Managed Care Organizations

  1. MCO's contracting with NYSDOH designated Health Homes to provide Health Home services must utilize and sign a contract (Administrative Health Home Services Agreement) with the Health Home.
  2. MCO's assign members to NYSDOH designated Health Homes based on Health Home eligibility lists received from NYSDOH utilizing loyalty and attribution data as augmented by MCO data.
  3. MCOs will bill Health Home services through eMedNY using the MCO's MMIS identification number using Health Home rates
  4. MCO's will continue to provide all in-plan services for Health Home members but will contract with Health Homes to coordinate services including in-plan and Medicaid fee-for-service benefits.
  5. MCO's and Health Homes share responsibility for outcomes for patients that are assigned to Health Homes
  6. MCO's will share member PHI with the Health Home that provides services. Guidance for sharing information prior to member consent can be found here.
  7. MCO's with members currently in OMH and AIDS/HIV COBRA, MATS and CIDP targeted case management (TCM) converting programs will follow special guidance below for these individuals
    • MCO's do not assign existing TCM patients to Health Homes, converting TCM programs assign their members to the Health Home that will best meet the member's needs and preserve the care management relationship.
    • MCO's will work with Health Homes on behalf of members in existing TCM slots to coordinate care and share data.
  8. Health Homes must utilize the MCOs contracted provider network for services that are included in the MCO's benefit package when arranging/coordinating care for Health Home members. MCOs may opt to expand provider networks based on Health Home member needs.

There are three options available for Health Homes to enter into Administrative Health Home Services Agreements with Managed Care Organizations (MCOs):

  1. MCOs may develop plan-specific agreements with Health Homes for Health Home services. Plan specific agreements must include the Key Contract Provisions that were developed collaboratively between the MCOs, Health Homes and NYSDOH. The MCO must submit the plan specific agreement to the NYSDOH Division of Health Plan Contracting and Oversight, Bureau of Managed Care Certification and Surveillance for review and approval. Once the MCO has an Approved Agreement for Health Home services on file with the Bureau of Managed Care Certification and Surveillance, the MCO and Health Home can use that as a template to negotiate mutually acceptable agreements/contracts. Changes may be made to the Approved Agreement, but the amended agreement must be submitted once again by the MCO to the Bureau of Managed Care Certification and Surveillance for final approval.
  2. If the MCO does not have a plan specific Approved Agreement on file with the Bureau of Managed Care Certification and Surveillance, or if the Health Home and MCO are unable to negotiate a mutually acceptable agreement/contract using the Approved Agreement, the Standard Health Home Administrative Services Agreement can be used. The signed agreement must be submitted by the MCO to the Bureau of Managed Care Certification and Surveillance for review and approval.
  3. If the MCO and Health Home modify the Standard Agreement, the modified Standard Agreement must be submitted by the MCO to the Bureau of Managed Care Certification and Surveillance for review and approval. When approved it becomes a plan specific Approved Agreement on file for that MCO
    • NOTE:
      • When submitting agreements for review and approval the MCO must include a completed and signed Health Home Statement and Certification form (DOH-5060).
      • The Standard Agreement may not be modified to include care manager requirements, credentialing requirements, the reporting of data beyond what is required by the Health Home or other similar additions.
      • The MCO agreement/contract that is being agreed upon with the Health Home (using any of the three methods outlined above) is NOT considered a Provider Agreement. It is an Administrative Health Home Services Agreement.

The Department of Health's Office of Health Insurance Programs (OHIP) is requiring MLTC Plans to ensure access to Health Homes on a statewide basis. An Administrative Services Agreement (ASA) template has been developed for Health Homes and MLTC Plans to delineate their respective care management roles when both are serving recipients, to ensure that services are not duplicated. The Department has released this ASA template for Statewide use along with additional guidance and a suggested care planning tool that can be used to more clearly define the roles of the Health Home care manager and the MLTC Plan care coordinator. It is recommended that MLTC Plan’s execute Administrative Services Agreements (ASAs) with as many Health Homes in their service areas as practical to achieve this access requirement. The following documents below were developed to facilitate formalizing such arrangements. The model Statewide Administrative Health Home Services Agreement template is to be used for all aforementioned Agreements (excluding DAI2 class members). This Agreement may NOT be altered in any way by the MLTC Partial Capitation Plans and/or the Health Homes.

Administrative Service Agreements (ASAs) Specific to Class Members named in the U.S. v. State of New York and O'Toole v. Cuomo
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