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Medicaid Health Homes: A Profile of Newer Programs

Section 2703 of the Affordable Care Act (ACA) established a new state option in the Medicaid program to implement “health homes” for individuals with chronic conditions, giving states a new tool to develop models of care designed to improve care coordination and reduce costs for high-need populations. The ACA also provided a 90% federal match rate for health home services during the first two years an approved health home program is in effect. As of this writing, 15 states have at least one health home program in place. In August 2012, the Kaiser Commission on Medicaid and the Uninsured (KCMU) issued a brief examining the first six health home programs. This update profiles health home programs in the nine states that have taken up the option in the intervening two years – Alabama, Idaho, Maine, Maryland, Ohio, South Dakota, Washington, Wisconsin, and Vermont. States implement their health home programs in their own ways, reflecting different targeting priorities, underlying delivery and payment systems, and visions of delivery system reform, as well as other state-level factors. Both diversity and themes can be seen in key areas of the more recent health home programs, as follows:

  • Geographic Scope. While the first health home states generally implemented their initiatives statewide, several states with newer programs limited their initiatives to selected counties initially. Local factors such as the existing provider infrastructure or geographic concentration of the target population may support a more limited approach.
  • Target Population. The newer health home states have used health homes to target both Medicaid beneficiaries with a broad cross-section of chronic conditions and narrower Medicaid populations defined by a particular chronic condition. Consistent with the vision of health homes as a tool for better integrating physical and behavioral health services for people with mental health conditions, the one constant among almost all health home states is the inclusion of individuals with serious mental illness in their target populations.
  • Health Home Providers. States whose programs serve a Medicaid population with a particular condition typically designate a narrower set of health home provider entities with significant experience serving that population. States targeting beneficiaries with a broader spectrum of chronic conditions generally rely on their existing network of primary care providers to provide health home services, with the health home structure and payment bolstering their capacity to serve people with complex chronic care needs. Two states also make separate payments to community-based or regional care coordination teams that support primary care practices operating as health homes.
  • Payment. While payment approaches vary, states generally pay health homes a per member per month (PMPM) rate based on the intensity of beneficiary needs and the staff resources required to meet them. Several states tier their payment rates to reflect different levels of beneficiary acuity and different interventions, and one state is implementing a payment withhold designed to incentivize provider-patient engagement and the development of care plans for health home beneficiaries. As health home programs become more firmly established and the parameters of what is approvable by CMS are more clearly defined, more states are likely to move in the direction of value-based payment.
  • Fee for service vs. managed care. Most of the nine states profiled in this brief are implementing their health home initiatives in a fee-for-service environment, in contrast to some of earlier states, which integrated health homes into their capitated managed care programs. This shift may, in part, reflect some of the complexities inherent in sorting out roles and responsibilities between managed care plans and health homes and preventing duplication of services and payment on behalf of health home enrollees.
  • HIT. Health home providers’ use of HIT to support care coordination and other health home services varies greatly by state, reflecting variation across states in the current capacity of providers, as well as in states’ ability to support health homes with HIT and their progress in developing a state HIE.

Looking Ahead

In a recent 50-state survey of Medicaid directors conducted by the KCMU, 21 states indicated that they planned to adopt or expand their use of health homes, evidence of the popularity of this new state plan option with enhanced federal financing. As state Medicaid programs continue to take action to improve health care delivery, the 90% federal match remains available for new health home programs, expansions of existing programs, and additional programs in states that already have health home programs in place. Later in 2014, the HHS Secretary is due to submit an interim Report to Congress on the five-year evaluation of the health home program required by the ACA. In the meantime, these state profiles of the health home programs now in operation illustrate how the option can be adapted to states’ diverse priorities and capacities, and inform their efforts to provide better care for Medicaid beneficiaries, advance health outcome goals, and spend Medicaid dollars more effectively.

 

Key Dimensions of Newer Medicaid Health Home Programs
Target Population Providers Payment Geographic Scope Enrollment*
Alabama 2 chronic conditions; one & risk for another; or SMI. ACA conditions, cancer, HIV, sickle cell anemia, organ transplant, others. Existing Enhanced PCCM practices & Primary Care Networks of  Alabama PMPM 4 regions covering 21 of 67 counties. 70,206
Idaho Diabetes & asthma; or diabetes or asthma & risk for another condition; or SMI or SED. PCCM PCPs, if required  infrastructure & provider capabilities are in place. PMPM Statewide 9,179
Maine 2 chronic conditions or one & risk for another; & SMI or SED (not yet approved by CMS) . ACA conditions, tobacco use, COPD, HBP, hyperlipidemia, DD or autism spectrum disorders, acquired brain injury, others. Qualified PCCM practices in partnership with Community Care Teams or, for SMI/SED population, in partnership with behavioral health home organizations. PMPM. Higher rate for more complex patients. Statewide 42,958
Maryland SMI or SED; or opioid substance use disorder and risk for another condition. Licensed psychiatric rehabilitation programs, mobile treatment services, & opioid treatment programs One-time payment for intake & assessment, & PMPM. Statewide 2,516
Ohio SMI or SED. Community Behavioral Health Centers (CBHC) PMPM 5 counties initially; statewide expansion planned 10,312
South Dakota 2 chronic conditions; one & risk for another; or SMI or SED. ACA conditions, COPD, HBP, others. Primary care physicians, PAs, advanced practice NPs, FQHCs, Indian Health Service Units, Rural Health Centers, & CMHCs Tiered PMPM Statewide 5,655
Vermont Opioid addiction. Opioid Treatment Programs & physicians licensed to prescribe buprenorphine in Office-Based Opioid Treatment settings,  with PCMHs & Community Health Teams PMPM Statewide (in 3 phases) 2,949
Washington 1 chronic condition & risk for another. Most ACA conditions, cancer, chronic respiratory conditions, dementia/Alzheimer’s, GI conditions, HIV/AIDS, intellectual disabilities, others. Regional health home lead entities contract with community-based care coordination organizations (CCOs) to provide health home services. One-time payment for outreach/care plan development, 2 PMPM levels, & incentives. Statewide except for Duals demonstration counties (King & Snohomish) 22,792
Wisconsin HIV/AIDS & another chronic condition or risk for another. AIDS Service Organizations One-time payment for initial assessment/care plan development, & PMPM. 4 counties with highest prevalence of HIV/AIDS 188
* Source: http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Approved-Health-Home-State-Plan-Amendments.html
Issue Brief