Statewide Webinar-June 6,2012

Downstate Town Hall Meeting-June 19, 2012Upstate Town Hall Meeting-June 22, 2012

Address Health Home concerns

◦ List assignments

◦ Reporting requirements

◦ Contracting

◦ Billing and payment

Provide a progress report on Health Home implementation

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New Implementation Timeline

High Risk Health Home Population

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Chronic Episode Diagnostic Categories

Health Home Eligibles Adults 21+ Years

With a Predictive Risk Score 75% or Higher (n=27,752)                                   

  Percent of Adult Recipients with Co-Occurring Condition

Condition Total

Severe Mental Illness

Mental Illness

Subst-ance

AbuseHyper-tension

Hyper-lipidemi

a Diabetes Asthma

Congest-ive Heart

Failure

Angina & Ische-

mic Heart

Disease HIV ObesityOsteo-

arthritis

COPD & Bronch-iectasis Epilepsy CVD

Kidney Disease

Severe Mental Illness 43.5 100.0 74.7 77.2 33.8 28.1 23.2 34.1 6.8 8.5 9.6 14.8 23.2 13.9 20.1 31.9 10.9

Mental Illness 46.2 70.4 100.0 70.9 42.0 33.7 28.0 35.8 11.0 12.6 8.7 16.9 29.9 17.8 19.4 41.0 16.4

Substance Abuse 54.4 61.9 60.3 100.0 35.4 25.9 21.4 32.8 7.5 9.4 11.2 10.7 23.1 14.5 16.4 34.4 11.2

Hypertension 37.6 39.1 51.6 51.1 100.0 47.4 41.4 30.7 28.2 22.1 5.6 17.8 29.3 22.6 13.9 62.2 30.8

Hyperlipidemia 29.8 41.0 52.2 47.1 59.8 100.0 54.9 37.7 27.8 33.4 5.6 23.6 30.9 25.1 15.0 70.4 31.5

Diabetes 27.8 36.3 46.5 41.8 56.0 58.8 100.0 35.4 25.7 25.3 5.4 24.3 28.1 22.8 13.2 64.9 34.3

Asthma 28.3 52.4 58.5 62.9 40.8 39.7 34.8 100.0 15.3 17.4 12.3 22.0 34.3 33.0 16.7 47.7 18.4

Congestive Heart Failure 13.4 22.1 37.9 30.6 79.5 61.9 53.5 32.3 100.0 41.2 4.1 21.1 26.1 33.9 8.9 100.0 50.3

Angina & Ischemic HD 12.2 30.5 47.8 41.8 68.2 81.5 57.6 40.3 45.1 100.0 4.6 24.1 33.8 31.5 11.7 100.0 41.9

HIV 8.3 50.2 48.4 73.5 25.2 20.0 18.1 41.9 6.7 6.8 100.0 4.9 26.6 16.4 13.2 31.1 17.9

Obesity 12.7 50.5 61.4 45.8 52.6 55.4 53.1 49.0 22.2 23.1 3.2 100.0 39.3 25.7 16.5 60.1 27.2

Osteoarthritis 22.1 45.7 62.7 56.8 49.9 41.8 35.5 44.0 15.8 18.7 10.0 22.7 100.0 25.5 15.1 52.0 24.9

COPD & Bronchiectasis 15.5 38.8 53.0 50.6 54.7 48.1 40.7 60.1 29.2 24.8 8.7 21.0 36.1 100.0 14.0 67.2 27.0

Epilepsy 13.5 65.1 66.6 66.3 38.8 33.2 27.2 35.1 8.9 10.6 8.1 15.6 24.8 16.2 100.0 41.1 16.3

CVD 41.9 33.2 45.3 44.6 55.9 50.2 43.1 32.3 32.0 29.2 6.2 18.3 27.4 25.0 13.2 100.0 35.4

Kidney Disease 18.8 25.2 40.4 32.4 61.5 49.9 50.6 27.6 35.8 27.2 7.9 18.3 29.1 22.3 11.7 78.6 100.0

Total 100.0 43.5 46.2 54.4 37.6 29.8 27.8 28.3 13.4 12.2 8.3 12.7 22.1 15.5 13.5 41.9 18.8Note: Diagnosis History During Period of July 1, 2010 through June 30, 2011.

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New York State Health Home Analytical Products◦ CRG Based Attribution – For Cohort Selection◦ CRG Based Acuity – For Payment Tiers◦ Predictive Model - Predicts future negative events

(Inpatient, Nursing Home Death) using claims and encounters – For Assignment Priority

◦ Ambulatory Connectivity Measure – For Assignment Priority

◦ Provider Loyalty Model – Establishes Patient Connectivity to Existing Care Management, Ambulatory (including BH), ED and Inpatient – For Matching to Appropriate HH and to Guide Outreach activity.

Loyalty analysis goal – keep members with meaningful (ambulatory) provider connections

State reviewed where eligible Health Home members seek care:◦ Current Case Management services ◦ Ambulatory care◦ Emergency or inpatient use

Members assigned to Health Homes where they have the most connectivity

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Eligible for Health Home services with either two or more chronic conditions, HIV/AIDS or serious persistent mental illness; members given a risk score and an ambulatory connectivity score Risk Score◦Scale of 0-100◦High score means a higher chance the member would have an adverse event (inpatient or nursing home admission, death)◦Based on John Billings algorithm at NYU Ambulatory connectivity◦Scale of 0-100◦The fewer ambulatory care visits the higher the score Risk and Ambulatory score added together = DOH Composite

Score-members with scores 125 and above (for initial launch) assigned to Health Homes based on loyalty

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Will explore assigning members with higher risk scores but higher ambulatory connectivity.

Converting TCM members will be included on May rosters (due to DOH in June)

Dual eligibles will be assigned

Contracts are being expedited to facilitate assignment of Managed Care members

Guidance on accepting community referrals is being developed

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Health Home FFS Assignments To Date

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Potential Assignments from Managed Care Plans-Phase 1

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New referrals (via HRA, county, SPOA, care management agency, practitioners, hospital, prisons, BHO, etc) meeting Health Home criteria must be assigned to Health Homes to ensure access to care management

For Managed Care Members, the referring entity will contact the Plan to actuate the Health Home assignment

For FFS members, the referring entity will contact DOH (contact information to be provided shortly) to actuate an appropriate Health Home assignment. Process will include collaboration with OMH, AIDS Institute, and OASAS to ensure these assignments best serve member needs

State assigned FFS members to Health Homes based on their score and loyalty analysis

Managed Care Plans will assign MC members to Health Homes based on similar information

Tracking file lists are not perfect

◦ State ‘cleaned up’ lists but challenges remain

◦ Medicaid eligibility and MC enrollment status changes daily

◦ List Generation is in the process of being more automated

Health Homes identify the members for outreach and enrollment through the Member Tracking System

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Initial lists went out to Managed Care Plans and Lead Health Homes 2/21 – 2/22

Updated lists of members w/ composite scores >125 sent Health Homes 3/28

Loyalty files sent to Health Homes 4/9 Addresses and last 5 claims sent to Health Homes 4/12 Health Homes were sent members enrolled in converting

case management programs 5/9 Managed Care Plans were sent members currently enrolled

in converting case management programs 5/15 – 5/16 May lists from HH for FFS due in June 5th.

Next Submission Date for Managed Care and FFS – July 3rd. Working on capacity to give recent claims and encounters to

HHs for assigned members.

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Weekly calls to provide technical assistance with Member Tracking System logistics

Development of an OHIP Datamart Portal for Member Tracking

Restriction codes to identify potential candidates for Health Home services and to indicate Health Home assignments

Design of portals to allow real-time access to member-level Medicaid data

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TCMs identify the Health Homes that best meet their members’ needs

DOH will make assignments to Health Homes based on these recommendations

Managed Care Plans and Health Homes will receive member tracking sheets that reflect assignments

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TCMs identify the Health Homes that best meet their members’ needs

TCMs make Health Home assignment and sends assignment information DIRECTLY to Health Homes

Health Homes send member tracking file collected from downstream providers to DOH for FFS members and to Managed Care Plans for MC members

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Transitioning TCMs bill Medicaid directly for all Health Home services provided

Transitioning TCMs can bill for members enrolled in Managed Care without signed MC contracts

Health Homes can negotiate upstream payments to cover administrative costs

Transitioning TCMs only submit tracking file information to Health Homes, not DOH directly

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Guidance on retroactive billing will be provided

DOH (with OMH, OASAS, and the AIDS Institute) are scheduling conference calls with the TCM provider community to discuss Health Home tracking system and billing issues

Ground rules for referrals, transitions from shelters and criminal justice system are being developed

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Key provisions for Plans to use in executing Health Home contracts were approved by DOH

Several plans submitted contracts that went beyond the key provisions

Plans have been directed to limit contracts with Health Homes to the key provisions

Once contracts are in place Plans can assign Managed Care members to Health Homes

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Health Homes must provide at least one of the five core Health Home services per month

There will be no requirement for minimum face-to-face contacts, however, there must be active outreach or active care management and evidence of activities that support billing, including:

◦ Contacts (face-to-face, mail, electronic, telephone)◦ Patient assessment ◦ Development of a care management plan◦ Active progress towards achieving goals

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Detailed billing guidance provided in the Health Home Special Edition of the Medicaid Update (April 2012) for billing guidance

Provider enrollment assistance is available◦ TCM providers-automatically enrolled for Health Home

Category of Service 0265

◦ Lead Health Homes can contact the Health Home team for assistance with provider enrollment

Provider manual in development

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http://www.health.ny.gov/health_care/medicaid/program/update/2012/april12muspec.pdf

Process metrics will be collected to assess the level of case management services provided and the degree to which the core Health Home services have been delivered as required

Outcome metrics will be derived in part from claims data and other variables. State outcome metrics are included in the SPA, guidance still pending from CMS on specifications for additional measures

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Statewide Health Home and Managed Care Plan workgroups are being established to develop recommendations for a standardized set of process and outcome measures

DOH is developing a customized reporting module based on CMART, an case management reporting utility for reporting to Managed Care Plans, as the framework for all Health Home process metrics

Goal is to have a uniform platform and a standard set of metrics in place by Fall 2012

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State is finalizing instructions and scoring criteria for a functional self-assessment tool based on the FACT-GP to evaluate each Health Home participant on a range of measures. See:http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/forms/

Validated tool administered upon enrollment, annually thereafter and at discharge; results reported to the State

Results of assessments used to adjust initial rates, which were based on calculated acuity and risk scores

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Adding a Health Home administrative payment to Plan capitation rate

Ensuring equitable distribution of members and payments

Adjusting payment rates for homelessness and predictive risk of negative event

Medicare and Medicaid gainsharing

Assignment of duals

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Updating partner lists to refine loyalty analysis

Medicaid eligibility (uninsured, spend downs)

Separating Health Homes from TCM rules and regulations

Having biweekly calls with the larger Health Home community to hear concerns and answer questions

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Discussion

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