Monroe County Health Home Eligibles – Updated 1-4-12
The eligibles in Monroe County are as follows according to 2009 information available on the Health
Home Website (It is unknown what percentage of these individuals are in Medicaid Managed Care vs.
Fee for Service. We have requested Monroe County data and the DOH is working on it. Plans should
receive the final list of health home eligibles enrolled in their plans by 12/16. It will include the analytics
performed by the state -- acuity, risk for inpatient admission, loyalty analysis, etc.):
2009 Recipients
Costs
MH/SA HH
17,353
$144,636,428
Initial Target:
Chronic
5,333
$23,342,981
MH/SA + Chronic =
Medical
Dev
Disabled
2,117
$186,205,640
22,686 HH eligibles
LTC
5,424
$216,134,134
30,227
$570,319,183
 All Medicaid enrollees will be carved in to Managed Care within 3 years. Health Home services
will become part of the benefit structure.
2009 Claim Information for Recipients Assigned* to the Chronic Medical Health Home Group by
Recipient County and Diagnosis Class (Updated August 2011)
Medical:
County/Diagnosis Class
MONROE
CERTAIN CAUSES OF PERINATAL MORBID/MORALITY
CIRCULATORY SYSTEM DISEASES
CONGENITAL ANOMALIES
DELIVERY AND COMPLICATIONS OF PREGNANCY
DIGESTIVE SYSTEM DISEASES
DISEASES OF BLOOD & BLOOD FORM
DISEASES OF THE MUSCULOSKELETAL SYSTEM
DISEASES OF THE NERVOUS SYSTEM
DISEASES OF THE RESPIRATORY SYSTEM
DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE
ENDOCRINE, NUTRITIONAL, METABOLIC
EXTERNAL CAUSE OF INJURY
GENITOURINARY SYSTEM DISEASES
INFECTIVE AND PARASITIC DISEASE
LIVEBORN INFANTS ACCORDING TO TYPE OF BIRTH
MENTAL DISORDERS ALL DSMIII C
NATURE OF INJURY, ADVERSE EFFECTS & POISONING
NEOPLASMS
NOT AVAILABLE
REASON FOR SPECIAL ADMISSIONS AND EXAMS
SIGNS, SYMPTOMS, AND ILL-DEFINED CONDITIONS
SUPPLE CLASS/DESC OF PATIENT STATUS & OTHER
HLTH
2009 Fee for
Service Dollars
$ 23,342,981
$
99,128
$
1,418,738
$
164,508
$
401,878
$
725,449
$
271,881
$
574,765
$
353,769
$
649,661
$
122,761
$
481,345
$
259
$
352,688
$
666,308
$
627,043
$
813,896
$
328,505
$
423,605
$
618,189
$
92,497
$ 13,481,155
$
674,953
2009 Fee for
Service
Claims
135,567
341
9,445
201
536
2,988
1,286
7,767
3,924
5,782
1,589
7,124
5
3,703
4,061
52
12,017
2,074
3,289
12,570
1,550
48,319
2009 Fee for
Service
Recipient
Count
5,333
30
1,900
118
133
883
239
1,594
1,202
1,411
582
1,789
5
860
788
42
393
658
731
1,434
706
4,810
6,944
1,815
1
*Recipients that meet federal and state health home criteria of having: (1) two chronic conditions; (2) one
chronic condition and are at risk for a second chronic condition; (3) one serious persistent mental health
condition; or (4) HIV/AIDs.
Mental Health/Substance Abuse:
County/Diagnosis Class
MONROE
CERTAIN CAUSES OF PERINATAL MORBID & MORALITY
CIRCULATORY SYSTEM DISEASES
CONGENITAL ANOMALIES
DELIVERY AND COMPLICATIONS OF PREGNANCY
DIGESTIVE SYSTEM DISEASES
DISEASES OF BLOOD & BLOOD FORM
DISEASES OF THE MUSCULOSKELETAL SYSTEM
DISEASES OF THE NERVOUS SYSTEM
DISEASES OF THE RESPIRATORY SYSTEM
DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE
ENDOCRINE, NUTRITIONAL, METABOLIC
EXTERNAL CAUSE OF INJURY
GENITOURINARY SYSTEM DISEASES
INFECTIVE AND PARASITIC DISEASE
LIVEBORN INFANTS ACCORDING TO TYPE OF BIRTH
MENTAL DISORDERS ALL DSMIII C
N/A
NATURE OF INJURY, ADVERSE EFFECTS AND POISONING
NEOPLASMS
NOT AVAILABLE
REASON FOR SPECIAL ADMISSIONS AND EXAMS
SIGNS, SYMPTOMS, AND ILL-DEFINED CONDITIONS
SUPPLE CLASS/DESC OF PATIENT STATUS AND OTHER
HLTH
2009 Fee for
Service Dollars
$ 144,636,428
$
5,299
$
2,771,282
$
45,810
$
1,377,982
$
2,377,960
$
684,493
$
1,696,564
$
961,821
$
2,115,071
$
619,465
$
1,213,533
$
3,718
$
975,232
$
2,059,939
$
26,838
$ 62,245,959
$
1,761
$
2,655,146
$
623,634
$
6,255,369
$
378,741
$ 50,369,058
$
5,171,754
2009 Fee for
Service
Claims
777,981
60
11,872
307
2,023
8,267
2,221
19,549
8,234
13,414
3,775
11,284
49
8,570
18,795
3
378,539
3
9,405
4,037
74,028
5,671
171,767
2009 Fee
for Service
Recipient
Count
17,353
19
3,230
142
552
2,780
387
4,486
2,905
3,826
1,608
3,011
29
2,611
2,193
2
12,915
2
2,597
1,258
5,347
2,455
15,714
26,108
6,957
2009 Claim Information for Recipients Assigned* to the Chronic Medical Health Home Group by
Recipient County and Age Group
Medical:
2009 Fee for Service
2009 Fee for Service
2009 Fee for Service
County/Age Group
Dollars
Claims
Recipient Count
MONROE
$
23,342,981
135,567
5,333
0 - 20
$
3,652,419
21,266
503
21 - 64
$
16,455,929
77,813
3,663
65 AND OVER
$
3,234,632
36,488
1,167
*Recipients that meet federal and state health home criteria of having: (1) two chronic conditions; (2) one chronic
condition and are at risk for a second chronic condition; (3) one serious persistent mental health condition; or (4)
HIV/AIDs.
2
Mental Health/Substance Abuse:
2009 Fee for Service
2009 Fee for Service
2009 Fee for Service
County/Age Group
Dollars
Claims
Recipient Count
MONROE
$
144,636,428
777,981
17,353
0 - 20
$
23,495,812
86,964
1,957
21 - 64
$
117,330,688
662,234
14,730
65 AND OVER
$
3,809,927
28,783
666
*Recipients that meet federal and state health home criteria of having: (1) two chronic conditions; (2) one chronic
condition and are at risk for a second chronic condition; (3) one serious persistent mental health condition; or (4)
HIV/AIDs.
Projected Average Health Home Payments by Base Health Status and Severity of Illness - Excludes
LTC and OPWDD Populations
DRAFT FOR REVIEW AND COMMENT ONLY - (November 17, 2011)
Base Health Status1
Single SMI/SED
Statewide
Average
Severity
Case
of
Manager
Illness
Ratio 2
Low
79:1
Upstate
Eligible
Recipients3
25,182
Average
CRG
Average
Acuity
Monthly
Score4 Payment5
6.3382
$119
Mid
61:1
9,772
8.0239
$150
High
12:1
60
16.6197
$312
73:1
35,014
6.8419
$128
Low
116:1
89,006
4.0091
$75
Mid
76:1
36,731
7.0456
$132
High
37:1
6,031
11.4136
$214
100:1
131,768
5.2032
$98
Low
89:1
5,155
5.7358
$108
Mid
62:1
7,608
8.2540
$155
High
34:1
2,609
11.8749
$223
65:1
15,372
8.0018
$150
Low
93:1
1,686
5.1243
$96
Mid
51:1
2,215
9.0280
$169
High
12:1
247
16.7148
$313
HIV/AIDS Total
64:1
4,148
7.9328
$149
Grand Total
91:1
186,302
5.7903
$109
Single SMI/SED Total
Pairs Chronic
Pairs Chronic Total
Triples Chronic
Triples Chronic Total
HIV/AIDS
1.
2.
3.
Mutually exclusive categories based on Clinical Risk Grouping. SED and OASAS children are included in price
model but will be excluded from initial assignment.
Statewide average staff to patient ratio for the selected group of patients.
Includes members that may currently be enrolled in care management programs (OMH TCM, COBRA, MATS
and CIDP).
3
4.
5.
The acuity scores are draft. While based on actual data, the acuity scores may be rescaled. This rescaling
should not affect the average monthly payment.
Average health home payment for the members in the given rate/severity group - these groups are for
illustration purposes - actual payments to health home provider will be based on a blend of a given provider's
health home patients from across all applicable rate/severity cells. Actual payments are calculated at the patient
level based on the predicted service intensity (staff to patient ratio) required for each patient and then rolled up
to a blended amount (i.e., one HH rate per provider for a given timeframe) for the entire group of patients
assigned to the health home provider and include a Wage Equalization Factor of 1.2437 (ratio of "CRG score
neutral" downstate payment to upstate payment). These payments will eventually be recalculated (and any
changes will be paid prospectively) based on service intensity and functional status data. DOH will closely
review payment adequacy during health home implementation.
NOTE: Changes from previously released health home draft rates: Dropped maximum ratio of patients to case
managers from 150:1 to 140:1. Added a 3 point acuity bump for HIV/AIDS and removed the severity level acuity
bumps for catastrophic and malignant cases. Increased funding for data management. These changes increased the
statewide average cost/payment per case manager to over $110,000, with the following estimated allocations; direct
salary and fringe benefits - $71,500, agency admin and program admin (direct supervision) - $15,000, non-personal
service - $10,000, other admin including data management - $6,500, capital - $7,200.
Projected Average Health Home Payments - Sample Populations
Patient
#
Base Health
Status
1
2
Pairs Chronic
Pairs Chronic
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Dx Description
Diabetes and Hypertension
Diabetes and Asthma
Diabetes - Hypertension - Other Dominant Chronic
Triples Chronic Disease
Triples Chronic Cystic Fibrosis
Conduct, Impulse Control, and Other Disruptive
Single SMI/SED Behavior Disorders
Pairs Chronic
Schizophrenia and Other Chronic Disease
Pairs Chronic
Diabetes and Advanced Coronary Artery Disease
Congestive Heart Failure - Diabetes Triples Chronic Cerebrovascular Disease
Single SMI/SED Schizophrenia
Pairs Chronic
Asthma and Other Moderate Chronic Disease
HIV/AIDS
HIV Disease
Diabetes - 2 or More Other Dominant Chronic
Triples Chronic Diseases
Triples Chronic Non-Hodgkin's Lymphoma
Single SMI/SED Schizophrenia
HIV/AIDS
HIV Disease
Triples Chronic Brain and Central Nervous System Malignancies
Severity
of
Illness
CRG
Acuity
Score
Upstate
Monthly
Payment
Low
Low
0.8114
4.0729
$13
$67
Low
Low
5.3524
5.6337
$88
$93
Low
Mid
High
5.6522
6.9474
7.0289
$93
$114
$116
Mid
Mid
Mid
Mid
7.4909
7.9318
8.3686
10.0992
$123
$131
$138
$166
High
High
High
High
High
12.3349
15.7499
16.6288
17.7378
25.1181
$203
$259
$274
$292
$414
New Rate-related Q& A’s on Health Home Website:
 The Health Home care management rates were calculated using three main variables – 1) caseload
variation (scaled from 12 to 1 at highest intensity end and 140 to 1 at lowest intensity end), 2) case
management cost and 3) patient specific acuity. Caseload variation (from 12:1 to 140:1) was derived
from a combination of sources including existing targeted case management programs, chronic illness
4



demonstration programs and other demonstrations of chronic illness management from other states
(e.g., Mass and Washington). Case management cost was derived utilizing cost data reported to the
State from existing programs. Patient specific acuity factors were utilized from 3M Clinical Risk
Group software. These raw acuity scores were then adjusted for a predicted functional status factor
(i.e., Mental Health, Substance Abuse and higher medical acuity groups were "up-weighted" until
functional status data become available to more accurately adjust clinical acuity). Patient specific
adjusted acuity scores were utilized to "predict" case management need based on a regression
formula.
The care management rates in the current chart are regional. The current regional factor pays 24.37%
more for the downstate region in comparison to the upstate region.
In the newly revised rate chart, HIV patients have had their acuity scores upweighted. Functional
status data when available may be used to further adjust the acuity scores for this group of patients. If
patients are in existing HIV COBRA case management then they will be billed at their existing rates
for one year. This will give us time to adjust all care management rates including the HIV rates for
functional status data. All HIV patients should be in the HIV group on the rate chart. The possible
exception is HIV patients that may have be receiving dialysis services – we are checking on this
possible exception now.
In person staff time versus telephonic staff time will vary based on the acuity level and diagnosis of
the patient (and eventually functional status). Behavioral Health and higher severity level cases will
require more in person staff time. Patients that fall in the low touch group (with patient to manager
ratios as high as 140 to 1) were priced as requiring primarily telephonic/tracking staff time.
Information received from: Laura Mahoney, NYS Department of Health, Office of Health Insurance
Programs, Division of Financial Planning and Policy, Bureau of Strategic Planning and Data Analysis on
12/21/11:
“Please note that the allocations of the $110,000 estimated case manager cost breakdown is meant to be
informational and is subject to change.
 Total statewide average cost/payment per case manager: $110,000
 Direct salary and fringe benefits ($71,500) - includes cost of case manager salaries and fringe
benefits (non-wage compensation provided to employees in addition to their normal wages or
salaries, such as health care, time off, retirement, social security).
 Agency admin and program admin (direct supervision) ($15,000) - includes administrative/
HR costs of maintaining program. Also includes direct supervision of case managers.
 Non-personal service ($10,000) - includes overhead type costs: equipment, repairs, maintenance,
supplies, telephone, travel, transportation, utilities.
 Other admin including data management ($6,500) – other administration costs including, but
not limited to, data management.
 Capital ($7,200) – lease, rental or purchase of land, buildings, construction and equipment to be
used for the rendering of services; expenditures creating future benefits. A capital expenditure is
incurred when a business spends money either to buy fixed assets or to add to the value of an
existing fixed asset.”
5