Guide to Medicaid Health Home Design and Implementation
This Guide to Medicaid Health Home Design and Implementation includes resources to help states plan their health home programs and prepare a health home state plan amendment for submission. The guide includes resources from the Centers for Medicare & Medicaid Services, select external resources, as well as materials created by states that are currently implementing health home programs.
New resources will be continuously added to help states advance health home models.
Health Home Background Resources
This section provides background information on the structure and purpose of Medicaid health homes and their regulatory authority.
- Health Home State Medicaid Director Letter (CMS/November 2010) SMDL 10-024 Re: Health Homes for Enrollees with Chronic Conditions.
- Health Home State Medicaid Director Letter (CMS/January 2013) SMDL 13-001 Re: Health Home Core Quality Measures.
- Social Security Act Sec. 1945 (March 2010) Affordable Care Act Section 2703 – State Option to Provide Coordinated Care Through a Health Home for Individuals with Chronic Conditions.
- Health Homes (Section 2703) Frequently Asked Questions (CMS/May 2012) Addresses key areas for health home design, including providers, enrollment and eligibility; delivery models; quality measurement; reporting; HIT; funding and payment; and SPA/waiver authorities.
- Section 2703: State Option to Provide Health Homes for Enrollees with Chronic Conditions (CMS/July 2011) Provides an overview of the health homes opportunity.
Developing Health Home Population Criteria
Medicaid health homes must be targeted to beneficiaries with chronic conditions or serious mental illness. States should carefully define their target population to maximize program impact. Questions to ask include:
- How many beneficiaries would be eligible for the health home program?
- Where do beneficiaries currently receive care?
- Do eligible beneficiaries “cluster” in a certain geographic area, around certain providers, or among specific chronic conditions?
- Do subsets of the population offer opportunities for reductions in avoidable emergency department and inpatient hospital use?
- Developing Health Homes for Children with Serious Emotional Disturbance: Considerations and Opportunities (CMS/February 2014) Highlights health home opportunities for children with Serious Emotional Disturbance and considerations for states developing models for this population.
- Designing Medicaid Health Homes for Individuals with Opioid Dependency: Considerations for States (CMS/January 2015) Highlights key features of approved health home models in Maryland, Rhode Island, and Vermont that are tailored to individuals with opioid dependency and identifies important considerations in developing opioid dependence-focused health homes.
Designing Medicaid Health Homes for Individuals with Opioid Dependency: Considerations for States (CMS/January 2015) Highlights key features of approved health home models in Maryland, Rhode Island, and Vermont that are tailored to individuals with opioid dependency and identifies important considerations in developing opioid dependence-focused health homes.
- Five Key Considerations for Exploring the Medicaid Health Homes Opportunity (CMS/October 2011) Outlines key considerations to help states determine whether to invest in health homes and how to get started in doing so.
- Initial Considerations to Guide the Development of Medicaid Health Homes (Center for Health Care Strategies/June 2011) Outlines key initial considerations to guide State health-home program design, including a hands-on checklist that walks States through a list of decision points.
- Data Analysis Considerations to Inform Medicaid Health Home Program Design (CMS/June 2012) Guides state discussions and decisions around claims data analysis for the development of Medicaid health homes.
- Washington: Characteristics of High-Risk Medicaid Enrollees and Dual Eligibles: Implications for Health Home Design and Care Management Strategies (February 2012)
- New York: Transforming Care Delivery via Health Homes for Medicaid Beneficiaries with Chronic Conditions. (March 2012)
Defining Health Home Services
Medicaid health homes must provide six core services: (1) comprehensive care management; (2) care coordination and health promotion; (3) comprehensive transitional care/follow‐up; (4) patient and family support; (5) referral to community and social support services; and (6) use of health information technology to link services.
Establishing Health Home Payment Methodologies
States have considerable flexibility in establishing payment methodologies for Medicaid health homes. In selecting a payment method, considerations include:
- What financial incentives will help ensure that providers will deliver health home services effectively and efficiently?
- What reimbursement methods will promote accountability and flexibility?
- Will the state use a tiered reimbursement methodology based on provider capability or patient acuity?
- Health Home Consideration for a Medicaid Managed Care Delivery System: Avoiding Duplication of Services and Payments (CMS/February 2012) Outlines options for health home approaches that complement, but do not replicate services and reimbursement within existing managed care delivery arrangements.
- ROI Forecasting Calculator for Health Homes and Medical Homes (Center for Health Care Strategies/May 2011) Identifies the cost-savings potential of health-home or medical-home strategies through a step-by-step process. Also see companion User's Guide.
- New York: Health Home Billing and Rate Information Includes details about New York’s health home payment rates and billing requirements
- Rhode Island: CEDARR Health Home Services and Payment Methodology: Service Crosswalk (February 2012) Outlines health home team roles.
Meeting Health Home Quality Measurement and Reporting Requirements
Medicaid health home programs will need to meet federal and state quality and reporting requirements. Providers of health home services will be required to report quality measures to their state as a condition for receiving payment.
- Health Home Core Set of Quality Measures: Technical Specifications and Resource Manual
- Health Homes SMD Letter (CMS/January 2013) SMD 13-001 Re: Health Home Core Quality Measures.
- Interim Report to Congress: Phase II Evaluation Activities (NORC-University of Chicago) Describes the web survey, stakeholder interviews, site visits, and focus groups that are part of Phase II of the Health Home evaluation.
- Section 2703 Health Home Long-Term Evaluation Activities (Urban Institute) Describes the aims of the long-term Health Home evaluation and the types of data that will be collected by the evaluation team.
Using Managed Care for Health Home Implementation
Some states may choose to create Medicaid health homes within or outside of managed care delivery systems. In developing their programs, states will need to consider the implications for health plan accreditation and non-duplication of care management services.
- Implications of Health Homes for NCQA Health Plan Accreditation (CMS/June 2012) Provides guidance on considerations related to National Committee for Quality Assurance health plan accreditation, particularly when the state designates primary care or other community-based providers to deliver health home services.
- Health Home Considerations for a Medicaid Managed Care Delivery System: Avoiding Duplication of Services and Payments (CMS/February 2012) Outlines options for health home approaches that complement, but do not replicate services and reimbursement within existing managed care delivery arrangements.
- Implementing Health Homes in a Risk-Based Medicaid Managed-Care Delivery System (Center for Health Care Strategies/June 2011) Explores how states might advance their health-home strategy in whole or in part through their existing Medicaid risk-based managed-care.
- Massachusetts: Service Inventory of Managed Care Entities to Support Development of a Health Homes State Plan Amendment (March 2012) Created to gather information about managed care entity’s (MCE) Care Management Services as supporting information for a state plan amendment (SPA) application.
- Rhode Island: Operational Protocols for Collaboration between Health Plans and Health Homes (September 2011) Outlines operational protocols for communication and care coordination between health plans and health homes for Medicaid managed care enrollees.
Integrating Physical Health/Behavioral Health in Health Homes
Medicaid health homes provide states with an important opportunity to integrate physical and behavioral health care for beneficiaries with complex care needs. Although states have considerable flexibility to define health home services and provider qualification as they see fit, effective integration of physical and behavioral health services is a critical aspect of program design.
- Financing and Policy Considerations for Medicaid Health Homes for Individuals with Behavioral Health Conditions: A Discussion of Selected States’ Approaches (Center for Integrated Health Solutions/July 2013) Reviews the policy considerations and options for states and providers to establish reimbursement methodologies and payment rates for health homes.
- The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes (CMS/May 2013) This brief details the Collaborative Care Model, developed by Dr. Jürgen Unützer and colleagues in Washington State, as one evidence-based approach to physical-mental health integration for states to consider in developing Medicaid health homes. See also the Patient-Centered Integrated Behavioral Health Care Principles & Tasks checklist referred to in the brief. Also available are webinar slides , recording, and transcript from a January 2013 webinar profiling the Collaborative Care Model.
- State Options for Integrating Physical and Behavioral Health Care (CMS/October 2011) Explores state options for integrating physical and behavioral health services within managed delivery systems, including examples of current state programs and critical considerations for implementation.
- Integrating Physical and Behavioral Health Care in Medicaid: An Online Toolkit (Center for Health Care Strategies/January 2011) Clearinghouse of resources addressing strategies for identification, stratification, integration, consumer engagement, information exchange, and financial alignment linked to physical/behavioral health integration.
- Webinar Resources: Integrating Physical and Behavioral Health -- An Exploration of State Options (Center for Health Care Strategies/November 2011) Explores promising options for integrating physical and behavioral health services within coordinated delivery systems.
- Center for Integrated Health Solutions This center, funded jointly by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration, promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions.
- Health Homes and Primary and Behavioral Health Care Integration This Substance Abuse and Mental Health Services Administration (SAMHSA) resource page includes a map of state integration efforts and guidance for states on working with SAMHSA to develop health-homes approaches prior to SPA submission. See also SAMHSA Health Reform Webinar Series.
- Health Homes and Individuals with Behavioral Health Issues -- SAMHSA’s Guidance Document Affordable Care Act Health Home Provision (SAMHSA/September 2011) Details key considerations for states in integrating behavioral health into health home strategies.
- Behavioral Health Homes for People with Mental Health & Substance Use Conditions: The Core Clinical Features (Center for Integrated Health Solutions/May2012) Report outlines a proposed set of core clinical features for behavioral health homes.