NYAPRS Note: The following piece examines the move to health homes for commercially insured beneficiaries with serious mental health conditions.
An update on New York’s Medicaid health homes initiative will be provided as a part of our state policymakers’ panel at the April 24-5 NYAPRS Albany Executive Seminar.
Register by April 4th and save with our early bird rates.
See registration and program materials at https://rms.nyaprs.org/2014-executive-seminar/
Health Homes Go Private!
By Laura Morgan Market Intelligence Manager Open Minds March 25, 2014
Developed by Open Minds, www.openminds.com. All rights reserved. You may not alter, transform, or build upon this work. You may not use this work for commercial purposes without written permission from Open Minds
Last week we reported on the launch of HealthPlan—a first-of-its-kind commercial health home for commercially insured clients with serious mental illness (SMI) (see Rhode Island Blues Plan, Care New England & Continuum Behavioral Health Launch Commercial Health Home Pilotpremium members). Commercial payers have experimented with some specialty medical homes over the past couple years. This interdisciplinary clinician-led team approach delivers and coordinates care, and manages acute episodes of service and recovery. Additionally, this model provides access to physical and behavioral services, and to community and social services. But, this new commercial model goes much beyond.
So how does this new commercial model compare to the Medicaid model? To date, health homes have been a Medicaid only construct—defined by federal statute, and included in state Medicaid plans only after approved state plan amendments (SPAs) by the Centers for Medicare and Medicaid Services (CMS). Currently, there are 18 CMS-approved SPAs for 14 states— Alabama, Idaho, Iowa (2), Maine, Maryland, Missouri (2), New York, North Carolina, Ohio, Oregon, Rhode Island (3), South Dakota, Washington, and Wisconsin—and another 12 states plus the District of Columbia have—at the least—an approved health home planning request (see State Health Home CMS Proposal Status, Effective February 2014premium members).
Medicaid health homes are statutorily designed to provide six core services previously not reimbursable under Medicaid:
- Comprehensive care management
- Care coordination and health promotion
- Comprehensive transitional care from inpatient to other settings, including appropriate follow-up
- Individual and family support
- Referral to community and social support services
- Use of health information technology to link services
At a high level, the commercial model does this and more. Both models:
- Target high cost/high needs populations
- Base care coordination at the primary health care point of contact for the target population—i.e., behavioral health providers in the case of those with SMI
- Seek to reduce overall medical spending while improving outcomes and maintaining people in their communities
- Include social supports as a key element in achieving cost and outcome goals
- Reimburse on a per member per month (PMPM) basis
- Provide incentives based on shared savings (still a largely dormant option in Medicaid, but an option)
Where they differ is in the details. From a cost and reimbursement standpoint, the primary payer, Blue Cross Blue Shield of Rhode Island (BCBSRI), will pay a significantly higher PMPM for health home services ($963 compared to anywhere from $80.31 in Missouri to $442.21 in Rhode Island). HealthPlan, however, covers a more robust set of behavioral health services than are covered by the Medicaid health home, i.e., it also covers counseling, psychiatry, and medication management. These services are Medicaid benefits, but are reimbursed separately either through fee-for-service or a member’s health plan.
|
Reimbursement By Select Health Home Programs Serving Individuals With SMI |
|
|---|---|
|
Health Home |
PMPM |
|
Missouri (CMHC SPA) |
$80.31 |
|
Maryland |
$98.87 |
|
Iowa Integrated Health Home (SPMI) |
$127.97 |
|
Washington State |
$172.61 |
|
New York |
$209.00 |
|
Maine |
$330.00 |
|
Rhode Island |
$442.21 |
|
HealthPlan |
$963 |
More interesting, is that the launch of this first commercial health home pilot underscores some important and fundamental changes in the marketplace. Federal health care reform has moved from launch to reality. Previously, the operating assumption has been that individuals with serious mental illness are predominantly served in the public health system. The reasons cited include issues with maintaining employment (hence, keeping insurance), unstable housing, and absence of social supports.
However, health care reform significantly expands private coverage via the health insurance marketplace and also allows individuals to remain on their parent’s (likely commercial) insurance until the age of 26. Since the average onset for schizophrenia is late teens and bipolar disorder is 20 (two primary diagnoses included in any definition of SMI), more individuals are likely to be in need of care while commercially insured.
The payer behind HealthPlan anticipates serving as many as 230 commercially insured adults with SMI. For behavioral health providers interested in becoming health homes, this may be the first wave in an expanding marketplace for payer partners.
For a more in-depth look at Medicaid managed long term services and supports, see our latest Market Intelligence Report, How Are Medicaid Health Homes Reimbursed For Services?premium members