Draft Preliminary Health Home Rate Chart

August 23, 2011

The table below contains a DRAFT listing of preliminary Health Home rates. The Department will monitor these rates to assure that they strike the right balance between Health Homes program needs while operating under efficient costs. The average health home payment for the members in the given groups are for illustration purposes only. Actual payments will be based on a blend of all of the provider's assigned health home patients. Payments will eventually be recalculated (and any changes will be paid prospectively) based on service intensity and functional status data.

Projected Average Health Home Payments by Base Health Status and Severity of Illness - (Excludes LTC and OPWDD populations)

Note: Draft for review and input only - these rates and projections are not final.

Base Health Status1 Severity of Illness Recipients2 Average Monthly Payment3 Patient to Case Manager Ratio Range4 SFY 11/12 Percent Enrolled in HH5 SFY 11/12 HH Enrolled Recips6
Single Serious Mental Illness (SMI)/ Seriously Emotionally Disturbed (SED) Low 75,528 $122 From 51 to 107 25% 18,882
Mid 28,562 $155 From 34 to 71 35% 9,997
High 320 $319 From 12 to 47 50% 160
Single SMI/SED Total / Avg 104,410 $132 From 12 to 107 28% 29,039
Pairs Chronic Low 365,718 $60 From 51 to 150 5% 18,286
Mid 140,714 $121 From 34 to 115 10% 14,071
High 24,200 $207 From 11 to 63 20% 4,840
Pairs Chronic Total / Avg 530,632 $83 From 11 to 150 7% 37,197
Triples Chronic Low 20,748 $97 From 51 to 149 20% 4,150
Mid 29,167 $153 From 34 to 104 30% 8,750
High 10,136 $279 From 11 to 45 50% 5,068
Triples Chronic Total / Avg 60,051 $154 From 11 to 149 30% 17,968
HIV/AIDS Low 20,353 $49 From 103 to 143 30% 6,106
Mid 21,372 $166 From 51 to 108 40% 8,549
High 2,316 $324 From 11 to 22 50% 1,158
HIV/AIDS Total / Avg 44,041 $122 From 11 to 143 36% 15,813
Grand Total   739,134 $98 From 11 to 150 14% 100,016

Footnotes

  • 1. Mutually exclusive categories based on Clinical Risk Grouping. SED and OASAS Children are included in price model but will be excluded from initial assignment.
  • 2. Includes members that may currently be enrolled in care management programs (OMH TCM, COBRA, MATS and CIDP).
  • 3. Average health home payment for the members in the given rate/severity group - these groups are for illustration purposes - actual payments to health home provider will be based on a blend of a given provider's health home patients from across all applicable rate/severity cells. Actual payments are calculated at the patient level based on the predicted service intensity (staff to patient ratio) required for each patient and rolled up to a blended amount (1 rate per provider for a given timeframe) for the entire group of patients assigned to the health home provider. These payments will eventually be recalculated (and any changes will be paid prospectively) based on service intensity and functional status data. DOH will closely review payment adequecy during health home implementation.
  • 4. Range of staff to patient ratio variation for the selected group of patients - (for example high severity SMI/SED rate would support a range of staff to patient ratios from 1:12 to 1:47).
  • 5. Possible percentage of patients in a given rate/severity group assigned to Health Home services. This percentage is for planning and illustration purposes only - actual number of patients will be based on predictive modeling, ambulatory connectivity and regional Health Home capacity analyses.
  • 6. Total HH recipients times the percent enrolled for SFY 11/12 - this includes individuals currently in care management programs (OMH TCM, COBRA, MATS and CIDP) that may not be paid at the Health Home rate level during the first year. This is a draft planning and illustration number only.