THE HEALTH HOME PROGRAM

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. CMS expects states health home providers to operate under a “whole-person” philosophy. Home health providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.

A "health care home," also called a "medical home," or a “group home”, is an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.

States receive a 90% enhanced Federal Medical Assistance Percentage (FMAP) for the specific health home services in Section 2703. The enhanced match doesn’t apply to the underlying Medicaid services also provided to people enrolled in a health home.

The 90% enhanced FMAP is good for the first eight quarters the program is effective. A state can get more than one period of enhanced FMAP, but can only claim the enhanced FMAP for a total of eight quarters for one enrollee.

ELIGIBILITY

Health Homes are for people with Medicaid who:

• Have 2 or more chronic conditions
• Have one chronic condition and are at risk for a second
• Have one serious and persistent mental health condition

Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease and being overweight. Additional chronic conditions, such as HIV/AIDS, may be considered by CMS for approval.

• States can target health home services geographically
• States cannot exclude people with both Medicaid and Medicare from health home services

SERVICES

• Comprehensive care management
• Care coordination
• Health promotion
• Comprehensive transitional care/follow-up
• Patient & family support
• Referral to community & social support services

PROVIDERS

States have flexibility to determine eligible health home providers. Health home providers can be: 

• A designated provider: May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, or other provider.
• A team of health professionals: May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and can be free-standing, virtual, hospital-based, or a community mental health center.
• A health team: Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractic, licensed complementary and alternative practitioners.

REPORTING REQUIREMENTS

Health Home service providers must report quality measures to the state. States are also required to report utilization, expenditure and quality data for an interim survey and an independent evaluation.

HMOs

As we already know, a health maintenance organization is defined as “an organization that combines the provision of health insurance and the delivery of health care services.” (Given 1994)

Today, HMOs provide health insurance to over 75 million Americans. They play a strong role in determining how health care is delivered and how health care dollars are distributed. In particular, HMOs have played the leading role in bringing market competition to health care (Zwanziger et al 2000). HMO enrollment has considerable effects on several aspects of the health care system (Escarce et al 2000). Frequently, HMO enrollment growth has led to substantial reductions in hospital costs and other health care costs (Baker et al 2000, Miller and Luft 2001).

HMOs AND MEDICAID

For people with Medicaid, finding doctors who accept their health plan can be a challenge. Enrolling in a Medicaid HMO (health maintenance organization), in which the insurance provider has lined up a roster of participating physicians, can simplify finding care.

Some Medicaid plans are sold by health-insurance companies and others are "community" plans. Community plans are usually nonprofit, while health insurers can be either for profit or nonprofit. The top 10 ranked Medicaid plans are all community nonprofit plans, but some of the lowest ranked are, too.

Ranking

Six of the top 10 ranked Medicaid HMOs are members of the Alliance of Community Health Plans (ACHP)

• Fallon Community Health Plan (Mass.)
• Kaiser Foundation Health Plan of Hawaii (Hawaii)
• Capital District Physicians' Health Plan (N.Y.)
• Security Health Plan of Wisconsin (Wis.)
• Priority Health (Mich.)
• UPMC For You (Pa.)

Association for Community Affiliated Plans (ACAP) has more than 50 member plans and focuses on advocating for community plans and the populations they serve. Seventeen of their members are ranked by NCQA and five of them are in the top 10 Medicaid HMOs

• Boston Medical Center HealthNet Plan (Mass.)
• Neighborhood Health Plan (Mass.)
• Network Health (Mass.)
• Neighborhood Health Plan of Rhode Island (R.I.)
• UPMC For You (Pa.)

Four health insurers with recognizable brand names—Amerigroup, Blue Cross/Blue Shield, Molina, and United Health—reported results to NCQA for at least four of their plans. None of these brand-name plans ranked in the top 10 nationally, but BlueCaid of Michigan ranked 12th. When we analyzed our rankings, we found that many plans from United Health scored in the top half.

MEDICARE OVERVIEW

The years following World War II witnessed an increase in chronic conditions that overwhelmed hospitals and institutions, which, in turn, renewed interest in home health as an alternative to institutional care (Benjamin, 1993). Still, the reductions in institutional care assumed to flow from home health care proved elusive to document, and it was difficult to identify the appropriate population requiring home health care. Enormous variation in services contributed to the Health Insurance Association of America’s conclusion in 1959 that home health care had not produced cost savings and, furthermore, home health services were appropriate in only limited cases (Buhler-Wilkerson, 2007).

Medicare home health care suffered a significant downturn following the 1997 Balanced Budget Act and is recovering under Prospective Payment. Like most sectors of care, home health care has often operated in a "silo" but there is increasing recognition of the need to bridge care settings and provide care continuity for sick, chronically ill individuals. This is an important challenge for the future. Agencies that have strong information technology infrastructure and chronic care management systems along with a seasoned clinical workforce will be well positioned for key roles in home health care in decades to come.

HOME HEALTH PROSPECTIVE PAYMENT SYSTEM (HHPS)

To qualify for the Medicare home health benefit, the Social Security Act requires a Medicare beneficiary be confined to the home under the care of a physician; receiving services under a plan of care established, certified, and periodically reviewed by a physician; in need of skilled nursing care (other than solely venipuncture) on an intermittent basis; in need of physical therapy; in need of speech-language pathology; or in continuous need of occupational therapy. Accordingly, the Medicare Home Health benefit covers the following: part-time or intermittent skilled nursing services; part-time or intermittent home health aide services; physical therapy; speech-language pathology; occupational therapy; medical social services; medical supplies; and durable medical equipment with a 20 percent coinsurance.

REIMBURSEMENT

The Medicare home health benefit provides care to homebound individuals who are ill or injured and require intermittent (part-time) skilled nursing services or skilled therapy (CMS, Medicare and Home Health Care, 2010), covering about 3.3 million beneficiaries and resulting in $16.5 billion in total Medicare payments in 2008 (CMS, Data Compendium, 2009).

PAYMENT POLICY

Medicare payment policy for home health services has changed several times in the last decade, One such significant change occurred with the creation and implementation of HHPPS, which was designed to bundle Medicare payment on the basis of a national standardized 60-day episode of care for all covered home health services, including medical supplies, paid on a reasonable cost basis, adjusted for patient severity by a case mix that is based on a patient’s clinical, functional and service utilization as well as geographic variation in costs and unusually low utilization or high-cost outliers.

Covered home health services include:

n  Skilled nursing services

n  Home health aide services

n  Physical therapy services

n  Speech-language pathology services

n  Occupational therapy services

n  Medical social work

n  And routine (built into the visit rates) and non-routine medical supplies

Beneficiaries may receive an unlimited number of consecutive home health episodes as long as they meet the eligibility standards for the benefit.

MANAGED CARE

States have traditionally provided people Medicaid benefits using a fee-for-service system. However, in the past 15 years, states have more frequently implemented a managed care delivery system for Medicaid benefits. In a managed care delivery system, people get most or all of their Medicaid services from an organization under contract with the state. Almost 50 million people receive benefits through some form of managed care, either on a voluntary or mandatory basis.

States can allow people to voluntarily enroll in a managed care program, but more frequently, states require people to enroll in a managed care program. Increasing numbers of States are using Managed Long Term Services and Supports (MLTSS) as a strategy for expanding home- and community-based services, promoting community inclusion, ensuring quality and increasing efficiency. When states implement a managed care program, it can use any one of the following types of entities:

• Managed Care Organizations (MCOs) – like HMOs, these companies agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state.
• Limited benefit plans – these companies may look like HMOs but only provide one or two Medicaid benefits (like mental health or dental services).
• Primary Care Case Managers – these individual providers (or groups of providers) agree to act as an individual’s primary care provider, and receive a small monthly payment for helping to coordinate referrals and other medical services.

There are three categories of managed care plans: health management organizations (HMO), preferred provider organizations (PPO) and point of service (POS).

HEALTH MANAGEMENT ORGANIZATIONS (HMO)

HMOs provide medical treatment on a prepaid basis, which means that HMO members pay a fixed monthly fee, regardless of how much medical care is needed in a given month. In return for this fee, most HMOs provide a wide variety of medical services, from office visits to hospitalization and surgery. With a few exceptions, HMO members must receive their medical treatment from physicians and facilities within the HMO network.

When you join an HMO, you choose a primary care physician who is your first contact for all medical care needs. The primary care physician provides your general medical care and must be consulted before you can see a specialist. Because of this control system, HMO costs tend to increase less rapidly than other insurance plans.

PREFERRED PROVIDER ORGANIZATIONS (PPO)

A PPO is a group of doctors or hospitals that offer medical services at discounted rates as part of a specific network. The PPO may be sponsored by a particular insurance company, by one or more employers, or by some other type of organization, such as a union or association. PPO physicians provide medical services to the policyholders, employees or members at discounted rates. In return, the sponsor creates incentives for employees or policyholders to use the physicians and facilities within the PPO network.

Rather than paying in advance for medical care, PPO members pay for services as they occur. The PPO sponsor (the employer or insurance company) generally reimburses the member for the cost of the treatment, minus any out of pocket costs such as co-payments. In some cases, the doctor submits the bill directly to the insurance company for payment. The insurance company then pays the covered amount directly to the doctor and the member pays his or her co-payment amount. The doctors and the PPO sponsor are the ones who negotiate the price for each type of service in advance.

POINT OF SERVICE (POS)

A Point of Service (POS) plan is a type of managed healthcare system that combines characteristics of the HMO and the PPO. Like an HMO, you pay no deductible and usually only a minimal co-payment when you use a healthcare provider within your network. You choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside the network for care, POS coverage functions more like a PPO. You will likely have to pay a deductible and your co-payment will probably include a certain percentage of the total cost.