Health Home Plus (HH+) for AOT

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      • October 11, 2016

      Dear Health Home Provider,

      In 2014, the New York State Office of Mental Health (OMH) and the New York State Department of Health (DOH) implemented an enhanced service and rate code package for Health Homes called Health Home Plus. Health Home Plus (HH+) is an intensive Health Home Care Management (HHCM) service established for defined populations with Serious Mental Illness (SMI) who are enrolled in a Health Home. Health Home members receiving Assisted Outpatient Treatment (AOT) were identified as the first population eligible for HH+. The enclosed document entitled Health Home Plus (HH+) Program Guidance for Assisted Outpatient Treatment (AOT) provides additional background and details regarding HH+, as well as important updates to the HH+ requirements for AOT; please review carefully.

      Attached to the guidance is an updated NYS DOH/OMH Health Home Plus Standard Attestation Form. The attached attestation form is required to be completed by all lead Health Homes and will allow for billing the HH+ rate for those CMAs who meet the requirements. The Health Home's attestation must include a list of all contracted downstream Care Management Agencies (CMAs) that will provide HH+ services to your eligible members. By listing a CMA provider on the attestation form, the Health Home attests that the CMA meets all the requirements described in the HH+ guidance, and is therefore qualified to provide HH+ services and receive the HH+ rate.

      The updated HH+ attestation form applies to AOT HH+, as well as expansion populations that have since been deemed HH+ eligible populations: adults being discharged from OMH State Psychiatric Center, and Central New York Psychiatric Center and its corrections-based mental health units.

      Completed attestation forms must be submitted to the NYS Department of Health no later than 12/1/16. A completed form must be on record with DOH before any HH+ billing by the Health Home can occur. Attestation forms submitted to OMH by legacy providers upon original HH+ AOT implementation, remain in effect until attestation forms from Health Homes are submitted, or no later than 12/1/16, whichever comes first.

      Any questions regarding the HH+ program or rate code can be directed to Stacey Hale by email (Stacey.Hale@omh.ny.gov).

      Sincerely,

      Robert Myers, PhD
      Senior Deputy Commissioner
      Director, Division of Adult Services

      Emil Slane
      Deputy Commissioner, Chief Fiscal Officer
      Office of Financial Management

      Attachment: Health Home Plus Program Guidance for Assisted Outpatient Treatment

      Cc: County Mental Health Directors
             OMH Field Office Directors
             Moira Tashjian, OMH Associate Commissioner, Division of Adult Community Care Group
             Nicole Haggerty, OMH Director of Bureau of Rehabilitation Services and Care Coordination
             Peggy Elmer, DOH Office of Health Insurance Programs

      Health Home Plus (HH+) Program Guidance for
      Assisted Outpatient Treatment (AOT)

      Revised October 2016

      Description

      Health Home Plus (HH+) is an intensive Health Home Care Management (HHCM) service established for defined populations with Serious Mental Illness (SMI) who are enrolled in a Health Home. In order to ensure their intensive needs are met, Health Homes must assure HH+ members receive a level of service intensity consistent with requirements for caseload ratios, reporting, and minimum levels of staff experience and education outlined below. The differential monthly rate for HH+ is higher compared to the "high," "medium" and "low" rates for HARP and non-HARP HHCM enrollees and is intended to appropriately reimburse for the additional management and oversight standards for this population.

      Population

      This guidance applies to people receiving court-ordered AOT who are enrolled in a Health Home. Given that someone must meet AOT criteria for a judge to grant an order, this group, by definition, requires a more intensive level of care management. Clients receiving enhanced or voluntary service agreements that serve as step-up or step-down from court-ordered AOT are not eligible for HH+. This guidance does not apply to AOT clients receiving ACT, a program that by design includes an intensive level of care management.

      Care Management Agencies (CMAs) eligible to serve people receiving AOT

      Former OMH Targeted Care Management (TCM) providers, or OMH Legacy providers, are currently able to serve individuals receiving AOT and bill the HH+ rate code. Once program and training requirements are completed and verified by the State, Non-Legacy CMAs will also be able to serve and bill for the HH+ population. Further guidance will follow regarding specific training requirements for Non-Legacy providers.

      Assertive Community Treatment (ACT) programs may also serve individuals receiving AOT. However, ACT programs are not eligible for the HH+ rate code since these programs bill the ACT rate code, and therefore are not included in this guidance document.

      Attestation

      It will be the responsibility of the lead Health Homes to attest that the HH+ program requirements described below are being met by all contracted Care Management Agencies (CMAs) providing HH+ services.

      The OMH and DOH will have joint oversight of HH+ compliance including the approval of attestation forms. Health Homes and CMA providers who are approved for the HH+ rate are subject to audit by the State. Agencies shall understand that failure to comply with HH+ requirements may jeopardize the agency's opportunity to bill the HH+ rate, and potentially affect their status as a downstream Health Home Care Management provider.

      Program Requirements for AOT HH+ are as follows:
      • Program requirements for AOT HH+ are to be carried out consistent with the "Health Home Standards and Requirements for Health Homes, Care Management Providers and Managed Care Organizations" guidance document distributed by the Department of Health.
      • The preferred caseload ratio for HH+ enrollees shall be 1 staff to 12 HH+ recipients, but no greater than 1:15.
      • For the purposes of case load stratification and resource management; a caseload mix of HH+ and non HH+ is allowable if and only if the HH+ ratio is less than 12 recipients to 1 Health Home Care Manager. Caseload sizes should always allow for adequate time providing care management as outlined in this guidance to individuals recently discharged from State PCs or CNYPC while allowing for thoughtful consideration of the care coordination needs of non HH+ recipients.
      • HH+ will always be delivered by a Health Home Care Manager who has the experience and credentials appropriate to serve the behavioral health population, specifically those with high needs. The following Minimum Qualifications1 apply:
      Education
      1. A bachelor's degree in one of the fields listed below2; or
      2. A NYS teacher's certificate for which a bachelor's degree is required; or
      3. NYS licensure and registration as a Registered Nurse and a bachelor's degree; or
      4. A Bachelor's level education or higher in any field with five years of experience working directly with persons with behavioral health diagnoses; or
      5. A Credentialed Alcoholism and Substance Abuse Counselor (CASAC).

      And

      Experience
      Two years of experience:

      1. In providing direct services to people with Serious Mental Illness, developmental disabilities, or alcoholism or substance abuse; or
      2. In linking individuals with Serious Mental Illness, developmental disabilities, or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g., medical, psychiatric, social, educational, legal, housing and financial services).

      A master's degree in one of the qualifying education fields may be substituted for one year of Experience.

      And

      Supervision
      Supervision from a licensed level healthcare professional (e.g., RN, licensed clinician, psychologist) with prior experience in a behavioral health clinic or care management supervisory capacity; OR Master's level professional with 3 years prior experience supervising clinicians and/or CMs who are providing direct services to individuals with SMI/serious SUDs.

      • Individuals receiving AOT can be billed at HH+ rate for as long as the court order is active.
      • If the individual has a current AOT order at any time during the month, the HH+ rate code may be billed, assuming all minimum requirements for HH+ have been met that month.
      • Care Management Agencies shall provide face-to-face contact at least four (4) times per month. The HH+ rate code can be billed only when this minimum requirement is met (see exception below) and clearly documented in the member's record.
      • If the individual with an AOT court order cannot be located and has had no credibly reported contact within 24 hours of the time the care manager received either notice that the individual had an unexplained absence from a scheduled treatment appointment, or other credible evidence that the AOT individual could not be located, the individual will be deemed Missing. A diligent search shall commence, as outlined in the OMH guidance "Assisted Outpatient Treatment Program: Guidance for AOT Program Operation" (Reissued February 2014).
        • If the care manager made effort to provide four (4) face-to-face contacts and was unable to due to Missing status, HH+ rate can continue to be billed as long as the diligent search procedures referenced above are followed and clearly documented in the individual's care management record. The individual's record shall also clearly indicate when the determination was made that the individual was missing. The diligent search shall continue until either the person is located, or the court order is no longer active.
          • If all activities for performing a diligent search cannot reasonably be completed within the same month the individual is deemed Missing, the HH+ rate may still be billed for that month so long as the diligent search process commenced within timeframes specified in AOT Program Operation guidance.
      • A missing AOT individual is considered a significant event that must be reported to the LGU within 24 hours, following the LGU's protocol for reporting significant events. Continued communication with the LGU should be made in order to determine what additional follow-up efforts may be required and shall also be documented clearly in the individual's record.
      • If the care manager made effort to provide four (4) face-to-face contacts and the individual was not home, did not show up for an appointment or was otherwise not available, the CMA must report all efforts made to follow up with the individual using notification procedures as developed by the Local Government Unit (LGU).
        • If the individual was not able to be seen, continued communication with the LGU should be made in order to determine what additional follow-up efforts may be required. All efforts must be documented in the individual's record.
        • If at least one (1) Health Home core service was provided by a qualified care manager and the above requirements have been completed:
          • While legacy billing is still allowed, the CMA will bill the regular Health Home rate and receive a payment based on the acuity on file for the individual,
          • After legacy billing is eliminated, the HARP/non-HARP (High) Health Home rate code may be billed for that given month.
      • Individuals receiving court-ordered AOT will be assigned to a CMA with behavioral health expertise or otherwise qualified to serve HH+ individuals, through the Local Governmental Unit's (LGU) AOT process.
        • In many counties, SPOA may be included in the process by which the LGU assigns AOT individuals to a CMA.
        • If an individual already receiving HH care management in the community is later ordered to AOT, the LGU must ensure that the care management entity serving that individual meets the HH+ criteria described in this guidance. If the CMA does not meet this criteria, the LGU must direct a transfer to a CMA with the appropriate experience. It will then be the responsibility of the CMA to promptly notify the Health Home of the CMA transfer.
      • When the examining physician includes HHCM in the court-ordered treatment plan and the individual refuses to enroll in the Health Home, a copy of the AOT order shall be made available to the Health Home, which will then be able to enroll the individual and bill the HH+ rate code. However, the AOT order does not substitute for the individual's consent to share clinical information. Absent such specific consent, the HHCM may share clinical information for care coordination purposes to the extent permitted by section 33.13(d) of the Mental Hygiene law, which provides a limited treatment exception for the exchange of clinical information between mental health providers and Health Homes.
      • The CM will work with the LGU to ensure timely delivery of services as listed in the court order. Such services must include coordination of all categories of service listed in the AOT treatment plan.
      • All categories of service listed in the court-ordered AOT treatment plan shall also be included in the individual's integrated health home plan of care.
        • The CMA and/or other members of the treatment team must consult with the treating physician and the LGU's Director of Community Services or County AOT coordinator, who can then petition to the court for any material change needed to be made to the AOT treatment plan. Any additions or deletions of categories of service are considered material changes.
        • Changes needed to other services in the HH plan of care that are not listed in the AOT treatment plan (e.g., primary care services not listed in the AOT treatment plan), are not considered material changes and therefore do not require consult with the LGU.
      • Health Homes and Care Management Agencies shall be familiar with the statutory basis of the AOT program, or Kendra's Law (§9.60 of NYS Mental Hygiene Law), including the requirement that care management is a mandatory service category on every court-ordered treatment plan. This guidance outlines the contact requirements for care management.
      • The CMA shall comply with all reporting requirements of the AOT Program as established by the LGU. Localities may have their own requirements that are above the minimum contact standards of four times per month. Additionally, the CMA must report assessment and follow-up data to the Office of Mental Health (OMH) through the Child and Adult Integrated Reporting System (CAIRS) at 6-month intervals.
      • Communicating with Managed Care Plans regarding AOT HH+ members:
        • The Care Management Agency (CMA) must inform the HH when a member has been placed on court-ordered AOT, or when the court order has expired and has not been renewed.
        • The HH must inform the Managed Care Plan of the members' AOT status.
      LGU Requirements

      The LGU is responsible to operate, direct, and supervise their County's AOT program and work in collaboration with the CMA to arrange or provide for all categories of AOT services. As part of these responsibilities the LGU:

      • Uses their established system to respond to and investigate all AOT referrals;
      • Ensures that the services in the treatment plan are made available and monitors delivery of these services.
      • Monitors the AOT individuals served;
      • Follows the county-specific procedure for implementation of MHL section 9.60 removal orders;
      • Follows their established system for notification regarding AOT recipients who are missing within 24 hours, diligent search, removal orders, and missing person report (see link below for detail); and
      • Uses their established system to be notified of all significant events and reports them to OMH as required (see link here for details); and
      • Provides data to OMH as required.

      For more detail on AOT program and reporting requirements

      Billing and Tracking Guidance

      Upcoming changes to Health Home Care Management reimbursement

      Targeted to commence December 2016, Health Home Care Management Agencies (CMAs) will no longer bill Medicaid directly for either Health Home Care Management or HH+ Care Management. For reimbursable HHCM and HH+ services delivered on December 1, 2016, and thereafter, CMAs are to use either the MAPP HHTS or the Health Home's own system (which then feeds into MAPP HHTS) to attest that billable services were provided (minimum required HH+ services or HHCM core service) in a given month. The MCOs will use the MAPP HHTS billing support to pay the HH. HHs will bill eMedNY for HH enrollees not in mainstream MCOs (including mainstream plans, HIV-SNPs and HARPs). The HHs are to send the HH funds for a CMA, less the contracted administrative fee, to the CMA.

      Billing and Tracking System
      • There is a unique rate code for HH+ services (1853).
      • There is one HH+ payment rate for Downstate and one for Upstate.
      Rate Code Rate Description
      (OMH) HH+       		Monthly HH+ Rate
      1853 Downstate (applicable to Dutchess,
      Putnam, Rockland, Westchester,
      Nassau and Suffolk counties,
      and New York City.      		 $800
      Upstate (applicable to all counties
      other than Downstate)      		 $700
      • The HH+ rates were added to OMH HHCM provider rate profiles in eMedNY for legacy providers under rate code 1853 (Health Home Plus/Care Management), with an effective date of April 1, 2014. Providers were notified with a letter from the Department of Health/CSC. HH+ rates will be added to lead HH rate profiles in eMedNY effective December 1, 2016, to allow lead HHs to bill on behalf of Care Management Agencies providing HH+ services.
      • The Department of Health (DOH) Medicaid Analytics Performance Portal (MAPP) will be used to identify individuals as HH+. In December 2016, MAPP users will be prompted in the monthly HML questionnaire with the question "Is the member in AOT?" If the user responds "Yes", the user is then prompted with "Were the minimum required HH+ services provided?" By responding "Yes", the CMA attests that the minimum service requirements for HH+ have been provided.
      • CMAs are allowed to exceed the number of legacy slots originally allotted to them in order to accommodate HH+ members. CMAs will bill the HH+ rate code consistent with direct billing to eMedNY for legacy slots, until direct billing is eliminated. Until then, CMAs must ensure all HH+ members currently receiving Health Home services have a value of "Y" in the Direct Biller Indicator field in the Health Home Tracking System. Upon discontinuation of legacy rates, CMAs will attest that the HH+ services were provided and receive HH+ payment from the Health Home.

      ___________________________________

      1. CMAs currently serving AOT HH+ populations on or before 11/15/16 have up to 9 months, or by 8/15/17, to meet the new Supervision requirement. CMA Supervisors who requested a waiver of qualifications needed to supervise HCBS Assessors and were approved prior to 11/15/16, will be considered qualified Supervisors for HH+ for that CMA. The CMA has the option to arrange for a licensed or Master's level professional within the organization to provide regular clinical supervision to the CMs, jointly with the care managers' direct program supervisor.
      An individual receiving AOT as of 11/15/16 can continue to work with their current Care Manager for the duration of the individual’s court-ordered status, even if the CM does not meet updated HH+ qualifications. Also, CMs whose requests for HCBS Assessor qualification waiver were approved prior to 11/15/16 are considered qualified to serve HH+ individuals (all HH+ populations) for that CMA.
      NOTE: If a Supervisor or CM currently permitted to serve HH+ individuals (as described above) later leaves the agency, the CMA is required to replace them with new staff that meet the HH+ Staff qualifications. 1
      2. Qualifying education includes degrees featuring a major or concentration in social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field.
      NOTE: If a Supervisor or CM currently permitted to serve HH+ individuals (as described above) later leaves the agency, the CMA is required to replace them with new staff that meet the HH+ Staff qualifications. 2