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Member Basics

1) Am I required to join a Health Home?
2) How was I selected for this?
3) Is there a charge for participating in a Health Home?
4) Do I need to fill out an application?
5) Will I be seeing a new doctor?
6) Can I change my Health Home?
7) I don’t want to be in a Health Home. How can I get out of this program?
8) If I am not in a Health Home, how will my care be affected?
9) If I join a Health Home, what do I do if I have an emergency?
10) Will transportation be provided for me to get to my Health Home?
11) When does my enrollment officially start?
12) Why was I put in this particular Health Home?
13) What is a Care Manager?
14) When will I find out who my Care Manager is?

Facts

1) Why is the state planning to implement Health Home services?
2) Who is eligible to receive Health Home services?
3) What kind of supports will be provided to individuals receiving Health Home services?
4) Who provides Health Home services?
5) When will Health Home services be available?

Services

1) What services will be provided by a Health Home?
2) How are Health Homes different than the services we have in place now?
3) Does the State intend to identify and credential providers, or will identification and credentialing be the responsibility of the Managed Care Organization or health home lead organization?
4) How does the state plan to sustain this effort once the CMS 2703 funds end?

Qualification and Networks

1) Will Health Homes be certified by the State?
2) Who will be the agency responsible for the qualification process?
3) Will there be a maximum number of Health Homes in an area/county?
4) What will Health Home Networks look like?
5) What type of organization can be qualified as a Health Home?
6) Why should organizations consider participating in a Health Home network?
7) What will be required of Health Homes to show their networks are in place?
8) Will there be multiple networks in the same community?
9) How is the state going to recruit organizations for Health Home designs to ensure geographic and demographic coverage?
10) What will the protocol be if a provider within the Health Home network refers a member to a non-Health Home provider?
11) If Health Homes are a network, what will be the requirements for the overarching entity that maintains the network?

Lead Entity

1) What is a Lead entity and what are their responsibilities?
2) What are the advantages of being a Lead entity?
3) Since Health Homes are designed to integrate medical and social supports for eligible individuals, is the medical provider or community provider in the best position to become a lead entity?
4) How will a Health Home Lead be paid and how much will they be paid?
5) In the Qualification and Standards document, it states that lead entities must have an NPI on file. What is an NPI?
6) Who qualifies for an NPI?

Information Technology and Assessment

1) Is access to PRISM considered sufficient Health Information Technology? If yes, will PRISM access be granted to the Health Home lead once an application is accepted?
2) Will there be a uniform health assessment tool?
3) Who will review and approve the health assessment tools?
4) Does the state intend for Managed Care Organizations to build HIT functionalities that will connect all specialties or can the MCO coordinate care via alternate channels?
5) Who will be responsible for tracking the selection, enrollment and disenrollment of beneficiaries within Health Homes?
6) How will systems be set up so that data exchange is seamless between Health Home networks?

Performance Evaluation

1) How will monitoring and evaluation of health Homes work?
2) Who will be monitoring all the component providers in the Health Home?
3) Will the State require a specific set of guidelines?
4) What are the evaluation measures?
5) Will the measures be consistent with measures currently reported in other HCA programs, such as HEDIS measures?
6) What guidelines will be used to assure the receipt of evidence‐based care?
7) Who is accountable for utilization management decisions and where does the risk, accountability, and liability lie, with the health home lead organization or contracted providers?
8) Will the State directly monitor some portion of the client’s plan and client outcomes for health home contractors, how intensive and frequent would this monitoring be?

Payment

1) What is the payment structure for Health Homes?
2) How will payment mechanism work?
3) Under Managed Care, will the payment be built into the PMPM rate?
4) Will the plans receive payment regardless of services delivered?
5) How will payment be adjusted when beneficiaries decline service?
6) If the Health Home is not managed by a MCO, will there be funding for start up costs?
7) Will all organizations that are a part of a Health Home network receive payment?
8) Will Health Home network providers be at financial risk with Capitated reimbursement, risk corridors/risk adjustment, or would they operate on a fee-for-service?

Beneficiaries

1) Will beneficiaries have a say in the services they receive?
2) Who will help beneficiaries make decisions about which Health Home to participate in?
3) Will beneficiaries be locked into a Health Home?
4) How will beneficiaries know where to go to “enter” the Health Home network?
5) How will consumers/beneficiaries be informed and educated on Health Homes?
6) Who will choose a beneficiaries’ Health Home Care coordinator?
7) Will a beneficiary have more than one Health Home Care Coordinator?
8) How many beneficiaries will Health Home Care Coordinator support?
9) Who determines the level of care coordination a client receives?


Health Home Member Basics


1) Am I required to join a Health Home?
No. But we strongly encourage you to participate. The Health Home program will help you with all of your health-related and social services needs, not merely treat a specific chronic condition.

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2) How was I selected for this?
You were selected for this new program based on your health needs and the providers that you use.

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3) Is there a charge for participating in a Health Home?
No, the Health Home care management services are free.

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4) Do I need to fill out an application?
No. You will only be required to fill out and sign a Consent Form with your Health Home which will allow all of your doctors and other healthcare providers to share information on your health in order to plan and work together.

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5) Will I be seeing a new doctor?
In most cases you will be seeing all the healthcare providers that you do now.

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6) Can I change my Health Home?
Yes. You will need to contact your health plan or the assigned Health Home you are in and let them know that you want to change.

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7) I don’t want to be in a Health Home. How can I get out of this program?
The program is voluntary so you can decide not to be in a Health Home. To do so, you must contact your assigned Health Home within 30 days of receiving your letter. You should call them at the number provided on the letter.

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8) If I am not in a Health Home, how will my care be affected?
You will continue to receive the services as you have in the past unless you already are in a case management program; in this situation you should contact your case manager.

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9) If I join a Health Home, what do I do if I have an emergency?
Contact your care manager. Health Homes are required to have crisis coverage 24 hours a day and 7 days a week.

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10) Will transportation be provided for me to get to my Health Home?
Your care manager will help you with transportation if you need it.

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11) When does my enrollment officially start?
As soon as the Consent Form is signed.

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12) Why was I put in this particular Health Home?
You were matched to this Health Home based on where you live and which providers currently care for you.

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13) What is a Care Manager?
This is a trained person who will help you get access to necessary medical and behavioral health needs (including substance abuse and mental health), specialty care and social services.

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14) When will I find out who my Care Manager is?
Once enrolled in a Health Home, you will be contacted by your Care Manager.

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Health Home Facts


1) Why is the state planning to implement Health Home services?
No one enjoys going to the emergency room or being in a hospital. When people have multiple chronic health conditions, getting the care they need can be as challenging as assembling a jigsaw puzzle in the dark. This is especially true when people also have needs for mental health and chemical dependency treatment or require assistance with daily tasks such as taking medication, bathing, transportation, or work. They may have several doctors and care providers that each provide part of the help they need, but they may not communicate with one another about the care needs of the individual being served. We know that when the pieces of an individual’s healthcare puzzle fit together they do better and their
care costs less.

We want New Yorkers with complex care needs to have the ability and supports to better manage their own health care, to get right services at the right time and place, and to improve their health and quality of life. Based on experience here in New York and in other states, we know how to make that happen.

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2) Who is eligible to receive Health Home services?
Health Home services will be available to individuals with chronic illnesses and who are enrolled in Medicaid or both Medicare and Medicaid. Individuals must also be at significant risk for health problems that can lead to unnecessary use of hospitals, emergency rooms, and other expensive institutional settings such as psychiatric hospitals and nursing homes.

New York uses a predictive risk modeling system called PRISM to identify individuals who are at significant risk.

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3) What kind of supports will be provided to individuals receiving Health Home services?
Individuals receiving Health Home services will be assigned a Health Home coordinator who will partner with beneficiaries, their families, doctors, and other agencies providing services to ensure coordination across these systems of care. In addition, the health home coordinator will make in-person visits and be available by telephone to help the individual, their families, and service providers to:

  • Conduct screenings to identify health risks and referral needs;
  • Set goals that will improve beneficiaries’ health and service access;
  • Improve management of health conditions through education and coaching;
  • Make changes to improve beneficiaries’ ability to function in their home and community and their self-care abilities;
  • Slow the progression of disease and disability;
  • Access the right care, at the right time and place;
  • Successfully transition frm hospital to other care settings and get necessary follow-up care;
  • Reduce avoidable health care costs; and
  • Make health care decisions during evenings or weekends when the Health Home coordinator is not available.

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4) Who provides Health Home services?
Health Home services are provided by a Health Home coordinator who will often work at some place the individual already has a relationship with, such as their doctor’s office, community mental health agency, tribal clinic, area agency on aging, or similar community based provider.

The Health Home coordinator will be part of a larger network of services that can be called on to help meet an individual’s need for medical, mental health, chemical dependency, long term services, and supports.

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5) When will Health Home services be available?
Health Home services will be phased-in geographically between April and November 2013. Individuals eligible for Health Home services will be automatically enrolled in a Health Home and will then be contacted to confirm whether they want to receive health home services.

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Health Home Services


1) What services will be provided by a Health Home?
A health home network provides six services identified in section 2703 of the Affordable Care Act. A health home is qualified by the State and is responsible for the integration and coordination of primary, acute, behavioral health (mental health and substance use disorder) and long-term services and supports for high cost/risk persons with chronic illness across the lifespan. Health homes services cannot duplicate other care management or care coordination services provided under Medicaid. The following services are provided by health home care coordinators.

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care and follow-up
  • Patient and family support
  • Referral to community and social support services
  • Use of information technology to link services, if applicable

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2) How are Health Homes different than the services we have in place now?
The health home care coordinator will use PRISM, health screening and engagement of the beneficiary to identify the root causes for inappropriate or gaps in health care utilization. The Health Home care coordinator assesses client activation levels through administering the Patient Activation Measure (PAM) tool. Information is used to work with the beneficiary in developing a person-centered health action plan that contains beneficiary driven goals to improve health and ability to self-manage chronic conditions. The health home is accountable for reducing avoidable health care costs, specifically preventable hospital admissions/readmissions and avoidable emergency room visits; providing timely post discharge follow-up, and improving patient outcomes by addressing health care needs.

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3) Does the State intend to identify and credential providers, or will identification and credentialing be the responsibility of the Managed Care Organization or health home lead organization?
The state will qualify health home networks which include the lead entity and community based care coordination entities. The qualification process will be formalized through a “Request for Application.” The state expects to release the application in the fall.

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4) How does the state plan to sustain this effort once the CMS 2703 funds end?
The project will need to achieve performance outcomes to sustain health home services.

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Health Home Qualification and Networks


1) Will Health Homes be certified by the State?
No. Health Homes will be qualified by the state.

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2) Who will be the agency responsible for the qualification process?
The Health Care Authority and the Department of Social and Health Services will be jointly responsible for reviewing and qualifying health home network applications.

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3) Will there be a maximum number of Health Homes in an area/county?
Yes, there will be a limited number of qualified health homes in a geographic area. We have not yet determined that number.

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4) What will Health Home Networks look like?
Health Home networks must include a wide range of community partners to serve the diverse need of high cost/high risk beneficiaries that meet the standards determined by the state. Networks must also be able to provide services throughout a defined geographic region, include in its network providers who have experience and expertise providing services to high cost/high risk beneficiaries and have the capacity to provide health home services to at least 1,000 clients

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5) What type of organization can be qualified as a Health Home?
There is no single entity that we foresee at this point in time that would by itself qualify as a health home. Qualification requires a community based network that is able to integrate services across the service domains needed by high cost/high risk clients including medical, long term services and supports, mental health, and chemical dependency. Individual organizations will not be qualified. The State will qualify a limited number of health home networks that meet the qualifications requirements.

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6) Why should organizations consider participating in a Health Home network?
Fragmented and uncoordinated care across service domains and funding streams is a long standing problem that leads to poor health outcomes, gaps in care, individuals falling through the cracks when transitioning frm one care setting or provider to another, duplication of services and avoidable health care costs. The implementation of health homes is an opportunity to provide intensive care coordination and integration of service delivery that supports individuals in managing their chronic conditions, improving health outcomes and impacts of chronic disease and reducing avoidable health care expenditures. Participation in health home networks provides an opportunity to be at the forefront of an important health reform initiative.

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7) What will be required of Health Homes to show their networks are in place?
This will be detailed in the application process which will be released in October.

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8) Will there be multiple networks in the same community?
The state will limit the number of health homes, but there is likely to be more than one health home in a community. Organizations that agree to provide the care coordination services may elect to participate in more than one health home.

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9) How is the state going to recruit organizations for Health Home designs to ensure geographic and demographic coverage?
The state initiated a letter of interest process for health homes to identify interested organizations. The state will be hosting regional forums in the fall of 2012. These forums will be designed to facilitate collaboration and partnerships to assure geographic and demographic coverage. The state intends to implement health home geographically as networks are qualified.

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10) What will the protocol be if a provider within the Health Home network refers a member to a non-Health Home provider?
One of the health home services is referrals to needed services. Not all Medicaid providers are expected to be part of a health home network. Health action plans and coordination is anticipated to occur with any provider the beneficiary identifies as part of their care team.

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11) If Health Homes are a network, what will be the requirements for the overarching entity that maintains the network?
This entity will be known as a Lead entity. Lead entities will be responsible for administrative functions that need to occur with network partners, including payment disbursement, contracting, data collection and reporting, quality metrics reporting and quality oversight.

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Health Home Lead Entity


1) What is a Lead entity and what are their responsibilities?
Lead entities will be responsible for administrative functions of the health home entities within the network including payment disbursement, contracting, data collection and reporting, quality metrics reporting and quality oversight. A small portion of the per member per month (PMPM) payment may be retained by the lead entity to support administrative functions. The state is currently working with an actuarial firm to establish the administrative rate within the payment.

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2) What are the advantages of being a Lead entity?
The lead entity is going to have a lot of administrative responsibility associated with data, reporting, contracting, payments, etc. There are natural community entities that have the administrative capacity and sophistication to be able to do those administrative functions. Motivating factors for being a lead entity may include being at the forefront of integration efforts, providing community based coordination and leadership functions in support of health home activities for high cost/high risk beneficiaries in the local community.

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3) Since Health Homes are designed to integrate medical and social supports for eligible individuals, is the medical provider or community provider in the best position to become a lead entity?
The lead entity must be able to demonstrate the capacity and expertise to perform the administrative functions required by the lead entity. This will likely vary by geographic area

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4) How will a Health Home Lead be paid and how much will they be paid?
The lead entity will receive a PMPM payment in months where a health home service is provided to an enrolled beneficiary. A small portion of the PMPM payment may be retained by the lead entity to support administrative functions. The state is currently working with an actuarial firm to establish the administrative rate within the payment.

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5) In the Qualification and Standards document, it states that lead entities must have an NPI on file. What is an NPI?
NPI stands for National Provider Identifier. NPI is a CMS federal regulation designed to comply with the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard.

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6) Who qualifies for an NPI?
All individual HIPAA covered healthcare providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapists, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) can apply and obtain an NPI. All standard HIPAA transactions must have an associated NPI.

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Health Home Information Technology and Assessment


1) Is access to PRISM considered sufficient Health Information Technology? If yes, will PRISM access be granted to the Health Home lead once an application is accepted?
No, PRISM is just one of many Health Information Technology (HIT) tools that will be used to identify gaps in care and determine where avoidable utilization of emergency room, hospital and institutional care is happening. The network must use data systems to collect, analyze and report financial and health status outcome performance measures, establish protocols to share usage of emergency room visits, inpatient hospitalizations, missed prescription refills and the need for evidence-based preventative care.

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2) Will there be a uniform health assessment tool?
Yes, the state will establish requirements for the use of standardized and evidence based/informed screening tools. Standardized screens will be required for:

  • Depression using the PHQ-9
  • Falls risk (tool to be determined)
  • Pain assessment (tool to be determined)
  • Alcohol and chemical use using GAIN-SS
  • Functional impairment (tool to be determined)
  • Patient Activation Measure using the Insignia data base

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3) Who will review and approve the health assessment tools?
The health assessment tools will be approved by DSHS and HCA.

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4) Does the state intend for Managed Care Organizations to build HIT functionalities that will connect all specialties or can the MCO coordinate care via alternate channels?
Any organization that takes on the responsibilities of the lead entity must have mechanisms in place to collect and store health care data and methods to share that data under a secure system. That may be achieved via alternative channels.

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5) Who will be responsible for tracking the selection, enrollment and disenrollment of beneficiaries within Health Homes?
Enrollment into a health home will be an automatic process with an opt-out feature. Enrollment notification is sent to the lead entity through an automated 834 HIPAA compliant transaction. Once the beneficiary is enrolled, the lead entity will be responsible for assigning the beneficiary to one of their contracted care coordination organizations, either through a “smart” assignment process or beneficiary choice. A “smart” assignment can usually be determined by examining claims or encounter data to establish the provider the beneficiary sees the most often.

Beneficiaries may voluntarily disenroll frm a health home by calling the Health Care Authority’s toll-free line and asking for disenrollment.

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6) How will systems be set up so that data exchange is seamless between Health Home networks?
This will be an on-going process as Health IT systems are developed.

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Health Home Performance Evaluation


1) How will monitoring and evaluation of health Homes work?
There will be evaluation at the state and national levels and a standardized set of performance measures. The details of the evaluation are under development with the Center for Medicare and Medicaid Services. The state will delegate a portion of the evaluation and monitoring process to the Lead entity and provide oversight and technical assistance on that process.

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2) Who will be monitoring all the component providers in the Health Home?
The State will have some oversight and some will be delegated frm the State to the lead entity.

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3) Will the State require a specific set of guidelines?
Yes

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4) What are the evaluation measures?
The state specific evaluation measures are:

  • Decrease emergency room visits for ambulatory care-sensitive conditions
  • Decrease skilled nursing facility placements
  • Reduce hospital readmissions
  • Decrease selected ambulatory care-sensitive condition admissions for Diabetes and adult asthma.
  • Follow-up after hospitalization for mental illness
  • Increase percent of enrolled health home beneficiaries who set a health action goal
  • Increase average “Patient Activation Measure” (PAM) of participating health home beneficiaries
  • Increase screening for clinical depression
  • Measure the initiation and engagement rate of alcohol and other drug dependence treatment

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5) Will the measures be consistent with measures currently reported in other HCA programs, such as HEDIS measures?
Some measures are consistent with HEDIS standards, but not all measures are frm HEDIS. When designing the state specific measures, only those that were collectable through claims, encounter data or health enrollment data were included in the State Plan Amendment.

The CMS required Health Home Core measurement set and CMS required the Managed Fee-for-Service measurement set are closely aligned with the National Quality Forum recommendations but not all the CMS required measures can be derived frm encounter or claims data.

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6) What guidelines will be used to assure the receipt of evidence‐based care?
Practice guidelines should be frm nationally accepted sources, such as Agency for Healthcare Research and Quality.

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7) Who is accountable for utilization management decisions and where does the risk, accountability, and liability lie, with the health home lead organization or contracted providers?
Authorizing entities are responsible for utilization management decisions and accountability for delivery of the services resides in those entities providing authorizations, direct services and treatment.

The health home care coordination services do not require prior authorizations. To ensure that care coordination is an active, high touch benefit, the state is discussing a performance based payment mechanism, in the form of a small withhold. Those funds would be returned if selected measures are met.

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8) Will the State directly monitor some portion of the client’s plan and client outcomes for health home contractors, how intensive and frequent would this monitoring be?
There will be monitoring and program review of health home networks and services. Outcomes will be measured as part of the national and state program evaluation activities.

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Health Home Payment


1) What is the payment structure for Health Homes?
We are anticipating 2-3 tiers in the payment methodology that vary based upon intensity of the intervention expected. The PMPM rate is anticipated to be between $140-$180 at the highest tier.

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2) How will payment mechanism work?
The payment mechanism will be based upon submitted encounters.

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3) Under Managed Care, will the payment be built into the PMPM rate?
Yes

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4) Will the plans receive payment regardless of services delivered?
No

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5) How will payment be adjusted when beneficiaries decline service?
Health home services under 2703 funding can only occur when an eligible and enrolled beneficiary receives a qualified health home service. If a beneficiary declines a care coordination service, then no encounter should be submitted.

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6) If the Health Home is not managed by a MCO, will there be funding for start up costs?
There is no funding for start up costs in either the MCO or fee for service health home networks.

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7) Will all organizations that are a part of a Health Home network receive payment?
No. Organizations that are contracted to provide the six care coordination services will receive the bulk of the payment, with a small portion dedicated for administration of the program via the lead entity. HCA and ADSA are currently in discussions with the actuarial firm of Milliman to determine the most appropriate distribution of health home funds and that may include a performance based payment mechanism, in the form of a small withhold.

The health home care coordination services do not require prior authorizations. To ensure that care coordination is an active, high touch benefit, the state is discussing a performance based payment mechanism, in the form of a small withhold. Those funds would be returned if selected measures are met.

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8) Will Health Home network providers be at financial risk with Capitated reimbursement, risk corridors/risk adjustment, or would they operate on a fee-for-service?
Health homes services for dual eligible will be provided on a fee for service basis and may include a performance based payment mechanism, in the form of a small withhold.

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Health Homes and Beneficiaries


1) Will beneficiaries have a say in the services they receive?
Yes. We believe that beneficiary choice is a big piece of health home service delivery success. Beneficiaries will be able to choose among qualified health home care coordination organizations within a health home network. Health action plans are developed with active participation and agreement of the beneficiary.

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2) Who will help beneficiaries make decisions about which Health Home to participate in?
The state will automatically enroll beneficiaries into qualified health home networks based upon capacity and service areas. Individuals have a choice of whether or not to receive health home services and may disenroll at any time. If a beneficiary does not disenroll and does not want to receive services, that beneficiary will not count against the 50 to 1 care coordinator to beneficiary ratio.

Once the beneficiary is enrolled, the lead entity will be responsible for assigning the beneficiary to one of their contracted care coordination organizations, either through a “smart” assignment process or beneficiary choice. A “smart” assignment can usually be determined by examining claims or encounter data to establish the provider the beneficiary sees the most often.

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3) Will beneficiaries be locked into a Health Home?
No, beneficiaries cannot be locked into a health home. Beneficiaries will be automatically enrolled in a health home with the option to “opt-out” and may disenroll at any time.

CMS does not allow mandatory enrollment in a health home under section 2703 of the ACA. Beneficiaries must consent to receiving health home services. To be successful in achieving the outcomes, beneficiaries must be engaged in determining their health action goals and making the behavior changes necessary to work toward those goals.

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4) How will beneficiaries know where to go to “enter” the Health Home network?
The state will assign eligible beneficiaries to a qualified health home network. Outreach and education materials will be developed to assist beneficiaries in learning about health home networks.

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5) How will consumers/beneficiaries be informed and educated on Health Homes?
Participation in a health home will be voluntary on the part of an eligible beneficiary. The state will be developing outreach materials and informational materials that will be sent to individuals who are eligible for health home services. We also anticipate referrals to health home networks frm organizations that work with this population as well as self-referral frm beneficiaries.

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6) Who will choose a beneficiaries’ Health Home Care coordinator?
Health Home care coordinators will be embedded in one of the Health Home’s contracted care coordination organizations. Once the beneficiary is enrolled, the lead entity will be responsible for assigning the beneficiary to one of their contracted care coordination organizations, either through a “smart” assignment process or beneficiary choice. A “smart” assignment can usually be determined by examining claims or encounter data to establish the provider the beneficiary sees the most often.

Once assigned to a care coordination organization, a process must be in place to allow a beneficiary to select their care coordinator.

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7) Will a beneficiary have more than one Health Home Care Coordinator?
No. Beneficiaries will have one Health Home care coordinator.

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8) How many beneficiaries will Health Home Care Coordinator support?
The standards require an average beneficiary to Health Home care coordinator ratio as 50 to 1.

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9) Who determines the level of care coordination a client receives?
All six Health Home care coordination services are part of the health home benefit and a beneficiary should expect to receive those services during active care coordination. Care coordination will likely be handled by definitions, expectations and eligibility criteria the state will establish. The health home is expected to coordinate services across service domains and work with the beneficiary to establish health action goals, coordinate with the beneficiary, their family and their care team to assist in achieving health action goals.

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