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).
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.
