Medicaid Health Homes: A Profile of Newer Programs

Appendix:  Key Dimensions of Newer Medicaid Health Home Programs
Providers Payment
Relationship to MCOs HIT Geographic
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: Plan-Amendments.html
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