New York State Health Homes Phase I Implementation Update

New York State Health Homes Phase I Implementation Update Statewide Webinar Presented by: New York State Department of Health December 9, 2011 1

Health Homes Phase I Applications reviewed for: Meeting Provider Qualifications and Standards and providing adequate choice within Health Home partnerships Care Management “Bandwidth” ability to meet needs of all facets of complex populations (e.g., Mental Health, Housing, Substance Use Disorder, etc.) Promoting the State vision to minimize silos and concentrate volume over a few rather than many Health Home networks/systems thereby assuring a more limited accountability structure and more financially viable Health Homes. Creating choices where applicable between institutional lead and community based lead Health Homes 2

Final Phase I counties Bronx Hamilton Brooklyn Clinton Nassau Franklin Schenectady Warren Washington Essex Monroe and Saratoga moved to Phase II St. Lawrence moved to Phase III 3

Contingently Approved Designated Provider-led Phase I Health Homes Bronx Brooklyn Nassau Schenecta dy Adirondac k Counties Bronx Accountable Health Network (Joint Venture) Maimonides Medical Center North ShoreLIJ Health System Visiting Nurse Service of Schenectady Co. Adirondack Health Institute (AHI) NYC Health and Hospitals Corporation NYC Health and Hospitals Corporation FEGS Health & Human Services System (CBC) Visiting Nurse Service of NY Home Care Community Health Care Network Bronx Lebanon (Joint Venture with Institute for Community Living (ICL/CBC) Glens Falls Hospital 4

Managed Care Plans Health Homes-Phase I Bronx Brooklyn Nassau Schenecta dy Adirondac k Counties Fidelis Care New York Fidelis Care New York EmblemHealt h Fidelis Care New York Fidelis Care New York United Healthcare Community Plan United Healthcare Community Plan United Healthcare Community Plan Health First PHSP, Inc. Health First PHSP, Inc. Health First PHSP, Inc. Affinity Health Plan Inc. Affinity Health Plan Inc. Affinity Health Plan Inc. United Healthcare Community Plan 5

Managed Care Plans Health Homes – Phase I Bronx (cont) Brooklyn (cont) Nassau (cont) Health Plus PHSP Health Plus PHSP Health Plus PHSP Amerigroup New York, Amerigroup New York, Inc Inc NewYork-Presbyterian System SelectHealth, LLC NewYork-Presbyterian System SelectHealth, LLC Amida Care Amida Care EmblemHealth 6

Health Plans and Health Home Contracting DOH will approve health plan health home applications so plans may assist with arranging for health home services. This approval is contingent on the following: Contracting with State Designated Provider-led Health Homes is required in areas with sufficient approved State Designated Provider-led Health Homes capacity. In instances where the plan is contracting with State Designated Provider Based Health Homes the plan may: choose which State Designated Provider Based Health home(s) to contract with. assist with the provision of certain health home services (e.g., data management) as contractually agreed to by the State Designated Provider-led Health Home and the Health Plan - in this any case dollars retained by the plan shall be proportional to effort. Plans should only directly provide health home services in areas where such approved capacity is insufficient as agreed upon by the State and the Health Plan. 7

Continued Opportunities for Partnerships The Contingent Designated Provider-led Health Homes are still finalizing joint governance arrangements and contracts The State is still suggesting additional providers and provider types to designated Health Homes to include in their partnership – some of this is necessary to address approval contingencies. 8

What if my application was not designated as a Health Home? Many high-quality providers submitted Health Home applications The State could not approve all of the applicants as Health Homes Applicants who were not designated as Health Homes and are not currently partnering with an approved Health Home provider should reach out to designated provider-led Health Homes and discuss possible partnerships 9

HH Rosters and Sharing of lists State has started to share lists with Plans about their members who qualify for Health Home services Lead Health Homes will be required to submit a Data Exchange Agreement Application (DEAA) to share lists with their health home network providers Lead Health Homes are responsible for securing member consent at enrollment to allow full access to member data. 10

Monthly Roster Elements Patient Demographic information Health Plan Assigned Health Home Health Home Direct Care Management Provider TCM, MATS, CIDP MCO, CBO Enrollment/Disenrollment Status Various Dates Consent Enrollment/disenrollment Patient Profile (e.g., Risk Score, Acuity Score, Ambulatory Connectivity and Loyalty) 11

Updated Rates on Website 12

Projected Health Home Payments Projected Average Health Home Payments - Sample Populations Previous Patient # Base Health Status 1 2 3 Pairs Chronic Pairs Chronic Triples Chronic 4 Triples Chronic 5 Single SMI/SED 6 Pairs Chronic 7 Pairs Chronic 8 9 Single SMI/SED Pairs Chronic 10 11 12 HIV/AIDS Triples Chronic Triples Chronic 13 Triples Chronic 14 15 16 Triples Chronic Single SMI/SED HIV/AIDS Dx Description Diabetes and Hypertension Diabetes and Asthma Diabetes - Hypertension - Other Dominant Chronic Disease Congestive Heart Failure - Diabetes Cerebrovascular Disease Conduct, Impulse Control, and Other Disruptive Behavior Disorders Schizophrenia and Other Chronic Disease Asthma and Other Moderate Chronic Disease Schizophrenia Diabetes and Advanced Coronary Artery Disease HIV Disease Cystic Fibrosis Diabetes - 2 or More Other Dominant Chronic Diseases Brain and Central Nervous System Malignancies Non-Hodgkin's Lymphoma Schizophrenia HIV Disease Severity Acuity of Illness Score Downstate Upstate Downstate Upstate Monthly Monthly Acuity Monthly Monthly Payment Payment Score Payment Payment Low Low Low 1.6947 4.6947 5.7894 39 109 135 32 88 108 0.8114 4.0729 5.3524 17 83 110 13 67 88 Mid 6.0001 140 112 7.4909 153 123 Low 6.3574 148 119 5.6522 116 93 Mid 7.1434 166 134 6.9474 142 114 Mid 7.1434 166 134 8.3686 171 138 Mid High 7.9093 8.818 184 205 148 165 7.9318 7.0289 163 144 131 116 Mid Low High 10.0992 10.1255 10.8664 235 236 253 189 189 203 10.0992 5.6337 12.3349 207 115 253 166 93 203 High 11.1186 259 208 21.1181 433 348 High High High 11.1186 16.6197 17.7378 259 387 413 208 311 332 11.7499 16.6288 17.7378 241 341 363 194 274 292 13

Billing Principles Prior to billing, the HH roster must be completed including identification of each member’s: Designated health home (MCO/FFS provider) Contracted provider Care management agency MCO/FFS HH Lead Care Manager/TCM MCO can only bill for non-TCM members The roster supports the claim path. 14

Assignment and Billing For Fee-for-Service Members State will assign members into Health Homes State Designated Health Homes will bill eMedNY PMPM Rate Codes: 1386- Health Home Services 1387- Outreach & Engagement – for up to 3 months initially, additional 3 months allowed, 3 months after last claim Subcontractors bill the State Designated Health Home 15

Assignments and Billing (cont’d.) For Managed Care Members, Managed Care Plans: Assign members to State Designated Providerled Health Homes based on the information provided by the State and information the Plan has such as Primary Care Provider assignment State Designated Provider-led Health Homes bill Managed Care Plans for delivering Health Home services to the Plans’ members (not including members assigned to TCM programs). 16

Assignments and Billing (cont’d.) For Plans that are NOT State Designated Health Homes: Plans will receive a ‘kick’ payment to pay the Health Homes the plan assigned members Plans will bill the state the Rate Codes: 1386- Health Home Services 1387- Outreach & Engagement 17

Assignments and Billing (cont’d.) For Plans that ARE Health Homes Plans need to register for a NPI number and enroll in the Medicaid program as a case management provider Plans that are Health Homes will bill the state the Rate Codes: 1386- Health Home Services 1387- Outreach & Engagement 18

Billing for Existing Case Management Providers Bill eMedNY for BOTH their current slots and additional members assigned to them through Health Homes Current slots –working on consolidating rates for average PMPM New rate codes: COBRA–1880 MATS- 1386 OMH- (still working on OMH billing and rate code consolidation) CIDP- receive current PMPM – new rate code- 1885 19

Billing for Existing Case Management Providers (cont’d.) Case Management programs that add slots through Health Homes Bill eMedNY for the additional slots the average PMPM using: Health Home Rate codes 1386 & 1387 20

Plans and Health HomesRoles and Responsibilities Plans: State’s partners in assigning members and monitoring the quality of Health Homes Assign members using the state algorithm and their own data to appropriate Health Homes Contract with provider-led Health Homes in areas with sufficient provider-led Health Home capacity Reimburse health homes commensurate with the Health Home services being provided Monitor quality, assist Health Homes with Health Home care management network development/maintenance and move members out of Health Homes that are not achieving quality goals and/or meeting the member’s needs. 21

Plans and Health HomesRoles and Responsibilities (cont’d.) Provider – Lead Health Homes Continually meet provider qualification standards Meet Quality Measures and reporting responsibilities Develop their Health Information Plans Utilize all of their partners appropriately in the delivering of Health Home services Reimburse partners commensurate with level of Health Home services delivered Work closely with health plans to coordinate care management and service access 22

Expected “Wave One” HH Enrollment Health Hom e Enrollm ent Phasing Phase Tier Phase 1 State Fiscal State Year Quarter SFY '11-'12 FFY & Qrt - - - - - - - - - Qrt 2 FFY '10-'11 Qrt 4 - - - - - - - - - - Qrt 3 FFY '11-'12 Qrt 1 - - - - - - - - - - Qrt 4 FFY '11-'12 Qrt 2 3,715 10,661 16,401 - - - - - - 30,778 3,715 10,661 16,401 - - - - - - 30,778 9,289 26,652 41,003 3,663 10,510 16,168 - - - 107,285 807 2,314 3,560 82,533 2,016 5,785 8,901 62,869 Qrt 1 FFY '11-'12 Qrt 3 Qrt 2 FFY '11-'12 Qrt 4 - - - 9,157 26,274 40,421 Qrt 3 FFY '12-'13 Qrt 1 5,573 15,991 24,602 - - - Qrt 4 FFY '12-'13 Qrt 2 3,715 10,661 16,401 5,494 15,764 24,253 - - - 76,289 18,577 53,305 82,007 18,313 52,548 80,842 2,823 8,100 12,461 328,976 1,858 5,330 8,201 3,663 10,510 16,168 1,210 3,471 5,340 55,751 Qrt 1 FFY '12-'13 Qrt 3 Qrt 2 FFY '12-'13 Qrt 4 - - - 1,831 5,255 8,084 807 2,314 3,560 21,851 Qrt 3 FFY '13-'14 Qrt 1 1,858 5,330 8,201 - - - 403 1,157 1,780 18,729 Qrt 4 FFY '13-'14 Qrt 2 1,858 5,330 8,201 1,831 5,255 8,084 - - - 30,559 5,573 15,991 24,602 7,325 21,019 32,337 2,420 6,943 10,681 126,891 Qrt 1 FFY '13-'14 Qrt 3 - - - 1,831 5,255 8,084 403 1,157 1,780 18,511 Qrt 2 FFY '13-'14 Qrt 4 - - - - - - 403 1,157 1,780 3,340 Qrt 3 FFY '14-'15 Qrt 1 - - - - - - - - - - Qrt 4 FFY '14-'15 Qrt 2 - - - - - - - - - - - - 1,831 5,255 8,084 807 2,314 3,560 21,851 27,866 79,957 27,470 78,822 121,263 6,049 17,356 26,702 508,496 SFY '14-'15 Total Total High Cost Mid Cost Low Cost High Cost Mid Cost Low Cost High Cost Mid Cost Low Cost - SFY '13-'14 Total SFY '14-'15 Total FFY '10-'11 Qrt 3 SFY '12-'13 Total SFY '13-'14 Phase 3 Qrt 1 SFY '11-'12 Total SFY '12-'13 Phase 2 123,010 - * Low Cost Members are not slated for Health Home enrollment under the current plan but this could change as the project progresses and as high and mid- cost members are assigned in a given region. 23

Average Amount Paid per Claim/Prescription for Top Ten Categories of Service that Contribute to Overall Spend by County for Dates of Service 7/1/10 to 6/1/11 Phase 1 County Drugs Inpatient D&TC OMH Case Hospital Rehabilitative Management Outpatient Services Services Skilled Nursing Facility Home Health Agency Physician Professional Services Transportation Services BRONX 5,474 6,743 125 140 990 160 1,599 27 60 107 BROOKLYN 4,464 6,081 112 155 867 175 1,494 19 60 124 CLINTON 3,462 4,098 135 118 495 519 1,208 28 69 83 ESSEX 3,771 4,229 120 120 556 485 370 34 45 87 FRANKLIN 3,876 5,116 151 141 910 391 1,359 34 65 115 HAMILTON 3,451 8,793 69 86 1,925 25 117 140 NASSAU 3,405 5,253 128 126 1,051 276 1,363 19 91 107 SAINT LAWRENCE 3,621 4,787 117 354 881 246 892 33 100 96 SARATOGA 3,367 2,950 112 88 1,085 309 476 21 53 65 SCHENECTADY 3,512 3,149 86 122 926 170 1,072 27 41 65 WARREN 2,779 4,571 81 104 938 336 1,287 31 53 86 WASHINGTON 3,356 3,844 84 85 1,144 424 1,226 25 37 117 756 NA 24

* Updated HH Attribution from June 1, 2010 through May 31, 2011 – County as of last date of Medicaid Eligibility. Saratoga and St. Lawrence have been moved out of phase one. 25

Type Name Bronx Brooklyn AMIDA CARE SN 1,025 1,557 AIDS SNP METPLUS SN 1,570 1,517 NY PRESB SYS SELECT HEALTH 2,136SN 1,322 AIDS SNP Total 4,731 4,396 AFFINITY HEALTH PLAN 11,230 4,254 AMERIGROUP NY 600 3,652 CDPHP EXCELLUS FIDELIS HC NY 8,567 13,954 GHI HMO SELECT 1 HMO / GHI PPO PHSP HEALTHFIRST 19,488 16,607 HEALTHPLUS 4,096 13,139 HIP 5,136 9,199 METROPLUS 13,465 13,090 NEIGHBORHOOD 3,297 6,604 UNITED HEALTHCARE COMM PLAN 796 17,660 WELLCARE 1,757 3,031 HMO/PHSP Total 68,433 101,190 AFFINITY PROVIDER 22 4 FIDELIS PROVIDER 80 169 GHI HMO SELECT 8 9 HIP ADVANTAGE 124 230 MEDICAID LIBERTY HEALTH ADVANTAGE 14 14 ADVANTA MANAGED HEALTH INC PROVIDER 13 17 GE METROPLUS PROVIDER 17 16 SENIOR WHOLE HEALTH OF NY TOUCHSTONE/PRESTIGE 27 51 UNITED HEALTHCARE COMM PLAN 1 MEDICAID ADVANTAGE Total 305 511 FFS Total 24,934 41,462 Grand Total 98,403 147,559 Clinton Essex Franklin Hamilton Nassau Saint Lawrence Saratoga Schenect ady Warren Washingt on 1,618 1 1 826 376 1 150 44 2,304 2 313 1 1,606 1,594 4 334 908 1,213 1 479 539 2,514 2,808 483 873 1 2,279 1,122 3,400 1 2,735 827 376 153 44 13,460 315 11 1 86 1 2,091 2,918 464 840 1,281 1,434 32 76 88 7,631 21,179 3,269 3,584 15 37 17 2 15 1,313 3,842 48 1,677 4,533 17 1,070 1,570 2 664 1,539 Grand Total 2,582 3,087 3,458 9,127 17,102 4,252 3,539 315 29,361 2 3 38,374 18,357 17,735 26,555 9,902 21,191 4,788 191,476 26 260 18 440 29 30 33 71 78 1 986 85,888 287,477 * Updated HH Attribution from June 1, 2010 through May 31, 2011 – Plan enrollment as of last date of Medicaid Eligibility Saratoga and St. Lawrence have been moved out of phase one. 26

Health Home – Open Issues WMS Flag to identify Health Home Care Management Metrics Functional Status Tool Timing of State Plan and Start Date OMH TCM Rate Collapsing MATS Rates Next Webinar Date and Time TBD-Focus on Billing Health Home Website: http://www.health.ny.gov/health care/medicaid/pro gram/medicaid health homes/ 27