Health Home Care Management Rates
The current rate structure is administratively complex and does not fully reflect the work required to serve patients with complex chronic conditions. As we move into a new high, medium and low rate structure, iHealth members are concerned about what services will be possible at these different rates. In addition, there is interest in considering a focus on the high and medium groups more intensively while finding another model for serving low need individuals. With data gathered during this initial phase of implementing the new rate structure, it may also be possible to propose a single rate. Wherever we land on rates, the model must focus more on producing desired outcomes such as increased connection with primary care, reduced emergency room use and reduced inpatient stays in the hospital.
iHealth has advocated for an increase in the lowest rate of $62.00. An increase in this rate has been announced and when finalized will be retroactive to May, 2017.
Outreach and Engagement
iHealth is working on proposals to significantly improve top-down enrollment efforts while also developing a rate model that incentivizes bottom-up enrollments that result from identifying the highest need individuals where they are most likely to be found: health clinics, emergency rooms, hospitals, homeless shelters, at local department of social services (public assistance, etc) within the criminal justice system, within community-based organizations.
For most of the health home program's five year existence there has not been a reliable way to ensure that a new enrollee was not already enrolled with another care management agency (CMA). As a result, many CMAs provided services that were not reimbursed because another provider had already billed for HH care management services. NYS DOH offered to reimburse CMAs in this situation for up to three months of services. However, there is not yet a plan to implement this proposal. iHealth will continue to advocate for information such as specific reimbursement periods, which claims would qualify, how to confirm these claims and finally distribution of payments. iHealth is also prepared to support the NYS DOH team with overcoming any barriers to completing these payments.
Moving HH Rates into Managed Care Premium
NYS DOH proposes moving the HH rates into the managed care premiums in February, 2018. In addition to adding another level in the claims and payment process, there are many more implications to this change. If this occurs, managed care plans may implement additional quality measures for health home care managers. The measures could vary widely by plan, causing additional burdens on the CMA and potentially reducing the effectiveness of the program. Although NYS DOH does not intend for the plans to negotiate the health home care management rate at the outset of this transition in 2018, it's not clear that the plans will not be able to do this if they choose. It is also not clear when rate negotiation would begin with plans.
Although we were unable to secure advance payments prior to the billing transition that began December 1, 2016, iHealth continues to advocate for relief when payments are significantly delayed. iHealth members have also highlighted the link between the duplicate enrollment payments described above, the fair distribution of HH development funds and the financial stability of care management agencies during the billing transition.
Payments for HARP Community Mental Health Assessments (CMHA)
iHealth continues to raise concerns about flow of payments for HARP CMHAs. Payments have either not begun from some managed care plans, been significantly delayed, only partial (not covering all assessments or sent without remittance for tracking. Advanced payments to CMAs for a portion of their HARP enrolled clients could provide incentive for increasing the number of assessments conducted. Currently total assessments are low.
Developing a broader funding strategy to support CBOs role in healthcare (Gov, payer, foundations).