The Affordable Care Act of 2010, Section 2703, created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions by adding Section 1945 of the Social Security Act. CMS expects states health home providers to operate under a “whole-person” philosophy. Health Home providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.
What is a “Health Home”?
A Health Home is a group of health and community agencies that have agreed to work together to help people with many health issues get what they need to keep them healthier and safer in the community. Each person who joins gets a “care manager”. A care manager will work closely with him/her to get the services he/she needs in his/her community. This service is being paid for through New York State Medicaid.
Why is this important for me?
You may be invited to join a Health Home if you have many health issues (including mental health), are having problems getting the care you need and are receiving Medicaid (either fee for service or in a health plan). If you are receiving special help (TCM, COBRA, MATS, CIDP), your care may already be changing to a Health Home.
The Health Home care manager will work with you to understand what you need to stay healthy. You may need housing. You may need help getting enough food. You may need transportation. You may have problems getting your medications or taking them. You may use the emergency room a lot or end up in the hospital often. Once the care manager knows what you need, he/she will work with you and the Health Home team to help you get those services and to teach you how to stay healthy.
What do I need to do?
If you are told that you can join a health home, make an appointment to meet with the care manager. The care manager will work with you to make a care plan. It is possible that the care manager will decide you are doing well and do not need this special help. Or you may decide it is not helpful to you. You will not lose any Medicaid benefits or services if you do not join. If you do join, you will work with your care manager and the team using the care plan to meet your health, safety and social needs.
Who Is Eligible for a Health Home?
New York State’s Health Home eligibility criteria is as follows
- Medicaid eligible/active Medicaid; and
- Two (2) or more chronic conditions; or
- One (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI)
Qualifying chronic conditions are defined in the State Plan Amendment as any of those included in the “Major” categories of the 3MTM Clinical Risk Groups (CRGs). A table of qualifying conditions included in these categories has been compiled and is shown below. Substance use disorders (SUDS) are in the list of qualifying chronic conditions, but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition (chronic medical or mental health) to qualify. A chronic condition in the context of determining eligibility for Health Homes implies a health condition that requires ongoing monitoring and care. The condition should not be incidental to the care of the member, but have a significant impact on their health and well-being.
In addition to having a qualifying condition, an individual must be appropriate for Health Home services. Individuals who are Medicaid eligible and have active Medicaid and meet diagnostic eligibility criteria may not necessarily be appropriate for Health Home care management. Individuals that meet the eligibility criteria for Health Homes and manage their own care effectively, do not need the level of care management provided by Health Homes. An individual must be assessed and found to have significant behavioral, medical, or social risk factors to deem them appropriate for Health Home services. An assessment must be performed for all presumptively eligible individuals to evaluate whether the person has significant risk factors and is appropriate for Health Home care management services. Determinants of medical, behavioral, and/or social risk can include
- Probable risk for adverse events (e.g., death, disability, inpatient or nursing home admission);
- Lack of or inadequate social/family/housing support;
- Lack of or inadequate connectivity with healthcare system;
- Non-adherence to treatments or medication(s) or difficulty managing medications;
- Recent release from incarceration or psychiatric hospitalization;
- Deficits in activities of daily living such as dressing or eating; and
- Learning or cognition issues.
Health Home Services
Comprehensive care management
- Care coordination
- Health promotion
- Comprehensive transitional care/follow-up
- Patient & family support
- Referral to community & social support services
Health Home Providers
States have flexibility to determine eligible health home providers. Health home providers can be:
- A designated provider: May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, or other provider.
- A team of health professionals: May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and can be free-standing, virtual, hospital-based, or a community mental health center.
- A health team: Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractics, licensed complementary and alternative practitioners.
Health Home service providers must report quality measures to the state. States are also required to report utilization, expenditure and quality data for an interim survey and an independent evaluation.
Health Home Financing
States have the flexibility in designing their payment methodologies and may propose alternatives.
States receive a 90% enhanced Federal Medical Assistance Percentage (FMAP) for the specific health home services in Section 2703. The enhanced match doesn’t apply to the underlying Medicaid services also provided to people enrolled in a health home.
The 90% enhanced FMAP is good for the first eight quarters the program is effective. A state can get more than one period of enhanced FMAP, but can only claim the enhanced FMAP for a total of eight quarters for one enrollee.
The Integrated Care Resource Center (ICRC) is available to provide technical assistance to States considering the health home Medicaid State Plan option. The ICRC website provides useful information on health homes, such as approved state plan amendments and frequently asked questions.
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