BACKGROUNDMedicaid Health Home ServicesThe Medicaid program provides medical assistance to low-income individuals and individuals with disabilities. The Federal and State Governments jointly fund and administer the Medicaid program. At the Federal level, the Centers for Medicare & Medicaid Services (CMS) administers the program. Each State administers its Medicaid program in accordance with a CMS-approved State plan. In New York, the New York State Department of Health (State agency) administers the Medicaid program.Effective January 2011, section 1945 of the Social Security Act (the Act) was amended to include an option for States to establish a health home program through a Medicaid State plan amendment (SPA) approved by CMS. Under a SPA, States can establish a health home program through a care management service model in which all parties involved in a beneficiary’s care communicate with one another so that medical, behavioral health, and social needs are addressed in a comprehensive manner. While States have flexibility to define the core health home services, they must provide all core services required in the Act. Specifically, the Act requires that health home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, patient and family support, and referral to community and social support services. Beneficiaries enrolled in a health home program receive services through provider networks, health plans, and community-based organizations.New York’s Medicaid Health Home ProgramNew York operates a Medicaid health home program which provides comprehensive care management for beneficiaries with at least two chronic conditions or a single qualifying condition (e.g., serious mental illness). Health home providers directly provide, or contract for the provision of, health home services to eligible beneficiaries. Core health home services provided include engaging and retaining beneficiaries enrolled in the program, coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating beneficiaries’ needs. New York relies on its health home providers to locate and enroll potentially eligible beneficiaries identified by the State agency or through community-based referrals (case-finding). Beneficiaries enrolled with a health home provider are assigned a dedicated care manager to assist them with obtaining medical, behavioral, and social services (referred to by the State agency as active care management). New York’s health home program provides for a per member per month (PMPM) payment for beneficiaries in case-finding or active care management status.The State agency is primarily responsible for monitoring and overseeing the health home program and works with its interagency partners to monitor the program and review providers’ performance.The State agency claimed Medicaid reimbursement totaling $341,936,568 ($193,238,148 Federal share) for payments made to health home providers for services provided to beneficiaries diagnosed with serious mental illness and/or substance use disorder (SUD) during the period January 2016 through December 2018 (audit period).OBJECTIVEOur objective was to determine whether the State agency’s claims for Federal Medicaid reimbursement for payments made to health home providers on behalf of beneficiaries diagnosed with serious mental illness and/or SUD complied with Federal and State requirements.
NY,
United States
