Mo. Code Regs. tit. 13 § 70-3.240

Current through Register Vol. 49, No. 11, June 3, 2024

Section 13 CSR 70-3.240 - MO HealthNet Primary Care Health Homes

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.

13 CSR 70-3.240

AUTHORITY: section 208.201, RSMo Supp. 2011.* Original rule filed Dec. 15, 2011 , effective July 30, 2012.

Amended by Missouri Register May 15, 2017/Volume 42, Number 10, effective 6/30/2017

Amended by Missouri Register May 1, 2020/Volume 45, Number 9, effective 6/30/2020

*Original authority: 208.201, RSMo 1987, amended 2007.