Form CMS-10398 (#22) CMS-10398 (#22) Health Home State Plan Amendment

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OMB Control Number: 0938‐1148
Expiration date: 10/31/2014

Health Home State Plan Amendment
Submission Summary
Transmittal Number:
Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and
0000 = a four digit number with leading zeros. The dashes must also be entered.

The State elects to implement the Health Homes State Plan option under Section 1945 of the Social Security Act.

Name of Health Homes Program:

State Information

State/Territory name:

ZZ Test State

Medicaid agency:

Authorized Submitter and Key Contacts
The authorized submitter contact for this submission package.

Name:
Title:
Telephone number:
Email:

The primary contact for this submission package.

Name:
Title:
Telephone number:
Email:

The secondary contact for this submission package.

Name:
Title:
Telephone number:

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Email:

The tertiary contact for this submission package.

Name:
Title:
Telephone number:
Email:

Proposed Effective Date

(mm/dd/yyyy)

Executive Summary
Summary description including goals and objectives:

Federal Budget Impact

Federal Fiscal Year

Amount

First Year

$

Second Year

$

Federal Statute/Regulation Citation

Governor's Office Review

No comment.
Comments received.
Describe:

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No response within 45 days.
Other.
Describe:

Submission - Public Notice
Indicate whether public notice was solicited with respect to this submission.
Public notice was not required and comment was not solicited
Public notice was not required, but comment was solicited
Public notice was required, and comment was solicited
Indicate how public notice was solicited:
Newspaper Announcement
Publication in State's administrative record, in accordance with the administrative procedures requirements.
Date of Publication:
(mm/dd/yyyy)

Email to Electronic Mailing List or Similar Mechanism.
Date of Email or other electronic notification:
(mm/dd/yyyy)

Description:

Website Notice
Select the type of website:
Website of the State Medicaid Agency or Responsible Agency
Date of Posting:
(mm/dd/yyyy)

Website URL:

Website for State Regulations
Date of Posting:

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(mm/dd/yyyy)

Website URL:

Other
Public Hearing or Meeting

Date

Time

Location

Other method
Indicate the key issues raised during the public notice period:(This information is optional)
Access
Summarize Comments

Summarize Response

Quality
Summarize Comments

Summarize Response

Cost
Summarize Comments

Summarize Response

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Payment methodology
Summarize Comments

Summarize Response

Eligibility
Summarize Comments

Summarize Response

Benefits
Summarize Comments

Summarize Response

Service Delivery
Summarize Comments

Summarize Response

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Other Issue

Submission - Tribal Input
One or more Indian health programs or Urban Indian Organizations furnish health care services in this State.
This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs or Urban Indian
Organizations.
The State has solicited advice from Tribal governments prior to submission of this State Plan Amendment.
Complete the following information regarding any tribal consultation conducted with respect to this submission:
Tribal consultation was conducted in the following manner:
Indian Tribes
Indian Tribes
Name of Indian Tribe:
Date of consultation:
(mm/dd/yyyy)

Method/Location of consultation:

Indian Health Programs
Indian Health Programs
Name of Indian Health Programs:
Date of consultation:
(mm/dd/yyyy)

Method/Location of consultation:

Urban Indian Organization
Urban Indian Organizations
Name of Urban Indian Organization:
Date of consultation:
(mm/dd/yyyy)

Method/Location of consultation:

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Urban Indian Organizations

Indicate the key issues raised in Indian consultative activities:
Access
Summarize Comments

Summarize Response

Quality
Summarize Comments

Summarize Response

Cost
Summarize Comments

Summarize Response

Payment methodology
Summarize Comments

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Summarize Response

Eligibility
Summarize Comments

Summarize Response

Benefits
Summarize Comments

Summarize Response

Service delivery
Summarize Comments

Summarize Response

Other Issue

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Submission - SAMHSA Consultation
The State provides assurance that it has consulted and coordinated with the Substance Abuse and Mental Health Services
Administration (SAMHSA) in addressing issues regarding the prevention and treatment of mental illness and substance abuse
among eligible individuals with chronic conditions.

Health Homes Population Criteria and Enrollment
Population Criteria
The State elects to offer Health Homes services to individuals with:
Two or more chronic conditions
Specify the conditions included:
Mental Health Condition
Substance Abuse Disorder
Asthma
Diabetes
Heart Disease
BMI over 25
Other Chronic Conditions
One chronic condition and the risk of developing another
Specify the conditions included:
Mental Health Condition
Substance Abuse Disorder
Asthma
Diabetes
Heart Disease
BMI over 25
Other Chronic Conditions
Specify the criteria for at risk of developing another chronic condition:

One or more serious and persistent mental health condition
Specify the criteria for a serious and persistent mental health condition:

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Geographic Limitations
Health Homes services will be available statewide
If no, specify the geographic limitations:
By county
Specify which counties:

By region
Specify which regions and the make-up of each region:

By city/municipality
Specify which cities/municipalities:

Other geographic area
Describe the area(s):

Enrollment of Participants
Participation in a Health Homes is voluntary. Indicate the method the State will use to enroll eligible Medicaid individuals into
a Health Home:

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Opt-In to Health Homes provider
Describe the process used:

Automatic Assignment with Opt-Out of Health Homes provider
Describe the process used:

The State provides assurance that it will clearly communicate the opt-out option to all individuals assigned to a
Health Home under an opt-out process and submit to CMS a copy of any letter or other communication used to
inform such individuals of their right to choose.
Other
Describe:

The State provides assurance that eligible individuals will be given a free choice of Health Homes providers.
The State provides assurance that it will not prevent individuals who are dually eligible for Medicare and Medicaid from
receiving Health Homes services.
The State provides assurance that hospitals participating under the State Plan or a waiver of such plan will be instructed to
establish procedures for referring eligible individuals with chronic conditions who seek or need treatment in a hospital
emergency department to designated Health Homes providers.
The State provides assurance that it will have the systems in place so that only one 8-quarter period of enhanced FMAP for
each Health Homes enrollee will be claimed. Enhanced FMAP may only be claimed for the first eight quarters after the
effective date of a Health Homes State Plan Amendment that makes Health Home Services available to a new population,
such as people in a particular geographic area or people with a particular chronic condition.
The State assures that there will be no duplication of services and payment for similar services provided under other
Medicaid authorities.

Health Homes Providers
Types of Health Homes Providers
Designated Providers
Indicate the Health Homes Designated Providers the State includes in its program and the provider qualifications and
standards:

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Physicians
Describe the Provider Qualifications and Standards:

Clinical Practices or Clinical Group Practices
Describe the Provider Qualifications and Standards:

Rural Health Clinics
Describe the Provider Qualifications and Standards:

Community Health Centers
Describe the Provider Qualifications and Standards:

Community Mental Health Centers
Describe the Provider Qualifications and Standards:

Home Health Agencies
Describe the Provider Qualifications and Standards:

Other providers that have been determined by the State and approved by the Secretary to be qualified as a health
home provider:
Case Management Agencies
Describe the Provider Qualifications and Standards:

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Community/Behavioral Health Agencies
Describe the Provider Qualifications and Standards:

Federally Qualified Health Centers (FQHC)
Describe the Provider Qualifications and Standards:

Other (Specify)
Teams of Health Care Professionals
Indicate the composition of the Health Homes Teams of Health Care Professionals the State includes in its program. For
each type of provider indicate the required qualifications and standards:
Physicians
Describe the Provider Qualifications and Standards:

Nurse Care Coordinators
Describe the Provider Qualifications and Standards:

Nutritionists
Describe the Provider Qualifications and Standards:

Social Workers
Describe the Provider Qualifications and Standards:

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Behavioral Health Professionals
Describe the Provider Qualifications and Standards:

Other (Specify)
Health Teams
Indicate the composition of the Health Homes Health Team providers the State includes in its program, pursuant to
Section 3502 of the Affordable Care Act, and provider qualifications and standards:
Medical Specialists
Describe the Provider Qualifications and Standards:

Nurses
Describe the Provider Qualifications and Standards:

Pharmacists
Describe the Provider Qualifications and Standards:

Nutritionists
Describe the Provider Qualifications and Standards:

Dieticians
Describe the Provider Qualifications and Standards:

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Social Workers
Describe the Provider Qualifications and Standards:

Behavioral Health Specialists
Describe the Provider Qualifications and Standards:

Doctors of Chiropractic
Describe the Provider Qualifications and Standards:

Licensed Complementary and Alternative Medicine Practitioners
Describe the Provider Qualifications and Standards:

Physicians' Assistants
Describe the Provider Qualifications and Standards:

Supports for Health Homes Providers
Describe the methods by which the State will support providers of Health Homes services in addressing the following components:
1. Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered Health Homes services,
2. Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice
guidelines,
3. Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and
substance use disorders,
4. Coordinate and provide access to mental health and substance abuse services,
5. 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,

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6. Coordinate and provide access to chronic disease management, including self-management support to individuals and
their families,
7. Coordinate and provide access to individual and family supports, including referral to community, social support, and
recovery services,
8. Coordinate and provide access to long-term care supports and services,
9. Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and nonclinical health-care related needs and services:
10. Demonstrate a capacity to 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. 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.
Description:

Provider Infrastructure
Describe the infrastructure of provider arrangements for Health Homes Services.

Provider Standards
The State's minimum requirements and expectations for Health Homes providers are as follows:

Health Homes Service Delivery Systems
Identify the service delivery system(s) that will be used for individuals receiving Health Homes services:
Fee for Service
PCCM
PCCMs will not be a designated provider or part of a team of health care professionals. The State provides assurance
that it will not duplicate payment between its Health Homes payments and PCCM payments.
The PCCMs will be a designated provider or part of a team of health care professionals.
The PCCM/Health Homes providers will be paid based on the following payment methodology outlined in the
payment methods section:
Fee for Service

Alternative Model of Payment (describe in Payment Methodology section)

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Other
Description:

Requirements for the PCCM participating in a Health Homes as a designated provider or part of a team of
health care professionals will be different from those of a regular PCCM.
If yes, describe how requirements will be different:

Risk Based Managed Care
The Health Plans will not be a Designated Provider or part of a Team of Health Care Professionals. Indicate how
duplication of payment for care coordination in the Health Plans' current capitation rate will be affected:
The current capitation rate will be reduced.

The State will impose additional contract requirements on the plans for Health Homes enrollees.

Provide a summary of the contract language for the additional requirements:

Other

Describe:

The Health Plans will be a Designated Provider or part of a Team of Health Care Professionals.
Provide a summary of the contract language that you intend to impose on the Health Plans in order to deliver the
Health Homes services.

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The State provides assurance that any contract requirements specified in this section will be included in
any new or the next contract amendment submitted to CMS for review.
The State intends to include the Health Homes payments in the Health Plan capitation rate.
Yes
The State provides an assurance that at least annually, it will submit to the regional office as part
of their capitated rate Actuarial certification a separate Health Homes section which outlines the
following:
• Any program changes based on the inclusion of Health Homes services in the health plan
benefits
• Estimates of, or actual (base) costs to provide Health Homes services (including detailed a
description of the data used for the cost estimates)
• Assumptions on the expected utilization of Health Homes services and number of eligible
beneficiaries (including detailed description of the data used for utilization estimates)
• Any risk adjustments made by plan that may be different than overall risk adjustments
• How the final capitation amount is determined in either a percent of the total capitation or an
actual PMPM
The State provides assurance that it will design a reporting system/mechanism to monitor the use
of Health Homes services by the plan ensuring appropriate documentation of use of services.
The State provides assurance that it will complete an annual assessment to determine if the
payments delivered were sufficient to cover the costs to deliver the Health Homes services and
provide for adjustments in the rates to compensate for any differences found.

No
Indicate which payment methodology the State will use to pay its plans:
Fee for Service
Alternative Model of Payment (describe in Payment Methodology section)
Other
Description:

Other Service Delivery System:

Describe if the providers in this other delivery system will be a designated provider or part of the team of health care professionals
and how payment will be delivered to these providers:

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The State provides assurance that any contract requirements specified in this section will be included in any new or
the next contract amendment submitted to CMS for review.

Health Homes Payment Methodologies
The State's Health Homes payment methodology will contain the following features:
Fee for Service
Fee for Service Rates based on:
Severity of each individual's chronic conditions
Describe any variations in payment based on provider qualifications, individual care needs, or the intensity
of the services provided:

Capabilities of the team of health care professionals, designated provider, or health team.
Describe any variations in payment based on provider qualifications, individual care needs, or the intensity
of the services provided:

Other: Describe below.

Provide a comprehensive description of the rate-setting policies the State will use to establish Health Homes
provider reimbursement fee-for-service rates. Explain how the methodology is consistent with the goals of efficiency,
economy and quality of care. Within your description, please explain: the reimbursable unit(s) of service, the cost
assumptions and other relevant factors used to determine the payment amounts, the minimum level of activities that
the State agency requires for providers to receive payment per the defined unit, and the State's standards and
process required for service documentation.

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Per Member, Per Month Rates
Provide a comprehensive description of the rate-setting policies the State will use to establish Health Homes
provider reimbursement fee for service or PMPM rates. Explain how the methodology is consistent with the goals of
efficiency, economy and quality of care. Within your description, please explain: the reimbursable unit(s) of service,
the cost assumptions and other relevant factors used to determine the payment amounts, the minimum level of
activities that the State agency requires for providers to receive payment per the defined unit, and the State's
standards and process required for service documentation.

Incentive payment reimbursement
Provide a comprehensive description of incentive payment policies that the State will use to reimburse in addition to
the unit base rates. Explain how the methodology is consistent with the goals of efficiency, economy and quality of
care. Within your description, please explain: the incentives that will be reimbursed through the methodology, how
the supplemental incentive payments are tied to the base rate activities, the criteria used to determine a provider's
eligibility to receive the payment, the methodology used to determine the incentive payment amounts, and the
frequency and timing through which the Medicaid agency will distribute the payments to providers.

PCCM Managed Care (description included in Service Delivery section)

Risk Based Managed Care (description included in Service Delivery section)

Alternative models of payment, other than Fee for Service or PM/PM payments (describe below)
Tiered Rates based on:
Severity of each individual's chronic conditions
Capabilities of the team of health care professionals, designated provider, or health team.
Describe any variations in payment based on provider qualifications, individual care needs, or the intensity of the
services provided:

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Rate only reimbursement
Provide a comprehensive description of the policies the State will use to establish Health Homes alternative models of
payment. Explain how the methodology is consistent with the goals of efficiency, economy and quality of care. Within
your description, please explain the nature of the payment, the activities and associated costs or other relevant factors
used to determine the payment amount, any limiting criteria used to determine if a provider is eligible to receive the
payment, and the frequency and timing through which the Medicaid agency will distribute the payments to providers.

Explain how the State will ensure non-duplication of payment for similar services that are offered through another method,
such as 1915(c) waivers or targeted case management.

The State provides assurance that all governmental and private providers are reimbursed according to the same rate
schedule
The State provides assurance that it shall reimburse Health Homes providers directly, except when there are employment
or contractual arrangements.

Submission - Categories of Individuals and Populations Provided Health Homes Services
The State will make Health Homes services available to the following categories of Medicaid participants:
Categorically Needy eligibility groups

Health Homes Services (1 of 2)
Category of Individuals
CN individuals
Service Definitions
Provide the State's definitions of the following Health Homes services and the specific activities performed under each
service:
Comprehensive Care Management
Definition:

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Describe how health information technology will be used to link this service in a comprehensive approach across
the care continuum:

Scope of benefit/service
The benefit/service can only be provided by certain provider types.
Behavioral Health Professionals or Specialists
Description

Nurse Care Coordinators
Description

Nurses
Description

Medical Specialists
Description

Physicians
Description

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Physicians' Assistants
Description

Pharmacists
Description

Social Workers
Description

Doctors of Chiropractic
Description

Licensed Complementary and Alternative Medicine Practitioners
Description

Dieticians
Description

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Nutritionists
Description

Other (specify):
Name

Description

Care Coordination
Definition:

Describe how health information technology will be used to link this service in a comprehensive approach across
the care continuum:

Scope of benefit/service
The benefit/service can only be provided by certain provider types.
Behavioral Health Professionals or Specialists
Description

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Nurse Care Coordinators
Description

Nurses
Description

Medical Specialists
Description

Physicians
Description

Physicians' Assistants
Description

Pharmacists
Description

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Social Workers
Description

Doctors of Chiropractic
Description

Licensed Complementary and Alternative Medicine Practitioners
Description

Dieticians
Description

Nutritionists
Description

Other (specify):
Name

Description

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Health Promotion
Definition:

Describe how health information technology will be used to link this service in a comprehensive approach across
the care continuum:

Scope of benefit/service
The benefit/service can only be provided by certain provider types.
Behavioral Health Professionals or Specialists
Description

Nurse Care Coordinators
Description

Nurses
Description

Medical Specialists

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Description

Physicians
Description

Physicians' Assistants
Description

Pharmacists
Description

Social Workers
Description

Doctors of Chiropractic
Description

Licensed Complementary and Alternative Medicine Practitioners
Description

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Dieticians
Description

Nutritionists
Description

Other (specify):
Name

Description

Health Homes Services (2 of 2)
Category of Individuals
CN individuals
Service Definitions
Provide the State's definitions of the following Health Homes services and the specific activities performed under each
service:
Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
Definition:

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Describe how health information technology will be used to link this service in a comprehensive approach across
the care continuum:

Scope of benefit/service
The benefit/service can only be provided by certain provider types.
Behavioral Health Professionals or Specialists
Description

Nurse Care Coordinators
Description

Nurses
Description

Medical Specialists
Description

Physicians

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Description

Physicians' Assistants
Description

Pharmacists
Description

Social Workers
Description

Doctors of Chiropractic
Description

Licensed Complementary and Alternative Medicine Practitioners
Description

Dieticians
Description

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Nutritionists
Description

Other (specify):
Name

Description

Individual and family support, which includes authorized representatives
Definition:

Describe how health information technology will be used to link this service in a comprehensive approach across
the care continuum:

Scope of benefit/service
The benefit/service can only be provided by certain provider types.
Behavioral Health Professionals or Specialists
Description

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Nurse Care Coordinators
Description

Nurses
Description

Medical Specialists
Description

Physicians
Description

Physicians' Assistants
Description

Pharmacists
Description

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Social Workers
Description

Doctors of Chiropractic
Description

Licensed Complementary and Alternative Medicine Practitioners
Description

Dieticians
Description

Nutritionists
Description

Other (specify):
Name

Description

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Referral to community and social support services, if relevant
Definition:

Describe how health information technology will be used to link this service in a comprehensive approach across
the care continuum.

Scope of benefit/service
The benefit/service can only be provided by certain provider types.
Behavioral Health Professionals or Specialists
Description

Nurse Care Coordinators
Description

Nurses
Description

Medical Specialists

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Description

Physicians
Description

Physicians' Assistants
Description

Pharmacists
Description

Social Workers
Description

Doctors of Chiropractic
Description

Licensed Complementary and Alternative Medicine Practitioners
Description

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Dieticians
Description

Nutritionists
Description

Other (specify):
Name

Description

Health Homes Patient Flow
Describe the patient flow through the State's Health Homes system. The State must submit to CMS flow-charts
of the typical process a Health Homes individual would encounter:

Medically Needy eligibility groups
All Medically Needy eligibility groups receive the same benefits and services that are provided to Categorically
Needy eligibility groups.
Different benefits and services than those provided to Categorically Needy eligibility groups are provided to some or
all Medically Needy eligibility groups.

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All Medically Needy receive the same services.
There is more than one benefit structure for Medically Needy eligibility groups.

Health Homes Monitoring, Quality Measurement and Evaluation
Monitoring
Describe the State's methodology for tracking avoidable hospital readmissions, including data sources and measurement
specifications:

Describe the State's methodology for calculating cost savings that result from improved coordination of care and chronic
disease management achieved through the Health Homes program, including data sources and measurement
specifications.

Describe how the State will use health information technology in providing Health Homes services and to improve
service delivery and coordination across the care continuum (including the use of wireless patient technology to improve
coordination and management of care and patient adherence to recommendations made by their provider).

Quality Measurement
The State provides assurance that it will require that all Health Homes providers report to the State on all
applicable quality measures as a condition of receiving payment from the State.
The State provides assurance that it will identify measureable goals for its Health Homes model and intervention
and also identify quality measures related to each goal to measure its success in achieving the goals.
States utilizing a health team provider arrangement must describe how they will align the quality measure reporting
requirements within section 3502 of the Affordable Care Act and section 1945(g) of the Social Security Act. Describe how
the State will do this:

Evaluations
The State provides assurance that it will report to CMS information submitted by Health Homes providers to inform the
evaluation and Reports to Congress as described in Section 2703(b) of the Affordable Care Act and as described by CMS.

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Describe how the State will collect information from Health Homes providers for purposes of determining the effect of the
program on reducing the following:
Hospital Admissions
Measure:
Measure Specification, including a description of the numerator and denominator.

Data Sources:

Frequency of Data Collection:
Monthly
Quarterly
Annually
Continuously
Other

Emergency Room Visits
Measure:
Measure Specification, including a description of the numerator and denominator.

Data Sources:

Frequency of Data Collection:
Monthly
Quarterly
Annually
Continuously
Other

Skilled Nursing Facility Admissions
Measure:
Measure Specification, including a description of the numerator and denominator.

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Data Sources:

Frequency of Data Collection:
Monthly
Quarterly
Annually
Continuously
Other

Describe how the State will collect information for purpose of informing the evaluations, which will ultimately determine the nature,
extent and use of the program, as it pertains to the following:
Hospital Admission Rates

Chronic Disease Management

Coordination of Care for Individuals with Chronic Conditions

Assessment of Program Implementation

Processes and Lessons Learned

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Assessment of Quality Improvements and Clinical Outcomes

Estimates of Cost Savings
The State will use the same method as that described in the Monitoring section.
If no, describe how cost-savings will be estimated.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1148. The time required to complete this information collection is
estimated to average 80 hours per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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