New York State Health Homes

Implementation and Billing Update

Statewide Webinar

Presented by:New York State Department of Health January 12, 2012

1

Issues Covered on Today’s WebinarTimelineApplicationsPayment Policy and Billing Patient Assignment and EnrollmentPatient ConsentDisenrollment ProcessPatient Rosters…and more

2

Health Home - Updated TimelineState Plan Amendment under review by CMS:

approval expected shortlyJanuary 1, 2012: Existing Case Management

(COBRA, MATS, TCMs) providers begin billing using HH ratesWorking on policy on patient consent timing

February 1, 2012: List Assignment begins for Health Plans and FFS

February 15, 2012: New Application Deadline for Phase II 3

Health Home Web Based ApplicationThe Health Home Application is being updatedThe updates primarily impact tables which list the

partners and providersCompleted updates expected by February 1, 2012New Phase 2 application deadline February 15,

2012Obtain link to import information from Phase 1

application into Phase 2 by emailing hh2011@health.state.ny.usSubject: Import Phase 1 application

Applications can be worked on before updates are completed but expect to submit Tables in a NEW FORMAT starting the beginning of February

4

Outreach and Engagement Payments Existing case management slots (i.e., OMH

TCM, COBRA, MATS) will bill at 100% of the approved PMPM rate for Outreach and Engagement

For new Health Home members, case management fee will be paid in two increments: outreach and engagement or active case managementOutreach and engagement for new members

will be paid at a reduced percentage (80%) of the active care management PMPM 5

Outreach and Engagement Payments and Time Period

The outreach and engagement PMPM will be available for the three (3)months. If outreach and engagement is unsuccessful, the provider may not bill again for three (3)months from the conclusion of the outreach and engagement period

All Health Home outreach and engagement activities are billable under the monthly PMPM as long as one of the six (6) core services are provided in the billed quarter

Once a patient has been assigned a care manager and has consented, the full active case management PMPM may be billed on the first day of that month

6

Health Home PaymentsRates will be set based on region and case mix

(clinical acuity). Eventually rates will be further adjusted by member functional status

Providers should submit one claim per month using the first of the month as the date of service

Monthly payments to health plans (MC patients), provider-led Health Homes (FFS patients) and converting TCM programs (both MC and FFS patients) will be made through eMedNY

7

Health Home Payments – Provider EnrollmentProviders already enrolled in Medicaid must

add Category of Service (COS) 0265New Health Home Providers that are not yet

enrolled in NYS Medicaid must enrollEnrollment instructions are posted on the

eMedNY website (https://www.emedny.org/ )New entities will need to obtain an NPI

number before enrolling in the Medicaid program

8

Patient Rosters/Health Home Member Tracking SheetBilling and member flow will be controlled through a

sharing of member rosters between the State, Health Plans, Health Homes and Care Management agencies

Rosters of eligible Health Home members will be shared with Phase 1 Health Homes and Health Plans via NYS Health Commerce System (HCS) – formerly known as the HPN – on or before February 1

Health Homes and Plans must populate member rosters on the HCS with required information to receive payment

Two options to populate rosters are being explored – data entry application and/or file transfer

Eventual amendments to WMS and eMedNY will be made to report out certain roster fields and to implement Health Home eligibility editing

9

Roster Sharing/Health Home Member Tracking SheetAll Provider-Led Health Homes must complete a

Data Exchange Agreement Application (DEAA) to obtain rosters for initial member assignment

Health Homes must have the ability to access the HCS to receive rosters

Identify the HCS Coordinator in your organization to obtain an HCS account

If unable to locate your HCS Coordinator contact your administration for assistance

10

Member Assignment & EnrollmentManaged Care Plans will assign plan members

who qualify for Health Home services to Provider-led Health Home

DOH will assign FFS members to Provider-led Health Homes

Plans will send enrollment letters to their members

Health Homes will send enrollment letters to their assigned FFS members

The Plans and the assigned Provider-led Health Homes are the member contacts

11

Patient Consent Process The assigned Health Home is required to secure

patient consent forms to officially enroll all Health Home members in a Health Home program

The signed consent form allows their patient information to be shared with Health Home partners, including a Regional Health Information Organization (RHIO), if applicable

The signed consent form documents patient enrollment in the program and the active case management fee may be billed for that month

Final consent form will be posted on the Health Home website

12

Disenrollment or Changing Health HomesMembers who decide to disenroll from Health

Homes must sign a disenrollment formMembers should request a disenrollment form from

their Plan or Provider-led Health HomeMembers who choose to be in a different Health

Home should notify their Plan or assigned Provider-led Health Home

Members who either cannot be located or refuse to sign the patient consent or disenrollment form must be disenrolled either immediately or after the three (3) month Outreach and Engagement period as appropriate 13

Chronic Illness Demonstration Program (CIDP) IssuesCIDP contracts will end on March 29, 2012 By March 29 all CIDPs must be in a Health

Home partnership to continue to provide care management services

For one year as of effective date of SPA, CIDPs bill eMedNY directly for existing CIDP members converting to Health Homes

CIDPs must use new Health Home rate codes for new Health Home members

14

Members in Multiple Counties

NYS has proposed to CMS that Health Home rates for case management providers serving existing members in multiple counties enrolled during different implementation Phases, be based either on county of residence or county of service

15

Care Management Process MetricsHealth Home Core Services

Comprehensive care managementCoordination and health promotionTransitional care from inpatient to other settingsIndividual and family supportsReferral to community and social support services

Must provide documentation demonstrating how requirements are being met

Reporting periodCase Management Data ElementsIncludes data elements from managed care planFunctional Assessment elementsMetrics will be on web shortly

16

Health Home Payments to PlansThe plan is paid for Health Home services outside of

their regional premium using a monthly care management fee paid under a rate code

The Plan will bill eMedNY for Health Home payments using the rate codes 1386 and 1387 as appropriate

The Health Home payment is made to the Plan after the member is assigned to a Health Home

The Plan and the Health Home must have a contract prior to making payments to the Health Home

The Health Home is paid by the Plan after Health Home services are provided

The date of service is the first day of the month

17

Data Exchange Agreement Application (DEAA)Health Homes must submit a completed Data

Exchange Agreement Application (DEAA) to the Medicaid Privacy Officer

Information sent to all Provider–led Health Homes on DEAAs also must be signed by all Health Home partners providing case management

DEAA process being customized for Health Homes

18

Health Commerce System (HCS) AccessHealth Homes must have access to the Health

Commerce System (HCS) to receive member rosters/Health Home member tracking sheets

Identify the HCS coordinator within the organization to obtain HCS accounts for appropriate staff

DOH Health Home staff are reaching out to Health Homes to verify and assist with HCS access

If there is a problem, contact DOH at hh2011@health.state.ny.us using subject line ‘HCS’

19

REVISED Health Home Rate Code Definitions1386: Health Home Services (Plans and FFS)1387: Health Home Outreach (Plans and FFS)

1851: Health Home/OMH TCM1852: Health Home Outreach /OMH TCM

1880: Health Home/AIDS/HIV Case Management1881: Health Home Outreach/ AIDS/HIV Case Management

1882: Health Home/ MATS1883: Health Home Outreach/MATS 1885: Health Home/CIDP Case Management

Billing Codes

20

How to Submit a Claim for Health Home ServicesManaged Care Plans & Provider-led Health

Homes will receive a letter from CSC that they are able to bill new Health Home rate codes

Health Home claims must be submitted/dated the first of the month

Claims can only be submitted once per month for assigned members

These are institutional type claims Bill electronically using 8371 format If paper, use UB-04

21

Health Home Lead Applicant Readiness ChecklistMust be enrolled in MedicaidMust resolve any approval contingencyMust have DEAAMust have HCS accessMust have contracts with plans & downstream care

managersSecure Health Home partnersConfirm ability to bill rate codes for FFS & TCMConfirm ability to share roster information (two way

communication) with downstream Health Home providersConfirm ability to pay downstream Health Home

providersDevelop procedures to collect and report monthly care

management process metrics & functional assessment for each enrolled member

22

Next Steps for DOH Implementation TeamSecure SPA approval from CMSContinue implementation work with the Health

PlansPost detailed billing guidelines to Health Home

website and publish in Medicaid UpdateComplete FFS loyalty matching to Health HomesShare final rosters with plans and Health HomesRegional meetings with Health Plans and

Provider-led Health Homes

23