Medicaid AgenciesMedicaid Coverage → Attaining Coverage Through a 2703 Medicaid Health Home

 

Attaining Coverage Through a 2703 Medicaid Health Home

 

A few states are considering using a 2703 Medicaid Health Home State Plan Amendment (SPA) to promote Medicaid reimbursement for the National DPP lifestyle change program.
 


 

About 2703 State Plan Amendments (SPA)

Section 2703 of the Affordable Care Act created the ability for states to establish Medicaid health homes, which focus on comprehensive care management and care coordination for eligible Medicaid beneficiaries with certain chronic conditions. To qualify for enrollment in a Medicaid health home, a person must be eligible for Medicaid and have:

  1. Two or more chronic diseases;
  2. One chronic condition and be at risk for another; or
  3. A serious and persistent mental health condition.

Given these requirements, a state cannot develop a health home that only targets prediabetes. To qualify for a 2703 Medicaid health home, a person must have prediabetes and have or be at risk for another chronic condition (defined by the state). As such, using the 2703 health home approach may only reach a portion of the Medicaid population that is diagnosed with prediabetes.

To most effectively use the health home model, states may want to select qualifying chronic conditions that align with prediabetes and that the National DPP lifestyle change program has proven to address such as cardiovascular disease or hypertension. (See Evidence section).

Qualifying Chronic Conditions

The chronic conditions that states may choose to target through a health homes include, but are not limited to, a mental health condition, substance use disorder, asthma, diabetes, heart disease, and being overweight (as evidenced by having a Body Mass Index (BMI) over 25).

While prediabetes is not listed in the statute as a qualifying chronic condition, at least two states have received approved 2073 SPAs that specifically target prediabetes as a chronic condition or an “at-risk” category:

  • West Virginia’s 2703 SPA application and approval letter can be found here. Note: In West Virginia, the SPA targets individuals with prediabetes, diabetes, or obesity who are also at risk for anxiety and/or depression.
  • South Dakota’s 2703 SPA application and approval letter can be found here. Note: In South Dakota, Medicaid beneficiaries must have two or more chronic diseases or one chronic condition and be at risk for another, where prediabetes is included as an “at-risk condition.”

Enhanced Federal Funds

Qualifying health home services receive a 90% federal medical assistance percentage (FMAP) rate for the first eight fiscal quarters that the 2703 SPA is in effect.

Application Process

States can apply for Medicaid health homes by submitting a 2703 SPA to the Centers of Medicare and Medicaid Services (CMS) using the online Health Home SPA Template which is submitted through the Medicaid and CHIP program (MACPro) Portal. States are permitted to submit multiple SPAs to target different populations at different times.

There is significant flexibility for states in designing the payment methodology, and states interested in using a capitated model to implement a 2703 SPA are “encouraged to work with CMS informally prior to developing an official submission.”

Medicaid funding is available to states to support health home planning efforts. Such funding is provided at the state’s regular Medicaid match rate, which is higher than the administrative match for many states. Health home planning funding must be requested prior to the submission of a 2703 SPA by sending a Letter of Request to CMS at healthhomes@cms.hhs.gov. Information outlining the required content of a Letter of Request is available here. If a state determines through its planning activities that a 2703 SPA is not feasible, such planning activities are still reimbursable at the regular FMAP.
 


 

How to Connect Qualifying Health Home Services to the National DPP

Qualifying health home services include:

  • Comprehensive care management
  • Care coordination and health promotion
  • Comprehensive transitional care/follow-up
  • Patient and family support
  • Referral to community and social support services
  • Use of health information technology to link services

States have flexibility in how they define these health home services and can include additional, state-specific activities as part of the definition as long as they can explain how these definitions contribute to the health home model. Two possible ways to reference the National DPP lifestyle change program are provided below. These can be separate approaches or used in combination.

  1. In defining “health promotion” a state could reference “providing healthy lifestyle interventions,” which could include enrollment in the National DPP lifestyle change program. In this case, funding may be able to be used to directly support program operations and the reimbursement of services.
  2. In defining “referrals to community and social support services,” a state could reference the identification of available community resources, active management of referrals, engagement with other community and social supports, coordination of services and follow up—specifically mentioning CDC-recognized organizations and the National DPP lifestyle change program. This approach could offset many of the costs associated with participant identification and referral.

If the National DPP lifestyle change program is not formally included or approved as part of a states’ application, the 2703 health home structure can still be used to increase referrals to the National DPP lifestyle program since there is a natural match between the comprehensive care a health home provides and the program’s services. For example, West Virginia is currently encouraging health home providers to refer eligible patients to the National DPP lifestyle change program.

States receive the 90% enhanced FMAP for these specific health home services for the first eight fiscal quarters that the 2703 SPA is in effect. However, the enhanced match only applies to the six health home services listed above, and does not apply to other Medicaid services provided to individuals enrolled in a health home.
 


 

Health Home Providers

There are three provider arrangements permitted for health homes, and states can choose which of these provider arrangements to offer:

  • designated providers
  • a team of health care professionals
  • a health team

Examples of providers that may qualify as a “designated provider” include physicians, clinical practices or clinical group practices, rural clinics, community health centers, community mental health centers, home health agencies, or “any other entity or provider (including pediatricians, gynecologists, and obstetricians) that is determined appropriate by the State and approved by the Secretary…”

States may include additional providers for this category, potentially including CDC-recognized organizations or trained National DPP lifestyle coaches. States need to describe all the designated providers in the proposed SPA, which is subject to CMS approval. Each designated provider must have systems in place to provide health home services, and to satisfy certain qualification standards. For more information regarding these qualification standards, see the CMS Preliminary Guidance on Health Homes.

CDC-recognized organizations or trained National DPP lifestyle coaches could also potentially fall under a “team of health care professionals” or a “health team” depending on:

  1. how the state defines these provider arrangements under the 2703 SPA; or
  2. the requirements the state outlines for CDC-recognized organizations or trained National DPP lifestyle coaches in terms of qualifying as Medicaid-enrolled providers.

Providers that qualify as a “team of health care professionals” include, but are not limited to, physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, or “any professionals deemed appropriate by the State.” A state’s SPA should include a description of the composition of these teams. The team of health care professionals may operate in a free-standing clinic, hospital, community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or “any entity deemed appropriate by the State and approved by the Secretary.” The team of health care professionals is also permitted to operate virtually.

The term “health team” is defined by the Secretary and should be an interdisciplinary, inter-professional team that may include “medical specialists, nurses, pharmacists, nutritionists, dietitians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians’ assistants.”

Health home providers are expected to care for the “whole-person,” such as linking patients to long-term community care services and supports, social services, and family services. Health homes may be located in a provider’s office, coordinated virtually, or located in another setting based on the beneficiary’s needs.
 


 

Additional Resources

CMS Preliminary Guidance on Health Homes, November 16, 2010

Health Homes on Medicaid.gov