GenIC #22 - Health Home State Plan Amendment (SPA)

Consolidated Implementation Guide:
Medicaid State Plan – Health Homes
Health Homes Intro ________________________________________________________________ 1
POLICY CITATION __________________________________________________________________________
BACKGROUND ____________________________________________________________________________
General Assurances _____________________________________________________________________
INSTRUCTIONS ____________________________________________________________________________
Program Authority ______________________________________________________________________
Executive Summary _____________________________________________________________________
General Assurances _____________________________________________________________________
REVIEW CRITERIA__________________________________________________________________________

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Health Homes Population and Enrollment Criteria _______________________________________ 6
POLICY CITATION __________________________________________________________________________
BACKGROUND ____________________________________________________________________________
Eligible Population ______________________________________________________________________
Enrollment of Participants ________________________________________________________________
INSTRUCTIONS ____________________________________________________________________________
Categories of Individuals and Populations Provided Health Homes Services ________________________
Population Criteria ______________________________________________________________________
Enrollment of Participants ________________________________________________________________
REVIEW CRITERIA__________________________________________________________________________

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Health Homes Geographic Limitations ________________________________________________ 11
POLICY CITATION _________________________________________________________________________ 11
BACKGROUND ___________________________________________________________________________ 11
INSTRUCTIONS ___________________________________________________________________________ 11
Geographic Limitations _________________________________________________________________ 11
REVIEW CRITERIA_________________________________________________________________________ 12

Health Homes Services ____________________________________________________________ 13
POLICY CITATION _________________________________________________________________________ 13
BACKGROUND ___________________________________________________________________________ 13
INSTRUCTIONS ___________________________________________________________________________ 18
Service Definitions _____________________________________________________________________ 18
Health Homes Patient Flow ______________________________________________________________ 18
REVIEW CRITERIA_________________________________________________________________________ 18

Health Homes Providers ___________________________________________________________ 20
POLICY CITATION _________________________________________________________________________ 20
BACKGROUND ___________________________________________________________________________ 20
INSTRUCTIONS ___________________________________________________________________________ 23
Types of Health Homes Providers _________________________________________________________ 23
Provider Infrastructure __________________________________________________________________ 24
Supports for Health Homes Providers ______________________________________________________ 24

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Other Health Homes Provider Standards ___________________________________________________ 24
Upload Documents _____________________________________________________________________ 24
REVIEW CRITERIA_________________________________________________________________________ 24

Health Homes Service Delivery Systems _______________________________________________ 26
POLICY CITATION _________________________________________________________________________ 26
BACKGROUND ___________________________________________________________________________ 26
INSTRUCTIONS ___________________________________________________________________________ 27
REVIEW CRITERIA_________________________________________________________________________ 29

Health Homes Payment Methodologies _______________________________________________ 31
POLICY CITATION _________________________________________________________________________ 31
BACKGROUND ___________________________________________________________________________ 31
INSTRUCTIONS ___________________________________________________________________________ 33
Health Homes Payment Methodologies ____________________________________________________ 33
Agency Rates__________________________________________________________________________ 34
Rate Development _____________________________________________________________________ 34
Assurances ___________________________________________________________________________ 35
REVIEW CRITERIA_________________________________________________________________________ 35
Fee for Service ________________________________________________________________________ 35
Alternative Models of Payment ___________________________________________________________ 36
Assurances – Non-Duplication of Payment __________________________________________________ 36

Health Homes Monitoring, Quality Measurement and Evaluation __________________________ 38
POLICY CITATION _________________________________________________________________________ 38
BACKGROUND ___________________________________________________________________________ 38
INSTRUCTIONS ___________________________________________________________________________ 39
Monitoring ___________________________________________________________________________ 39
Quality Measurement and Evaluation ______________________________________________________ 39
Go to Quality Measure Reports ___________________________________________________________ 39
REVIEW CRITERIA_________________________________________________________________________ 39

Health Homes Program Termination – Phase-out Plan ___________________________________ 40
POLICY CITATION _________________________________________________________________________ 40
BACKGROUND ___________________________________________________________________________ 40
INSTRUCTIONS ___________________________________________________________________________ 40
REVIEW CRITERIA_________________________________________________________________________ 41

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Health Homes Intro

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to provide an executive summary of their Health
Homes program including the goals and objectives of the program, the population served,
provider requirements, services provided, and the service delivery model used in the program.
This section also covers general assurances related to Health Homes regulatory requirements
including a mandatory consult with SAMHSA, regardless of the targeted chronic conditions;
agreement to reporting on quality measures as a condition for payment; understanding that dualeligible beneficiaries cannot be excluded from a Health Home program; guaranteeing that
beneficiaries will be given a free choice of providers; assuring the active participation of local
hospitals; and ensuring non-duplication of services.
The Affordable Care Act of 2010, Section 2703, created an optional Medicaid State Plan benefit
for states to establish Health Homes to coordinate care for people with Medicaid who have
chronic conditions by adding Section 1945 of the Social Security Act. In 2010, a State Medicaid
Director Letter was released to expand upon the purpose of the benefit and the requirements for
implementation. The benefit is intended to enhance the integration of services and coordination
of care for beneficiaries with chronic illnesses across their lifespan. Health Homes must operate
under a “whole-person” philosophy and be responsible for coordinating primary and acute care,
behavioral health (mental health and substance use) and long term services and supports;
providing wellness support and transitional services; as well as linkages to community and social
support services.
Health Homes provide an opportunity for: improved access to primary care services; improved
prevention; early identification and intervention to reduce the incidence of serious physical
illnesses, including chronic disease; and increased availability of integrated, holistic care for
physical and behavioral disorders, as well as better overall health status for individuals. Health
Homes are expected to operate within a culture of continuous quality improvement to enhance
health outcomes and quality of life for individuals with chronic conditions by working with all of
the individual’s care providers, establishing prevention strategies, and having ways to support the
individual by educating and developing the knowledge and activities that support wellness.
States which elect to implement the Health Homes benefit will be able to define, within certain
parameters, the population of Medicaid beneficiaries with chronic conditions that they wish to
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target for Health Home services. States may also decide whether to provide their Health Homes
benefit statewide or only in certain geographic areas of the state. States electing the Health
Homes benefit will be required to cover a comprehensive package of Health Homes care
coordination services delivered by certain types of providers who meet specified qualifications
and standards. The Health Homes services are intended to be comprehensive and to enhance and
be integrated into the care otherwise needed and received by the beneficiary. States electing this
optional benefit are given considerable flexibility in designing and developing the delivery
system for Health Home services as well as in developing a payment methodology/s for those
services.
Health Home providers are required to report on health home quality measures to the state as a
condition of receiving payment. States electing the optional Health Homes benefit will be
required to collect, track/monitor and report information and data for the evaluation of the
program. States are also required to report utilization, expenditure and quality data for an interim
survey and an independent evaluation. States will have to work in concert with their Health
Homes providers to obtain the necessary information and data. Health Home quality measures
are an integral part of a larger payment and care delivery reform effort that focuses on quality
outcomes for enrollees. This data is reported in the Quality Measures section of the system.
States which elect to implement the Health Homes benefit will be able to define, within certain
parameters, the population of Medicaid beneficiaries with chronic conditions that they wish to
target for Health Home services. To be eligible for Health Homes services, a beneficiary must
have either: two or more chronic conditions; one chronic condition and are at risk for a second;
or a serious and persistent mental health condition. Chronic conditions identified in statute
include mental health, substance use disorder, asthma, diabetes, heart disease, and being
overweight (as evidenced by a BMI of >25). States may request that CMS approve other chronic
conditions for purposes of eligibility.
States electing the Health Homes benefit will be required to cover a comprehensive package of
Health Homes care coordination services including: comprehensive care management; care
coordination; health promotion; comprehensive transitional care/follow-up; patient and family
support; and referral to community and social support services. The Health Homes services are
intended to be comprehensive and to enhance and be integrated into the care otherwise needed
and received by the beneficiary.
Section 1945 of the Social Security Act permits states to waive the comparability provision
under the state plan at 1902(a)(10)(B) of the Act, which allows for Health Homes services to be
provided in a different amount, duration, and scope than services provided to individuals who are
not in the targeted Health Home population. States electing the Health Homes benefit must
cover, at a minimum, all Categorically Needy eligible individuals who have the chronic
conditions the state specified/selected in their SPA. Section 1945 does not mandate beneficiary
enrollment in the Health Homes program, so beneficiary enrollment in the program is voluntary.
The target population cannot be based on the age of the beneficiary and dual-eligibles cannot be
specifically excluded from the target population. Although the statute does not permit states to
target their Health Homes programs by age, we recognize that states have faced challenges
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developing Health Homes that serve both children and adults, and to address this challenge,
states may tailor their standards or specifications for Health Homes to meet the unique needs of
children and adult populations. For example, a state may adopt standards for designating
providers or for teams of health care professionals that require specialized provider qualifications
or team members when serving children, or that require systems and infrastructure that
coordinate with different types of community-based service providers. States may also identify
different providers for different age groups, for example: identifying providers who serve adults
and separately identifying providers who serve children. This could be done as two separate
Health Homes programs or within one program.
Health Homes services will be delivered by certain types of providers who meet specified
qualifications and standards. States have flexibility to determine eligible Health Homes
providers. Health Homes providers can be a designated provider; a team of health professionals;
or a health team, as described in section 3502 of the Affordable Care Act. States also have
considerable flexibility in designing and developing the delivery system for Health Homes
services as well as in developing a payment methodology/s for those services. States may also
decide whether to provide their Health Homes benefit statewide or only in certain geographic
areas of the state.
States will receive a 90 percent enhanced FMAP for the specific Health Home services in
Section 2703. The enhanced match does not apply to the underlying Medicaid services also
provided to individuals enrolled in a Health Home. The 90 percent enhanced match is in effect
for the first 8 quarters in which the program is operational, after which rates return to the regular
service match rate. A state may receive more than one period of enhanced match by expanding
the Health Home program geographically or by adding a new chronic condition, understanding
that they will only be allowed to claim the enhanced match for a total of 8 quarters for one
beneficiary.
States with one or more existing care management program must assure that there will be no
duplication of services and no duplicate payment for the same services as those provided through
the Health Home. Potential sources of duplication may include care management and/or care
coordination services provided under managed care, home and community-based services waiver
programs, and targeted case management programs. States must account for care management
services that are provided to Medicaid individuals through other program authorities, such as
CMMI demonstrations, and design their Health Home program to complement these services by
ensuring that Health Home services are distinct and are not duplicating existing care
management services.
When designing a Health Home program, states will need to consider strategies to avoid
duplication when an individual is eligible to receive care management/care coordination services
under separate program authorities. For example, under Health Homes, states may integrate the
existing care management services into Health Homes by allowing providers of the duplicative
services to be integrated within the Health Home structure. Some states have incorporated their
targeted case management providers into their Health Home program. Another strategy is to
allow an eligible individual to choose between the duplicative services/programs to avoid
duplication. However, if the state can clearly differentiate the care management and care
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coordination services provided by another provider (that is, a waiver case manager or a health
plan from the services provided by a Health Home), the beneficiary can receive services from
both providers without duplication.
General Assurances
States must assure that:
•

Eligible individuals will be given a free choice of Health Homes providers;

•

Individuals who are dually-eligible for Medicare and Medicaid will not be prevented
from receiving Health Homes services;

•

There will be no age restrictions and that Health Homes services will be made available
to all individuals who meet the eligibility criteria;

•

Participating hospitals 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. We expect that states will need to
communicate with hospitals and other stakeholders on the expectations for referring
eligible individuals to a Health Home. We interpret this section to mean that hospitals
will work with Health Homes to make referrals and to provide timely medical
information on potential or current Health Homes enrollees who have received medical
treatment at the hospital, whether through emergency room or inpatient admissions.
Health Homes providers must develop a working relationship with hospitals to assure that
information is shared and communicated efficiently to all community providers.

•

FMAP for Health Homes services shall be at 90% for the first eight fiscal quarters from
the effective date of the SPA. After the first eight quarters, expenditures will be claimed
at the regular matching rate;

•

The state will have systems in place so that only one 8-quarter period of enhanced FMAP
for each Health Homes enrollee will be claimed;

•

There will be no duplication of services and payment for similar services provided under
other Medicaid authorities. States with one or more existing care management program
must assure that there will be no duplication of services and no duplicate payment for the
same services as those provided through the Health Homes program.

INSTRUCTIONS
Program Authority
This section displays the following:
•

The statutory authority citation under which the Health Homes program may be
implemented (1945 of the Social Security Act).

•

A statement as to the state’s election to implement Health Homes.

•

The name of the Health Homes program either entered or selected in the Submission
Summary screen will display opposite “Name of Health Homes Program.”

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Executive Summary
You must provide a summary of the Health Homes program including the goals and objectives
of the program; the population, providers, services and service delivery model. This summary is
limited to 4000 characters.
General Assurances
In the last section, read and check the general assurances.

REVIEW CRITERIA
The state’s executive summary (description/explanation) of this Health Home program must
include the goals and objectives, population, providers, services and service delivery model
used for this Health Homes program.

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Health Homes Population and Enrollment Criteria

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to identify the population and chronic conditions it
plans to target and the method for enrolling beneficiaries into the Health Homes program being
described. (The Health Homes program name was either entered or selected previously in the
Submission Summary screen.)
Eligible Population
Section 1945 of the SSA permits states to waive the comparability provision under the state plan
at 1902(a)(10)(B) of the Act, which allows for Health Homes services to be provided in a
different amount, duration, and scope than services provided to individuals who are not in the
targeted Health Homes population. States electing the Health Homes benefit must cover, at a
minimum, all Categorically Needy eligible individuals who have the chronic conditions
specified/selected in their SPA.
The target population cannot be based on the age of the beneficiary and dual eligibles cannot be
specifically excluded from the target population. Although the statute does not permit states to
target their Health Homes programs by age, we recognize that states have faced challenges
developing Health homes that serve both children and adults, and to address this challenge, states
may tailor their standards or specifications for Health Homes to meet the unique needs of
children and adult populations. For example, a state may adopt standards for designating
providers or for teams of health care professionals that require specialized provider qualifications
or team members when serving children, or that require systems and infrastructure that
coordinate with different types of community-based service providers. States may also identify
different providers for different age groups, for example: identifying providers who serve adults
and separately identifying providers who serve children. This could be done as two separate
Health Homes programs or within one program.
Section 1945(h) of the Act sets forth the minimum criteria that an “eligible individual with
chronic conditions” must meet. The state must identify who is an “eligible individual with
chronic conditions.” The Statute defines the minimum criteria as follows: an individual who is
eligible for assistance under the state plan or under a waiver of such plan and has at least 2
chronic conditions; 1 chronic condition and is at risk of having a second chronic condition; or 1
serious and persistent mental health condition, per the state’s defined chronic condition
eligibility criteria.
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Health Home services can be provided to individuals who have chronic conditions, or categories
of conditions, specified under section 1945(h)(2) of the Act, but states may choose to include
other chronic conditions, as well. Specific chronic conditions, and categories of chronic
conditions, authorized under section 1945(h)(2) of the Act include the following: mental health
condition; substance use disorder; asthma; diabetes; heart disease; and being overweight, as
evidenced by having a body mass index (BMI) over 25.
While all individuals served must meet the minimum statutory criteria, in accordance with
section 1945(h)(1)(B) of the Act, states may elect to have a medical necessity test that makes
Health Homes services available only to individuals with higher severity of chronic or mental
health conditions.
Enrollment of Participants
The state, health care providers and hospitals may refer individuals to the Health Homes
providers. Individuals may choose among the qualified Health Homes providers, and may
change or disenroll at any time. However, individuals may only receive Health Homes services
from one provider in a given period of time. Enrollment must be documented by the provider,
and that documentation should at a minimum indicate that the individual has received required
information explaining the Health Homes program and has consented to receive the Health
Homes services noting the effective date of their enrollment.
Section 1945 does not mandate beneficiary enrollment in the Health Homes program, so
beneficiary enrollment in the program is voluntary. Consistent with Medicaid state plan
requirements, eligible individuals must be allowed the choice of a qualified Health Homes
provider. While states may refer eligible individuals to a qualified Health Homes provider,
enrollment of the individual would occur only if the individual consents and is accepted by the
Health Homes provider. The state must allow an individual to change Health Homes providers
or to opt out of receiving the Health Homes services at any time.
Eligible individuals may receive Health Homes services from any qualified and willing Health
Homes provider, however, an eligible individual may only be enrolled with one Health Homes
provider at a time. To assist individuals in obtaining services, the state may refer eligible
individuals to particular Health Homes providers based on geographic area, established
relationship with a provider, or other criteria, but must inform individuals of the option to receive
such services from other qualified providers (if there are any). Eligible individuals may also be
referred to a Health Homes program by a hospital or other health care provider. The eligible
individual must provide active consent to enroll in that Health Homes program and must be
allowed to change Health Homes providers or opt out of the service at any time.
The state will need to make sure that the Health Homes providers maintain documentation
indicating that the individual has, in fact, enrolled and given consent to participate in the Health
Homes program. This documentation should, at a minimum, indicate that the individual has
received required information explaining the Health Homes program and the date that the
individual enrolled in the program. Documentation of the individual’s enrollment, and of any
subsequent disenrollment, must be maintained in the enrollee’s health record by the Health
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Homes provider. The Health Homes provider should notify the state of the disenrollment and
cease Health Homes billing for the disenrolled person.

INSTRUCTIONS
Categories of Individuals and Populations Provided Health Homes Services
Identify and select the categories or groups of individuals for whom the Health Homes program
will be available:
•

The state must cover all Categorically Needy (mandatory and options for coverage)
eligibility groups (i.e., CN individuals who have the chronic conditions specified by the
state) in their Health Homes program. The system, therefore, will automatically indicate
that Health Homes services will be available to all the Categorically Needy eligibility
groups. (Note that the state cannot elect to cover Categorically Needy groups or
individuals based on their age. Also, dual-eligibles cannot be excluded from the target
population.)

•

If the state has a Medically Needy program, and it will also be covering Medically Needy
eligibility groups in its Health Homes program, you must select the Medically Needy
Eligibility Groups option.

•

If Medically Needy Eligibility Groups is selected:
o The following groups will display as pre-selected:
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Medically Needy Pregnant Women

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Medically Needy Children under Age 18

o Additional groups (Optional Medically Needy) will display as options for
selection. Select any of these groups as included in the population of this Health
Homes program.
Population Criteria
In this section, select the target population of individuals with chronic conditions that will be
served by this Health Homes program.
•

Select one or more of the following three options:
o Individuals with two or more chronic conditions,
o Individuals with one chronic condition with the risk of developing another
chronic condition,
o Individuals with one serious and persistent mental health condition.



If “Two or more chronic conditions” was selected as a target population:
o A list of chronic conditions will display.
 Select one or more of these options to indicate which chronic conditions are
included in the population for this Health Homes program.
 Select “Other” if there is a chronic condition included in the program that is
not listed.

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o Enter the name of the chronic condition and briefly describe why it is
considered chronic and how Health Homes services will help improve
overall care and reduce costs for these individuals. You may add more
than one “Other” chronic condition.




If “One chronic condition and the risk of developing another” was selected as a target
population:
o A list of chronic conditions will display.
 Select one or more of these options
 Select “Other” if there is a chronic condition included for this criterion that is
not listed.
o Enter the name of the chronic condition and briefly describe why it is
considered chronic and how Health Homes services will help improve
overall care and reduce costs for these individuals. You may add more
than one “Other” chronic condition.
 Briefly describe the criteria for determining that the individual is at risk of
developing another chronic condition and how Health Homes services will
help improve overall care and reduce costs for these individuals.
If “One serious and persistent mental health condition” was selected as a target
population:
o Specify the criteria for identifying the serious and persistent mental health
condition and briefly describe why it is considered serious and persistent and how
Health Homes services will help improve overall care and reduce costs for these
individuals.

Enrollment of Participants
In this section, indicate which one of the following methods will be used to enroll eligible
individuals into the Health Homes program. Only one selection may be made.
•
•

•

Opt-in to Health Homes provider
o If this is selected, describe the process used in the text box provided.
Referral and assignment to Health Homes provider with opt-out
o If this is selected, describe the process used in the text box provided.
o Check the assurance that the state will clearly communicate the individual’s right
to opt out or to change providers.
o Upload a copy of any letters or other communications used to information
individuals of their rights. At least one document must be uploaded, and more
than one may be uploaded.
Other
o If this is selected, describe the process used in the text box provided.

REVIEW CRITERIA
Review Criteria for Population Section: The state’s description/explanation for considering a
condition chronic, determining an individual at risk for developing a chronic condition, or
considering a mental health condition serious and persistent plus its explanation for how
Health Homes services will improve care and reduce costs for such individuals, should be
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sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s
election meets applicable federal statutory, regulatory and policy requirements. One thing to
note is that while states are not permitted to select a target population based on the age of the
individual, there are a number of chronic conditions and serious and persistent mental health
conditions that involve or impact individuals generally within a certain age range (e.g.,
juvenile diabetes, juvenile rheumatoid arthritis, adult-onset diabetes, Alzheimer’s disease,
etc.). If a state selects a chronic disease or condition that is a well-recognized and established
condition by the medical profession, then the condition should be acceptable for population
targeting under the Health Homes benefit. If the state specifically selects an age range or a
chronic condition based on age that is not a recognized or established chronic condition (e.g.,
individuals 65 and older with congestive heart failure or adult onset congestive heart failure),
then this would be unacceptable.
Review Criteria for Enrollment Section: During the SPA review process, states will need to
explain their enrollment process including how they determine eligible enrollees and how they
inform and educate eligible enrollees. For example, individuals eligible for Health Homes
services may be identified through claims or encounter data, referrals from providers, or any
other system the state has developed to identify those who would benefit from Health Homes
services.
The information should clarify that selection of a Health Homes provider is optional, that the
individual may have other choices of Health Homes providers and explain that the individual
may disenroll from a Health Homes provider at any time. This information should also
explain that the Health Homes program will not restrict access to providers or limit access to
other Medicaid benefits.
Regardless of which option is selected, the enrollment is considered voluntary and the eligible
individual must agree to receive Health Homes services and provide consent that would be
maintained in the enrollee’s health record.

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Health Homes Geographic Limitations

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to identify the geographic limitations, if any, to be
imposed by the state on the population included in the Health Homes program.
States are able to target their Health Homes program geographically. The statewide provision at
1902(a)(1) is waived by section 1945, so states may elect to have their Health Homes program
operate statewide or only in specific geographic regions of the state. Unlike traditional state plan
benefits, Health Homes do not have to be provided on a statewide basis. If the state provides
Health Homes less than statewide, the state must specify the geographic areas in which the
services will be offered in the state plan. States may also choose to phase-in their Health Homes
programs geographically by adding one phase at a time. States may start with the first phase
when they create the Health Homes programs and then amend their state plan to add new
geographic areas over time. As new geographic areas are added to the state plan, the state
receives a new period of enhanced match for the beneficiaries receiving Health Home services in
the new coverage area.

INSTRUCTIONS
Geographic Limitations
In this section, indicate if the services for this Health Homes programs will be provided
statewide from the beginning, permanently limited to certain geographic areas, or phased-in by
geographic area to eventually be statewide. Select one of the following three options:
•

Health Homes services will be available statewide.

•

Health Homes services will be limited to the following geographic areas.

•

Health Homes services will be provided in a geographic phased-in approach.

If Health Homes services will be limited to the following geographic areas is selected, select the
option which best describes the limited geographic area.
•

If county is selected, indicate in which counties the services will be available by entering
the county names, one by one. As you start typing, a pop-up list will display county
names for you to choose from.

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•

If region or other geographic area is selected, describe the region(s) or other geographic
area(s).

•

If city/municipality is selected, enter the name(s) of the city(ies) and/or municipality(ies).

If Health Homes services will be provided in a geographic phased-in approach is selected, enter a
description of each phase, one at a time, by clicking on the Add Phase button. The first phase
should be entered when the program starts. Enter subsequent phases by amending the program –
one additional phase per Submission Package.


For each phase:
o Enter the date the phase will be implemented.
o Select the option which best describes the geographic area designated for that
phase, following the instructions described above. Indicate whether, with this
phase, Health Homes services become available state-wide.


For the phase where the answer to this question is Yes, enter the effective
date of the state-wide implementation.

o Enter any additional information you believe would clarify how the phase will be
accomplished. This field is optional.


When you are ready to enter another phase (under a new Submission Package), click the
Add Phase button and follow the steps above.

REVIEW CRITERIA
States will need to identify whether the Health Homes benefit will be made available statewide
or be limited to certain geographic areas in the state. In this section the state will need to be
strategic about how they plan to phase-in their Health Homes benefit statewide, if they intend
to do so. Ensure that only one new phase is added with each Submission Package.

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Health Homes Services

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to define the six types of Health Homes services that
are statutorily required to be provided by each Health Homes provider arrangement and covered
under the Health Homes benefit. The state also will describe how health information technology
will be used to link each Health Homes service in a comprehensive approach across the care
continuum, including a flow chart illustrating how Health Homes services will be integrated into
the overall care received by the beneficiary.
Section 1945(h)(4) of the Act defines Health Homes services as “comprehensive and timely high
quality services,” and includes the following list of services to be provided by Health Homes
providers. Health Homes must provide all six of the required Health Homes services, based on
the individual’s needs as appropriate:
•

Comprehensive Care Management
Comprehensive Care Management means the initial and ongoing assessment and care
management services aimed at the integration of primary, behavioral and specialty health
care and community support services, using a comprehensive person-centered care plan
which addresses all clinical and non-clinical needs and promotes wellness and
management of chronic conditions in pursuit of optimal health outcomes.
Comprehensive care management services include, but are not limited to the following
activities:
o Conducting outreach and engagement activities to gather information from the
enrollee, the enrollee’s support member(s), and other primary and specialty care
providers.
o Completing a comprehensive needs assessment.
o Developing a comprehensive person-centered care plan.
The comprehensive assessment includes current and historical information provided by
the enrollee, as well as information received from available health care records, input
received through consultation with other health care providers and the enrollee’s support
member, and assessments performed by telemedicine or other information technology
medium as appropriate.

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The comprehensive assessment includes a physical examination, behavioral assessment,
medication reconciliation, functional limitations, screenings as deemed appropriate,
assessment of clinical and social support needs, and any “at risk” concerns. Information
received from the comprehensive assessment then serves as the basis for the personcentered care plan.
The comprehensive needs assessment should be conducted at least every 12 months (or
more frequently as needed), when the individual’s needs or circumstances change
significantly, or at the request of the enrollee or the enrollee’s support member.
•

Care Coordination
Care Coordination means facilitating access to, and the monitoring of, services identified
in a person-centered care plan to manage chronic conditions for optimal health outcomes
and to promote wellness. Care coordination includes the facilitation of the
interdisciplinary teams to perform a regular review of person-centered care plans and
monitoring service delivery and progress toward goals. This is accomplished through
face-to-face and collateral contacts with the Health Homes enrollee, family, informal and
formal caregivers, and with primary and specialty care providers. It also includes
facilitation and sharing of centralized information to coordinate integrated care by
multiple providers through use of electronic health records (EHRs) that can be shared
among all providers.
Care coordination services include, but are not limited to, the following activities:
o Implementing the person-centered care plan.
o Continuous monitoring of progress towards goals identified in the personcentered care plan through face-to-face and collateral contacts with enrollee,
enrollee’s support member(s) and primary and specialty care providers.
o Supporting the enrollee’s adherence to prescribed treatment regimens and
wellness activities.
o Participating in hospital discharge processes to support the enrollee’s transition to
a non-hospital setting.
o Communicating and consulting with other providers and the enrollee and
enrollee’s support member, as appropriate.
o Facilitating regularly scheduled interdisciplinary team meetings to review care
plans and assess progress.
The person-centered care plan serves as the basis for the coordination of care among
Health Homes providers. The Health Homes interdisciplinary team develops a personcentered care plan jointly with each Health Homes enrollee consistent with §441.725.
The care plan is to be developed by a licensed health care professional for the Health
Homes program, in collaboration with the Health Homes enrollee, and individuals chosen
by the enrollee to serve as contributors to the planning process. In addition, it must
include input from an interdisciplinary team and other key providers (the individual’s
primary care physician, nurse care manager, behavioral health providers, social work
professionals and other providers as appropriate) to assess and evaluate the health,
behavioral health, and long term services and supports, as well as the social needs of the
14

participant. The proposed requirements for the person-centered care plan are consistent
with those required in the January 16, 2014 HCBS final rule. We expect that the personcentered care plan reflects what is important to the individual and important for his or her
health and welfare and is developed at a time and location of convenience to the Health
Homes enrollee. The plan reflects the Health Homes enrollee’s values and preferences,
and current and long term needs and goals for care and specifies the types and frequency
of all planned health, rehabilitation, behavioral health treatments, medications, home care
services and supports and other services as needed. The plan also identifies who is
responsible for providing each service and any areas that may require further follow up or
revisions to the plan. The plan must be accessible to the Health Homes enrollee and the
Health Homes team.
•

Health Promotion
Health Promotion means the education and engagement of an individual in making
decisions that promote his/her maximum independent living skills and lifestyle choices
that achieve the following goals: good health, pro-active management of chronic
conditions, early identification of risk factors, and appropriate screening for emerging
health problems.
Health promotion services include, but are not limited to, the following activities:

o
o
o
o

•

Promoting enrollee’s education of their chronic condition.
Teaching self-management skills.
Conducting medication reviews and regimen compliance.
Promoting wellness and prevention programs by assisting Health Homes enrollees
with resources that address exercise, nutrition, stress management, substance use
reduction/cessation, smoking cessation, self-help recovery resources, and other
wellness services based on enrollee needs and preferences.

Comprehensive Transitional Care from Inpatient to Other Settings (including appropriate
follow-up)
Comprehensive Transitional Care means the facilitation of services for the individual and
family/caregiver when the individual is transitioning between levels of care (including,
but not limited to hospital, nursing facility, rehabilitation facility, community based group
home, family or self-care) or when an individual is electing to transition to a new Health
Homes provider. This involves developing relationships with hospitals and other
institutions and community providers to ensure and to foster the efficient and effective
care transitions. Health Homes should establish a written protocol on the care transition
process with hospitals (and other community-based facilities) to set up real time sharing
of information and care transition records for Health Homes enrollees.
Comprehensive transitional care services include, but are not limited to, the following
activities:
o Establishing relationships with hospitals, residential settings, rehabilitation
settings, other treatment settings, and long term services and supports providers to

15

o

o

o

o

•

promote a smooth transition if the enrollee is moving between levels of care and
back into the community.
This includes prompt notification and ongoing communication of enrollee’s
admission and/or discharge to and from an emergency room, inpatient residential,
rehabilitative or other treatment settings.
If applicable, this relationship should also include active participation in discharge
planning with the hospital or other treatment settings to ensure consistency in
meeting the goals of the enrollee’s person-centered care plan;
Communicating and providing education to the enrollee, the enrollee’s support
member and the providers that are located at the setting from which the person is
transitioning, and at the setting to which the individual is transitioning.
Developing a systemic protocol to assure timely access to follow-up care post
discharge that includes at a minimum all of the following:
 Receipt of a summary of care record from the discharging entity.
 Medication reconciliation.
 Reevaluation of the care plan to include and provide access to needed
community support services.
 A plan to ensure timely scheduled appointments.

Individual and Family Support (which includes authorized representatives)
Individual and family supports mean the coordinating of information and services to
support enrollees and the enrollee’s support members to maintain and promote the quality
of life, with particular focus on community living options.
Individual and family support services include, but are not limited to, the following
activities:
o Providing education and guidance in support of self-advocacy.
o Providing caregiver counseling or training to include, skills to provide specific
treatment regimens to help the individual improve function, obtain information
about the individual’s disability or conditions, and navigation of the service
system.
o Identifying resources to assist individuals and family support members in
acquiring, retaining, and improving self-help, socialization and adaptive skills.
o Providing information and assistance in accessing services such as: self-help
services, peer support services; and respite services.

•

Referral to Community and Social Support Services
Referral to community/social supports means the provision of information and assistance
for the purpose of referring enrollees and enrollee support members to community based
resources, regardless of funding source, that can meet the needs identified on the
enrollee’s person-centered care plan.

16

Referrals to community/social support services include, but are not limited to, the
following activities:
o Providing referral and information assistance to individuals in obtaining
community based resources and social support services;
o Identifying resources to reduce barriers to help individuals in achieving their
highest level of function and independence.
o Monitoring and follow up with referral sources, enrollee, and enrollee’s support
member, to ensure appointments and other activities, including employment and
other social community integration activities, were established and enrollees were
engaged in services.
Based on the statute and the 2010 State Medicaid Director’s (SMD) letter, each type of Health
Homes provider arrangement (Designated Provider, Team of Health Care Professionals and
Health Team) in a state’s Health Homes program must be able to provide the six core Health
Homes services identified in section 1945(h)(4) in order to assure that beneficiaries receive
comprehensive, coordinated, and high quality care throughout their lifespan, using a personcentered care process. Both section 1945 and the SMD letter mention the importance of using
health information technology in delivering coordinated care and meeting the purpose of the
Health Homes benefit.
The Health Homes service delivery model effectively transforms the way care has traditionally
been provided by coordinating care and focusing on the goals of maintaining and protecting
wellness. Health Homes provide an opportunity to transition away from the traditional model of
chronic illness care. Under the traditional model, separate providers treat symptoms on an
individual and episodic basis as they occur, without necessarily coordinating care for multiple
symptoms and considering the overall causes and implications of the chronic condition. The
Health Homes program is focused on activities that maintain wellness and improve overall health
quality through coordinated care for all the individual’s needs. It is important to note that even if
a state has not elected to target individuals with mental illness or substance use disorders, the
state must specify how it plans to meet the enrollee’s behavioral health needs.
Health Homes services do not replace treatment of chronic conditions which is otherwise
covered under Medicaid; instead, Health Homes services coordinate and support such treatment
to ensure that the result is better health and quality of life. The Health Homes providers must
work with all of the individual’s care providers, establish prevention strategies, and have ways to
support individuals by educating and developing the knowledge and activities that support
lifestyle changes. Health Homes are the support system that encourages the Health Homes
enrollee to be educated about their chronic condition and to take control of their own wellbeing
by partnering with their providers, health coaches, and others to get the outcomes they want for
themselves.
Key to the success of care coordination is the ability to engage the individual and build trust and
support on an ongoing basis. We want to emphasize the importance of engaging the Health
Homes enrollee to achieve successful health outcomes. Health Homes team members may need
to meet with the Health Homes enrollee multiple times in person in their home or in a
community setting to build trust and establish a relationship.
17

INSTRUCTIONS
Service Definitions
Indicate whether or not the common Health Homes services definition, as noted in the
background section, is used. If not, provide a detailed definition of the service, including the
specific activities to be performed under the service. Regardless of which definition is used:
• Clearly explain how it will operate under a whole-person approach to care.
• Describe how the approach to care will be person-centered, taking into account each
person’s unique needs, culture, values and preferences, with the person involved in
the care plan.
• Describe the comprehensive team-based approach to care provided by a cohesive
team, including:
o The roles and responsibilities of team members;
o How primary and behavioral health will be integrated;
o Describe how the team will coordinate care across all elements of the
health care system and provide the linkages to medical and social
resources in the community.
Describe how health information technology will be used to link each service in a comprehensive
approach across the continuum of care.
Describe the scope of services, by provider types.
• Select one or more provider types that can provide the Health Homes service and
enter a description of each provider type selected.
• If “Other” is selected, enter the provider type in addition to a description.
• More than one “Other” provider type may be entered
Health Homes Patient Flow
Describe a typical patient’s flow through the Health Homes system, including how Health
Homes services are integrated into the overall care received by the beneficiary. Upload via the
“Saved Documents” feature one or more flow-charts which describe this process. At least one
flow-chart is required.

REVIEW CRITERIA
The description for each of the Health Homes services should clearly explain how it will
operate under a whole-person approach to care. The descriptions should include how the
approach to care will be person-centered, taking into account each person’s unique needs,
culture, values and preferences, with the person involved in the care plan. There needs to be a
comprehensive, team-based approach to care provided by a cohesive team that includes a
description of how the team will operate, the roles and responsibilities of each team member,
and how primary and behavioral health will be integrated. The description needs to include
how the team will coordinate care across all elements of the health care system and provide
the linkages to medical and social resources in the community.
CMS will review state service definitions and compare them to the defined Health Homes
services identified above in the Background section, which were developed based upon the
18

experience from approved Health Homes programs. The activities identified under each
service definition should be incorporated into the state’s definitions to achieve a common
approach to the delivery of Health Homes services.
The state’s description of how health information technology will be used to link each Health
Homes service should be sufficiently clear, detailed, and complete to permit the reviewer to
determine that the state’s election meets applicable federal statutory, regulatory and policy
requirements.

19

Health Homes Providers

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to select/identify the types of providers of Health
Homes services to be included in its Health Homes program and for the state to describe the
standards and qualifications that these Health Homes providers must meet in order to participate
in the program. The state will also describe how its Health Homes providers will be able to
provide timely, comprehensive, and high-quality Health Homes services and how the state will
support providers in this effort.
Section 1945(a) of the Act describes three distinct types of Health Homes provider arrangements
from which a beneficiary may receive Health Homes services: designated providers, as defined
in section 1945(h)(5) of the Act; a team of health care professionals, which links to a designated
provider, as defined in section 1945(h)(6) of the Act; and a health team, as defined in section
1945(h)(7) of the Act. Note that section 1945(h)(7) defines Health Team to have the same
meaning given health teams in section 3502 of the ACA.
Section 1945(h)(5) of the Act includes examples of providers that may qualify as a “designated
provider,” such as physicians, clinical practices or clinical group practices, rural health clinics,
community health centers, community mental health centers, home health agencies, or any other
entity or provider (including pediatricians, gynecologists, and obstetricians) that is determined
appropriate by the state and approved by the Secretary. The statutory list, therefore, is not an
exhaustive list. States may include additional providers in this category, meeting the criteria of
section 1945(h)(5) of the Act. States will need to identify all designated providers in its SPA.
As discussed in more detail below, each designated provider must have the systems and
infrastructure in place to provide Health Home services and to be able to satisfy the core Health
Homes functions and service delivery principles.
States will be expected to develop a Health Home model of service delivery that has designated
providers operating under a whole-person approach to care within a culture of continuous quality
improvement. A whole-person approach to care looks at all the needs of the person. Providers of
Health Homes services are expected to use a person-centered planning approach to identifying
needed services and supports, providing care and linkages to care that address all of the clinical
and non-clinical care needs of an individual. Health Home providers must agree to report on the
health home quality measures as a condition of receiving payment for health home services. In
addition, Health Homes must have mechanisms in place to share health information, link
services, facilitate communication among the interdisciplinary team members and other
20

providers to coordinate care and improve service delivery across the care continuum. States will
need to describe the provider infrastructure and how their providers will meet the Health Homes
core functions and service delivery requirements, and incorporate them into the state’s provider
standards.
States will need at a minimum, to include a designated provider or team of health care
professionals that includes, employs, contracts with, or otherwise has access to interdisciplinary
teams that consist of the following:
(1) Primary care physician/nurse practitioner;
(2) Nurse;
(3) Behavioral health care provider;
(4) Social work professional; and
(5) Other providers appropriate for the condition of the enrollees.
For each kind of provider/practitioner the state includes in it Health Homes program, the state
will need to describe the qualifications and standards that each must meet in order to participate
in its program.
States are expected to describe the infrastructure in place to provide timely, comprehensive,
high-quality Health Homes services. The state also will need to describe the methods by which
the state will support providers of these services in addressing the following core functional
components.
Health Home Core Functional Components:
•
•
•
•
•

•
•
•
•

Provide quality-driven, cost-effective, culturally appropriate, and person- and familycentered health home services;
Coordinate and provide access to high-quality health care services informed by evidencebased clinical practice guidelines;
Coordinate and provide access to preventive and health promotion services, including
prevention of mental illness and substance use disorders;
Coordinate and provide access to mental health and substance abuse services;
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;
Coordinate and provide access to chronic disease management, including selfmanagement support to individuals and their families;
Coordinate and provide access to individual and family supports, including referral to
community, social support, and recovery services;
Coordinate and provide access to long-term care supports and services;
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;

21

•
•

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; and
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.

Section 1945(b) of the Act directed the Secretary to establish standards for qualification as a
designated provider of Health Home services. CMS is sharing Health Home service delivery
principles to assist States who are submitting Health Home SPAs. CMS has worked
collaboratively with States implementing Health Homes to assure that the benefit aligns with the
requirements in 1945 of the Act. In reviewing best practices and lessons learned from states
with approved Health Home SPAs, several states require designated Health Homes providers to
obtain certification from a national accrediting organization as a patient-centered medical
home/Health Home or meet state specific certification standards similar to those of a national
accrediting organization.
To support the key Health Home service delivery system principles, CMS recommends that
Health Home providers use one of the following options:
•
•

Meet state specific standards for a patient-centered medical home/Health Home
which, at a minimum, encompass the health home delivery system requirements
(listed below), or
At state option, be accredited by a national accreditation organization that has
standards equal to or more stringent than applicable state-specific standards.

Health Homes Service Delivery System Principles:
•
•
•
•

•
•

Demonstrate clinical competency for serving the complex needs of health home
enrollees using evidence based protocols.
Demonstrate the ability for effectively coordinating the full range of medical,
behavioral health, long-term services and supports, and social services for medically
complex individuals with chronic conditions.
Provide health home services that operate under a “whole-person” approach to care
using a comprehensive needs assessment and an integrated person-centered care
planning process to coordinate care.
Have conflict of interest safeguards in place to assure enrollee rights and protections
are not violated, and that services are coordinated in accordance with enrollee needs
expressed in the person-centered care plan, rather than based on financial interests or
arrangements of the health home provider.
Provide access to timely health care 24 hours a day, 7 days a week to address any
immediate care needs of their health home enrollees.
Have in place operational protocol, as well as communication procedures to assure
care coordination across all elements of the health care system (hospitals, specialty
providers, social service providers, other community based settings, etc.).

22

•
•

•
•

Have protocols for ensuring safe care transitions, including established agreements
and relationships with hospitals and other community based settings.
Establish a continuous quality improvement program that includes a process for
collection and reporting of health home data for quality monitoring and program
performance; permits evaluation of increased coordination and chronic disease
management on individual-level clinical outcomes, experience of care outcomes, and
quality of care outcomes at the population level.
Use data for population health management, tracking tests, referrals and follow-up,
and medication management.
Use health information technology to link services and facilitate communication
among interdisciplinary team members and other providers to coordinate care and
improve service delivery across the care continuum.

Finally, if the state is involved in other types of care coordination or medical home projects or
initiatives, which impose additional or other requirements on the Medicaid Health Homes
program, the state will be asked to identify and specify these additional requirements. States are
expected to describe how these standards align with the Health Homes delivery system
principles, and/or have been modified to address the specific Health Homes services States will
also be asked to describe how their model will avoid duplication with other care coordination
programs.
It is important to note that each Health Homes/provider type arrangement must have the
capability of providing all six of the Health Homes services identified in the Health Homes
Services screen, and that all payments for Health Homes services will be paid to the single entity
that is qualified by the state as the Health Homes provider or the entity that is permitted to
receive payments on behalf of the Health Homes provider. This will be described in more detail
in the Health Homes Payment Methodologies and Health Homes Services screens.

INSTRUCTIONS
Types of Health Homes Providers
Select one or more of the following three types of Health Homes provider arrangements that can
participate in the Health Homes program:
•
•
•

Designated Providers
Teams of Health Care Professionals
Health Teams.

For each type of Health Homes provider arrangement selected, select from the list provided the
specific kinds of professionals/practitioners or providers who are qualified to participate in the
program.
For each specific kind of professional/provider selected, describe the qualifications and standards
that must be met in order for that kind of professional/provider to participate in the Health
Homes program, including professional degrees, certifications and licenses to practice in the
state and the capability to provide all of the following required Health Homes services:
23

•
•
•
•
•
•

Comprehensive care management
Care coordination
Health Promotion
Comprehensive transitional care from inpatient to other settings (including appropriate
follow-up)
Individual and family support (which includes authorized representatives)
Referral to community and social support services

If the list of professionals/providers under Designated Providers or Teams of Health Care
Professionals does not include a kind that is used in the program, select “Other” and enter the
provider type in addition to a description of the provider qualifications and standards. You may
add more than one “Other.”
If Health Teams is selected, in addition to selecting one or more of the kinds of
professional/provider listed, also check the assurance, “The state provides assurance that it will
align the quality measure reporting requirements within section 3502 of the Affordable Care Act
and section 1945 of the Social Security Act.”
Provider Infrastructure
Describe how the infrastructure of the selected Health Homes provider arrangements will meet
the eleven core functional components of a Health Homes program identified by CMS in its
SMD letter as being critical in assuring timely, comprehensive, and high-quality Health Homes
services. (The eleven core functional components of a Health Homes program are listed above in
the Background section.) In addition, states will need to address how their providers will adhere
to the Health Homes service delivery system principles, also listed above in the Background
section.
Supports for Health Homes Providers
Describe the methods by which the state will support the Health Homes providers in addressing
each of the eleven components of a Health Homes program identified by CMS as being critical
in assuring timely, comprehensive and high-quality Health Homes services.
Other Health Homes Provider Standards
Describe the state’s requirements and expectations for Health Homes providers. Indicate how
these requirements align with the key Health Homes expectations, and how they address specific
Health Homes services.
Upload Documents
At the state’s option, upload any provider standards documents which support the descriptions
provided of provider standards and qualifications. More than one document may be uploaded.

REVIEW CRITERIA
Provider Qualifications: The descriptions of the providers’ qualifications and standards must
include appropriate professional degrees, certifications and licenses to practice in the state,
and the capability to provide all six Health Homes services, as well as to meet expectation of
24

high quality care. The descriptions of the providers’ qualifications should also include an
explanation of how they are consistent with the Health Homes Service Delivery System
Principles, described in the Background section.
Infrastructure: The description of the infrastructure of provider arrangements must include
how they will meet the eleven core functional components identified as being critical in
assuring timely, comprehensive and high-quality Health Homes services. In addition, states
will need to address how their providers will adhere to the Health Home Service Delivery
System Principles. Include in the description providers who may not be employed by the
Health Homes program but to whom enrollees may be referred for needed services.
Supports for Health Homes Providers: The description of the methods by which the state will
support the Health Homes providers must include how the state will support the providers in
addressing each of the eleven core functional components of a Health Homes program
identified by CMS as being critical in assuring timely, comprehensive and high-quality Health
Home services.
Other Health Homes Provider Standards: The description of other requirements and
expectations should include how the requirements align with the key Health Homes
expectations, and how they address specific Health Home services.

25

Health Homes Service Delivery Systems

POLICY CITATION
Statute: 1945 of the SSA
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to identify the type(s) of service delivery system(s) that
will be used for individuals receiving Health Homes services. Depending on the type of service
delivery system to be used, in this screen states may also be asked to specify the payment
methodology, as well as to provide assurances and descriptions of the service delivery system(s).
Health Homes providers must have an infrastructure in place to provide timely, comprehensive,
and high-quality Health Home services. Neither the statute nor the SMD letter requires a specific
system for delivering Health Homes services under section 1945. Therefore, states are given the
flexibility to determine which service delivery system or combination of systems will be used in
its Health Homes program. The state may use a fee-for-service, primary care case management
(PCCM), risk-based managed care delivery system and/or some other model of service delivery.
Regardless of the service delivery system, Health Homes providers will need to meet the core
Health Homes functional requirements and Health Homes service delivery principles as
described under Provider Standards.
The Health Homes statute provides states considerable flexibility to design a Health Homes
service delivery model appropriate to the needs of the population and each State’s existing
delivery system. States may utilize managed care, including prepaid inpatient health plans
(PIHPs) and prepaid ambulatory health plans (PAHPs); primary care case management (PCCM);
fee-for-service; or a combination of these delivery system arrangements to provide Health
Homes services. We recognize that as states enroll more clinically complex individuals into a
managed care delivery system, Health Homes models may provide an effective strategy and tool
for managed care organizations that are responsible for providing the medical, behavioral, and/or
long term care services and supports for Medicaid beneficiaries with chronic conditions.
CMS can work with states to assist in developing models that incorporate Health Home services
into capitated managed care arrangements. In addition, some states have chosen to carve Health
Homes services out of the managed care contracts and capitation and pay for Health Homes
services directly, often using a per member per month payment to Health Homes providers for
the Health Homes services. Because health plans typically have systems for data analytics,
quality improvement, and reporting capabilities, approved Health Homes states are generally
requiring a partnership between their contracted health plans and the community-based Health
Homes providers, even if Health Homes services are carved out.
26

All states with an existing Medicaid managed care delivery system that are implementing a
Health Homes program must compare the care coordination activities provided by the health
plan to the care coordination activities required for Health Homes in order to avoid duplicative
payment for the same service. If the state determines that there is some duplication of activity,
the state must take measures to account for that duplication and avoid duplicate payment. The
most frequently observed examples seen from approved Health Homes state plans include
adjusting the health plan’s capitation payment downward to address the duplicative care
management activities or imposing additional contract requirements so that the managed care
plans perform additional non-duplicative services. If a Health Homes program is provided under
an MCO, a PIHP, PAHP or a PCCM, the arrangements must comply with both the Health
Homes requirements as well as with the requirements of 42 CFR part 438 regarding Medicaid
managed care.
To support Health Homes providers, CMS encourages states to obtain and utilize Medicare
claims data to support delivery and oversight of Health Homes services for beneficiaries who are
dually eligible for Medicare and Medicaid. For more information on accessing Medicare claims,
please see the following link: State Data Resource Center.

INSTRUCTIONS
Select the service delivery system(s) that will be used for individuals in the Health Homes
program from the following list. One service delivery system must be selected and more than
one may be selected.
•
•
•
•

Fee-For-Service
Primary Care Case Management (PCCM)
Risk-Based Managed Care
Other Service Delivery System

If Fee-for-Service is selected, no other information about this service delivery system is
requested in this screen. The payment methodology will be described in the Health Homes
Payment Methodologies screen.
If PCCM is selected, indicate Yes or No if the PCCM will be a Designated Provider or part of a
Team of Health Care Professionals.
• If Yes is selected (PCCM will be a Designated Provider or part of a Team of Health Care
Professionals):
o Select the option(s) which best describe on what basis the PCCM/Health Homes
providers will be paid:
• Fee-for-Service methodology that is described in the Payment
Methodologies screen
• Alternative Model of Payment that is described in the Payment
Methodologies screen
• Other payment methodology. If Other is selected, describe the payment
methodology.

27

o Select Yes or No whether the requirements for the Health Homes PCCM will be
different from those of a regular PCCM.
• If Yes is selected (the requirements for the Health Home PCCM will be
different than those for non-Health Home PCCMs):
o Describe how the requirements will be different.
o Check the assurance, “The state provides assurance that these
requirements will be incorporated into the next PCCM contract
submitted to CMS.”
• If No is selected, this option is complete.
o At your option, upload any documents which support the information/descriptions
provided of the proposed PCCM system. More than one document may be
uploaded.
•

If No is selected (PCCM will NOT be a Designated Provider or part of a Team of
Health Care Professionals), check the assurance, “The State provides assurance
that it will not duplicate payment between its Health Homes payments and PCCM
payments.”

If Risk Based Managed Care is selected, indicate Yes or No if the Health Plans will be a
Designated Provider or part of a Team of Health Care Professionals.
• If Yes is selected (Health Plans will be a Designated Provider or part of a Team of Health
Care Professionals):
o Provide a summary of the contract language imposed on the Health Plans in order
to deliver Health Homes services
o Check the assurance, “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.”
o At your option, upload a copy of the Health Plan contract.
o Select Yes or No whether Health Homes payments will be included in the Health
Plan capitation rate.
 If Yes is selected, check the three assurances displayed.
 If No is selected, select one or more of the options to indicate which
payment methodology(ies) will be used to pay the Health Plans:
o Fee-for-Service methodology that is described in the Payment
Methodologies screen
o Alternative Model of Payment that is described in the Payment
Methodologies screen
o Other payment methodology. If Other is selected, describe the
payment methodology.
•

If No is selected (Health Plans will NOT be a Designated Provider or part of a Team of
Health Care Professionals), select one or more of the options to indicate how duplication
of payment for care coordination in the Health Plans’ current capitation rate will be
avoided:
o The current capitation rate will be reduced

28

o The state will impose additional contract requirements on the plans for Health
Homes enrollees.
 If this option is selected, provide a summary of the contract language
containing these additional requirements.
o Other
 If this option is selected, provide a description of the other method used to
avoid duplication of payment.
If Other Service Delivery System is selected:
• Describe whether or not 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.
• Check the assurance, “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.”
• At your option, upload a copy of pertinent contract requirements.

REVIEW CRITERIA
PCCM Other Payment Methodology: The description of a different payment methodology
should be sufficiently clear, detailed and complete to permit the reviewer to determine that the
state’s election meets applicable federal statutory, regulatory and policy requirements.
PCCM Requirements Different from Regular PCCM: The description of the requirements for
Health Homes PCCM that are different than those for regular PCCM should include how the
PCCM requirements add value or enhance the level of service activity beyond the care
coordination that a regular PCCM provides. Health Homes services must go above and
beyond the services otherwise provided through PCCM.
Summary of Health Plan Contract Language: Under Risk Based Managed Care, if the health
plans will be a Designated Provider or part of a Team of Health Care Professionals, the state
must provide a summary of the additional contract language explaining how the health plans
will work with the Health Homes program. This summary should include an explanation of
the roles and responsibilities of health plans versus those of the Health Homes providers.
Specifically, it should explain what additional activities the health plans may be providing
instead of adjusting the capitation rate. It should also summarize the contract language with
respect to the responsibilities of the health plans providing and/or coordinating services with
the Health Homes providers. It is preferable that the contract have a separate addendum for
Health Homes.
Health Homes Payments Not Included in Health Plan Capitation Rate: Under Risk Based
Managed Care, if Health Homes payments will not be included in the Health Plan capitation
rate, and the state indicates that it will use a payment methodology other than Fee-for-Service
or Alternative Model of Payment, the description of the different payment methodology should
be sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s
election meets applicable federal statutory, regulatory and policy requirements.
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Health Plans Will NOT Be a Designated Provider or Part of a Team of Health Care
Professionals: Under Risk Based Managed Care, if the Health Plans will not be a Designated
Provider or part of a Team of Health Care Professionals, and the state has indicated that it
will avoid duplication of payment for care coordination by imposing additional contract
requirements on the plans for Health Homes enrollees who are also enrolled in a health plan,
the state must provide a summary of the Health Plan contract language related to these
additional requirements. This summary should include an explanation of the roles and
responsibilities of health plans versus those of the Health Homes providers which
demonstrates how the state will avoid duplication of payment. Specifically, it should explain
what additional activities the health plans may be providing instead of adjusting the capitation
rate. It should also summarize the contract language with respect to the responsibilities of the
health plans providing and/or coordinating services with the Health Homes providers. It is
preferable that the contract have a separate addendum for Health Homes.
Other Method of Avoiding Duplication of Payment: Under Risk Based Managed Care, if the
Health Plans will not be a Designated Provider or part of a Team of Health Care
Professionals, and the state has indicated that it will avoid duplication of payment for care
coordination by some method other than reducing the capitation rate or adding requirements
to the Health Plan contract, the state must provide a description of the other method it will
use. This description of the other method to avoid duplication of payment should be
sufficiently clear, detailed and complete to permit the reviewer to determine that the method
meets applicable federal statutory, regulatory and policy requirements.
Other Service Delivery System: If a service delivery system other than Fee-for-Service, PCCM
or At Risk Managed Care is selected, the state must completely describe the other service
delivery system. This description should include whether the providers will be a Designated
Provider or part of a Team of Health Care Professionals and how payment will be delivered to
these providers. It should distinguish between Health Homes services and other similar
programs and authorities and explain how the state will avoid duplication of activities, such as
care coordination, between Health Homes and other Medicaid services.

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Health Homes Payment Methodologies

POLICY CITATION
Statute: 1945 of the SSA; 1902(a)(30)(A)
Regulations: 42 CFR 430.10; 42 CFR 447.10; 42 CFR 447.205
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to select/identify the type of payment methodology(s) it
will use to reimburse for Health Homes services. The state may use fee-for-service, PCCM
(Primary Care Case Management), risk-based managed care, and/or an alternative methodology
for reimbursing Health Homes services.
Under section 1945, states are given considerable flexibility in developing payment
methodologies to reimburse for Heath Homes services. The statute requires that the payment
methodology used be specified in the state plan. The statute states that Health Homes payments
may be tiered to reflect the severity or number of chronic conditions which a beneficiary has
and/or to reflect the capabilities of the Health Homes provider. States could, for example,
include medical necessity criteria to target individuals with a specific chronic condition who
have a level of severity that required an inpatient stay in the past 12 months, repeated emergency
room visits, or equivalent measures of severity. The statute requires that the payment
methodology promote the principles of economy, efficiency and quality care consistent with
section 1902(a)(30(A). The statute also permits states to propose an “alternative” model for
paying for Health Homes services.
States seeking to establish a new Health Homes program or to change a payment methodology
for an existing Health Homes program must publish notification consistent with the public notice
requirements at 42 CFR 447.205.
Section 1945(c)(1) of the Act authorizes states to make payments for Health Homes services
delivered by a designated provider, a team of health care professionals, or a Health Team.
Consistent with the “whole-person” philosophy that requires the Health Homes to have the
systems and infrastructure in place for coordinating and integrating all primary, acute, behavioral
health (mental health and substance use), long term services and community and social supports
for the Health Homes enrollees, only one Health Homes entity can bill for an enrollee’s services
in any time period, to prevent duplication of services. The Health Homes is accountable for
meeting all the Health Homes delivery system requirements and responsible for distributing
payments to the other Health Homes team members as appropriate.

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Section 1902(a)(30)(A) of the Act requires that state plan rates be economic and efficient and
provide for quality care. Regulations at 42 CFR 430.10 require that the State plan include a
comprehensive description of the methods and standards used to set payment rates and provide a
basis for Federal financial participation. These requirements are applied in reviewing all SPAs,
including those for Health Homes.
Health Homes rates must be based on Health Homes units of service, whether on a fee-forservice basis, a per member per month (PMPM) basis, or another approved methodology. These
rates may reflect any service overhead costs. Separate payments, apart from payment for Health
Homes services rendered, may not be made for such costs. The Health Homes payment
methodology should include a description of how the state will review the rates and rebase, if
necessary. This should include an explanation of the factors that will be reviewed (such as staff
salaries and other cost data) and the state’s procedures and timetable (at least annually) for
reviewing the rates to ensure that they remain economic and efficient and ensure the provision of
quality care.
States are required to provide for the non-federal share of the payment through an allowable
source (i.e., appropriations from state or local funds, intergovernmental transfers (IGTs) derived
from state or local taxes, certified public expenditures by a governmental entity (CPEs) for costs
payable under the approved state plan, or permissible provider taxes or donations). CMS cannot
approve the SPA until we understand and document that the state is using permissible sources for
the non-federal share of payments.
In reviewing Health Homes rates, CMS will ask for the amount of the rate and an explanation of
how the state developed the rate based on cost or other considerations and how it determined that
the rate was appropriate for the particular covered services. Any variations in payment or any
tiered structure (based on beneficiary need or qualifications or composition of the health home
team) must be described. The state plan should identify the unit of service that will be billed,
that payment will be triggered by the provision of at least one billable unit of service, and
identify where auditable documentation of the provision of service will be located, such as in a
patient’s chart. CMS will also ask the state to explain in the SPA how the State will track
billable services if claims are not submitted through the MMIS and include assurances and a
description of the manner in which the state will identify Health Homes services to ensure that
there will be no duplication of services and payment for similar services provided under other
Medicaid authorities.
State officials clearly have much to consider in constructing state plan payment methodologies
for Health Home services that improve service delivery, provide for quality health outcomes for
Medicaid participants and help to document the evaluative measures at section 2703(b) of the
Affordable Care Act. We encourage states to work closely with their stakeholder and provider
communities, and to draw upon national experience in developing payment methodologies for
these services. We also invite states to work with CMS before formally submitting a SPA to
ensure that proposed payment methodologies meet these objectives and all applicable federal and
statutory requirements. While we envision a Health Homes model of service delivery with either
a fee-for-service or capitated payment structure, we would consider other methods or strategies
utilizing additional payment models.
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INSTRUCTIONS
Any state plan amendment submitted to establish a new Health Homes program or to change
payment methodologies for an existing program must also include the public notice and tribal
input screens indicating how and when the public was notified of the change.
Health Homes Payment Methodologies
Select one or more of the following payment methodologies it will use to reimburse for Health
Homes services:
• Fee-for-Service
• PCCM
• Risk-Based Managed Care
• Alternative models of payment
If Fee-for-Service is selected:
• Select one or more of the following options to describe how the payments are structured:
o Individual rates per service
o Per member, per month rates
o Comprehensive methodology included in the plan
o Incentive payment reimbursement
• For each of the options above selected:
o First select “Fee for Service Rates based on”
o Next select one or more of the following options to describe the basis of the rates:
 Severity of each individual’s chronic conditions
 Capabilities of the team of health care professionals, designated provider,
or health team
 Other
o If “Other” is selected, provide a description.
• After the Fee-for-Service selection(s) have been made, describe any variations in
payment based on provider qualifications, individual care needs, or the intensity of the
services provided. This includes a description of tiered rates, if appropriate. If not posted
on a website (described below), include the amount of the rates in this section.
If PCCM is selected, no further description of the PCCM payment methodology is needed here
because it was described in the Service Delivery Systems screen.
If Risk Based Managed Care is selected, no further description of the PCCM payment
methodology is needed here because it was described in the Service Delivery Systems screen.
If Alternative models of payment other than Fee for Service or PMPM payments is selected:
• Indicate if the alternative model of payment includes tiered rates by checking that box.
o If Tiered Rates is selected:
 Select one or more of the following options to describe the basis of the
rates:
o Severity of each individual’s chronic conditions
o Capabilities of the team of health care professionals, designated
provider, or health team
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•

o Other
• If “Other” is selected, provide a description.
 Describe any variations in payment based on provider qualifications,
individual care needs, or the intensity of the services provided.
Regardless of whether or not you checked “Tiered Rates based on”, provide a
comprehensive description of the policies the state will use to establish Health Homes
alternative models of payment, which must include:
o How the methodology is consistent with the goals of efficiency, economy and
quality of care
o Nature of the payment, the activities and associated costs or other factors used to
determine the amount
o Any limiting criteria used to determine if a provider is eligible to receive payment
o Frequency and timing of distribution of payments to providers.

Agency Rates
If Fee for Service was selected as a payment methodology, the Agency Rates section must be
completed. Select one option which best describes the rates used from the following:
• FFS rates included in the plan
• Comprehensive methodology included in the plan
• The agency rates are set as of the following date and are effective for services provided
on or after that date.
o If this is selected:
 Enter the effective date
 Enter the website where the rates are displayed
Note: If the fee-for-service rates are not displayed on a website, they should be
entered above in the text box for the description of variation of fee-forservice rates.
Rate Development
If Fee for Service was selected as a payment methodology, the Rate Development section must
be completed. Provide a comprehensive description of the manner in which rates were set,
which must include:
• Cost data and assumptions used to develop each of the rates
• Reimbursable units of service
• Minimum level of activities required for providers to receive payment per the defined
unit
• Standards and process required for service documentation
• Procedures for reviewing and rebasing the rates, including:
o Frequency of review
o Factors that will be reviewed in order to understand if the rates are economic,
efficient and sufficient to ensure quality services.

34

Assurances
Check the four assurances at the bottom of the screen and describe how the state will ensure nonduplication of payment for services similar to Health Homes services that are offered/covered
under a different statutory authority, such as 1915(c) waivers or targeted case management.

REVIEW CRITERIA
Fee for Service
Other Basis for Fee-for-Service Rates: Under Individual Rates Per Service, Per Member, Per
Month Rates, Comprehensive Methodology Included in the Plan, and Incentive Payment
Reimbursement, the state selects the basis of the rates. If a basis other than severity of each
individual’s chronic conditions and the capabilities of the team of health care professionals,
designated provider or health team is selected, the description of the other basis for the rates
should be sufficiently clear, detailed and complete to permit the reviewer to determine if the
basis of the rate meets applicable federal statutory, regulatory and policy requirements.
Variation in Payments: The description of variations in payment based on provider
qualifications, individual care needs, or the intensity of the services provided should be
sufficiently clear, detailed and complete to permit the reviewer to determine that it meets
applicable federal statutory, regulatory and policy requirements. If the rates will not be
displayed on a website, the rate amounts must be included in this section.
Fee-for-Service Rate Development
The description of the rate setting (development) policies should be sufficiently clear, detailed
and complete to permit the reviewer to determine that they meet applicable federal statutory,
regulatory and policy requirements. Generally, the rate narrative should include all of the
factors included in the formulation of the payments, the basis or unit through which the
providers are reimbursed and (as appropriate) the expected level of service within the unit.
Any variation in payments based on geography, higher levels of provider qualification or other
factors should also be explained in this section. The description must include:
• Cost data and assumptions that were used to develop each of the rates;
• Payable unit(s) of service - identify the unit of service that will be billed, that payment
will be triggered by the provision of at least one billable unit of service, and identify
where auditable documentation of the provision of service will be located, such as in a
patient’s chart;
• Variations in payment - Any variation in payments based on geography, higher levels
of provider qualification or other factors should be explained in this section.
• The minimum level of activities that the state agency requires for providers to receive
payment per the defined unit;
• How the state determined that the rate was appropriate for the particular covered
services;
• The state's standards and process required for service documentation;
• Procedures for reviewing and rebasing the rates, including the frequency with which
the state will review the rate and the factors that will be reviewed by the state in order to

35

•

understand if the rates are economic and efficient and sufficient to ensure quality
services; and
Payment adjustments - for example, if a state adjusts rates based on a nationally
recognized inflation factor, the state should name the factor and/or the percentage
adjustment that will be applied in accordance with the factor for the applicable rate
year. Similarly, if the state is making an adjustment that is not based on inflation, such
as a percentage increase to the rates based on a state specific index, the state should
note so and include the percentage increase applicable to the rate year.

Alternative Models of Payment
Other Basis for Tiered Rates: Under Tiered Rates, the state selects the basis of the rates. If a
basis other than severity of each individual’s chronic conditions and the capabilities of the
team of health care professionals, designated provider or health team is selected, the
description of the other basis for the rates should be sufficiently clear, detailed and complete to
permit the reviewer to determine if the basis of the rate meets applicable federal statutory,
regulatory and policy requirements.
Variation in Payments: The description of variations in payment based on provider
qualifications, individual care needs, or the intensity of the services provided should be
sufficiently clear, detailed and complete to permit the reviewer to determine that it meets
applicable federal statutory, regulatory and policy requirements. The rate amounts may be
included in this section, or may be included in the comprehensive description, below.
Comprehensive Description for Alternative Models of Payment: The description of the policies
used in establishing alternative models of payment should be sufficiently clear, detailed and
complete to permit the reviewer to determine that they meet applicable federal statutory,
regulatory and policy requirements.
The description must include:
• The amount of the rates, if not included in the Variations in Payments section;
• How the methodology is consistent with the goals of efficiency, economy and quality of
care;
• The nature of the payment;
• How the state determined that the rate was appropriate for the particular covered
services;
• 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.
Assurances – Non-Duplication of Payment
The description of how the state will not be duplicating payment in its Health Homes program
for the same or similar services offered/covered in a different program or under another
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statutory authority should be sufficiently clear, detailed and complete to permit the reviewer to
determine that the state’s approach meets applicable federal statutory, regulatory and policy
requirements and should include:
• The manner in which the state will identify health homes services to ensure that there
will be no duplication of services and payment for similar services provided under
other Medicaid authorities, including whether billing and payment is handled through
MMIS and how the State will track billable services if claims are not submitted
through the MMIS.

37

Health Homes Monitoring, Quality Measurement and Evaluation

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is for the state to describe its methodology for calculating costsavings; describe how it will use health information technology to improve service delivery and
coordination of care; and to provide assurances related to quality measurement and evaluation
reporting.
States should collect, track/monitor and report specific types of information and data for
evaluation purposes that are statutorily required for the Health Homes benefit. This information
and data also will be used to inform stakeholders including the state, CMS and Congress about
the success of the Medicaid Health Homes program in improving the coordination and quality of
health care for the beneficiary with chronic conditions while reducing costs. The information and
data collected and reported also will be used to inform and assist in the continuous improvement
of the state’s Health Homes program/model.
The statute at 1945(f) requires that states include in their Health Homes SPAs a methodology for
tracking avoidable hospital readmissions and calculating savings that result from improved
chronic care coordination and management. Section 1945(f) also requires states to describe in
their state plan how health information technology will be used to improve service delivery and
coordination across the continuum of care, including the use of wireless patient technology to
improve coordination and management of care and patient adherence to recommendations made
by their providers. In its November 16, 2010 Health Homes State Medicaid Director (SMD)
letter, CMS makes several suggestions for how states can measure and track avoidable hospital
readmissions and calculate cost savings, including what baselines/controls/comparison groups
could be used in demonstrating the effect of the Health Homes program on these two measures.
The statute at 1945(g) indicates that as a condition for receiving payment for Health Homes
services that providers report to the state in accordance with the requirements specified by the
Secretary on all applicable measures for determining the quality of such services. The SMD
letter discusses in some detail the quality measurement reporting requirements for states and
providers of Health Homes services. In a separate component of MACPro, Health Homes
Quality Measures, states should submit their Quality Measure reporting for each Health Homes
program, for each federal fiscal year, starting with 2013. The Quality Measures reporting
includes core measures, utilization measures and state-specific measures. States should enter the

38

specific goals and related measures for each Health Homes program in the state-specific section
of the report.

INSTRUCTIONS
Monitoring
Describe the state’s methodology for calculating cost saving. The description should include:
•

Savings resulting from improved coordination of care and chronic disease management,
including data sources and measurement specifications;

•

Savings associated with serving dual-eligibles, including if Medicare data was available
to the state and used in calculating the estimate.

Quality Measurement and Evaluation
Check the four assurances related to:
•

Requiring providers to report to the state all applicable quality measures as a condition of
receiving payment;

•

Identifying measureable goals and quality measures for each goal;

•

Reporting information to CMS; and

•

Tracking avoidable hospital readmissions and reporting annually in the Quality Measures
report.

Go to Quality Measure Reports
States may click on this link to either view and/or update Health Homes Quality Measures
reporting.

REVIEW CRITERIA
Cost Savings Methodology: The state’s description for calculating cost savings should be
sufficiently clear, detailed and complete to permit the reviewer to determine that the state’s
election meets applicable federal statutory, regulatory and policy requirements. It should
include the methodology used to calculate savings that result from improved coordination of
care and chronic disease management achieved through the Health Homes Program,
including data sources and measurement specifications, as well as any savings associated with
dual eligibles, and if Medicare data was available to the state to utilize in arriving at its costsavings estimates.
Use of Health Information Technology: The state’s description for using health information
technology in providing Health Homes services should be sufficiently clear, detailed and
complete to permit the reviewer to determine that the state’s election meets applicable federal
statutory, regulatory and policy requirements. It should include the use of wireless patient
technology to improve coordination and management of care and patient adherence to
recommendations made by their provider.
39

Health Homes Program Termination – Phase-out Plan

POLICY CITATION
Statute: 1945 of the Social Security Act
Formal Guidance: SMDL #10-024 dated November 16, 2010; Health Homes FAQs dated May
5, 2012 and December 20, 2015

BACKGROUND
The purpose of this screen is to provide detailed information about the state’s plans to terminate
a specific Health Homes Program. It may be necessary to terminate a Health Homes Program
due to state legislative action, reduction of funding or some other reason making the continuation
of the program not possible. When this happens, the state may choose to terminate the program
statewide as of a certain date, or may phase-out the program over time. Notifications of the
program termination should be sent to all participants and providers, giving information about
the program termination and how it will affect them. CMS must approve the state’s plans to
terminate the program, as described in this screen.

INSTRUCTIONS
This screen can be accessed in either of the following two ways:
• There is an existing approved Health Homes program and the state creates a submission
package to end the program by selecting the option, “Terminate existing Health Homes
program” in the Medicaid State Plan reviewable unit.
• A Termination – Phase-Out Plan reviewable unit has already been completed and the
submission package has been approved, and now the state has to change the information
previously provided in this reviewable unit. This is done by selecting “Amend existing
Health Homes program” in the Medicaid State Plan reviewable unit, and selecting the
Health Homes Program – Termination – Phase-Out Plan reviewable unit.
Under “Provide a description of the phase-out or transition plan for the Health Homes Program
that is being terminated, complete the following:
•
•
•

Enter a reason the program is being terminated.
Describe the overall approach to be used in terminating the program
Under “Indicate the method of termination,” choose whether the state will terminate all
participants on the same date or phase-out the termination.
o If you select “The state will terminate all participants from the Health Homes
Program on the same date, you must enter the effective date of the termination.
o If you select “The state will phase-out the termination of participation in the
Health Homes Program:”
 You must enter a date in two fields, to indicate the period of the phase-out:
o Begin phase-out date
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•

o Complete phase-out date
 You must also upload the state’s phase-out plan. This plan must include a
description of the phase-out, as well as the strategy for communicating the
phase-out to participants and providers, including the dates of
communication.
Regardless of whether the program will be terminated for all participants at the same time
or the termination is phased-out, you must describe the process that will be used to
transition all of the participants and how referrals will be made to other health care
providers.

Note: When terminating a Health Homes Program, the state must continue to submit Health
Homes Quality Measures reports covering the entire period the program was active,
through to the end of the program.

REVIEW CRITERIA
Reason for termination: The state’s description of the reason for termination should be clear
and provide enough detail for the reviewer to understand the underlying causes of the decision
to terminate, for example: lack of funding; provider capacity; change in administration or
legislation; new service delivery systems.
Overall approach the state will use to terminate the program: The state’s description of the
overall approach used to terminate the program should summarize the termination plan in a
way that is sufficiently clear, detailed and complete to permit the reviewer to determine that it
meets applicable federal statutory, regulatory and policy requirements.
Description of the process used to transition all participants: The state’s description of the
process used to transition all beneficiaries should include how the beneficiaries may continue
to access services, how referrals will be made to other services and the methods of
communication that will take place to the beneficiaries, providers and other stakeholders so
that the affected beneficiaries will continue to be able to access medical care and other social
and supportive services.

41