Medicaid Health Home Provider Application

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APPLICANT INFORMATION

Application ID
Organization Name    NPI#
Corporation Name (optional)
Correspondence Address
City   State   Zip Code
Telephone Number  County
 
Type of Organization  
Licensure/Certification Number
Pay-To-Address
City  State  Zip Code
Organization Contact Person
Title  Telephone Number
Fax Number  E-mail

Health Home Service Regions (Must add at least one)
    
  

  Region:   County:   


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.

  1. Provide a general description of your organization and experience in providing integrated care services. (Limit 1000 characters)


  2. 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)


  3. Provide the description of the proposed care manager positions, including professional discipline (if applicable), and relevant
    education, training and experience. (Limit 1000 characters)


    1. Describe level and intensity of care management that will be provided to the following populations: (Limit 1000 characters each)
      1. Low need- e.g. stable in ambulatory care with episodic crisis or inpatient need


      2. Intermediate need- e.g. not as connected to ambulatory care, more frequent emergency room and inpatient use


      3. High need- e.g. very unstable such as those serviced by OMH and HIV/AIDS COBRA TCMs and the MATS program


  4. Describe the process and time frames for providing crisis intervention for both medical and behavioral health events. (Limit 1000 characters)


  5. 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)


  6. 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)

    1. Health home provider has structured information systems, policies, procedures and practices to create, document, execute,
      and update a plan of care for every patient.


    2. 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.


    3. 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.


    4. 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.

    1. 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.


    2. 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.


    3. Health home provider will be required to comply with the current and future version of the Statewide Policy Guidance
      (http://www.health.ny.gov/technology/statewide_policy_guidance.htm) which includes common information policies, standards
      and technical approaches governing health information exchange.


    4. 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)


    5. 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 PSYCKES.




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 management
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
 (e.g. TCMs, public assistance support services, housing services, etc.).

  1. 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 capacity.

    Types of Providers: (Please check applicable box)
    Targeted Case Management Providers
            
            
    Ambulatory Providers/Clinic (Please specify)
            
            
            
            
    Other:


    1. 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)
        

    2. 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.

      1. Date Started Affiliation- List the date a provider or organization began their affiliation or partnership with the designated Health Home
      2. Date Ended Affiliation- List the date a provider or organization ended their affiliation or partnership with the designated Health Home
      3. 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 service providers.
      4. 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.
      5. Service Address Line 1- List the service address of each provider or organization on a separate line.
      6. Service Address Line 2- List additional address information for suite number, floor number, name of department , or a billing address if different.
      7. 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.
      8. 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.

    Instructions for Using the Form
    • Type information into the box next to each line of the form- use one entry for each provider;
    • All fields with an asterisk (*) is required information;
    • Keep all data and data terms consistent when entering in free text fields (font, case, same terms etc);
    • Review information entered for consistency and completeness;
    • Click on “ Add Network Provider “ button to save provider information;
    • Click on “Clear Network Provider Fields” to remove data entry – this will not save information entered;
    • If manually entering a larger number of providers, it is recommended that you save often to prevent any loss of work.

    Instructions for Uploading a Populated Table 1.1 from Excel spreadsheet
    • Successful uploads- Check that Column headers are on the first row; must have the same number of columns in the same order as
      listed under Table 1.1 of application;
    • Data must be in the first sheet of the spreadsheet workbook; Please remove any other unused sheets;
    • Do not merge cells or add blank rows;
    • Each unique entry should be on a different line. Do not list multiple values in one cell.
      (For example, Health Home partners with three locations should be listed on three separate lines with the
      partner's name and NPI listed on each line.);
    • File type must be .xls. A .xlsx file will have to be saved as .xls before uploading;.
    • If file does not upload correctly, check that the columns are the same order in your spreadsheet and then try uploading again
      (this will overwrite the previous upload).
    • Please double check your input before uploading. Avoid using any abbreviations, except for street names (ST, BLVD, AVE, etc.)


    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 City State Zip Code Licensure Type Certification Type- List specialty of Providers (if any) Service Type Additional Information
    Table 1.1

    Add New Health Home Network Provider (Table 1.1):
    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:
    *City:
    *State:
    *Zip Code:
    *Licensure Type:
    *Certification Type- List specialty of Providers (if any):
    *Service Type:
    Additional Info:


    Instructions for Using the Form
    • Type information into the box next to each line of the form- use one entry for each provider;
    • The asterisk (*) signifies required information;
    • Keep all data and data terms consistent when entering in free text fields (font, case, same terms etc);
    • Review information entered;
    • Click on “ Add Network Provider “ button to save provider information;
    • Click on “Clear Network Provider Fields” to remove data entry – this will not save information entered;
    • If manually entering a larger number of providers, it is recommended that you save often to prevent any loss of work.

    Instructions for Uploading a Populated Table 1.2 from Excel spreadsheet
    • Successful uploads- Check that Column headers are on the first row; must have the same number of columns in the same order as
      listed under Table 1.2 of application;
    • Data must be in the first sheet of the spreadsheet workbook; Please remove any other unused sheets;
    • Do not merge cells or add blank rows;
    • Each unique entry should be on a different line. Do not list multiple values in one cell.
      (For example, Health Home partners with three locations should be listed on three separate lines with the
      partner's name and NPI listed on each line.);
    • File type must be .xls. A .xlsx file will have to be saved as .xls before uploading;.
    • If file does not upload correctly, check that the columns are the same order in your spreadsheet and then try uploading again
      (this will overwrite the previous upload).
    • Please double check your input before uploading. Avoid using any abbreviations, except for street names (ST, BLVD, AVE, etc.)


    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 City State Zip Code Licensure Type Certification Type- List specialty of Providers (if any) Service Type Additional Information
    Table 1.2

    Add New Health Home Network Organization (Table 1.2):
    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:
    *Address Line 1:
    Address Line 2:
    *City:
    *State:
    *Zip Code:
    *Licensure Type:
    *Certification Type- List specialty of Providers (if any):
    *Service Type:
    Additional Info:


  2. 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.

    1. 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.
    2. Not currently in Care Management refers to the enrollee population that is not currently in a TCM, CIDP, or MATS.
    3. Initiation refers to the number of enrollees (capacity) that the Health Home can effectively provide HH services to upon implementation.
    4. Maturity refers to the number of enrollees (capacity) that the Health Home expects to serve once it grows to its desired size.
    5. 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
    Number of Health Home Slots (as applicable)
    New Proposed Slots
    (Not currently in Care Management)
    Current Slots to be Converted to HH
    Populations
    Fee for Service and
    Plan Member Assignments
    OMH
    TCM
    COBRA
    TCM
    CIDP
    MATS
    High need
    Intermediate need
    Low need
    Table 2.1

                                                  Proposed Health Home Program Enrollee Capacity/Slots: At Maturity
    Number of Health Home Slots (as applicable)
    New Proposed Slots
    (Not currently in Care Management)
    Current Slots to be Converted to HH
    Populations
    Fee for Service and
    Plan Member Assignments
    OMH
    TCM
    COBRA
    TCM
    CIDP
    MATS
    High need
    Intermediate need
    Low need
    Table 2.2



SECTION C. ATTESTATION

  1. Health Home Program Requirements

    1. Home applicant will be required to attest that their services will include following:

      1. Coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge;
      2. Language access/ translation capability;
      3. 24 hour 7 days a week telephone access to a care manager;
      4. Crisis intervention;
      5. Links to acute and outpatient medical, mental health and substance abuse services;
      6. Links to community based social support services-including housing;
      7. Beneficiary consent for program enrollment and for sharing of patient information and treatment.

    2. 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 agreement.

    3. 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 year.

    4. 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.

  2. 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

    1. 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)

      1. Comprehensive Care Management


      2. Care Coordination and Health Promotion


      3. Comprehensive Transitional Care


      4. Patient and Family Support


      5. Referral to Community and Social Support Services


      6. Use of Health Information Technology (HIT) to Link Services


      7. Quality Measure Reporting to NYS



    2. 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)

      1. How will the health home provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered health
        home services?


      2. How will the health home coordinate and provide access to high-quality health care services informed by evidence-based
        clinical practice guidelines?


      3. How will the health home coordinate and provide access to preventive and health promotion services, including prevention of
        mental illness and substance use disorders?


      4. How will the health home coordinate and provide access to mental health and substance abuse services?


      5. 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.


      6. How will the health home coordinate and provide access to chronic disease management, including self-management support to
        individuals and their families?


      7. How will the health home coordinate and provide access to individual and family supports, including referral to community, social
        support, and recovery services?


      8. How will the health home coordinate and provide access to long-term care supports and services?


      9. 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;


      10. 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?


      11. 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.



  3. Rights of the State

    1. The State reserves the right to assign beneficiaries to a specific health home.

    2. 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.

    3. 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 Policy
NYS Department of Health
Office of Health Insurance Programs
Medicaid Policy & Care Delivery Group, OCP-716
Empire State Plaza
Corning Tower
Albany, New York 12237


Submitting is not currently allowed for Phase 2 applications. Applications will be taken between 2/1/2012 12:00 AM and 2/15/2014 11:59 PM