Health Home HML Rate For Adults

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Health Home High, Medium, Low (HML) Billing For Adults


Health Home Rates: High, Medium, and Low (HML) Rates with Clinical and Functional Adjustments Effective December 1, 2016

  • Effective 12/1/16, the monthly HML Assessment questionnaire is used to determine the rate code a member should be billed under for a that month.
  • HML Assessment created and approved by the HH/MCO Workgroup and uses clinical/functional questions to determine a member´s HML status for each month based on real time member attributes.
  • Providers should skip any questions that don´t apply to a member or any questions that they cannot answer.
  • Each answered question qualifies as either High, Medium, or Low (see following slides).
  1. Does the member have at least one response in the "High" category?
    • Yes – bill for member using the "High" rate code
    • No – see # 2
  2. Does the member have at least one response in the "Medium" category?
    • Yes – bill for member using the "Medium" rate code
  3. Bill for member using the "low" rate code

HML Rate Determination - Examples

**Responses for 12/1/16 Service Date****
Clinical & Functional Adjustments Jane Juan Maria
Response HML Response HAL Response HML
Base Acuity (unadjusted) unknown   2.1 L 1.9 L
Predictive Risk unknown   10% L 47% M
HIV Viral Load 100 L 150 L 260 M
HIV T-Cell Count 250 M 400 L unknown  
Homelessness HUD 1 H NA   HUD 2 M
Incarceration Release Date NA   NA   11/24/2014 M
IP Stay for Mental Illness Discharge Date NA   NA   NA  
IP Stay for SUD Treatment Discharge Date 9/4/2014 M NA   12/15/2014 M
SUD Active Use/Functional Impairment NA   NA   NA  
HML Rate for August 2015 Service Date High Low Medium

MAPP HML Monthly Billing Assessment Questions

See Billing Support section of MAPP HHTS Specifications Document for the complete listing of HML fields (questions regarding ACT, AOT, and Adult Home members not listed here)
Quest. # Question in MAPP COMMENT Field # upload Field # download
1. Does the member meet the HARP criteria based on claims and encounters? This will be auto populated within MAPP by DOH NA 31
2. Base Acuity This will be auto populated within MAPP by DOH NA 27
3. Risk This will be auto populated within MAPP by DOH NA 30
Clinical Adjustments
4. What is the member´s Diagnosis code (primary reason for Health Home eligibility)? This field will not be edited at go live and is optional. 4 9
5. Is the member HIV positive? Questions 5a and 5b appear when the response to Q5 is "Yes" 7 32
5a. What is the member´s viral load? Questions 5a and 5b appear when the response to Q5 is "Yes" 8 33
5b. What is the member´s T-Cell count? Questions 5a and 5b appear when the response to Q5 is "Yes" 9 34
Functional Adjustments
6. Is the member homeless? Question 6a appears when the response to 6 is "Yes". 10 35
6a. Does the member meet the HUD Category 1 or HUD Category 2 level of homelessness? Drop down box with two options: HUD Category 1 and HUD Category 2 11 36
7. Was the member incarcerated within the past year? Question 7a appears when the response to 7 is "Yes". 12 37
7a. When was the member released? must enter a valid date. Date must be in the past 13 38
8. Did the member have a recent Inpatient stay due to mental illness? Question 8a appears when the response to 8 is "Yes". 14 39
8a. When was the member discharged from the mental illness inpatient stay? must enter a valid date. Date must be in the past 15 40
9. Did the member have a recent inpatient stay for substance abuse? Question 9a appears when the response to 9 is "Yes". 16 41
9a. When was the member discharged from the substance abuse inpatient stay? Question 9a appears when the response to 9 is Yes. 17 42
10a. Did the member have a Positive Lab test OR other documentation of substance use? Each question must have response: Y/N. Must have at least 1 Y to 10a-10c AND at least one Y in 11a-11b 18 43
10b. Did the member have an LDSS positive screening for referral to SUD service?
10c. Was member referredfor SUD service from parole/probation within last 30 days?
11a. Is there documentation from family and/or criminal courts that indicates member involvement in a domestic violence and/or child welfare incident within the last 60 days?
11b. Is there documentation from Drug court OR a police report alleging member´s SUD including, but not limited to, operating a vehicle under the influence, harassment, disorderly conduct, and/or public lewdness within the last 60 days.
12 Was a Health Home core service provided this month? Y/N 19 44
Attribute Low Medium High
Base Acuity (unadjusted) ≤ 2.5 Between 2.5 and 5.0 ≥ 5.00
Clinical Adjustments
Predictive Risk < 30% between 30% and 50% > 50%
HIV Viral Load < 200 between 200 and 400 > 400
HIV T-cell Counts > 350 between 200 and 350 < 200
Functional Adjustments
Homelessness Medium High
Meets HUD Category 2: Imminent Risk of Homelessness definition Meets HUD Category 1: Literally Homeless definition
Incarceration Recent Incarceration between seven and twelve months Recent Incarceration within six months
IP Stay for Mental Illness IP Stay for Mental Illness within seven and twelve months IP Stay for Mental Illness within six months
Functional Adjustments
IP Stay for SUD Treatment Medium High
IP Stay for SUD Treatment within 7 and 12 months IP Stay for SUD Treatment within six months
SUD Active Use/ Functional Impairment   Positive Lab test OR other documentation of substance use OR LDSS positive screening for referral to SUD service OR referral for SUD service from parole/probation within last 30 days AND documentation from family and/or criminal courts that indicates domestic violence and/or child welfare within the last 60 days OR documentation from Drug court within the last 60 days OR police report alleging SUD involvement including, but not limited to, operating a vehicle under the influence, harassment, disorderly conduct, and/or public lewdness within the last 60 days.

Health Home Rates: High Medium and Low Rates with Clinical and Functional Adjustments Effective December 1, 2016 For Adults

Health Home Rates - High, Medium and Low
Population Region Low Medium High
HARP Downstate $125.00 $311.00 $479.00
non -HARP Downstate $62.00 $249.00 $383.00
HARP Upstate $117.00 $293.00 $450.00
non -HARP Upstate $58.00 $234.00 $360.00
Other Health Home Rates Rate
Health Home Plus * Downstate   $800.00
Health Home Plus * Upstate $700.00
Adult Home ** Downstate $700.00
Outreach Statewide $135.00
* Limited to AOT members that are not receiving ACT services.
** Limited to Impacted Adult Home members assessed for transition to the community. If an impacted Adult Home member transitions to the upstate region, the rate is $563.