Key considerations in designing the medicaid health home spa
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Key Considerations in Designing the Medicaid Health Home SPA. Alicia D. Smith, MHA Senior Consultant Health Management Associates. Discussion Points. Defining health homes CMS expectations Key planning and implementation considerations Submitting the SPA. Measures Reimbursement

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Key considerations in designing the medicaid health home spa

Key Considerations in Designing the Medicaid Health Home SPA

Alicia D. Smith, MHA

Senior Consultant

Health Management Associates

Discussion points
Discussion Points

  • Defining health homes

  • CMS expectations

  • Key planning and implementation considerations

  • Submitting the SPA

  • Measures

  • Reimbursement

  • Cost savings

  • States’ proposed approaches

  • Parting thoughts

Defining health homes
Defining health homes

  • Enumerated in Sec. 1945 of the Social Security Act

  • Provides states the option to cover care coordination for individuals with chronic conditions through health homes

  • Eligible Medicaid beneficiaries have:

    • Two or more chronic conditions,

    • One condition and the risk of developing another, or

    • At least one serious and persistent mental health condition

Defining health homes1
Defining health homes

  • Provides 90% FMAP for eight quarters for:

    • Comprehensive care management

    • Care coordination

    • Health promotion

    • Comprehensive transitional care

    • Individual and family support

    • Referral to community and support services

  • Services by designated providers, a team of health care professionals or a health team

Defining health homes2
Defining health homes

  • Beneficiaries choose the provider, team of health professionals or health team

  • States may apply for matchable planning grants up to $500K

  • Reimbursement may be on a PMPM or alternative basis


  • No immediate CMS plans to issue regulations. Guidance from:

  • SSA Sec. 1945 (Sec. 2703 of the ACA)

  • November 16, 2010 Dear State Medicaid Director letter issued by CMS

  • Medicaid SPA Pre-Print

  • Informal feedback from CMS and SAMHSA

Cms expectations
CMS Expectations

  • Client choice

  • Whole-person service orientation

  • Person-centered care that improves outcomes

  • Services provide value for State Medicaid programs

  • Support CMS’ three areas for improvements (experience of care, health status, reduce costs)

  • Reduce hospital and nursing facility admissions, lower hospital ED use

Planning considerations
Planning Considerations

  • Transformation vs. match-grab

  • Define the health home model

  • It is okay to:

    • Convert existing services to be claimable under health home

    • Stagger implementation (must track unique users)

    • Ramp up services on a less than statewide basis

  • Determine the role managed care will play

  • Complement vs. duplicate existing services

  • Coordinating services for the whole-person

  • Measuring outcomes

Implementation considerations
Implementation Considerations

  • States’ ability to make the SPA operational

  • Payment for coordination and linkage; not treatment

  • Data sources to calculate measures

  • Consider use of HIT to facilitate HIE

  • Developing transitional care agreements with local hospitals

  • Partnering with primary care providers (e.g., FQHCs)

Submitting the spa
Submitting the SPA

  • SAMHSA consultation

    • Single state Medicaid agency as lead (or “hall pass” to SMHA)

    • Overview of health home model

    • Areas of consultation

    • Available dates for teleconference

  • Suggested draft SPA documents to CMS

    • Cover letter

    • SPA template

    • Client process narrative

    • Graphic depiction of model

Key spa sections
Key SPA Sections

  • Geographic area

  • Population criteria

  • Provider infrastructure

  • Service descriptions / HIT

  • Provider standards

  • Assurances

    • Hospital referrals

    • SAMHSA coordination

    • Report evaluation results

  • Monitoring

    • Tracking avoidable hospitalizations

    • Cost savings

    • Proposal for using HIT

  • Quality measures

    • Clinical outcomes

    • Experience of care

    • Quality of care

  • Evaluations

States should spend time addressing
States Should Spend Time Addressing

Use of HIT

Quality Measures

Clinical outcomes relate to changes in health status

Experience of care measures should derive from client surveys

Quality of care measures relate to processes of care

CMS will assist states in mapping measures to service definitions

  • Identify sources and uses of existing data (e.g., claims and MCO encounter data)

  • Leverage EHR use

  • Explore connections with statewide HIE initiatives

  • Identify options for HIE between behavioral health and primary care providers (e.g., National TA Center)


  • Leverage data already being collected (e.g., NOMS)

  • Claims-based data for clinical outcomes measures

  • Survey data for experience of care

  • Care management and registry data for quality outcomes (suggest limiting record reviews)

  • CMS is aligning measures across the ACA

  • CMS will provide guidance on a core set of measures states can use for health homes

Likely feedback from samhsa and cms
Likely feedback from SAMHSA and CMS


From CMS

Choice and opt-out

No age restrictions

No exclusion of duals

Provider and client notification

Leveraging existing services (e.g., TCM, HCBS waiver)

Non-duplication of payment

Mapping quality measures to services

Need help (e.g., quality measures, reimbursement)?

  • Use of a chronic care model

  • Provider qualifications

  • Health team members

  • Engaging primary care

  • Addressing SUD

  • Capacity for new service users

  • Use of HIT

  • Interim outcome measures

  • Need help (e.g., screening tools, integration models)?




Start-up costs


Health team composition


  • Case rate

  • PMPM

    • Base rate

    • Tiered by severity

    • Performance incentive

    • Other

Cost savings
Cost Savings

  • Most savings accrue to physical health

  • Consider how savings can be applied to sustaining health home services

  • Unlikely that states will experience two-year savings

  • Costs likely to increase for a period before savings estimates achieved

  • Consider a longer tail (e.g., savings or slower rate of increase over 5 years)

Parting thoughts
Parting thoughts

  • Leadership and buy-in is paramount for planning and SPA development

  • Start with a model and develop the SPA; not the other way around

  • Ask CMS early and often about confounding issues (i.e., how demonstrate cost savings for duals)

  • Everything takes 3 times longer than time estimates