Session 6October 10, 2012

Status of Health Home Implementation

Payment updates

Projected Health Home Assignment

Overview of Datamart Portal Role of LGU and BHOs as Health Home partners

Interim Referral Guidance

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Bronx: BAHN, HHC,VNS of NY Home Care, Bronx Lebanon Hospital Ctr.

Brooklyn: Maimonides, Community Health Care Network, ICL, HHC

Nassau: NS-LIJ, FEGS

Schenectady : VNS of Schenectady and Saratoga

Northern Region: Adirondack Health Institute, Inc., Glens Falls Hospital

13 Health Homes designated, HHs, MCPs and converting CM programs may bill for Health Home services.

DOH, HH and MCPs developing operational policies and procedures and improving the transmission of Health Home Patient Tracking file information between NYS DOH and Health Homes and MCPs through the DOH OHIP Portal.

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Monroe : Anthony L. Jordan , Huther Doyle

Erie : Alcohol & Drug Dependency Services, Inc., Mental Health Services Erie County -SE Corp V, Urban Family Practice,

Hudson Valley : Hudson River HealthCare, Inc., Open Door Family Medical Ctr. Inc., Institute for Family Health

Suffolk: FEGS,, Inc, NS-LIJ, Hudson River HealthCare Staten Island : Jewish Board of Family &

Children’s Services (JBFCS)

Queens : Community Healthcare Network, HHC, NS-LIJ with PSCH, JBFCS

Manhattan: Heritage Health & Housing Inc., Presbyterian, HHC, St. Luke’s-Roosevelt Hospital Center, VNS of NY, and JBFCS

21 Health Homes designated, HHs are in the process of submitting updated network partner lists, entering into Data Exchange Application Agreements (DEAA) with DOH and executing contracts with MCPs.

DOH in discussions with CMS re: SPA approval, HH services cannot be billed until SPA is approved and rates are loaded

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Northern Region : Hudson River HealthCare, Inc., St. Mary’s Healthcare, Samaritan Hospital, Adirondack Health Institute, Glens Falls Hospital, Visiting Nurse Service of Schenectady & Saratoga Counties,

◦ Central Region: Thomas R. Mitchell, Onondaga Care Management Services, Inc., Upstate Cerebral Palsy, Huther Doyle ,North Country Children’s Clinic, St. Joseph’s Hospital Health Center, Catholic Charities of Broome County, United Health Services Hospitals

Western Region: Mental Health Services Erie County-Southeast Corp V, Niagara Falls Memorial Medical Center, Chautauqua County Dept. of Mental Hygiene

17 HH designated, DOH is in the final stages of designating Phase 3 HHs (pending for Albany, Otsego, Schoharie, Delaware and Chenango counties).

Designated Phase 3 HHs are working on addressing any contingencies identified in the review of their applications ,entering into DEAAs and MCP contracts and formalizing network partnerships.

DOH in discussions with CMS re: SPA approval, HH services cannot be billed until SPA is approved and rates are loaded .

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The base patient acuity factors are weighted averages based on total claim costs associated with CRGs for a Health Home eligible population for a given time period.

Initial Phase 1 base acuity scores were adjusted upward for HIV, MHSA and Single SMI illnesses as well as severity level.

These adjusted acuity scores for Phase 1 HH eligible individuals have been provided to Phase 1 Health Homes and Managed Care Plans.

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In addition to adjusting the acuity scores for Severity and MHSA/HIV/Single SMI conditions, new weights include additional upward adjustments for:

Individuals that are in the Pairs Chronic and Triples Chronic populations that also have serious mental illness

A risk based add-on from the predictive model (drives dollars to members at higher risk for using more inpatient services)

The new acuity scores are effective October 1, 2012 and will be made available to health homes and plans via the OHIP HCS Portal.

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Revised Payment Rates and Method

Effective October 1, 2012, Health Home payments will be based on the new acuity scores and will be member specific.

The new acuity scores or “member specific weights” will be loaded to eMedNY within the next week .

If an individual does not have an acuity score at the time a claim is submitted, the claim will go into pend status for 30 days. A statewide average acuity score (from the HH assigned population) will be provided to eMedNY so that the claim will pay.

Member Specific Payment Calculation: member specific acuity x applicable HH base rate

Example: 8.2564 x $23.27 = $192.13The payment will be automatically calculated when

the claim is submitted to eMedNY by the claims payment system.

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Medicaid RateRate Code Description Upstate Downstate

1386 Health Home Services 18.71$ 23.27$ 1387 Health Home Services - Outreach 14.97$ 18.62$

Rate Code

Health Home Base Rates

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Base Health Status SMISeverity of

IllnessEligible

Recipients

Average CRG Acuity Score (with Phase I Adj)

Average CRG Acuity Score (with NEW Adj)

Ave. Monthly Payment (based on Ave. CRG

Acuity with Phase I Adj)

Ave. Monthly Paymet (Ave.

CRG Acuity with New Weights)

% Increase

Eligible Recipients

Average CRG

Acuity Score (with

Phase I

Average CRG

Acuity Score (with NEW

Ave. Monthly Payment (based on Ave. CRG

Acuity with Phase I Adj)

Ave. Monthly Paymet (Ave.

CRG Acuity with New Weights)

% Increase

Pairs Chronic No Low 39,736 2.9200 3.0966 $67.95 $72.06 6.0% 13,270 3.4841 3.6602 $65.19 $68.48 5.1%Mid 20,983 5.9911 7.2789 $139.41 $169.38 21.5% 7,804 6.4872 7.6747 $121.38 $143.59 18.3%High 9,140 10.4891 13.8438 $244.08 $322.14 32.0% 3,045 10.8318 13.9366 $202.66 $260.75 28.7%

Yes Low 12,231 5.1901 10.6780 $120.77 $248.48 105.7% 5,244 5.2480 10.5974 $98.19 $198.28 101.9%Mid 14,357 7.6233 15.8052 $177.39 $367.79 107.3% 6,771 7.6472 15.4097 $143.08 $288.32 101.5%High 2,881 13.0050 25.4821 $302.63 $592.97 95.9% 1,276 12.8137 24.2513 $239.74 $453.74 89.3%

Pairs Chronic Total 99,328 5.5171 8.3888 $128.38 $195.21 52.1% 37,410 6.0276 9.1355 $112.78 $170.92 51.6%Triples Chronic No Low 2,562 4.7862 4.9587 $111.37 $115.39 3.6% 963 5.2209 5.3808 $97.68 $100.67 3.1%

Mid 7,762 7.2532 7.8965 $168.78 $183.75 8.9% 3,053 7.6720 8.2988 $143.54 $155.27 8.2%High 6,148 11.6339 13.7811 $270.72 $320.69 18.5% 2,057 12.1024 14.3990 $226.44 $269.40 19.0%

Yes Low 2,519 6.5921 12.5158 $153.40 $291.24 89.9% 747 6.6217 12.4206 $123.89 $232.39 87.6%Mid 4,266 9.1188 17.4123 $212.19 $405.18 90.9% 1,649 9.1996 17.4152 $172.12 $325.84 89.3%High 1,306 13.7219 25.2165 $319.31 $586.79 83.8% 530 13.7226 25.0789 $256.75 $469.23 82.8%

Triples Chronic Total 24,563 8.6925 12.1102 $202.27 $281.80 39.3% 8,999 8.9715 12.3819 $167.86 $231.66 38.0%

Downstate Upstate

Projected Regional Average Health Home Payment Comparison by Base Health Status and Severity of Illness - Pairs Chronic and Triples ChronicExcludes LTC and OPWDD Populations

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Base Health Status SMISeverity of Illness

Eligible Recipients

Average Acuity Score

Average Monthly Payment

Eligible Recipients

Average Acuity Score

Average Monthly Payment

Single SMI/SED Yes Low 15,989 6.6993 $155.89 7,231 6.6775 $124.93Mid 7,261 9.3623 $217.86 3,621 9.0329 $169.00High 292 22.1821 $516.18 68 21.9944 $411.52

Single SMI/SED Total 23,542 7.7127 $179.48 10,920 7.5539 $141.33Pairs Chronic No Low 39,736 3.0966 $72.06 13,270 3.6602 $68.48

Mid 20,983 7.2789 $169.38 7,804 7.6747 $143.59High 9,140 13.8438 $322.14 3,045 13.9366 $260.75

Yes Low 12,231 10.6780 $248.48 5,244 10.5974 $198.28Mid 14,357 15.8052 $367.79 6,771 15.4097 $288.32High 2,881 25.4821 $592.97 1,276 24.2513 $453.74

Pairs Chronic Total 99,328 8.3888 $195.21 37,410 9.1355 $170.92Triples Chronic No Low 2,562 4.9587 $115.39 963 5.3808 $100.67

Mid 7,762 7.8965 $183.75 3,053 8.2988 $155.27High 6,148 13.7811 $320.69 2,057 14.3990 $269.40

Yes Low 2,519 12.5158 $291.24 747 12.4206 $232.39Mid 4,266 17.4123 $405.18 1,649 17.4152 $325.84High 1,306 25.2165 $586.79 530 25.0789 $469.23

Triples Chronic Total 24,563 12.1102 $281.80 8,999 12.3819 $231.66HIV/AIDS No Low 5,997 5.4996 $127.97 752 5.4517 $102.00

Mid 5,160 10.5293 $245.02 815 9.5101 $177.93High 1,424 18.9814 $441.70 160 17.6933 $331.04

Yes Low 192 5.5550 $129.26 36 5.5029 $102.96Mid 3,713 10.4834 $243.95 450 9.6692 $180.91High 507 20.1222 $468.24 65 19.3610 $362.24

HIV/AIDS Total 16,993 9.6825 $225.31 2,278 8.9943 $168.28Grand Total 164,426 8.9816 $209.00 59,607 9.3305 $174.57

Downstate Upstate

Projected Average Health Home Payments by Base Health Status and Severity of IllnessExcludes LTC and OPWDD PopulationsEffective October 1, 2012

Additional Phase 1 assignments will include Health Home eligible individuals with a Composite Score > 125 and individuals with a Predictive Model Risk of > 30%

Additional assignments anticipated to be available late fall of 2012 via the OHIP HCS Portal instead of manually.

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Health Home assignment files will be available once DEAAs and Portal Functionality is complete.

Assignments will be available via the OHIP HCS Portal

Each Health Home and Managed Care Plan should have at least one HCS contact to download assignment files and upload patient tracking files. Test files should be sent now.

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Members that are not in converting TCM slots - members with a Composite Score > 125 and members with a Predictive Model Risk > 30%

Phase FFS * MMC * TotalPhase 1 22,781 49,062 71,843 Phase 2 25,790 55,243 81,033 Phase 3 11,639 18,139 29,778 Unmatched ** 5,404 555 5,959

sub-total 65,614 122,999 188,613 Members in Converting TCM Slots

Phase FFS * MMC * TotalPhase 1 5,404 7,224 12,628 Phase 2 8,394 7,629 16,023 Phase 3 3,213 2,842 6,055 Unmatched *** 653 61 714 sub-total 17,664 17,756 35,420 Total 83,278 140,755 224,033 * MMC counts are higher as more individuals have moved to MMC.** Members to be matched to Health Home based on loyalty.*** Members to be matched to Health Home by Case Management Agency

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Phase 1 Projected Assignments at Full Implementation (Includes Duals)

Members in Non Converting SlotsMembers in Converting TCM Slots

Grand

COUNTY FFS MMC sub-total Total

CLINTON 581 216 797 146 943

ESSEX 147 95 242 47 289

FRANKLIN 315 29 344 122 466

HAMILTON 8 12 20 0 20

NASSAU 1,864 4,266 6,130 1,475 7,605

NYC - BRONX 8,836 19,689 28,525 5,221 33,746

NYC - BROOKLYN 10,019 23,255 33,274 5,195 38,469

SCHENECTADY 465 1,141 1,606 254 1,860

WARREN 380 110 490 92 582

WASHINGTON 166 249 415 76 491

Total Phase 1 22,781 49,062 71,843 12,628 84,471

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Phase 2 Projected Assignments at Full Implementation (Includes Duals)

Members in Non Converting Slots Members in Converting TCM Slots

Grand

COUNTY FFS MMC sub-total TotalDUTCHESS 580 1,076 1,656 834 2,490 ERIE 1,826 5,873 7,699 1,437 9,136 MONROE 1,596 4,302 5,898 1,445 7,343 NYC - MANHATTAN 7,877 11,024 18,901 3,529 22,430 NYC - QUEENS 6,033 15,138 21,171 2,995 24,166 NYC - STATEN ISLAND 1,230 3,281 4,511 803 5,314 ORANGE 891 1,780 2,671 388 3,059 PUTNAM 103 197 300 65 365 ROCKLAND 464 1,121 1,585 313 1,898 SUFFOLK 2,615 6,055 8,670 2,767 11,437 SULLIVAN 274 616 890 220 1,110 ULSTER 435 974 1,409 125 1,534 WESTCHESTER 1,866 3,806 5,672 1,102 6,774

Total Phase 2 25,790 55,243 81,033 16,023 97,056

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Phase 3 Projected Assignments at Full Implementation (Includes Duals) Members in Non Converting Slots Members in

Converting TCM Slots

Grand

COUNTY FFS MMC sub-total TotalALBANY 783 1,973 2,756 397 3,153 ALLEGANY 146 192 338 98 436 BROOME 621 1,082 1,703 324 2,027 CATTARAUGUS 201 537 738 209 947 CAYUGA 312 230 542 98 640 CHAUTAUQUA 339 965 1,304 305 1,609 CHEMUNG 409 439 848 121 969 CHENANGO 309 51 360 58 418 COLUMBIA 165 347 512 78 590 CORTLAND 95 264 359 72 431 DELAWARE 256 48 304 33 337 FULTON 166 450 616 76 692 GENESEE 115 269 384 99 483 GREENE 144 370 514 62 576 HERKIMER 162 289 451 71 522 JEFFERSON 656 36 692 126 818 LEWIS 116 21 137 31 168 LIVINGSTON 109 235 344 70 414 MADISON 195 215 410 85 495 MONTGOMERY 134 429 563 90 653 sub-total 5,433 8,442 13,875 2,503 16,378

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Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd)

Members in Non Converting

Slots Members in Converting TCM Slots

Grand

COUNTY FFS MMC sub-total TotalNIAGARA 443 1,246 1,689 679 2,368 ONEIDA 625 1,444 2,069 565 2,634 ONONDAGA 1,108 2,436 3,544 695 4,239 ONTARIO 163 340 503 161 664 ORLEANS 95 240 335 54 389 OSWEGO 205 669 874 159 1,033 OTSEGO 132 257 389 56 445 RENSSELAER 383 1,205 1,588 308 1,896 SAINT LAWRENCE 1,004 51 1,055 106 1,161 SARATOGA 294 820 1,114 138 1,252 SCHOHARIE 72 77 149 39 188 SCHUYLER 113 22 135 31 166 SENECA 72 109 181 57 238 STEUBEN 647 90 737 119 856 TIOGA 239 28 267 28 295 TOMPKINS 198 232 430 148 578 WAYNE 200 297 497 112 609 WYOMING 184 25 209 66 275 YATES 29 109 138 31 169 Total Phase 3 11,639 18,139 29,778 6,055 35,833

Currently available to Health Homes and Managed Care Plans with Health Commerce System Access.

Current Capabilitieso Tracking file submissiono Recipient look-up

find out member’s HH eligibility, Medicaid eligibility, HH enrollment, and assigned member’s last 5 claims

o Enrollment record download (“data dump”) Creates a file containing all records that a provider

has successfully submitted to the portal Upcoming Capabilities

o Assignment file downloado Member acuity score file downloado Member claim detail Report

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Local District Social Services offices (LDSS) and local government units (LGUs) can be a valuable source of information to help outreach to and manage care for assigned members and a referral source for new members.

HH can exchange data with an LDSS or LGU by completing a DEAA subcontractor packet. The LDSS or LGU should determine which staff members need to access HH data (in addition to Medicaid staff who are automatically permitted access ) These staff members should be listed on the DEAA, and access to HH member data would be approved only for these individuals.

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The State has entered into contracts with five regional Behavioral Health Organizations (BHOs). The BHOs are monitoring FFS Medicaid admissions for inpatient psychiatric care and detox and reviewing discharge planning.

HHs can execute a Confidentiality Agreement with their regional BHO and arrange to receive alerts if a member is admitted for these services. The HH and BHO can work together on discharge planning and the BHO can also insure the Health Home is part of the discharge planning process.

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Potential members may be referred for Health Home services Members do not have to be on DOH lists or be approved by DOH

in order to be accepted for Health Home referral. HHs and MCPs are responsible for determining whether the individual presumptively meets criteria for referral.

A Health Home and MCP work group is in the process of developing “rule-in, rule-out” criteria for referrals. Interim guidance has been developed.

This process will be used to prioritize referrals in the initial phases of Health Home implementation (to focus initial Health Home resources to our neediest members). This process will be revisited when Health Homes are more fully implemented.

There are 3 steps to making a Health Home referral:

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STEP 1- ASSESS ELIGIBLITY: Must meet eligibility for Health Home Services as described in the New York State Health Home State Plan Amendment (claims data should be used whenever available to verify medical and psychiatric diagnoses)

◦ Two chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI over 25, or other chronic conditions, OR

◦ One qualifying chronic condition (HIV/AIDS) and the risk of developing another, OR

◦ One serious mental illness

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STEP 2-ASSESS APPROPRIATENESS FOR HEALTH HOME: Has significant behavioral, medical or social risk factors which can be modified/ameliorated through care management including any of the following:

◦ Probable clinical risk for adverse event, 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, eating, etc ◦ Learning or cognition issues

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STEP 3 -INITIATE REFERRAL: If member meets criteria described in Steps 1-2, the referral can be made on the basis of this presumptive assessment.

◦ Referrals for FFS members are made to the lead HH, referrals for plan members can directly to the MCP or to the lead HH to make the MCP connection.

◦ HHs and plans have access to assignment information in the HCS portal and should check an individual’s assignment status prior to making a referral.

◦ If the individual is already assigned to a Health Home, that Health Home should be contacted to discuss the appropriate course of action.

(Additional factors which will quantify criteria in Step 2 are under development by the clinical workgroup-see next slide)

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Developing Step (coming soon) - QUANTIFY RISK/ACUITY: Has a history of poor connectivity to care, including but not limited to: No primary care practitioner (PCP) No connection to specialty doctor or other practitioner Poor compliance (does not keep appointments, etc)Inappropriate ED useRepeated recent hospitalization for preventable conditions either medical or psychiatricRecent release from incarcerationCannot be effectively treated in an appropriately resourced patient centered medical home Homelessness

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NOTE If a comprehensive assessment subsequently reveals that the

individual does not meet Health Home services criteria, the individual must be transitioned to an appropriate level of care, such as a Patient Centered Medical Home (PCMH).

Referral process for converting TCM programs may differ, e.g., OMH TCM programs and services must be made in consultation with the LGU Single Point of Access (SPOA).

Detailed instructions on how to use the Health Home Member Tracking System to make a referral can be found in the Health Home Member Tracking System specifications document.

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• Member Tracking System Specifications Document: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2012-06-26_draft_hh_patient_tracking_system.pdf

• Document explaining Tracking System version updates: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/summary_updates_hh_patient_tracking_system.pdf

• April Medicaid Update Special Edition (watch for an article in the October Edition):

• Health Home Website: http://www.health.ny.gov/health_care/medicaid/program/update/2012/april12muspec.pdf http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/

• Member Assignment, Tracking System, Billing and Rates section of Health Home website: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/rate_information.htm

Discussion with CMS re: SPAs

Final recommendations re: referrals from Plans and Health Homes clinical workgroup

Working towards assigning children and duals to Health Homes

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Questions can also be submitted to the Health Home mailbox (hh2011@health.state.ny.us) with the subject

line “Questions Health Home Webinar #6”