Missouri Code of State Regulations
Title 13 - DEPARTMENT OF SOCIAL SERVICES
Division 70 - MO HealthNet Division
Chapter 3 - Conditions of Provider Participation, Reimbursement, and Procedure of General Applicability
Section 13 CSR 70-3.240 - MO HealthNet Primary Care Health Homes
Universal Citation: 13 MO Code of State Regs 70-3.240
Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment adds chronic pain as a stand-alone chronic condition that qualifies MO HealthNet participants as Primary Care Health Home patients. The amendment also clarifies Health Home certification requirements, adds provider requirements for primary care health homes offering services to patients with chronic pain as a qualifying condition, and clarifies which health home patients will generate per-member, per-month (PMPM) payments to health homes.
(1) Definitions.
(A) EMR-Electronic Medical Records, also
referred to as Electronic Health Records (EHR).
(B) Health Home-A primary care practice or
site that provides comprehensive primary physical and behavioral health care to
MHD patients with chronic physical and/or behavioral health conditions, using a
partnership or team approach between the Health Home practice's/site's health
care staff and patients in order to achieve improved primary care and to avoid
preventable hospitalization or emergency department use for conditions
treatable by the Health Home.
(C)
Meaningful Use Stage One-The American Recovery and Reinvestment Act (ARRA) of
2009 created the Electronic Health Records (EHR) incentive payments program to
provide Medicare or Medicaid incentive payments to eligible professionals in
primary care practices. Meaningful use means that the eligible professionals or
providers document that they are using certified EHR technology in ways that
can be measured significantly in quality and in quantity. Stage one of
meaningful use means the eligible professionals meet twenty (20) out of
twenty-five (25) meaningful use objectives as specified by the Centers for
Medicare and Medicaid Services (CMS).
(D) MHD-MO HealthNet Division, Department of Social
Services.
(E) NCQA-National
Committee for Quality Assurance, an entity chosen by MHD to certify that a
primary care practice has obtained a level of Health Home recognition after the
practice achieves specified Health Home standards.
(F) Needy Individuals-Patients whose primary care
services are either reimbursed by MHD or the Children's Health Insurance
Program (CHIP), or are provided as uncompensated care by the primary care
practice, or are furnished at no cost or at reduced cost to patients without
insurance.
(G) Patient Panel-The
list of patients for whom each provider at the practice site serves as the
primary care provider.
(H)
CMS-Centers for Medicare and Medicaid Services.
(I) Chronic Pain-Pain that lasts past the
time of normal healing and that can lead to other medical conditions such as
substance use disorder, becoming overweight/obese, anxiety, and depression. For
the purpose of participant eligibility for Primary Care Health Home, chronic
pain must be a pre-existing condition for at least twelve (12) consecutive
months.
(2) A primary care practice site shall meet the following requirements at the time of the site's application to be considered for selection as a Health Home site by MHD and for participation in a Health Home learning collaborative:
(A) It must have substantial Medicaid
utilization in its patient population, with needy individuals comprising no
less than twenty-five percent (25%) of its patient population;
(B) It must demonstrate that it has strong
engaged leadership committed to, and capable of, leading the practice site
through a continuing Health Home transformation process and sustaining
transformed practice processes;
(C)
It must have patient panels assigned to each primary care clinician;
(D) It must actively utilize MHD's
comprehensive electronic health record for care coordination and prescription
monitoring for MHD participants;
(E) It must utilize an interoperable patient
registry to input annual metabolic screening results, track and measure care of
individuals, automate care reminders, and produce exception reports for care
planning;
(F) It must meet the
minimum access requirements of third-next-available appointment within thirty
(30) days and same-day urgent care;
(G) It must have completed EMR implementation
and have been using EMR at stage one of meaningful use for at least six (6)
months prior to the beginning of Health Home services; and
(H) It must comply with established time
frames for Health Home applications, inquiry submission, learning collaborative
attendance, and any reporting deadlines.
(3) Health Home Responsibilities After Selection.
(A) Health Home practice sites will
have a physician champion to provide physician leadership and encourage
practice transformation to the Health Home model. Health Home practice sites
shall form a health team comprised of, at a minimum, a primary care physician
(i.e., family practice, internal medicine, or pediatrics) or nurse
practitioner, a behavioral health consultant, and a nurse clinical care
manager. The team will be supported as needed by the care coordinator, Health
Home Director, and the practice administrator or office manager. Other team
members may include, for example, dietitians, nutritionists, pharmacists, or
social workers.
(B) Practice sites
selected to be MHD Health Homes shall participate in Health Home webinars, care
team forums, and other training opportunities. A Health Home will participate
in topical work groups as requested by MHD.
(C) Health Homes shall convene practice team
meetings at regular intervals to assist with the practice's transformation into
a Health Home and to support continual Health Home evolution.
(D) A Health Home shall create and maintain a
patient registry using EHR software, a stand-alone registry, or a third-party
data repository and measures reporting system. The patient registry is the
system used to obtain information critical to the management of the health of a
primary care practice's patient population, including dates of services, types
of services, and laboratory values needed to track chronic conditions. The
Health Home's patient registry will be used for-
1. Patient tracking;
2. Patient risk stratification;
3. Analysis of patient population health
status and individual patient needs; and
4. Reporting as specified by MHD.
(E) Primary care practice sites
must transform how they operate in order to become Health Homes. Transformation
involves mastery of thirteen (13) Health Home core competencies to be taught
through the learning collaborative. The thirteen (13) core competencies are-
1.
Patient/family/peer/advocate/care-giver-centeredness or a whole-patient
orientation to care;
2.
Multi-disciplinary team-based approach to care;
3. Personal patient/primary care clinician
relationships;
4. Planned visits
and follow-up care;
5.
Population-based tracking and analysis with patient-specific
reminders;
6. Care coordination
across settings, including referral and transition management;
7. Integrated clinical care management
services focused on high-risk patients including medication management, such as
medication histories, medication care plans, and medication
reconciliation;
8. Patient and
family education;
9.
Self-management support by members of the practice team;
10. Involvement of the patient in goal
setting, action planning, problem solving, and follow-up;
11. Evidence-based care delivery, including
stepped care protocols;
12.
Integration of quality improvement strategies and techniques; and
13. Enhanced access.
(F) By the eighteenth month following the
receipt of the first MHD Health Home payment, a practice site participating in
the Health Home program shall demonstrate to MHD that the practice site has
either-
1. Submitted to the National
Committee for Quality Assurance (NCQA) an application for Health Home status
and has obtained NCQA recognition of Health Home status of at least Level 1
under the most recent NCQA standard; or
2. Applied to a nationally recognized
accrediting organization for certification as a Primary Care Medical
Home.
(G) A Health Home
shall submit to MHD or its designee the following information, as further
specified by MHD or its designee, within the specified time frames:
1. Monthly narrative practice reports that
describe the Health Home's efforts and progress toward implementing Health Home
practices;
2. Monthly clinical
quality indicator reports utilizing clinical data obtained from the Health
Home's patient registry or third-party data repository; and
3. Other reports as specified by
MHD.
(H) Practices
selected to participate in the Health Home program must provide evidence of
Health Home practice transformation on an ongoing basis using measures and
standards established by MHD. Evidence of Health Home transformation includes:
1. Development of fundamental Health Home
functionality at six (6) months and at twelve (12) months of entering the
Health Home program, based on an assessment process to be applied by MHD or its
designee;
2. Significant
improvement on clinical indicators specified by and reported to MHD or its
designee; and
3. Development of
quality improvement plans to address gaps and opportunities for improvement
identified during and after the Health Home application
process.
(I) A Health
Home must notify MHD within five (5) working days of the following changes:
1. Changes in the employment or contracting
of Health Home team members, or changes in the percentage of full-time
equivalent work time devoted to the Health Home by any Health Home team member;
or
2. If the Health Home
experiences substantive changes in practice ownership or composition,
including:
A. Acquisition by another
practice;
B. Acquisition of another
practice; or
C. Merger with another
practice.
(J)
Health Homes shall participate in evaluations determined necessary by CMS
and/or MHD. Participation in evaluations may require responding to surveys and
requests for interviews of Health Home practice staff and patients. Health
Homes shall provide all requested information to an evaluator in a timely
fashion.
(K) Within three (3)
months of selection to be a Health Home, a practice site will develop processes
with area hospitals to share information on Health Home participants admitted
to inpatient departments or seen in the emergency department.
(L) In order to provide Health Home services
to a participant with substance use disorder and who is eligible for Health
Home services in accordance with subparagraph (4)(A)2.A., a Primary Care Health
Home practice must have at least one (1) performing provider who qualifies and
applies for a waiver under the Drug Addiction Treatment Act of 2000 (DATA 2000)
to provide medication-assisted treatment.
(M) In order to provide Health Home services
to enrolled participants with chronic pain, clinicians in a Primary Care Health
Home must participate in monthly interactive video conferences on chronic pain
that will be scheduled by accredited academic institutions. The video
conferences will include pain management specialists who will provide guidance
on the care of participants with a chronic pain diagnosis. Health Homes will
directly collaborate with a pain management specialist on the management of
these individuals. A pain management specialist is defined as a licensed
physician (MD or DO) who is board certified in anesthesiology or pain
management.
(4) Health Home Patient Requirements.
(A) To become a MO
HealthNet Health Home patient, an individual-
1. Must be an MHD participant or a
participant enrolled in an MHD managed care health plan; and
2. Must have at least-
A. Two (2) of the following chronic
conditions:
(I) Asthma;
(II) Diabetes;
(III) Cardiovascular disease;
(IV) A developmental disability;
(V) Be overweight, as evidenced by having a
body mass index (BMI) of at least twenty-five (25) for adults, or being at or
above the eighty-fifth (85th) percentile on the standard pediatric growth chart
for children;
(VI)
Depression;
(VII)
Anxiety;
(VIII) Substance use
disorder; or
(IX) Chronic pain;
or
B. One (1) chronic
health condition and be at risk for a second chronic health condition as
defined by MHD. In addition to being a chronic health condition, diabetes shall
be a condition that places a patient at risk for a second chronic condition.
Smoking or regular tobacco use shall be considered at-risk behavior leading to
a second chronic health condition; or
C. One (1) of the following stand-alone
chronic conditions:
(I) Uncontrolled
pediatric asthma as defined by MO HealthNet;
(II) Obesity, as evidenced by having a BMI
over thirty (30) for adults, or being above the ninety-fifth (95th) percentile
on the standard pediatric growth chart for children; or
(III) Chronic
pain.
(B) A list of participants eligible for
Health Home services and identified by MHD as existing users of services at
Health Home practices will be provided monthly to each Health Home based on
qualifying chronic health conditions. Health Home organizations will determine
enrollees from the lists provided by MHD as well as practice patients
identified through the Health Homes' EMR systems.
(C) After being enrolled in Health Homes,
participants will be granted the option at any time to change their Health
Homes if desired. Participants will be given the opportunity to opt out of
receiving services from their Health Home providers.
(5) Required Health Home Services.
(A) All Health Homes shall provide clinical
care management services for enrolled patients, including those who are at high
risk for future hospital inpatient admissions or hospital emergency department
use.
1. Essential clinical care management
services include:
A. Identification of
high-risk patients and use of patient information to determine the level of
participation in clinical care management services;
B. Assessment of preliminary service
needs;
C. Individual treatment plan
development for each patient, including patient goals, preferences, and optimal
clinical outcomes;
D. Intensive
monitoring, follow-up, and clinical management of high-risk patients;
E. Assignment of health team roles and
responsibilities by the clinical care manager;
F. Monitoring of individual and population
health status and service use to determine adherence to, or variance from,
treatment guidelines;
G.
Development of treatment guidelines for health teams to follow across risk
levels or health conditions; and
H.
Development and dissemination of reports that indicate progress toward meeting
desired outcomes for client satisfaction, health status, service delivery, and
costs.
2. Clinical care
management activities generally include frequent patient contact, clinical
assessment, medication review and reconciliation, communication with treating
clinicians, and medication adjustment by protocol.
3. A Health Home shall employ or contract
with at least one (1) licensed nurse as the Health Home clinical care manager
responsible for providing clinical care management services. The clinical care
manager shall function as a member of the Health Home practice team whenever
patients of the practice team are receiving clinical care management
services.
4. Health Homes shall
ensure and document that funding for clinical care management services is used
exclusively to provide clinical care management services.
5. Recognized Health Homes may collaborate in
the provision of clinical care management services.
(B) Health Homes shall provide health
promotion services for their patients. Health promotion services include:
1. Providing health education specific to a
patient's chronic conditions;
2.
Emphasizing patient self-direction, planning, and skill development so patients
can help manage and monitor their chronic health conditions;
3. Providing support for improving social
networks; and
4. Providing
health-promoting lifestyle interventions, including but not limited to:
A. Substance abuse prevention;
B. Smoking prevention and
cessation;
C. Nutritional
counseling;
D. Obesity prevention
and reduction; and
E. Physical
exercise activities.
(C) All Health Homes shall provide
comprehensive care coordination services necessary to implement individual
treatment plans, reduce hospital inpatient admissions, and interrupt patterns
of frequent hospital emergency department use.
1. Care coordination requires that a member
of the Health Home team assist patients in the development, revision, and
implementation of their individual treatment plans.
2. Care coordination also includes
appropriate linkages, referrals, and follow-ups to needed services and
supports.
3. Health Homes that
specialize in primary physical health care shall obtain the services of a
licensed behavioral health professional to assist with care coordination
services.
4. Other essential care
coordination activities include:
A.
Appointment scheduling;
B.
Arranging transportation for medically-necessary services;
C. Monitoring referrals and
follow-ups;
D. Providing
comprehensive transitional care by collaborating with physicians, nurses,
social workers, discharge planners, pharmacists, and other health care
professionals to continue implementation of patients' treatment
plans;
E. For patients with
developmental disabilities (DD), coordinating with DD case managers for
services more directly related to habilitation and other DD-related
services;
F. Referring Health Home
patients to social and community resources for assistance in areas such as
legal services, housing, and disability benefits; and
G. Providing individual and family support
services by working with patients and their families to increase their
abilities to manage the patients' care and live safely in the
community.
(6) Hospitals and participating Health Home sites shall communicate transitional care planning for Health Home participants, including inpatient discharge planning, such that effective patient-centered, quality-driven provider coordination is ensured.
(7) Health Home Payment Components.
(A) General.
1. All Health Home payments to a practice
site are contingent on the site meeting the Health Home requirements set forth
in this rule. Failure to meet these requirements is grounds for revocation of a
site's Health Home status and termination of payments specified within this
rule.
2. MO HealthNet Health Home
reimbursement will be in addition to a provider's existing MHD reimbursement
for services and procedures and will not change existing reimbursement for a
provider's non-Health Home services and procedures.
3. No Health Home payments will be made to an
MHD Health Home until the calendar month immediately following the Health
Home's first learning collaborative session.
4. Should experience reveal to MHD that
elements of the Health Home payment methodology will not function, or are not
functioning, as MHD intended, MHD reserves the right to make changes to the
payment methodology after consultation with recognized Health Homes and receipt
of required federal approvals.
(B) MHD Health Homes shall receive
per-member-per-month (PMPM) payments to reimburse Health Home sites for costs
incurred for patient clinical care management services, comprehensive care
coordination services, health promotion services, and Health Home
administrative and reporting costs.
1. A
Health Home's PMPM reimbursement will be determined from the number of patients
that choose, or are assigned to, the Health Home site.
2. A current month's PMPM payments to a
Health Home site will be based on-
A. The
number of Health Home-eligible patients receiving Health Home services at the
Health Home in the month considered for payment;
B. The number of Health Home-eligible
patients in subparagraph (7)(B)2.A. who are assigned to the Health Home at the
beginning of the month considered for payment; and
C. The number of Health Home-eligible
patients in subparagraphs (7)(B)2.A. and (7)(B)2.B. who are Medicaid-eligible
at the end of the month considered for payment.
3. A Health Home will receive PMPM payments
only for MHD or MHD managed care participants who meet the payment requirements
in subparagraph (7)(B)2. and who have the required qualifying health home
conditions specified in section (4).
4. In order to generate a PMPM payment to a
Health Home, a patient assigned to the Health Home must have received at least
one (1) non-Health Home service based on paid Medicaid fee for service or
managed care claims.
5. In order to
receive PMPM payments, a Health Home must demonstrate to MHD that the Health
Home has hired, or has contracted with, a clinical care manager to provide
services at the Health Home site.
(8) Health Home Corrective Action Plans.
(A) Health Homes shall undergo an assessment
process to be applied by MHD or its designee at six (6) months and at twelve
(12) months of entering the Primary Care Health Home program. If the assessment
shows that a Health Home practice site fails to meet the Health Home
requirements as set forth in section (3) of this rule, or fails to provide the
required Health Home services as set forth in section (5) of this rule, the
Health Home practice site shall participate in a corrective action plan to
address any such failures disclosed as a result of the assessment process. The
corrective action plan will last for six (6) months and may be extended or
renewed at MHD's discretion. At the end of the corrective action plan period,
the Health Home practice site will be reassessed to determine its compliance
with the requirements of this rule.
(B) The Health Home practice site will be
reassessed at the end of the corrective action plan period, including any
extensions and renewals granted by MHD. If the reassessment shows that the
Health Home still fails to meet Health Home requirements or provide required
Health Home services, MHD shall terminate the Health Home practice site from
the Primary Care Health Home program.
*Original authority: 208.201, RSMo 1987, amended 2007.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
