The Medicaid Health Home State Plan Option, authorized under the Affordable Care Act (Section 2703/1945 of the Social Security Act), allows states to design health homes to provide comprehensive care coordination for Medicaid beneficiaries with chronic conditions. States will receive enhanced federal funding during the first eight quarters of implementation to support the roll out of this new integrated model of care. States with a substance use disorder-focused health home state plan amendment, approved after October 1, 2018, may request two additional quarters of enhanced funding, for a total of 10 fiscal year quarters.
The Health Home Information Resource Center was established by the Centers for Medicare & Medicaid Services (CMS) to help states develop these new models to coordinate the full range of medical, behavioral health, and long-term services and supports needed by Medicaid beneficiaries with chronic health needs. Recognizing that states are at various stages in developing health homes, the resource center offers a variety of technical assistance services as well as a resource library of continuously updated materials. States may use the resource center to request one-on-one technical assistance, access peer-learning opportunities, and find resources to guide their health home development and implementation. Technical assistance will include working with states on developing their draft health home proposals before submitting State Plan Amendments (SPAs) to CMS as well as ongoing support during the SPA development process.
Coordinating Care from Out-of-State Providers for Children with Medically-Complex Conditions
Other Resources
SUD-focused Health Homes: Guidance for States on the Availability of an Extension of the Enhanced Federal Medical Assistance Percentage (FMAP) Period for Certain Medicaid Health Homes for Individuals with Substance Use Disorders (SUD)
Map of State Health Home Activity View a snapshot of health home development and implementation across the states.
Medicaid Health Homes: SPA Overview View a list of all approved health home SPAs by state.
Health Home State Plan Amendment Matrix Compare key program design features for all approved health home SPAs.
Medicaid Health Homes Fact Sheet Read this factsheet for a quick overview of Medicaid health homes and current member enrollment by state.
Health Home SPA Submission Resources
States interested in establishing Medicaid health home programs will need to submit a state plan amendment (SPA) via an online template for approval by the Centers for Medicare & Medicaid Services (CMS).
Resources
- MACPro Use this web based portal for SPA submission.
- On the Guide to Medicaid Health Home Design and Implementation (see below) page, please make the following changes:
Guide to Medicaid Health Home Design & Implementation
This page includes resources to help states plan their health home programs and prepare a health home state plan amendment for submission. The guide includes resources from the Centers for Medicare & Medicaid Services and, select external resources.
New resources will be continuously added to help states advance health home models.
Health Home Background Resources
This section provides background information on the structure and purpose of Medicaid health homes and their regulatory authority.
Resources
- Health Home State Medicaid Director Letter (CMS/November 2010) SMDL 10-024 Re: Health Homes for Enrollees with Chronic Conditions.
- Health Home State Medicaid Director Letter (CMS/January 2013) SMDL 13-001 Re: Health Home Core Quality Measures.
- Social Security Act Sec. 1945 (March 2010) Affordable Care Act Section 2703 – State Option to Provide Coordinated Care Through a Health Home for Individuals with Chronic Conditions.
- Health Homes (Section 2703) Frequently Asked Questions (CMS/May 2012) Addresses key areas for health home design, including providers, enrollment and eligibility; delivery models; quality measurement; reporting; health information technology (HIT); funding and payment; and SPA/waiver authorities.
- Health Homes (Section 2703) Frequently Asked Questions (CMS/2015)
- Health Homes FAQ 12/18/2017
- Section 2703: State Option to Provide Health Homes for Enrollees with Chronic Conditions (CMS/July 2011) Provides an overview of the health homes opportunity.
- Medicare Data Guidance (State Data Resource Center)
Developing Health Home Population Criteria
Medicaid health homes must be targeted to beneficiaries with chronic conditions or serious mental illness. States should carefully define their target population to maximize program impact. Questions to ask include:
- How many beneficiaries would be eligible for the health home program?
- Where do beneficiaries currently receive care?
- Do eligible beneficiaries “cluster” in a certain geographic area, around certain providers, or among specific chronic conditions?
- Do subsets of the population offer opportunities for reductions in avoidable emergency department and inpatient hospital use?
Resources
- Conditions Targeted by Medicaid Health Homes (CMS/June 2024) Lists the conditions targeted by states’ health homes models.
- Customizing Health Homes for Children with Serious Behavioral Health Challenges (SAMHSA/ March 2013) Provides guidance to inform planning and decision-making regarding health homes for children with serious behavioral health conditions.
- Developing Health Homes for Children with Serious Emotional Disturbance: Considerations and Opportunities (CMS/February 2014) Highlights health home opportunities for children with Serious Emotional Disturbance and considerations for states developing models for this population.
- Designing Medicaid Health Homes for Individuals with Opioid Dependency: Considerations for States (CMS/January 2015) Highlights key features of approved health home models in Maryland, Rhode Island, and Vermont that are tailored to individuals with opioid dependency and identifies important considerations in developing opioid dependence-focused health homes.
- Five Key Considerations for Exploring the Medicaid Health Homes Opportunity (CMS/October 2011) Outlines key considerations to help states determine whether to invest in health homes and how to get started in doing so.
- Initial Considerations to Guide the Development of Medicaid Health Homes (Center for Health Care Strategies/June 2011) Outlines key initial considerations to guide State health-home program design, including a hands-on checklist that walks States through a list of decision points.
Defining Health Home Services
Medicaid health homes must provide six core services, linked as appropriate and feasible by HIT:
- Comprehensive care management
- Care coordination
- Health promotion
- Comprehensive transitional care/follow‐up
- Individual and family support
- Referral to community and social support services
Establishing Health Home Payment Methodologies
States have considerable flexibility in establishing payment methodologies for Medicaid health homes. In selecting a payment method, considerations include:
- What financial incentives will help ensure that providers will deliver health home services effectively and efficiently?
- What reimbursement methods will promote accountability and flexibility?
- Will the state use a tiered reimbursement methodology based on provider capability or patient acuity?
Resources
- Health Home Considerations for a Medicaid Managed Care Delivery System: Avoiding Duplication of Services and Payments (CMS/February 2012) Outlines options for health home approaches that complement, but do not replicate services and reimbursement within existing managed care delivery arrangements.
- ROI Forecasting Calculator for Health Homes and Medical Homes (Center for Health Care Strategies/May 2011) Identifies the cost-savings potential of health-home or medical-home strategies through a step-by-step process. Also see companion User's Guide.
Using Managed Care for Health Home Implementation
Some states may choose to create Medicaid health homes within or outside of managed care delivery systems. In developing their programs, states will need to consider the implications for health plan accreditation and non-duplication of care management services.
Resources
- Implications of Health Homes for NCQA Health Plan Accreditation (CMS/June 2012) Provides guidance on considerations related to National Committee for Quality Assurance health plan accreditation, particularly when the state designates primary care or other community-based providers to deliver health home services.
- Health Home Considerations for a Medicaid Managed Care Delivery System: Avoiding Duplication of Services and Payments (CMS/February 2012) Outlines options for health home approaches that complement, but do not replicate services and reimbursement within existing managed care delivery arrangements.
- Implementing Health Homes in a Risk-Based Medicaid Managed-Care Delivery System (Center for Health Care Strategies/June 2011) Explores how states might advance their health-home strategy in whole or in part through their existing Medicaid risk-based managed-care.
Integrating Physical Health/Behavioral Health in Health Homes
Medicaid health homes provide states with an important opportunity to integrate physical and behavioral health care for beneficiaries with complex care needs. Although states have considerable flexibility to define health home services and provider qualification as they see fit, effective integration of physical and behavioral health services is a critical aspect of program design.
Resources
- Promising Practices to Integrate Physical and Mental Health Care for Medi-Cal Members (Center for Health Care Strategies/June 2016) Outlines promising practices for successfully integrating mental health services into comprehensive health benefit packages and building partnerships between health plans and counties to coordinate mental health care benefits.
- Integrating Behavioral Health into Medicaid Managed Care: Lessons from State Innovators (Center for Health Care Strategies/April 2016) Provides insights from Medicaid officials and health plan representatives in five states that are integrating behavioral health services within a comprehensive managed care arrangement.
- Financing and Policy Considerations for Medicaid Health Homes for Individuals with Behavioral Health Conditions: A Discussion of Selected States’ Approaches (Center for Integrated Health Solutions/July 2013) Reviews the policy considerations and options for states and providers to establish reimbursement methodologies and payment rates for health homes.
- State Options for Integrating Physical and Behavioral Health Care (CMS/October 2011) Explores state options for integrating physical and behavioral health services within managed delivery systems, including examples of current state programs and critical considerations for implementation.
- Integrating Physical and Behavioral Health Care in Medicaid: An Online Toolkit (Center for Health Care Strategies/January 2011) Clearinghouse of resources addressing strategies for identification, stratification, integration, consumer engagement, information exchange, and financial alignment linked to physical/behavioral health integration.
- Health Homes and Individuals with Behavioral Health Issues - SAMHSA’s Guidance Document Affordable Care Act Health Home Provision (SAMHSA/September 2011) Details key considerations for states in integrating behavioral health into health home strategies.
Linking Health Homes Services with Information Technology
Health home programs must provide the six core health home services, linked as appropriate and feasible by HIT.
Resources
- Health Home Information Technology Questions (CMS/October 2017) Identifies key questions that states may want to address in their state plan amendments to describe how they will incorporate HIT tools to achieve the objectives of their health home program.