Health Home Eligibility Policy

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Eligibility Requirements: Identifying Potential Members for Health Home Services

This policy outlines the steps that must be taken to ensure every individual, adult and child/youth, meets the required eligibility criteria needed to support Health Home enrollment and continued enrollment in the Health Home program.

Individuals may be referred to Health Homes (HH) from providers or other entities, including Medicaid Managed Care Organizations (MCO), physicians and other healthcare and behavior health providers, emergency departments, schools, community-based providers, criminal justice, supportive housing providers, shelters, family members, self-referrals, and so forth. These referrals are known as community referrals. Regardless of referral source, the eligibility of the individual and their interest in Health Homes enrollment must be verified.

For Children (ages 0-21 years old) who may be eligible for Health Home services, the State has developed the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) Referral Portal. The Portal requires the referral source, “Indicate the chronic conditions which, in your best-informed judgement, you believe make the child you are referring eligible for Health Home.” Currently, Managed Care Plans, Health Homes, Care Management Agencies, Local Government Units (LGU), Single Point of Access (SPOAs) and Local Department of Social Services (LDSS) (In NYC, VFCA that contract with ACS will make Referrals on behalf of ACS) have access to the MAPP HHTS Referral Portal.

Additionally, CMAs/HHCMs, HHs and MCOs must routinely conduct a review of their enrolled Health Home members to determine whether the need and eligibility criteria exists for continued Health Home Program level of care management. Members who are no longer eligible or appropriate for Health Home services must be stepped down to a lower intensity care coordination service, such as their MCO, a Managed Long-term Care (MLTC) Plan, Patient-Centered Medical Home (PCMH), or family/natural supports.

Health Homes and Care Management Agencies should refer to Policy HH0007 Member Disenrollment From the Health Home Program to ensure appropriate steps are taken to transition members for disenrollment from the Health Home Program.

Determining Eligibility for Health Home Services

Step One

Step One is to determine Medicaid eligibility. Medicaid reimbursement for Health Home services can only be provided for individuals who are enrolled in Medicaid that is also compatible with Health Home services (refer to Guide To Coverage Codes and Health Home Services. The Health Home Care Management Agency (CMA)/Health Home Care Manager (HHCM) must confirm Medicaid eligibility required for enrollment. It is also important to note that a client’s Medicaid eligibility may change frequently. The care manager should continually verify Medicaid eligibility and work with eligible members to assist them in enrolling or renewing members for Medicaid benefits as required. It is important to note that Medicaid coverage may be granted retroactively.

Step Two

Step Two is to determine if the member is eligible for Health Home services. To be eligible for Health Home services, an individual must have two chronic conditions or one single qualifying condition. Having one chronic condition (other than the single qualifying conditions below) and being at risk of developing another condition does not qualify an individual as Health Home eligible in New York State.

Medicaid members eligible to be enroll in a Health Home must have:

  • Two or more chronic conditions OR
  • One single qualifying chronic condition:
    • HIV/AIDS or
    • Serious Mental Illness (SMI) (Adults) or
    • Sickle Cell Disease (both Adults and Children) or
    • Serious Emotional Disturbance (SED) or Complex Trauma (Children)

Substance use disorders (SUDS) are considered chronic conditions, but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition (as described below) to qualify.

Diagnostic eligibility criteria verifying the individual’s current condition(s) must be confirmed and maintained in the record. Information may be accepted from any one of these sources: Plan referrals, medical records or assessments, written verification by the individual’s physician or treating healthcare provider, the Regional Health Information Organization (RHIO), or the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES).

MCOs and medical providers may provide the Health Home Care Management Agency (CMA) or Health Home with a Clinical Discretion of Diagnostic Requirements, to allow the CMA/HH to service the member without documentation and verification of qualifying conditions.

Qualifying chronic conditions are any of those included in the “Major” categories of the 3MTM Clinical Risk Groups (CRGs) as described in the list below.

Major Category: Alcohol and Substance Use Disorder

  • Alcohol and Liver Disease
  • Chronic Alcohol Abuse
  • Cocaine Abuse
  • Drug Abuse – Cannabis/NOS/NEC
  • Substance Abuse
  • Opioid Abuse
  • Other Significant Drug Abuse

Major Category: Mental Health

  • Bi-Polar Disorder
  • Conduct, Impulse Control, and Other Disruptive Behavior Disorders
  • Dementing Disease
  • Depressive and Other Psychoses
  • Eating Disorder

Major Personality Disorders

  • Psychiatric Disease (Except Schizophrenia)
  • Schizophrenia

Major Category: Cardiovascular Disease

  • Advanced Coronary Artery Disease
  • Cerebrovascular Disease
  • Congestive Heart Failure
  • Hypertension
  • Peripheral Vascular Disease

Major Category: Developmental Disability

  • Intellectual Disability
  • Cerebral Palsy
  • Epilepsy
  • Neurological Impairment
  • Familial Dysautonomia
  • Prader-Willi Syndrome
  • Autism

Major Category: Metabolic Disease

  • Chronic Renal Failure
  • Diabetes

Major Category: Respiratory Disease

  • Asthma
  • Chronic Obstructive Pulmonary Disease Major Category: Other
Step Three

Step three is to determine appropriateness for Health Home services. Individuals who are Medicaid eligible and have active Medicaid and meet diagnostic eligibility criteria are not necessarily appropriate for Health Home care management. An individual can have two chronic conditions and be managing their own care effectively. An individual must be assessed and found to have significant behavioral, medical, or social risk factors that require the intensive level of Care Management services provided by the Health Home Program. Appropriateness for Health Home services must be determined for MAPP HHTS

Referral Portal referrals, as well as community or bottom up referrals. An assessment must be performed for all individuals to evaluate whether the person has significant risk factors.

Additionally, currently enrolled Members should be evaluated to determine whether they remain appropriate for the Health Home Program. Can the member manage their condition(s) using existing services and family/natural supports without evidence of risk that supported their HH enrollment? Can the member be disenrolled or transitioned to a lower level of care management?

Determinants of medical, behavioral, and/or social risk can include:

  • Probable risk for adverse events (e.g., death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement);
  • Lack of or inadequate social/family/housing support, or serious disruptions in family relationships;
  • Lack of or inadequate connectivity with healthcare system;
  • Non-adherence to treatments or medication(s) or difficulty managing medications;
  • Recent release from incarceration, detention, psychiatric hospitalization or placement;
  • Deficits in activities of daily living, learning or cognition issues; OR
  • Is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home

NOTE: When evaluating appropriateness for the enrollment of the adult population, there are varying factors that must be considered. HHs, CMAs and MCPs must follow guidance provided in the Eligibility Requirements: Identifying Potential Members for Health Home Services – Appropriateness Criteria, which supplements this policy by providing examples of determinants of risk identified in the above list.

Generally, it is the care management agency that determines eligibility for Health Home services. For managed care members, the MCOs and other providers often have more detailed information on a member’s diagnosis and care utilization.

Health Homes, Managed Care Organizations, and network care management partners should have policies and procedures that document the responsibilities for establishing and verifying diagnostic eligibility and need criteria, but the Medicaid biller remains ultimately responsible. As described in the New York State Plan Amendment (SPA) recent claims and/or encounter data or other clinical data should be used to verify medical and psychiatric diagnoses. It is expected that documentation of Medicaid eligibility, diagnostic eligibility, and risk assessment be maintained as defined by agreements between the Managed Care Organization, the Health Home, and the network care management agency.

Health Home Chronic Conditions
Acquired Hemiplegia and Diplegia
Acquired Paraplegia Acquired Quadriplegia
Acute Lymphoid Leukemia w/wo Remission
Acute Non-Lymphoid Leukemia w/wo Remission
Alcoholic Liver Disease
Alcoholic Polyneuropathy
Alzheimer's Disease and Other Dementias
Angina and Ischemic Heart Disease
Anomalies of Kidney or Urinary Tract
Apert's Syndrome
Aplastic Anemia/Red Blood Cell Aplasia
Ascites and Portal Hypertension
Atrial Fibrillation
Attention Deficit / Hyperactivity Disorder
Benign Prostatic Hyperplasia
Bi-Polar Disorder
Blind Loop and Short Bowel Syndrome
Blindness or Vision Loss
Bone Malignancy
Bone Transplant Status
Brain and Central Nervous System Malignancies
Breast Malignancy
Burns - Extreme
Cardiac Device Status
Cardiac Dysrhythmia and Conduction Disorders
Cardiovascular Diagnoses requiring ongoing evaluation and treatment
Cerebrovascular Disease w or w/o Infarction or Intracranial Hemorrhage Chromosomal Anomalies
Chronic Alcohol Abuse and Dependency
Chronic Bronchitis
Chronic Disorders of Arteries and Veins
Chronic Ear Diagnoses except Hearing Loss
Chronic Endocrine, Nutritional, Fluid, Electrolyte and Immune Diagnoses
Chronic Eye Diagnoses
Chronic Gastrointestinal Diagnoses
Chronic Genitourinary Diagnoses
Chronic Gynecological Diagnoses
Chronic Hearing Loss
Chronic Hematological and Immune Diagnoses
Chronic Infections Except Tuberculosis
Chronic Joint and Musculoskeletal Diagnoses
Chronic Lymphoid Leukemia w/wo Remission
Chronic Metabolic and Endocrine Diagnoses
Chronic Neuromuscular and Other Neurological Diagnoses
Chronic Non-Lymphoid Leukemia w/wo Remission
Chronic Obstructive Pulmonary Disease and Bronchiectasis
Chronic Pain
Chronic Pancreatic and/or Liver Disorders (Including Chronic Viral Hepatitis)
Chronic Pulmonary Diagnoses
Chronic Renal Failure
Chronic Skin Ulcer
Chronic Stress and Anxiety Diagnoses
Chronic Thyroid Disease
Chronic Ulcers
Cirrhosis of the Liver
Cleft Lip and/or Palate
Coagulation Disorders
Cocaine Abuse
Colon Malignancy
Complex Cyanotic and Major Cardiac Septal Anomalies
Conduct, Impulse Control, and Other Disruptive Behavior Disorders
Congestive Heart Failure
Connective Tissue Disease and Vasculitis
Coronary Atherosclerosis
Coronary Graft Atherosclerosis
Crystal Arthropathy
Curvature or Anomaly of the Spine
Cystic Fibrosis
Defibrillator Status
Dementing Disease
Depressive and Other Psychoses
Developmental Language Disorder
Developmental Delay NOS/NEC/Mixed
Diabetes w/wo Complications
Digestive Malignancy
Disc Disease and Other Chronic Back Diagnoses w/wo Myelopathy
Drug Abuse Related Diagnoses
Ear, Nose, and Throat Malignancies
Eating Disorder
Endometriosis and Other Significant Chronic Gynecological Diagnoses
Enterostomy Status
Esophageal Malignancy
Extrapyramidal Diagnoses
Extreme Prematurity - Birthweight NOS
Fitting Artificial Arm or Leg
Gait Abnormalities
Gallbladder Disease
Gastrointestinal Anomalies
Gastrostomy Status
Genitourinary Malignancy
Genitourinary Stoma Status
Gynecological Malignancies
Hemophilia Factor VIII/IX
History of Coronary Artery Bypass Graft
History of Hip Fracture Age > 64 Years
History of Major Spinal Procedure
History of Transient Ischemic Attack
HIV Disease
Hodgkin's Lymphoma
Hydrocephalus, Encephalopathy, and Other Brain Anomalies
Hyperthyroid Disease
Immune and Leukocyte Disorders
Inflammatory Bowel Disease
Intestinal Stoma Status
Joint Replacement
Kaposi's Sarcoma
Kidney Malignancy
Leg Varicosities with Ulcers or Inflammation
Liver Malignancy
Lung Malignancy
Macular Degeneration
Major Anomalies of the Kidney and Urinary Tract
Major Congenital Bone, Cartilage, and Muscle Diagnoses
Major Congenital Heart Diagnoses Except Valvular
Major Liver Disease except Alcoholic
Major Organ Transplant Status
Major Personality Disorders
Major Respiratory Anomalies
Malfunction Coronary Bypass Graft
Malignancy NOS/NEC
Mechanical Complication of Cardiac Devices, Implants and Grafts
Multiple Myeloma w/wo Remission
Multiple Sclerosis and Other Progressive Neurological Diagnoses
Neoplasm of Uncertain Behavior
Neurodegenerative Diagnoses Except Multiple Sclerosis and Parkinson's
Neurogenic Bladder
Neurologic Neglect Syndrome
Neutropenia and Agranulocytosis
Non-Hodgkin's Lymphoma
Obesity (BMI at or above 25 for adults and BMI at or above the 85th percentile for children)
Opioid Abuse
Other Chronic Ear, Nose, and Throat Diagnoses
Other Malignancies
Pancreatic Malignancy
Pelvis, Hip, and Femur Deformities
Peripheral Nerve Diagnoses
Peripheral Vascular Disease
Persistent Vegetative State
Pituitary and Metabolic Diagnoses
Plasma Protein Malignancy
Post-Traumatic Stress Disorder
Postural and Other Major Spinal Anomalies
Prematurity - Birthweight < 1000 Grams
Progressive Muscular Dystrophy and Spinal Muscular Atrophy
Prostate Disease and Benign Neoplasms - Male
Prostate Malignancy
Psychiatric Disease (except Schizophrenia)
Pulmonary Hypertension
Recurrent Urinary Tract Infections
Reduction and Other Major Brain Anomalies
Rheumatoid Arthritis
Secondary Malignancy
Secondary Tuberculosis Sickle Cell Anemia
Significant Amputation w/wo Bone Disease
Significant Skin and Subcutaneous Tissue Diagnoses
Spina Bifida w/wo Hydrocephalus
Spinal Stenosis
Spondyloarthropathy and Other Inflammatory Arthropathies
Stomach Malignancy
Tracheostomy Status
Valvular Disorders
Ventricular Shunt Status
Vesicostomy Status
Vesicoureteral Reflux