Questions and Answers

Q & A Topics

General | Billing and Payment | Chronic Illness Demonstration Project (CIDP) | Health Home Design | Health Home Development Funds | Health Home Letter of Intent/Applications/Provider Enrollment/Application Form | Health Home Network | Health Information Technology | Managed Care | Member Forms | Population Assignment/ Eligibility (Patient Tracking System) | Quality Metrics and Evaluation (CMART) | Spend Down | Targeted Case Management (TCM) |

Health Home Network

1. How has the implementation of Health Homes taken into account the potential to leverage the work that is already being done with the chronically ill population by community behavioral health providers, supportive housing providers, and health care for the homeless providers?

DOH has actively sought and used the advice and suggestions from experienced community medical, behavioral, and social services providers in developing Health Home requirements; most important of which is that Health Homes must develop strong community connections to meet the complex needs of Health Home enrollees. The work that is already being done to serve the needs of chronically ill individuals is a strong foundation for Health Homes, which requires the coordination of medical, behavior, and social services providers and community resources. In addition, to support existing enrollee/provider relationships and to the extent possible, eligible enrollees will be enrolled in Health Homes based on their existing relationships with a Health Home or the Health Home´s network of providers, or if no relationship exists, with a Health Home that provides services within the enrollee´s community.

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2. Are Health Homes a temporary phenomenon and will they be replaced by care management for all (e.g., integrated delivery system/SNPs/BHO/MCO)?

No. Health Homes are a care management service operated by a qualified network of providers which will be an integral part of other payment and accountability structures that may evolve from Medicaid Redesign.

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3. Can hospitals be part of more than one Health Home network?

Yes, hospitals can operate as a Health Home lead as well as a partner with other leads.

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4. If we are an integrated health system with hospital outpatient clinics and community based primary care physicians, are we required to include an FQHC in our Health Home network?

Specific partnerships are not required; however, all lead Health Homes applicants are strongly encouraged to partner with community based organizations that provide complimentary services as well as similar services.

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5. Do Health Homes have to provide the coordination of care and care management directly or can that be subcontracted?

Health Home providers can either directly provide, or subcontract for the provision of, Health Home Care services. The Health Home provider remains responsible for all program requirements, including care management services performed by the subcontractor – per the NYS Health Home Provider Qualification Standards.

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6. Can a provider that is not a Medicaid vendor but is funded by NYS OMH for housing or employment or other services become a subcontractor to a Health Home?

Yes, but the Health Home assumes certain risks for the activities of the subcontractor. See section 2 of the Health Home Provider Manual

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7. Do you agree that the description below of the three levels of participation in a Health Home is accurate?
  • Lead Agency – contractually obligated to DOH for Health Home care management services.
  • Shareholder/Down Stream Provider/CMA – member of the network holding a subcontract with the lead agency to provide care management (CM) services for a portion of the health home members. The agency would receive a portion of the PMPM for its CM services and be obligated to the lead agency on performance, etc. This agency also might benefit in any "gain share" arrangement with the lead agency (contingent upon negotiation and contractual arrangements).
  • Network Member – a member who receives referrals from the health home but is not performing CM services other than normal contacts between providers. While payment is unclear there most likely will not be any "gain share."

Yes. Health Homes can structure their governance models and networks as required to maximize efficiency and service delivery and this is an acceptable arrangement. The Department is open to several types of sub contractual relationships but the ultimate accountability and gain sharing will be with the State–approved lead Health Home provider and the health plan. Downstream movement of dollars will not be directly managed by the State.

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8. Can a Health Home member receive substance abuse services (or other services) from a non–networked provider and retain their enrollment in the Health Home, or is the Health Home member restricted to the networked provider, assuming that the service is available in the network?

At this point, the Health Home will not be a closed network and members can receive their services as they typically would (in–network for Managed Care members). However, the Health Home is charged with care coordination and managing the whole person, so Health Home members must get care in an integrated manner that is coordinated their Care Manager, unlike the "siloed" way care management had been provided.

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