Medicaid Health Homes - Comprehensive Care Management

In New York State, many people get their health benefits through the Medicaid Program. Most people are generally healthy, however, others may have chronic health problems. Many are unable to find providers and services, which makes it hard for people to get well and stay healthy. New York State´s Health Home program was created with these people in mind. The goal of the Health Home program is to make sure its members get the care and services they need. This may mean fewer trips to the emergency room or less time spent in the hospitals, getting regular care and services from doctors and providers, finding a safe place to live, and finding a way to get to medical appointments.

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Guidance after the Expirations of Executive Order 202:

Relevant COVID Guidance:

A ´Health Home´ is not a physical place; it is a group of health care and service providers working together to make sure you get the care and services you need to stay healthy. Once you are enrolled in a Health Home, you will have a care manager that works with you to develop a care plan. A care plan maps out the services you need, to put you on the road to better health. Some of the services may include:

  • Connecting to health care providers,
  • Connecting to mental health and substance abuse providers,
  • Connecting to needed medications,
  • Help with housing,
  • Social services (such as food, benefits, and transportation) or,
  • Other community programs that can support and assist you.

Health Home Member Brochure (PDF)

In order to be eligible for Health Home services, the individual must be enrolled in Medicaid and must have:

  • Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes*) or
  • One single qualifying chronic condition: HIV/AIDS or
  • Serious Mental Illness (SMI) (Adults) or
  • Serious Emotional Disturbance (SED) or Complex Trauma (Children)

If an individual has HIV or SMI, they do not have to be determined to be at risk of another condition to be eligible for Health Home services. Substance use disorders (SUDS) are considered chronic conditions and do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify. Chronic Condition Criteria is not population specific (e.g., being in foster care, under 21, in juvenile justice, etc.), and does not automatically make a child eligible for Health Home. In addition, the Medicaid member must be appropriate for the intensive level of care management services provided by the Health Home (i.e., satisfy the appropriateness criteria). The Health Home Chronic Conditions document outlines guidance for the Health Home Serving Children eligibility, appropriateness, enrollment prioritization, and Health Home Six Core Services.

Ask yourself these questions if you are a Medicaid recipient and believe that you may qualify for the Health Home Program:

  • Do you have chronic or mental health conditions for which you need regular doctor´s care?
  • Do you have a doctor you can see when you need to?
  • Do you have a safe place to live?
  • Do you have someone in your life to help you whenever you need help?
  • Do you have difficulty keeping and making it to your medical appointments?
  • Have you visited an emergency room or hospital more than once in the past six months? Twelve months?

You can talk to your Managed Care Plan, doctor, specialist, hospital emergency room, discharge planner or your Department of Social Services, or you can contact a Health Home at any time to find out if you are eligible to enroll.

There is a total of 30 designated Health Homes located throughout New York State. Out of the 30 designated health Homes, 15 are designated to serve children and 27 are designated to serve adults. To find a Health Home that serves your county, visit our Find a Health Home page.

  • Affordable Care Act Section 2703: Affordable Care Act Section 2703 of the Federal Patient Protection and Affordable Care Act (ACA) establishes authority for states to develop and receive federal reimbursement for a set of health home services for their state´s Medicaid populations with chronic illness. Health Home services support the provision of coordinated, comprehensive medical and behavioral health care to patients with chronic conditions through care coordination and integration that assures access to appropriate services, improves health outcomes, reduces preventable hospitalizations and emergency room visits, promotes use of health information technology (HIT), and avoids unnecessary care.
  • State Medicaid Director´s Letter 10-024: This letter is one of a series distributed by the Department of Health & Human Services intended to provide preliminary guidance on the implementation of the Patient Protection and Affordable Care Act.
  • Health Home Information Resource Center: The Health Home Information Resource Center was established by the Centers for Medicare & Medicaid Services (CMS) to help states develop these new models to coordinate the full range of medical, behavioral health, and long-term services and supports needed by Medicaid beneficiaries with chronic health needs.
  • Medicaid State Plan Amendments: The Health Home Program´s State Plans are official documents that describes the nature and scope of a State´s Medicaid program that has been approved by the Federal Department of Health & Human Services (DHHS).

Implementation of Health Homes for Medicaid enrollees with chronic conditions was recommended by the Medicaid Redesign Team. As a result, this initiative was included in the Governor´s SFY11/12 Budget and was adopted into law effective April 1, 2011. Social Services Law (SSL) Section 365-L authorizes the Commissioner of Health, in collaboration with the Commissioners of the Office of Mental Health, Office of Alcohol and Substance Abuse Services, and the Office of People with Developmental Disabilities, to establish health homes for NYS Medicaid enrollees with chronic conditions.

Medicaid Provider Enrollment Applications were required from organizations serving as lead Health Homes (e.g. that have received an approval letter from the New York State Department of Health identifying them as a "Designated Provider-lead Health Home") and any converting care management agencies such as OMH TCM, and COBRA providers that are billing directly for health home services. These organizations were required to enroll in Medicaid for category of service (COS) 0265, Health Home/ Care Management. Management Addiction Treatment (MATS) providers were instructed to obtain an NPI, and complete a Medicaid Provider Enrollment application. The application and instructions were found on the eMedNY website Provider Enrollment (Health Home link). Converting care management organizations on the following Care Management Organization list (Converting Case Management Provider Names) did not need to submit a Medicaid Provider Enrollment application.

Lessons for Health Homes Identified Through the Chronic Illness Demonstration Project Learning Collaborative:

In State Fiscal Year 2007-08, the New York State Commissioner of Health, in consultation with the Commissioners of the Office of Mental Health and the Office of Alcohol and Substance Abuse Services, were authorized to develop the Chronic Illness Demonstration Projects (CIDP). The project was established to improve health outcomes and reduce costs for persons with chronic medical and behavioral illness. The demonstrations were geographically diverse targeting medically complicated Medicaid fee-for-service beneficiaries across the state. The specific focus of the program was to provide better care coordination/management of individuals exempt or excluded from mandatory managed care. The demonstrations utilized integration of all health care services, aimed to improve access to needed services and assisted with the delivery of care in the most appropriate setting. The CIDPs utilized multifaceted interventions and were designed to enhance the patient-provider relationship, promote patient self-management and compliance to the prescribed treatment plan with the goal of reducing emergency department visits and inpatient hospitalization´s. While official outcomes are still being evaluated, the CIDP experience contributed to the development of New York´s Health Home strategy, which is focusing specifically on adults with complex needs. Thus, lessons from CIDP may provide valuable guidance for Health Home implementation given the similarly complex characteristics of beneficiaries targeted for enrollment in both programs.

Historical information pertaining to how Health Homes were phased-in across the State during the program´s implementation can be found on the Phase-in Plan for Applications page.

Preliminary Rates

Health Home Program Implementation Archive

Funding was made available for Health Home implementation and workforce training by both the Federal and State government. Select for further details.