CMS Guidance: Reporting Health Home Data in T-MSIS

Guidance History

Brief Issue Description

This guidance specifies state’s reporting requirements for an individual’s eligibility and enrollment into the Medicaid health home program as well as other relevant segments. This document outlines the challenges to reporting on the health home program in the Transformed Medicaid Statistical Information System (T-MSIS) and provides recommendations for health home reporting in the Eligible, Managed Care, Provider, and Claim-OT files.

Background Discussion

Context

Section 2703 of the Affordable Care Act (ACA) added Section 1945 to the Social Security Act which authorized the Medicaid state plan option to implement health homes for individuals with chronic conditions, including dual eligible beneficiaries. The ACA also provided states a 90% federal match for health home services during the first two years that an approved health home State Plan Amendment (SPA) is in effect^[1]. The health home option became available to states on January 1, 2011. Health home services include: comprehensive care management, care coordination, health promotion, comprehensive transitional care from inpatient to other settings, including appropriate follow-up, patient and family support, referral to community and social support services, if relevant and the use of health information technology (HIT), as feasible to link services. To be eligible for health home services, an individual must be a Medicaid beneficiary with: (1) two chronic conditions; (2) one chronic condition and risk for a second; or (3) a serious mental illness. States can target Medicaid beneficiaries with specific chronic conditions such as mental health conditions, substance abuse disorder, asthma, diabetes, heart disease, HIV/AIDS, and being overweight (body mass index over 25).^[2] States may also target other chronic conditions. States must designate one or more type of provider arrangements for the delivery of the health home services: designated provider, team of health care professional or health team. A state can have more than one health home SPA, serving different target groups or regions within the state but an individual can only be in one health home at a time. As of August 2019, twenty-one states and the District of Columbia have 36 approved health home programs^[3].

Challenges

There are wide variances in reporting health home data elements in T-MSIS among states with health home programs which lead to inconsistent reporting across state programs. These differences lead to misinterpretations when assessing health home programs, tracking enrolled beneficiaries, and monitoring utilization of health home services and health home expenditures. Without uniform reporting, trends and patterns across programs cannot be analyzed. The following list describes the issues that CMS observed from T-MSIS state submissions by file type.

• Eligible File: There are three segments on the Eligible File that should be reported to document a beneficiary’s enrollment in a health home program. All three of these segments should be populated if a beneficiary is enrolled in a health home program. These segments respectively document (1) the beneficiary’s enrollment in a specific health home state plan amendment, (2) identifies the beneficiary’s health home provider(s), and, (3) identify the beneficiary’s chronic condition(s). In some states, only one or two of the segments have been reported for health home enrollees. Additionally, states are misreporting health home participation on the managed care participation segment
• Managed Care Plan File: States are misreporting health home entities on the Managed Care Plan File
• Provider File: : Few states are reporting on health home providers. The health home provider receiving the payment is important as it tracks the provider’s enrollment with the state as a health home provider.
• Claim OT File: The OT file is used to report health home service utilization and payments to the health home provider. Few states are reporting the health home valid values for Benefit Type and Category of Service for health home authorized services; both of which are required fields. The absence of this information could lead to a misrepresentation of the type, volume, and expenditures of health home services. Additionally, there are reporting errors for the per-member-per-month (PMPM) payments for health home services.

CMS Guidance

To address the completeness and reliability of health home-related T-MSIS data, CMS has provided the following guidance on how to report health home participation on the eligible file; how to document health home provider participation; how to report services provided by a health home and; how to report PMPM payments for health home services. In addition to the guidance provided below, states are also encouraged to review the November 2010 State Medicaid Director (SMD) letter on Health Homes and the January 2016 FAQs on health homes^[4].

States unsure of which codes apply to the Health Homes SPA(s) should refer to the boxes checked in the approved SPA pages for each health home SPA. If the state does not have the approved SPA for reference, all approved health home SPAs can be found on the Medicaid Health Homes SPA Overview (PDF, 295.82 KB). 

Reporting Home Health Enrollment and Providers

Health Home SPA Participation

All beneficiaries enrolled in a health home should be reported on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 file segment of the Eligible File. It is important to correctly identify both the information reported in the HEALTH-HOME-SPA-NAME (ELG107) and HEALTH-HOME-ENTITY-NAME (ELG108) data elements. A state can have more than one health home SPA and a beneficiary can be eligible, and decide to enroll in, different health home entities, but can only participate in one health home program at a time.

• The HEALTH-HOME-SPA-NAME is used to report the name of the health home state plan amendment. If you are not sure of the program name, search for “Name of Health Home Program” in the approved SPA.
• The HEALTH-HOME-ENTITY-NAME field is used to document the name of the health home entity, which can be one of three types; (1) designated providers such as physicians, community health centers, community mental health centers, or group practices, (2) a team of health professionals (e.g. physician, nurse, social worker, etc.) co-located in a clinical setting, or virtually linked, or (3) a health team, including all specified providers
• Both the HEALTH-HOME-SPA-NAME and HEALTH-HOME-ENTITY-NAME data elements are used across multiple file segments. The values for the state plan amendment name and the health home entity name should be consistent across all file segments.

There are also three dates that are reported on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment which are used to capture the period of health home enrollment.

• The HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE (ELG109) and HEALTH-HOME-SPA-PARTICIPATION-END-DATE (ELG110) data elements are used to capture the period of time that the individual beneficiary participates in the health home program.
• • The HEALTH-HOME-ENTITY-EFF-DATE (ELG111) data element is used to document the date the health home was approved as a health home entity under the SPA.
• • A beneficiary’s health home participation is tied to the health home entity. The beneficiary should always have at least one active health home entity during the period of their health home enrollment.

If a beneficiary changes the health home entity through which they receive their care, the record with the previous health home entity should continue to be reported. A new record should be reported with the new health home entity information. The HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE (ELG109) under the new health home entity should be the same as under the prior health home entity unless there was also a break in the beneficiary’s Health Home SPA participation. The beneficiary’s dates of participation with the health home entities will be captured in the HEALTH-HOME-SPA-PROVIDERS-ELG00007 segment. In the example provided in Table 1, the beneficiary with MSIS ID 123456 is reported with a health home entity changes from Community Care to Evergreen Health. A beneficiary’s original record with Community Care is reported with a HEALTH-HOME-SPA-PARTICIPATION-END-DATE (ELG110) of June 30, 2018. A new record is added to reflect that the new health home entity is Evergreen Health and has the same HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE (ELG109) of December 1, 2016.

Health Home Providers in the HEALTH-HOME-SPA-PROVIDERS-ELG00007 segment

The HEALTH-HOME-SPA-PROVIDERS-ELG00007 file segment is used to identify a beneficiary’s health home provider. Any beneficiaries reported on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment should have at least one record reported on the HEALTH-HOME-SPA-PROVIDERS-ELG00007 file segment of the eligible file. The values reported in the HEALTH-HOME-SPA-NAME (ELG118) and HEALTH-HOME-ENTITY-NAME (ELG119) data elements should match the values reported in those fields on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment for the same beneficiary.

The health home provider’s state-assigned identification number should be reported in the HEALTH-HOME-PROV-NUM (ELG119) field. This state-assigned provider number should link to the SUBMITTING-STATE-PROV-ID field on the Provider File. The dates that the beneficiary is enrolled with a Health Home Entity should be reported in the HEALTH-HOME-SPA-PROVIDER-EFF-DATE (ELG121) field and HEALTH-HOME-SPA-PROVIDER-END-DATE (ELG122) field. Table 2 below provides a truncated example of how a beneficiary’s records should be reported if their health home entity changes. For the beneficiary reported MSIS ID 123456, the date of 6/30/2018 reported in HEALTH-HOME-SPA-PROVIDER-END-DATE (ELG122) is reported on the record with Community Care reflecting the beneficiary’s last day of enrollment with the health home entity. A new record is reported with a 7/1/2018 HEALTH-HOME-SPA-PROVIDER-EFF-DATE (ELG121) to capture the first day of the beneficiary’s participation with their new health home entity.

If a health home participant has a team of providers, then all the providers on the team should be reported on the HEALTH-HOME-SPA-PROVIDERS-ELG00007 segment. A record segment would be reported for each of the providers on the team.^[5] Please see table 2 under MSIS ID 654321 for a truncated example how to report more than one provider on the HEALTH-HOME-SPA-PROVIDERS-ELG00007 segment.

Health Home Chronic Conditions

The HEALTH-HOME-CHRONIC-CONDITION-ELG00008 file segment is used to report the beneficiary’s chronic condition(s) that qualifies for participation in the health home program. Any beneficiaries reported on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment should have at least one record reported on the HEALTH-HOME-CHRONIC-CONDITION-ELG00008 file segment of the eligible file. The HEALTH-HOME-CHRONIC-CONDITION (ELG130) should be populated with one of the valid values identified in the T-MSIS data dictionary (see table 3 for a list of the valid values). Some beneficiaries are eligible to participate in a health home because they have two or more chronic conditions. Each chronic condition identified by a unique T-MSIS valid value should be reported as a unique record for that beneficiary. If states have designated a health home chronic condition of “other” (HEALTH-HOME-CHRONIC-CONDITION (ELG130) = “H” (Other), then they should also provide an explanation of the other chronic condition in the HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION (ELG131) data element, which is a free text field. To find the list of other chronic conditions in each HH program in your state, search for “Population Criteria” in the approved SPA and see the condition names and descriptions listed in the “other” category. Note that there may be more than one set of other chronic conditions: (1) for individuals who qualify on the basis of two chronic conditions, and (2) for those who qualify on the basis of one chronic condition and the risk of developing another.

If a beneficiary changes their health home entity enrollment on HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 and HEALTH-HOME-SPA-PROVIDERS-ELG00007 segments, new records should be reported on HEALTH-HOME-CHRONIC-CONDITION-ELG00008 segment under the new health home entity for each of the beneficiary’s health home chronic conditions. All of the records reported under the previous health home entity should be reported with a HEALTH-HOME-CHRONIC-CONDITION-END-DATE value that reflects the last day of the beneficiary’s enrollment. The records reported under the new health home entity should be reported with a HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE that reflects the first date of the beneficiary’s enrollment with that entity. 

Health Home Providers in the PROV-AFFILIATED-PROGRAMS-PRV00009 Segment

A health home provider’s participation in a health home program should be documented in the PROV-AFFILIATED-PROGRAMS-PRV00009 segment of the provider file. The name of the health home entity should be reported in the AFFILIATED-PROGRAM-ID (PRV120) field. If the provider is identified on the HEALTH-HOME-PROVIDERS-ELG00007 file segment, the state-assigned provider number reported in the HEALTH-HOME-PROV-NUM (ELG119) should match the state-assigned identifier reported in the SUBMITTING-STATE-PROV-ID (PRV118) field on the PROV-AFFILIATED-PROGRAMS-PRV00009 segment. The record segment that identifies the provider’s affiliation with a health home entity should be reported with an AFFILIATED-PROGRAM-TYPE (PRV119) value of “4” (Health Home Entity). In addition, the health home entity name that is reported in the HEALTH-HOME-ENTITY-NAME (ELG119) field should match with the health home entity name that is reported in the AFFILIATED-PROGRAM-ID (PRV120) field.

In Table 4 and Table 5, a simplified example of the linking requirements is provided using records from the HEALTH-HOME-PROVIDERS-ELG00007 segment of the eligible file and the PROV-AFFILIATED-PROGRAMS-PRV00009 segment of the provider file. On the HEALTH-HOME-PROVIDERS-ELG00007 segment reported in Table 2, the beneficiary with MSIS ID “77895” participates the health home program with Evergreen Behavioral Health Clinic. The state-assigned provider number for Evergreen Behavioral Health Clinic is “45690123”, which is used to link to the provider identifier in the Submitting State Provider ID field on the PROV-AFFILIATED-PROGRAMS-PRV00009 reported in Table 3. These records are both reported with the “Evergreen Behavioral Health Clinic Name” in the HEALTH-HOME-ENTITY-NAME (ELG119) field and the AFFILIATED-PROGRAM-ID (PRV120) field.

Reporting Health Home Records in the Claims File

Reporting Health Home FFS Claims and Encounters

Fee-for-service (FFS) claims and managed care encounters that are related to one of the six health home services should be reported in the OT Claims file. 

• The information reported for a health home related claim on the OT header record should be the same as any other type of claim. For example, claims must have beneficiary information, provider information, diagnosis codes, payment fields, and other information. There are three data elements specific to health home claims that are reported at the header. 
  • HEALTH-HOME-PROV-IND (COT109) – A value of “1” (Yes) should be reported for health home related services. This indicator identifies if the claim is submitted by a provider or provider group participating in the health home program. 
  • HEALTH-HOME-ENTITY-NAME (COT138) – The name of the health home entity providing the health home service. This should match the HEALTH-HOME-ENTITY-NAME value reported for the same beneficiary on the eligible file. 
  • HEALTH-HOME-PROVIDER-NPI (COT146) – The national provider identifier for the health home provider. 
• Information reported for a health home related claim on the OT claim line detail should be the same as any other type of claim line record, except for two data elements. Claims for services provided to a beneficiary by their health home should have the following claim line detail fields populated as follows: 
  • BENEFIT-TYPE (COT209) – A value of “055” (Health Home Services) should be reported. This value identifies the service as a health home service.
  • XIX-MBESCBES-CATEGORY-OF-SERVICE (COT211) – A value of “43” (Health Home for Enrollees with Chronic Conditions) or “45” (Health Homes for Substance-Use-Disorder Enrollees per section 1006 of the SUPPORT for Patients and Communities Act) should be reported. This value identifies MBES category of service line on which health home services would be reported. 

Reporting PMPM Payments for Health Home Services

Most state Medicaid agencies pay health home providers a per-member per-month (PMPM) for delivery of health home services. These health home service payments should be reported using the capitation payment/PMPM type of claim value on the T-MSIS OT file. The information below provides information on how to report PMPM health home service payments on the OT file.

• The information reported for a care coordination and case management payment on the OT header record should be the same as any other any other record reported with a capitation payment/PMPM type of claim. For example, the PMPM payment must have beneficiary information, provider information, payment fields, and other information. The below information identifies specific reporting requirements for the care coordination and case management payment. 
  • TYPE-OF-CLAIM (COT037) – Report with a value of “2” to identify the record as a PMPM payment. 
  • HEALTH-HOME-PROV-IND (COT109) – A value of “1” (Yes) should be reported for health home related services. This indicator identifies that the payment is issued to a provider or provider group participating in the Health Home program. 
  • HEALTH-HOME-ENTITY-NAME (COT138) – The name of the health home entity providing the health home service. This should match the HEALTH-HOME-ENTITY-NAME value reported for the same beneficiary on the eligible file. 
  • HEALTH-HOME-PROVIDER-NPI (COT146) – The national provider identifier for the health home provider. 
  • BEGINNING-DATE-OF-SERVICE (COT033) and ENDING-DATE-OF-SERVICE (COT034) – These fields should be reported with the first date and last date of the period covered by the payment. 
• The information reported for a care coordination and case management payment on the OT line record should be the same as any other line record reported as part of a capitation payment/PMPM type of claim. The below information identifies specific reporting requirements at the line level for the care coordination and case management payment. 
  • BENEFIT-TYPE (COT209) – A value of “055” (Health Home Services) should be reported. This value identifies the service as a health home service.
  • XIX-MBESCBES-CATEGORY-OF-SERVICE (COT211) – A value of “43” (Health Home for Enrollees with Chronic Conditions) or “45” (Health Homes for Substance-Use-Disorder Enrollees per section 1006 of the SUPPORT for Patients and Communities Act) should be reported. This value identifies MBES category of service line on which health home services would be reported. 
  • TYPE-OF-SERVICE (COT186) - Report with a value of “138” is used to identify the PMPM payment for health home services. The TYPE-OF-SERVICE valid value of “138” will be added to the forthcoming version of T-MSIS Data Dictionary Appendix A. 
  • BEGINNING-DATE-OF-SERVICE (COT166) and ENDING-DATE-OF-SERVICE (COT167) – These fields should be reported with the first date and last date of the period covered by the payment.

Reporting Alternative Payment Methods for Health Home Services

States have the option to use alternative payment models for their health home programs^[6]. A state’s alternative payment model will likely be unique to the state’s program. As a result, the state should reach out to their state TA to determine how to accurately report the alternative payments in T-MSIS. 

Health Home in Managed Care Delivery Models

A beneficiary’s enrollment in a health home program should not be reported on the MANAGED-CARE-PARTICIPATION-ELG00014 segment. Specifically, a beneficiary participating in a health home program should not be reported with a MANAGED-CARE-PLAN-TYPE (ELG193) value of “70”. A beneficiary’s participation in a health home program should instead be reported on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment. Similarly, no records should be reported on the MANAGED-CARE-MAIN-MCR00002 segment with a MANAGED-CARE-PLAN-TYPE (MCR024) value of “70”. The managed care plan type value of “70” will be removed from future versions of the data dictionary. 

In some cases, states use a managed care organization for the delivery of health home services. If a managed care plan (either a comprehensive managed care plan or a prepaid health plan) furnishes health home services directly to the beneficiary or the managed care plan contracts with the health home provider, the guidance for reporting information on the eligible file, provider file, and reporting services on the OT file in the first section above does not change. In cases where a managed care entity is the health home entity, the managed care organizations should be identified in the three health home file segments reported on the eligible file. The beneficiary’s enrollment in the managed care plan would be document in the MANAGED-CARE-PARTICIPATION-ELG00014 segment as a comprehensive plan or as a prepaid health plan. As noted above, beneficiary’s enrollment in the managed care plan would not be reported with the deprecated “health home” MANAGED-CARE-PLAN-TYPE (ELG193) value. 

However, how the PMPM payment for health home services is documented may differ when reported by a managed care organization. In most cases, it is expected that the PMPM payment for health home services would be built into the capitation payment to the managed care organization. If the PMPM payment for health home services can be distinguished from the larger capitated payment for other health care services, then the payment should be reported on the capitation payment record as a distinct line record reported on the CLAIM-LINE-RECORD-OT-COT00003 segment of the capitation payment to the managed care organization. The PMPM payment for health home services line record should be reported with similar information as the capitation payment with the following data elements being reported distinctly. 

• BENEFIT-TYPE (COT209) – A value of “055” (Health Home Services) should be reported. This value identifies the service as a health home service.
• XIX-MBESCBES-CATEGORY-OF-SERVICE (COT211) – A value of “43” (Health Home for Enrollees w Chronic Conditions) or “45” (Health Homes for Substance-Use-Disorder Enrollees per section 1006 of the SUPPORT for Patients and Communities Act) should be reported. This value identifies MBES category of service line on which health home services would be reported. 
• TYPE-OF-SERVICE (COT186) - Report with a value of “138” is used to identify the PMPM payment for health home services. The TYPE-OF-SERVICE valid value of “138” will be added to the forthcoming version of T-MSIS Data Dictionary Appendix A. 
• BEGINNING-DATE-OF-SERVICE (COT166) and ENDING-DATE-OF-SERVICE (COT167) – These fields should be reported with the first date and last date of the period covered by the payment. 
• MEDICAID-PAID-AMT (COT178) – Report the health home services PMPM payment. 

If your health home program is integrated into managed care plans, you are encouraged to reach out to your state TA if your program structure may require adjustments to the reporting described in the sections above.

[1] Section 1006 of the SUPPORT for Patients and Communities Act provides for 10 quarters of the 90% federal match for substance use disorder focused health home programs. 
[2] Sec. 2703. State option to provide health homes for enrollees with chronic conditions. Patient protection and affordable care act. 
[3] For the most recent information on health home programs, please see: Health Home Information Resource Center
[4] SMD Letter - Health Homes for Enrollees with Chronic Conditions (PDF, 134.87 KB)
[5] See the 2017 Health Homes FAQ (PDF, 67.38 KB) for information on provider teams.
[6] Social Security Act, Section 1945 (c)(2)(B).