Medicaid Health Homes: A Profile of Newer Programs
| Appendix: Key Dimensions of Newer Medicaid Health Home Programs | ||||||||
| Target Population |
Chronic Conditions |
Providers | Payment Methodology |
Relationship to MCOs | HIT | Geographic Scope |
Enrollment* | |
| Alabama | Two chronic conditions; one & risk for another; or SMI | ACA conditions, cancer, HIV, cardiovascular disease, chronic obstructive pulmonary disease (COPD), sickle cell anemia, & organ transplant. | Existing Enhanced PCCM Primary Medicaid Providers (PMPs) & Primary Care Networks of Alabama (PCNAs). | PMPM paid to both PMPs & PCNAs. | N/A | Use of state’s Medicaid EHR & clinical support tool is encouraged. Secure, web-based system generates reports based on claims data. | Four regions encompassing 21 of 67 counties. | 70,206 |
| Idaho | Two chronic conditions; one & risk for another; or SMI or SED | SMI or SED; or diabetes & asthma; or diabetes or asthma & risk for another condition. Risk factors include BMI>25, abnormal lipid levels, hypertension, respiratory disease, or tobacco use. | PCCM PCPs, including physicians, group practices, rural clinics, CHCs, CMHCs, home health agencies, if required infrastructure & provider capabilities are in place. | PMPM based on estimated staffing costs of health home team. | N/A | Initial standards require information system to support tracking & managing chronic care patients. Final standards require use of HIT for follow-up & referral & population health management, and use of Idaho HIE as feasible. | Statewide | 9,179 |
| Maine | Two chronic conditions; or one & risk for another; or SMI or SED (not yet approved by CMS) | ACA list, plus tobacco use, COPD, hypertension, hyperlipidemia, developmental disabilities or autism spectrum disorders, acquired brain injury, seizure disorders, cardiac & circulatory congenital disorders. | PCCM practices qualified as Health Home Providers (HHP) in partnership with Community Care Teams (CCT). For beneficiaries with SMI/SED, PCCM practices in partnership with behavioral health home organizations are health homes. | PMPM paid to both HHPs and CCTs based on estimated staff costs; higher PMPMs paid to CCTs reflect more complex needs of CCT patients | N/A | HHPs must have fully implemented EHR. HHPs and CCTs have access to state-developed Health Home Enrollment System and Maine’s HIE for patient information, tracking, & referral. | Statewide | 42,958 |
| Maryland | SMI or SED; or one chronic condition & risk for another | SMI or SED; or opioid substance use disorder (i.e., individuals in opioid maintenance therapy) & risk for another condition. Risk factors include current or previous tobacco, alcohol, or other non-opioid substance use. | Licensed psychiatric rehabilitation programs, mobile treatment services, & opioid treatment programs. | One-time payment for intake and assessment, and PMPM based on estimated staffing costs | Behavioral health care is carved out of managed care contracts. | Access to state’s on-line e-Medicaid provider portal, and also must be enrolled in the state HIE to receive real-time hospital encounter alerts & pharmacy data. | Statewide | 2,516 |
| Ohio | SMI or SED | SMI or SED. | Community Behavioral Health Centers (CBHCs) | PMPM based on cost information submitted by CBHCs | Behavioral health care is carved out of managed care contracts; CBHCs must establish partnership with MCOs. | Must be able to receive utilization data electroni-cally. Must acquire certified EHR &, by end of Year 2, use to support all health home services. Must participate in state HIE once operational in their area. | Five counties initially; statewide expansion planned | 10,312 |
| South Dakota | Two chronic conditions; or one & risk for another; or SMI or SED | ACA conditions, COPD, hyperten-ion, & musculo-keletal & neck & back disorders. Risk factors include tobacco use, pre-diabetic condition, cancer, hypercholestero-lemia, depression, & use of >6 medications. | Primary care physicians, PAs, advanced practice NPs, FQHCs, Indian Health Service Units, Rural Health Centers, & CMHCs | Tiered PMPM rates based on patient risk score & estimated “Uncoordinated Care Costs” for enrollees in each tier | N/A | Health home providers required to have EHR; State Medicaid agency provides health homes with monthly claims data to manage care. | Statewide | 5,655 |
| Vermont | One chronic condition: individuals receiving Medication Assisted Therapy (MAT) for opioid addiction in specified settings | Opioid addiction. | Specialty methadone Opioid Treatment Programs (OTP) or physicians licensed to prescribe buprenorphine in Office-Based Opioid Treatment (OBOT) settings, in conjunction with PCMHs & Community Health Teams | PMPM based on added staff costs and paid to regional addictions centers and administering entities for CHTs | N/A | Hub and Spoke providers must document health home services in their EMRs & are eventually to be linked to state’s web-based central clinical registry through state HIE. | Statewide (in three phases) | 2,949 |
| Washington | One chronic condition & risk for another | ACA conditions (except BMI >25), cancer, cerebro-vascular disease, chronic respira-tory conditions, coronary artery disease, dementia/ Alzheimer’s, gastrointestinal conditions, hematological conditions, HIV/AIDS, intellectual disabilities, musculoskeletal conditions, neurological disease, & renal failure. Risk defined as expected costs >150% costs for SSI population. | Regional health home lead administrative entities contract with community-based care coordination organizations (CCO) (e.g., group practices, rural clinics, FQHCs, CMHCs, case management agencies, MCOs, hospitals, SUD treatment providers) to provide health home services. | 3-tiered approach: one-time payment for outreach/ care plan development; different PMPM rates for low level & intensive coordination; also, 2% withhold to incentivize outreach, care plan develop-ment, & provision of health home services. | Health home services for eligible beneficiaries in MCOs are built into MCO contracts and capitation rates. | Health homes have access to state’s secure, web-based clinical support tool to complement provider-specific EHRs. | Statewide except for King (Seattle) and Snohomish counties (location of Dual Eligible Demonstration) | 22,792 |
| Wisconsin | One chronic condition (HIV/AIDS) & another or risk for another | Risk factors include low CD4 cell count, BMI <18.5, elevated blood pressure, elevated fasting blood sugar level, and hyper-lipidemia. | AIDS Service Organizations (ASO) | Fee for initial assessment & development of an integrated care plan for each health home enrollee, & PMPM rate for health home services. | State assures there will be no duplication of services or payments associated with other Medicaid programs including MCOs. | All contacts with beneficiaries must be documented & treatment plans updated in EHR, which must be accessible to all members of care team. | Four counties with highest prevalence of HIV/AIDS in state | 188 |
| *Source: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State Plan-Amendments.html | ||||||||
