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.


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.


New York State’s Health Home eligibility criteria are 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 contained in these categories has been compiled and is shown below. Substance use disorders (SUDS) are in the list of qualifying chronic diseases 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 disease in the context of determining eligibility for Health Homes implies a health condition that requires ongoing monitoring and care. The state 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 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 suitable for Health Home care management services. Determinants of medical, behavioral, and social risk can include:

  • The probable risk for adverse events (e.g., death, disability, inpatient or nursing home admission);
  • Lack of or inadequate social/family/housing support;
  • Lack of sparse connectivity with the healthcare system;
  • Non-adherence to treatments or medication(s) or difficulty managing medications;
  • The recent release from incarceration or psychiatric hospitalization;
  • Deficits in activities of daily living such as dressing or eating; and
  • Learning or cognition issues.


Comprehensive care management

  • Care coordination
  • Health promotion
  • Comprehensive transitional care/follow-up
  • Patient & family support
  • Referral to the community & social support services
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