of people with multiple chronic illnesses

In other words, the Health Home takes the Medical Home concept across multiple care disciplines and into the community for high need Medicaid recipients

4

TCMs were developed to provide community-based case management to high need Medicaid recipients (HIV+/Mental Health) often disengaged from medical, mental health, and social services

TCMs have years of experience in outreach and engagement of persons difficult to locate and keep in care:

• unstably housed• mentally ill• history of incarceration• substance using• with multiple chronic illnesses • impacted by stigma

5

HHs networks were approved only if they included converting case management programs; in many cases multiple case management programs.

Lead HHs are expected to be using the value and expertise of their entire HH network to achieve the goals of the program.

6

Case management programs operated successfully, but programs were not anchored into formal comprehensive networks with medical providers.• Under HH case management agencies are transitioning as part

of larger networks.

TCMs are accountable to HH Leads; often multiple leads with different requirements.• TCMs work to ensure client outcomes are realized; provide direct

service to locate/engage clients and coordinate member care and services.

• TCM input into HH policies can help ensure more effective processes.

7

Fiscal Viability Converting programs ability to generate revenue to cover

agency administrative and infrastructure costs are dependant on volume of assignments, and amount and timing of payments• Concern about future cash flow beyond direct Medicaid billing

• Concern about survival beyond legacy rates

Administrative costs must be negotiated with multiple HH Leads and MCOs.

New infrastructure and HIT costs are not built into reimbursement; impacting lead HHs and network partners alike.

8

Administrative burden Tracking enrollee status for multiple HH Reporting to multiple MCOs and HH Leads

• Requirements vary - some have added reporting elements beyond state requirements

Maintaining databases/EHRs for multiple HH and ensuring staff are trained to use them

Building capacity

• Hiring, training, supervising staff

• Oversight and quality assurance

9

HH network partners have a joint responsibility to assure HH outcomes are reached. Establish systems to ensure:◦ Clear, regular communication between HH Leads, MCOs,

and converting care management providers◦ Policy input by all parties◦ Communication among HH systems in the same region, to

avoid overlap and encourage collaboration (e.g., HUNNY, CNYHHN)

10

State expects movement of partners as relationships develop.

HHs must notify DOH about changes to their network (changes in name, partners joining or leaving, etc). See instructions on the Health Home website: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/medicaid_enroll_prov-led_hh_rev.htm

HHs are responsible to assure they maintain an ability to meet provider standards and qualifications; much of which is met through comprehensive network partners working together.

11

Lead Health Home (HH) is responsible for assuring the HH network meets final HIT standards

Network care management partners are not required to join a RHIO but becoming a RHIO member will enhance the quality and quantity of EHR data shared

Lead HHs should be working with network partners to assure partners have any necessary HIT capability; Work with the partners to fill in gaps

12

Lead Health Home is responsible for a plan to adopt Certified Meaningful Use (MU) Electronic Health Records (EHR)◦ This HIT Standard applies to all Health Homes and is required

for Clinical Partners/Provider Organizations providing clinical care to Health Home patients (including BHOs).

◦ Care Managers do not necessarily need an EHR, but need an interoperable Care Plan application.

A future webinar will address this as well as other HIT related questions.

13

Partners should work with lead HH to understand how the HH will share information and meet HIT standards

Please contact Office of Health Information Technology Transformation for specific questions:

E-mail: healthit@health.state.ny.us Phone: 518-474-4987

14

NYS recognizes expense of HIT infrastructure on Health Homes

Lead HHs and partner agencies have varying degrees of HIT infrastructure

NYS requested funding for HIT infrastructure through the CMS waiver

• Funding would be prioritized for HH partners that have not already received funding through other initiatives.

15

NYS OMH is providing one-time HIT funding to assist former TCM providers to develop electronic care management system capacity to share information with their respective HHs.

HEAL 22 has funding to support technical assistance for Mental Health/Behavioral Health providers working with HHs.

16

Access to member information is important to the entire HH network.

Currently only HHs and MCPs can access the Health Home member tracking file through the Health Commerce System (HCS).

DOH recognizes that network partners would like access to the HCS but current system and resource issues prevent the ability to give all network partners HCS access.

17

DOH is looking to build a HH portal which would allow broader access and include additional features, such the ability to pull claims information.

In the interim, leads are responsible for sharing necessary information with the network partners.

DOH has a proposal to streamline the member tracking system process and will specify a standardized file layout to make it easier for network partners to manage data submission.

18

Tracking system calls are held on a regular basis for Health Homes and MCPs because they currently submit files directly to NYS.

Network partners submit files through their HHs and are encouraged to obtain tracking system information from the respective HHs.

Information is also available at: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2012-06-26_draft_hh_patient_tracking_system.pdf

19

Health Home Restriction Exception (R/E) codes will be implemented in mid-2013. These codes will allow member look-up through eMedNY and other systems.

This will be especially valuable to check before community referrals are made.

These codes will identify whether a member is potentially eligible for HH services and, if a member has been assigned, will identify the name of the member’s HH.

20

Currently Health Homes and MCPs can only share the five most recent encounters of HH members.

Until the portal is developed, DOH will work with HH and MCPs to see what can be done to improve the member information provided to network partners, for both assignments and referrals.

21

New lists will be based on more up-to-date member eligibility information but eligibility can change.

Health Homes should verify member eligibility and assist members on maintaining Medicaid eligibility.

Often Medicaid coverage is granted retroactively. However, the decision to provide it retroactively is up to the county of residence.

22

DOH is developing guidance on leveraging existing strategies for assisting clients with spend down. • New strategies are being explored, focused on

maintaining eligibility for spend down members.

Health Homes should work closely with their Local Government Unit (LGU) • It will still be necessary to work with members on an

individual basis to maintain eligibility.

23

New lists for Phase 1 and the first set of lists for Phase 2 are being finalized and were just released.

Members may also be assigned to HHs by network partners through community referrals.

See Medicaid Update November Special Edition: http://www.health.ny.gov/health_care/medicaid/program/update/2012/nov12sped.pdf

Community referrals can be transmitted to the lead HH through the member tracking system.

24

25

TCMs/MATS make assignments for their members For members previously enrolled in TCM, MATS

and CIDP programs, the member can choose which care manager they want as their HH care manager

For members of a plan that are not contracted with the TCMs/MATS HH; the lead HH should contact the member’s plan to initiate contract discussions• When a contract cannot be agreed upon, the member can

either choose a different HH or different plan

• The best option is for the HH and Plan to have a contract

As part of the States 1115 waiver, the Health Home development fund requested funds for a public education campaign to make it easier for outreach partners to engage with potential HH members.

Resources to assist with outreach will be made available on the Partner Resources section of the HH website.

The State is finalizing a letter HHs can use as part of their engagement materials that explains the Health Home program.

26

Center for Health Care Strategies (CHCS) with support from the New York Health Foundation is looking into launching an online community,

Designed to build on the Learning Collaborative.

Will provide a forum for online peer-to-peer exchange, between in-person Learning Collaborative meetings.

Will allow HH network care management partners to share best practices.

A demonstration of the site’s features and functionality will occur soon.

27

28

Outreach and Engagement HHs have three months to engage members; if

after three months a member is not found or cannot be engaged in active care management the member cannot be billed for;

HHs may decide to continue to try and engage a member during this non-billable period at their discretion. Network partners and lead HHs agencies should discuss process.

All clients who meet HH eligibility criteria can receive HH services regardless of the level of service intensity.

HHs are building capacity so members can be prioritized using acuity scores.

Health Homes who determine a member no longer needs HH services should discuss, with the member, the option of having their care management handled by a PCP and/or PCMH as appropriate.

It is the clients choice to opt out or disenroll from a HH. At the time the client opts out or disenrolls, they should be informed of options to join other HHs and told they may return to their original HH at any time.

Health Home Services

29

30

Health Home Services

Acuity scores will be recalculated quarterly based on updated claims and encounter data.

HHs and care management partners may not adjust acuity scores but the member’s FACT-GP scores, as well as other factors, will be used to adjust an individual’s acuity score on a prospective basis.

HHs will be able to download the acuity scores from the OHIP Data Portal in the near future to share with network partners.

31

Claims for members with no established acuity score will be set to “pend” status.

DOH will receive notification of the pended claims and will then submit an average acuity score for that member to the payment system.

There will be a delay in payment, but the acuity score will trigger payment of the pended claim.

32

Converting care management partners can bill up to the level of their approved legacy slots at the legacy rate, and bill for additional or expansion slots at the HH rate.

New clients can be billed at either the legacy rate or the HH rate, provided the total number of approved legacy slots is not exceeded.

Clients in a MATS legacy slot must have an SUD diagnosis

33

Legacy rates have been extended another year to allow converting care management partners time to transition to HH services by the end of the second year.

DOH will monitor funding levels and make an assessment as to when legacy rates will convert to a blended or HH rate.

34

The HH rates were calculated to allow 6% for administrative costs, to be split between HHs and MCPs. A larger percentage is justified only if HHs and/or MCPs are providing additional support or services. Network partners should be asking for justification for any additional amount.

TCMs/MATS bill directly and some have negotiated an administrative contribution. DOH is working on ways to provide administrative support directly to MCPs and TCMs/MATS and will be conducting a survey to determine the extent to which these arrangements have been negotiated.

35

Providers that have already have Phase 1 rates loaded can bill for Phase 2. Phase 2 only providers will have to wait until rates are loaded to bill for Phase 2.

It is now anticipated that converting TCM claims will be reprocessed in early 2013.

A client can be referred to a HH based on a presumptive assessment. If the assessment reveals that the individual does not meet HH criteria, outreach and assessment can be billed for that month.

36

37

Questions?

Visit the Health Home website: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/

Get updates from the Health Homes listserv. To subscribe send an email to: listserv@listserv.health.state.ny.us. In the body of the message, type SUBSCRIBE HHOMES-L YourFirstName

YourLastName Email questions or comments: hh2011@health.state.ny.us

Call the Health Home Provider Support Line: 518-473-8864

38