On December 5, 2016, New York Medicaid expanded its health home program to include children with two or more chronic medical conditions, serious emotional disturbance (SED), or complex trauma. The health home program provides comprehensive, person-centered care planning and coordination that is child and family-focused for all Medicaid services. Children in managed care plans or fee-for-service (FFS) Medicaid are eligible for the program. Enrollment of children in the program is voluntary and children must opt-in to the program. Almost 174,000 children are estimated to be eligible for the health home program. As of mid-December 2016, the New York State Department of Health (DOH) estimates that 2,586 children with disabilities have been referred to health homes, and 920 are enrolled.
The New York children’s health home model utilizes lead health homes, which are responsible for contracting with care management agencies (CMAs) that provide the majority of health home services. For children in managed care, the managed care plan is responsible for reimbursing the lead health home, which in turn reimburses the CMAs. For children in FFS, the state reimburses the lead health home, which in turn reimburses the CMAs. Reimbursement is tiered based on member acuity.
Eligibility for the children’s health homes is limited to children who have a single qualifying chronic health condition or two or more chronic conditions (such as substance use disorder, asthma, and diabetes). Single qualifying conditions for children include HIV/AIDS, serious emotional disturbance, and complex trauma. In addition to meeting the chronic condition criteria, potential health home enrollees must be “appropriate” for (or require) the intensive level of care management services provided by the health home program. Appropriateness is defined as:
- Risk for an adverse event, such as death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement
- Presence of inadequate social/family/housing support, or serious disruptions in family relationships
- Inadequate connectivity with health care system
- Does not adhere to treatments or has difficulty managing medications
- Recent release from incarceration, placement, detention, or psychiatric hospitalization;
- Deficits in activities of daily living, learning or cognition
Enrollment of children in the program is voluntary, and children must opt-in to the program. At minimum verbal consent from a parent or guardian is needed to refer a child to the health home program. Referrals will be the primary method used for health home enrollment. After referral, the child is determined to be eligible for the program and then the parent or guardian is asked to opt their child into the health home via signed consent forms.
In order to ensure initial health home capacity is not exceeded, the state is prioritizing enrollment for the following populations:
- Children enrolled in Office of Mental Health (OMH) targeted case management care management (TCM) programs that will convert to the health home program.
- Children on the OMH waiver waiting list (who are already Medicaid eligible) within 30 days of discharge from inpatient/residential/day treatment settings to participate in discharge planning, TCM waitlist
- Children who are on the Bridges to Health Wait list
- Children in licensed congregate care
- Children that are within 3 months of foster care discharge
- Children enrolled in prevention services where foster care placement is imminent
- Children prescribed three or more psychotropic medications
- Children who are within 30 days of discharge from inpatient, residential or detox setting
- Medically fragile children with multiple chronic conditions that have had recent (past 30 days) inpatient stay
- Children who have an emergency room referral but are not admitted for inpatient services or are discharged with a recommendation for community follow up
- Children with multiple system involvement (child welfare, criminal justice)
Health Home Structure & Services
The health homes are led by one provider organization, known as the lead health home, which is required to create a comprehensive network of provider organizations, called care management agencies (CMAs). The CMAs provide the majority of health home services. The health home model has been designed to incorporate the expertise of existing New York care managers, including Early Intervention, Office of Mental Health Targeted Care Management (OMH TCM), Care at Home I & II, and Voluntary Foster Care Agencies.
The health homes are required to provide the six health home services as outlined by the federal Centers for Medicare and Medicaid Services (CMS), including: comprehensive care management, care coordination and health promotion, comprehensive transitional care, referral to community supports, and use of health information technology to link services. Additionally, health homes can bill for outreach and enrollment, and assessment.
Reimbursement For Health Homes For Children
Two different health home reimbursement systems are used for children enrolled in managed care and Medicaid FFS. For children enrolled in managed care, the managed care plan remits funds to the lead health home. The lead health home than distributes the payments to the CMAs. For children enrolled in FFS Medicaid, the lead health home receives payment directly from the state and then distributes payments to the CMAs. Reimbursement is a per member per month health home care management rate based on the child’s acuity score on the Child and Adolescent Needs and Strengths (CANS) assessment and where they are located within the state.
|Per Member Per Month New York Medicaid Health Home Care Management Rates for Children under 21 (non-Legacy Providers)|
|Acuity (CANS Algorithm)||Upstate||Downstate|
Mid-December 2016 Enrollment Status
As of December 14, 2016, the New York State Department of Health (DOH) said 2,586 children with disabilities have been referred to health homes, and 920 are enrolled. About 73% of the enrolled children were enrolled in a Medicaid managed care plan; the remaining 28% of enrolled children were in fee-for-service (FFS) Medicaid. The health homes serve children enrolled in both Medicaid managed care and FFS Medicaid.
The DOH spokesperson said outreach has been made to another 1,666 children. Outreach means that the parent, guardian or legally authorized representative has verbally consented for a health home referral to be made and that a health home care manager is working to enroll the child by collecting all the proper consents to verify the child’s health home eligibility and appropriateness for health home care management services.
The Future Of Children’s Health Homes
The state is making a number of changes to the children’s Medicaid delivery system and financing system as a whole that will affect the delivery of health home services:
- During 2017 and 2018, currently carved out Medicaid behavioral health services will transition to the managed care plans.
- During 2017 and 2018, six new behavioral health services will covered including crisis intervention, community psychiatric supports and treatment (CPST), family peer support services, youth peer advocacy and training, other licensed practitioners, and psychosocial rehabilitation services.
- During 2017 and 2018, children receiving HCBS will move to managed care and the children’s 1915(c) care coordination service will transition to Medicaid health homes. Additionally, the HCBS that are in the state’s five 1915(c) children’s waivers will be aligned to a single array of HCBS benefits. The separate 1915(c) waivers will be discontinued once the transition is complete.
- In 2019, children in foster care will move to managed care and the managed care plans will be responsible for reimbursing health home services.
A link to the full text of “New York Medicaid Health Homes Serving Children: Eligibility, Appropriateness, Enrollment Prioritization & Health Home Six Core Services” may be found in The OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/120116nychildhealthhomeeligibility.htm.
A link to the full text of “New York Medicaid List Of Health Homes Serving Children” may be found in The OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/120716nychildhealthomesbycounty.htm.
A link to the full text of “New York Medicaid Letter To Early Intervention Providers & Health Homes Serving Children About Care Coordination” may be found in The OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/110116nychildhealthomeseip.htm.
OPEN MINDS last reported on this topic in “New York Pushes Back Managed Care Launch For Children In Foster Care Until Mid-2017,” which published on July 5, 2016.
For more information, contact: Health Homes for Children, New York Department of Health, Corning Tower, Empire State Plaza, Albany, New York 12237; Email: HHSC@health.ny.gov; Website: www.health.ny.gov.