Health Home Implementation Update-The Managed Care Perspective

1. Health Home Implementation Update-The Managed Care Perspective Session 8 -November 19, 2012

2. Health Home Managed Care Agenda • Program Details and Documentation • Administrative Costs and Rates • Contracting • Billing • Assignment • Data Exchange • Consent • Eligibility

3. Program Details and Documentation MCOs asked when certain elements of the Health Home Program will be finalized: • Patient Tracking System – Modifications are being considered • Care management matrix or CMART – December 2012 • Updated eligibility, loyalty, acuity –December 2012 • Benchmarks for performance – Will require assessment of baseline data and first year performance • Extent to which Phases 2 and Phase 3 will follow the same rules as Phase 1: 100%, • Timeline for rolling out Phases 2 and 3 –ASAP, once SPAs are approved.

4. Program Details and Documentation MCOs asked for a compilation of all current program guidance: • A Health Home Provider Manual will be released in January 2013 that will include guidance on: • Billing • Contracting • Member assignment and referral process • Claim submission • Manual will be updated as new policies are developed

5. Program Details and Documentation A new Special Edition of the Medicaid Update regarding Health Homes was released on November 14, 2012. It features information on: • Assignment, implementation and billing by phase • Billing rules for converting OMH, COBRA and MATS providers • Use of the tracking system • Increase in Health Home Payments • Community Referrals for Health Home Services • Priority Referrals for Converting Care Management Services

6. Administrative Costs and Rates MCOs are concerned about the administrative costs of the program for members receiving Health Home services from transitioning legacy case management providers: • DOH is exploring ways to increase the MCO rates to support Health Home administrative activities. • DOH is currently working with its actuary and will bring options to CMS for discussion.

7. Contracting MCOs asked that DOH share Health Home readiness reviews with MCOs: • Reviews can be shared with MCOs, for Health Homes in their contracted network. MCOs asked that DOH reinforce the importance of Health Homes signing Business Associate Agreements with MCOs, in order to receive PHI for members: • DOH will work to educate Health Homes that BAAs must be signed with contracted MCOs.

8. Contracting MCOs asked that Health Homes be required to report contract status to DOH: • The Bureau of Managed Care provides updates on contract negotiations and these are posted on the Health Home website, updates are provided during biweekly webinars. MCOs and Health Homes in Phase 2 and 3 counties should not wait for SPA approval to begin negotiating contracts.

9. Managed Care and Health Home Contracts • AMIDA CARE • Institute for Community Living • Community Healthcare Network • Maimonides Medical Center • VNS of NY Home Care • Bronx Lebanon Hospital • CDPHP • Glens Falls Hospital • VNS of Schenectady • EMBLEM HEALTH • Bronx Accountable Healthcare Network • Maimonides Medical Center • FEGS Health and Human Services • Bronx Lebanon Hospital Center • Institute for Community Living • North Shore Long Island Jewish Center • FIDELIS • VNS Schenectady • Maimonides Medical Center • FEGS Health and Human Services • Bronx Lebanon Hospital Center • Institute for Community Living • Bronx Accountable Healthcare Network • Adirondack Health Institute • Glens Falls Hospital • VNS of NY Home Care • MetroPlus • NYC Health and Hospitals Corp. • United Healthcare of New York • Community Healthcare Network • Bronx Lebanon Hospital Center • FEGS Health and Human Services • North Shore Long Island Jewish • Maimonides Medical Center • Hudson Valley Care Coalition • Glens Falls Hospital • VNSNY CHOICE • Bronx Lebanon Hospital Center • Community Healthcare Network • Institute for Community Living • Maimonides Medical Center • VNS of NY Home Care • Wellcare of NY • Bronx Lebanon Hospital Center • Institute for Community Living • Healthfirst PHSP • Bronx Lebanon Hospital Center • Institute for Community Living • Maimonides Medical Center • FEGS Health & Human Services • Community Healthcare Network • Bronx Accountable Healthcare Network • North Shore Long Island Jewish • VNS of NY Home Care • NYC Health and Hospital Corp. • Hudson Health Plan • Hudson Valley Care Coalition • Institute for Family Health • HealthPlus Amerigroup • Bronx Lebanon Hospital Center • FEGS Health and Human Services • Maimonides Medical Center • North Shore Long Island Jewish • Neighborhood Health Providers • Bronx Lebanon Hospital Center • Institute for Community Living • Maimonides Medical Center • Community Healthcare Network • Bronx Accountable Healthcare Network • VNS of NY Home Care Revised November 1, 2012

10. Billing MCOs requested clarification on the duration of the billing transition for converting TCM programs: • Just announced-TCMs will now bill legacy rates for two years from the effective date of the State Plan Amendment (SPA). MCOs asked if TCM programs will bill DOH directly indefinitely: • TCM programs are billing DOH directly as part of their transition to Health Homes; this billing arrangement is not indefinite.

11. Billing Cont’d • The only difference between Health Home claim and Capitation claim is the rate code used. • Capitation claims also require a diagnosis code and a revenue code. • DOH cannot provide coding guidance. MCOs and Health Homes must be familiar with valid diagnosis and revenue codes and choose the codes that best represent the services provided.

12. Billing – MC 0220 • Append location code to MMIS Provider number • Claim format 837 Institutional or paper UB04 • 820 Remittance • Use applicable HH Rate Code (1386/1387) • DOS = 1st of the Month in which services are provided • Valid diagnosis code required • Valid revenue code required (see NUBC code set) • Procedure Code not required • For additional information on how to submit a Medicaid claim, contact eMedNY at 1-800-343-9000

13. Assignment MCO’s are requesting updated assignment files: • Member assignment files with updated loyalty information are expected to be released on a quarterly basis. The next release is anticipated in December 2012 • In few weeks, member acuity scores will be available for download via the HCS portal as a fixed length text file. Members’ acuity scores will be refreshed quarterly (DOH will release specifications on this file shortly).

14. Assignment Cont’d MCOs asked how they should handle assignments of plan members to Health Homes that they do not contract with (these are likely members who were assigned when they were FFS): • A member has a right of choice for a MCO and Health Home. If a member is already assigned to a Health Home when joining the MCO, the MCO should honor that assignment. • If the Health Home is not contracted with the Plan, the MCO should advise the care manager who will work with the member to determine an alternative Health Home or Plan. • DOH expects Health Homes, with partner Care Management Agencies and MCOs to discuss and agree to appropriate assignment of Health Home members.

15. Assignment Cont’d MCOs asked if DOH is open to providing Health Home services to those members with lower and mid range scores: • The state is prioritizing the members at the highest level of risk for adverse outcomes at this time. • In addition to members assigned by the NYSDOH, Health Homes can accept community referrals. These may include members identified by the MCO as high risk and in need of intensive care management. Such members must still have one of the three basic Health Home diagnoses– 2 chronic, HIV/AIDS, SPMI. • The MCO-HH Work Group on Assignment and Quality is developing further guidance on community referrals.

16. Data Exchange MCOs have found the Health Home Portal very helpful and are looking forward to future improvements: • DOH is looking at a number of improvements to smooth data flow and timeliness. MCOs have requested clarification on the amount of data that can be shared with the Health Home prior to member consent: • MCO’s can share the last 5 claims/encounters.

17. Data Exchange (Cont’d) Some MCO’s are requesting a specified time period as an alternative to the last 5 claims/encounters. DOH is looking into whether that is an option. Health Home network providers (including contracted MCOs) must collaborate with the designated lead Health Home to obtain information necessary to perform outreach and engagement.

18. Consent MCOs asked about DOH expectations for timeliness of the member signing the Health Home consent: • DOH anticipates that the care manager will have the consent form signed to enable the exchange of Personal Health Information (PHI) in order to deliver quality Health Home services and care coordination, but a signed consent is not necessary to start care management services. • If a consent is not signed over an extended time, the MCO and Health Home may want to discuss the reasons why and together forge a solution .

19. Consent (Cont’d) MCOs asked if a care management provider can advise a member to change plans if the member’s current plan is not contracted with the care manager’s lead Health Home: • A member has a right of choice for an MCO and Health Home. The member and care manager can work together on the best option for the member. Alternately, the plan can contract with that Health Home. MCOs asked if a signed withdrawal of consent form is still required for members who wish to discontinue participating in the Health Home: • Yes, a signed withdrawal is required.

20. Eligibility MCOs asked about a process for active Health Home members who lose managed care coverage (e.g., due to loss of eligibility, incarceration) to transition back to services: • Health Homes will work with members to maintain eligibility. • A criminal justice workgroup is working on ways to connect post-release members to Health Homes.

21. Other Issues? Questions?