New York State Health Homes Implementation and Billing Update Statewide Webinar

1. New York State Health Homes Implementation and Billing Update Statewide Webinar Presented by: New York State Department of Health January 12, 2012

2. Issues Covered on Today’s Webinar • Timeline • Applications • Payment Policy and Billing • Patient Assignment and Enrollment • Patient Consent • Disenrollment Process • Patient Rosters • …and more

3. Health Home - Updated Timeline • State Plan Amendment under review by CMS: approval expected shortly • January 1, 2012: Existing Case Management (COBRA, MATS, TCMs) providers begin billing using HH rates • Working 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

4. Health Home Web Based Application • The Health Home Application is being updated • The updates primarily impact tables which list the partners and providers • Completed updates expected by February 1, 2012 • New Phase 2 application deadline February 15, 2012 • Obtain link to import information from Phase 1 application into Phase 2 by emailing hh2011@health.state.ny.us Subject: 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

5. 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 management • Outreach and engagement for new members will be paid at a reduced percentage (80%) of the active care management PMPM

6. 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

7. Health Home Payments • Rates 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

8. Health Home Payments – Provider Enrollment • Providers already enrolled in Medicaid must add Category of Service (COS) 0265 • New Health Home Providers that are not yet enrolled in NYS Medicaid must enroll • Enrollment 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

9. Patient Rosters/Health Home Member Tracking Sheet • Billing 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

10. Roster Sharing/Health Home Member Tracking Sheet • All 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

11. Member Assignment & Enrollment • Managed 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

12. 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

13. Disenrollment or Changing Health Homes • Members who decide to disenroll from Health Homes must sign a disenrollment form • Members should request a disenrollment form from their Plan or Provider-led Health Home • Members 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

14. Chronic Illness Demonstration Program (CIDP) Issues • CIDP 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

15. 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

16. Care Management Process Metrics • Health Home Core Services • Comprehensive care management • Coordination and health promotion • Transitional care from inpatient to other settings • Individual and family supports • Referral to community and social support services • Must provide documentation demonstrating how requirements are being met • Reporting period • Case Management Data Elements • Includes data elements from managed care plan • Functional Assessment elements • Metrics will be on web shortly

17. Health Home Payments to Plans • The 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

18. 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

19. Health Commerce System (HCS) Access • Health 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’

20. Billing Codes REVISED Health Home Rate Code Definitions • 1386: Health Home Services (Plans and FFS) • 1387: Health Home Outreach (Plans and FFS) • 1851: Health Home/OMH TCM • 1852: Health Home Outreach /OMH TCM • 1880: Health Home/AIDS/HIV Case Management • 1881: Health Home Outreach/ AIDS/HIV Case Management • 1882: Health Home/ MATS • 1883: Health Home Outreach/MATS • 1885: Health Home/CIDP Case Management

21. How to Submit a Claim for Health Home Services • Managed 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

22. Health Home Lead Applicant Readiness Checklist • Must be enrolled in Medicaid • Must resolve any approval contingency • Must have DEAA • Must have HCS access • Must have contracts with plans & downstream care managers • Secure Health Home partners • Confirm ability to bill rate codes for FFS & TCM • Confirm ability to share roster information (two way communication) with downstream Health Home providers • Confirm ability to pay downstream Health Home providers • Develop procedures to collect and report monthly care management process metrics & functional assessment for each enrolled member

23. Next Stepsfor DOH Implementation Team • Secure SPA approval from CMS • Continue implementation work with the Health Plans • Post detailed billing guidelines to Health Home website and publish in Medicaid Update • Complete FFS loyalty matching to Health Homes • Share final rosters with plans and Health Homes • Regional meetings with Health Plans and Provider-led Health Homes