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Note: Responses to questions must be complete. Responses must be fully contained
within this application form, except where noted for additional
email attachments and the attestation form.
SECTION A. HEALTH HOME PROVIDER SPECIFIC INFORMATION
Please respond to the following questions.
- Provide a general description of your organization and experience in providing integrated care services. (Limit 1000 characters)
- Identify the proposed health care professionals and other members of the
interdisciplinary provider team that will provide care
management and coordination of integrated services. (Limit 1000 characters)
- Provide the description of the proposed care manager positions, including
professional discipline (if applicable), and relevant
education, training and experience. (Limit 1000 characters)
Describe level and intensity of care management that will be provided to the following populations: (Limit 1000 characters each)
Low need- e.g. stable in ambulatory care with episodic crisis or inpatient need
Intermediate need- e.g. not as connected to ambulatory care, more frequent
emergency room and inpatient use
High need- e.g. very unstable such as those serviced by OMH and HIV/AIDS COBRA
TCMs and the MATS program
Describe the process and time frames for providing crisis intervention for both medical and behavioral health events. (Limit 1000 characters)
Describe the specific process that will be used to assure the Health Home prompt
notification of emergency room and inpatient
facility admissions/discharges. (Limit 1000 characters)
A. Describe your organization’s current health information technology (HIT)
capability to meet the initial HIT standards as referenced
in NYS Health Home Provider Qualification Standards items 6a.-6d. (Limit 1000
characters for each)
Health home provider has structured information systems, policies, procedures
and practices to create, document, execute,
and update a plan of care for every patient.
Health home provider has a systematic process to follow-up on tests, treatments,
services, and referrals which is incorporated
into the patient’s plan of care.
Health home provider has a health record system which allows the patient’s
health information and plan of care to be accessible to the
interdisciplinary team of providers and which allows for population management
and identification of gaps in care including preventive services.
Health home provider makes use of available HIT and accesses data through the
regional health information organization/qualified
entity to conduct these processes, as feasible and appropriate.
B. In order to be approved as a health home provider, the application must
provide your organization’s plan for achieving final HIT standards
within eighteen (18) months of program initiation as referenced in NYS Health
Home Provider Qualification Standards items 6e.-6i.
Instructions: For each of the standards listed below, if capabilities exist
today, please acknowledge with a ‘Yes’. For the standards you are not
able to comply with at the time of application, please document plans for
attaining the standards in the 18 month time-frame.
Health home provider has structured interoperable health information technology
systems, policies, procedures and practices to support
the creation, documentation, execution, and ongoing management of a plan of care
for every patient.
Health home provider uses an electronic health record system that qualifies
under the Meaningful Use provisions of the HITECH
Act, which allows the patient’s health information and plan of care to be
accessible to the interdisciplinary team of providers. If the
provider does not currently have such a system, they will provide a plan for
when and how they will implement it.
Health home provider will be required to comply with the current and future
version of the Statewide Policy Guidance
which includes common information policies, standards
and technical approaches governing health information exchange.
Health home provider commits to joining regional health information networks or
qualified health IT entities for data exchange
and includes a commitment to share information with all providers participating
in a care plan. RHIOs/QE (Qualified Entities) provides
policy and technical services required for health information exchange through
the Statewide Health Information Network of New York (SHIN-NY)
Health home provider supports the use of evidence based clinical decision making
tools, consensus guidelines, and best practices
to achieve optimal outcomes and cost avoidance. One example of such a tool is
SECTION B. HEALTH HOME PROVIDER NETWORK & PROGRAM CAPACITY
In order to provide comprehensive and timely high quality services, health home
providers are expected to develop health home networks to provide
enrollees access to needed services. Health home networks should include medical
care providers (e.g. primary care, ambulatory care, preventive and
wellness care, FQHCs, clinics, specialists including HIV/AIDS providers,
hospitals, rehabilitation/skilled nursing facilities, pharmacies/medication
services, home health services, chronic disease self-management and patient
education services, etc.); behavioral health care providers (e.g. acute and
outpatient mental health, substance abuse services and rehabilitation providers,
etc.); and community based organizations and social services providers
TCMs, public assistance support services, housing services, etc.).
Check the appropriate provider types included in your network. Inclusion of TCM
programs (including OMH and HIV/AIDS COBRA TCMs, and
Managed Addiction Treatment Services Providers (MATS)), housing and other
community based organizations is strongly encouraged. Beneficiary
assignment to health homes will partially be based on an organization’s network
Types of Providers: (Please check applicable box)
Provide a complete description and organizational structure of the applicants
Health Home Model, including how the applicant
will accomplish providing the required services, provider linkages and care
coordination necessary. (Limit 5000 characters)
Guidelines for Tables 1.1 and 1.2
Identify each Health Home network provider organization, as well as associated
individual practitioners for each of the locations
using the column headings in Table 1.1 and 1.2.
You can upload from an excel spreadsheet or manually populate the table below
using the form.
Date Started Affiliation- List the date a provider or organization began their affiliation or partnership with the designated Health Home
Date Ended Affiliation- List the date a provider or organization ended their affiliation or partnership with the designated Health Home
Provider Name (Table 1.1) or Organization Name (Table 1.2) - List all providers
that are part of the Health Home network including all
licensed and funded medical, behavioral, residential, homeless and social
NPI - List the NPI for all medical and behavior health facilities and
practitioners. This information helps us determine
loyalty and attribution for patient assignment. Non-health related network
providers (housing, etc.) will not have NPIs.
Service Address Line 1- List the service address of each provider or organization on a separate line.
Service Address Line 2- List additional address information for suite number, floor number, name of department , or a billing address if different.
Licensure type- specify the field the applicant is licensed using the drop down
list (facility license-Aricle 16,27,31,32, or professional
practice license-MD, RPh, etc.) Separate multiple licensure types for each
provider with a comma.
Certification Type- list any special designation a provider has, for example,
*NCQA PCMH, Center of Excellence, etc. For
practitioners, please indicate specialty (if any) or any special professional
designation or qualification provider has earned:
Internal medicine, psychiatry, etc. Separate multiple certification types for
each provider with a comma.
Added Health Home Network Providers
Date Started Affiliation
Date Ended Affiliation
Provider First Name
Provider Last Name
Provider NPI (10 digits)
Associated Clinic/Institution Name
NPI of Associated Clinic/Institution
Service Address Line 1
Service Address Line 2
Certification Type- List specialty of Providers (if any)
Added Health Home Network Organizations
Date Started Affiliation
Date Ended Affiliation
Health Home Partner Name
HH Partner NPI (10 digits) or MMIS # (8 digits)
Partner with Corporate Health Home Accountability - Shared governance or a
co-lead (yes or no)
Address Line 1
Address Line 2
Certification Type- List specialty of Providers (if any)
- Identify the proposed Health Home Program enrollee capacity at program
initiation and at full program maturity using the column headings in Tables
2.1 and 2.2.
- Include the number of care management slots for proposed Health Home enrollees
who are currently enrolled in an OMH or HIV/AIDS
COBRA TCM, MATS program, or Chronic Illness Demonstration Project (CIDP)
operated by your organization.
- Not currently in Care Management refers to the enrollee population that is not
currently in a TCM, CIDP, or MATS.
- Initiation refers to the number of enrollees (capacity) that the Health Home can
effectively provide HH services to upon implementation.
- Maturity refers to the number of enrollees (capacity) that the Health Home
expects to serve once it grows to its desired size.
- Program capacity/slots should be stratified into the following three levels
based on definition as provided in Section A#3.
Proposed Health Home Program
Enrollee Capacity/Slots: At Initiation
Proposed Health Home Program
Enrollee Capacity/Slots: At Maturity
SECTION C. ATTESTATION
Health Home Program Requirements
Home applicant will be required to attest that their services will include following:
Coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge;
Language access/ translation capability;
24 hour 7 days a week telephone access to a care manager;
Links to acute and outpatient medical, mental health and substance abuse services;
Links to community based social support services-including housing;
Beneficiary consent for program enrollment and for sharing of patient
information and treatment.
The health home applicant must attest that contractual agreements are in place
with all organizations included in the provider network prior to the
first request for reimbursement when partnerships involve a financial
arrangement. A business agreement or MOU is suitable only for partnerships
that do not involve a financial arrangement. All agreements (including
contracts) should describe the roles and responsibilities of each party to the
The health home applicant must attest that payment to an OMH or HIV/AIDS COBRA
TCM operating in a health home’s provider network will be at the
State set, mandated TCM rate for current and new TCM assignees for the first
The health home applicant must attest that payment to a CIDP will be made at the State set, mandated rate for current CIDP enrollees for the first year.
NYS Medicaid Health Home Provider Qualification Standards
Health Home Provider applicants must submit a written attestation that the core
health home requirements specified below will be provided in totality and in
accordance with the NYS Health Home Provider Qualification Standards for Chronic
Medical and Behavioral Health Patient Populations located at http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/docs/inter_health_home.pdf
Core Health Home Requirements
Describe for each of the following how the health home will meet each core
requirement included in the NYS Health Home Provider Qualification
Standards. (Limit 1000 characters each)
Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Patient and Family Support
Referral to Community and Social Support Services
Use of Health Information Technology (HIT) to Link Services
Quality Measure Reporting to NYS
CMS Health Home Provider Functional Requirements
Health Home Provider applicants must submit a written attestation that the
services specified below will be provided in accordance with the following
health home functional components referenced in the CMS State Medicaid
Director’s Letter, 10-024 (https://www.cms.gov/smdl/downloads/SMD10024.pdf):
Describe for each of the following how the health home will meet each functional component as required by CMS. (Limit 1000 character each)
How will the health home provide quality-driven, cost-effective, culturally
appropriate, and person- and family-centered health
How will the health home coordinate and provide access to high-quality health
care services informed by evidence-based
clinical practice guidelines?
How will the health home coordinate and provide access to preventive and health
promotion services, including prevention of
mental illness and substance use disorders?
How will the health home coordinate and provide access to mental health and substance abuse services?
How will the health home coordinate and provide access to comprehensive care
management, care coordination, and transitional
care across settings? Transitional care includes appropriate follow-up from
inpatient to other settings, such as participation in
discharge planning and facilitating transfer from a pediatric to an adult system
of health care.
How will the health home coordinate and provide access to chronic disease
management, including self-management support to
individuals and their families?
How will the health home coordinate and provide access to individual and family
supports, including referral to community, social
support, and recovery services?
How will the health home coordinate and provide access to long-term care supports and services?
How will the health home develop a person-centered care plan for each individual
that coordinates and integrates all of his
or her clinical and non-clinical health-care related needs and services;
How will the health home use health information technology to link services,
facilitate communication among team members
and between the health team and individual and family caregivers, and provide
feedback to practices, as feasible and appropriate?
How will the health home establish a continuous quality improvement program, and
collect and report on data that permits
an evaluation of increased coordination of care and chronic disease management
on individual-level clinical outcomes, experience
of care outcomes, and quality of care outcomes at the population level.
Rights of the State
The State reserves the right to assign beneficiaries to a specific health home.
The State reserves the right to cancel a Health Home provider’s approved status
based on upon failure of the provider to provide health
home services in accordance with the NYS Health Home Provider Qualification
Standards, provide quality health home services to its clients,
or upon other significant findings determined by the State.
The State reserves the right to cancel the program at any time for lack of
funding, and/or if, after evaluation of the program, desired results
in quality, efficiency and decreased costs are not shown, or any other reason
determined by the State.
Attestation Form (PDF)
The application will not be considered complete until a hardcopy with
original signature of the Health Home Provider Attestation Form with an original
signature is received by the DOH. Please send the form to:
Health Home Management Unit
Division of Financial Planning and
NYS Department of Health
Office of Health Insurance Programs
Policy & Care Delivery Group, OCP-716
Empire State Plaza
New York 12237
Submitting is not currently allowed for Phase 2 applications. Applications will be taken between 2/1/2012 12:00 AM and 5/16/2014 11:59 PM