Objective

To determine whether the Department of Health (DOH) has provided adequate oversight of Medicaid Health Homes to ensure that appropriate care was provided and that appropriate payments were made. The audit covered the period from January 2019 through June 2023, with analysis of selected performance measures extending through March 2024 and review of certain aspects of the redesignation process extending through October 2024.

About the Program

The Health Home Program (Program), implemented in New York in January 2012, is an optional benefit under the Medicaid State Plan that provides care coordination and case management to certain Medicaid members who have chronic health problems. The Program’s goals include removing individuals’ social and economic barriers to care, engaging people in the behavioral and general medical care needed to stay well, and reducing unnecessary services and costs.

Under New York State’s approach to Program implementation, a Health Home is the central point for directing patient-centered care and is accountable for reducing unnecessary health care costs. A Health Home is not a physical place; it’s a care management model that connects community and social supports with health care providers to ensure that all caregivers work together and focus on their clients’ needs. Health Home providers render services to eligible members either directly or through contracts with Care Management Agencies that assign members a dedicated care manager to help with obtaining medical, behavioral, and social services.

DOH administers New York’s Medicaid program and is responsible for overseeing the Program and ensuring Health Home providers comply with federal and State statutory, regulatory, and policy requirements and achieve intended results. DOH’s monitoring activities include periodic audits called redesignation reviews, which are designed to assess administrative management, service delivery, and operational integrity of Health Homes. DOH also calculates Health Home performance measures (e.g., the rate of inpatient admissions for chronic conditions) to evaluate the effectiveness of the Program and to guide quality improvement efforts. Health Homes must also submit supporting information to DOH’s Medicaid Analytics Performance Portal Health Home Tracking System (MAPP System) for each month a Medicaid member is enrolled in the Program, including an attestation that a billable service was provided. Based on the information submitted, the MAPP System determines whether a Health Home claim is warranted and calculates which rate code should be billed.

Key Findings

DOH has not consistently followed its monitoring and oversight guidelines for Health Homes to ensure effective delivery of services, nor has it used all available data and measurements to assess the Program’s value and effectiveness. Additionally, Health Homes lacked compliance with Program policies and procedures, and certain payments made to Health Homes lacked the required support in the MAPP System. The following details our findings:

• DOH did not complete redesignation reviews for all Health Homes within the required time frames, allowing Health Homes to operate for periods without this key monitoring process. While DOH cited the COVID-19 public health emergency and the implementation of redesignation process changes in 2023 as reasons for delays with many reviews, of the 18 recent redesignation reviews due before October 2024, 10 were delayed by more than 6 months.
• Health Homes frequently did not comply with Medicaid policies and procedures. For example, the majority of Health Homes had poor compliance with updating members’ care plans when needed.
• DOH’s performance measure calculations do not include baseline measurements, a crucial point of reference for evaluating the progress and effectiveness of the Program and Health Home providers. Without a baseline, it is difficult to determine whether goals are being met or if improvements are needed.
• For the period from January 2019 through June 2023, we identified $19.7 million in payments across 67,026 claims that lacked proper support in the MAPP System.

Key Recommendations

• Ensure redesignation reviews are conducted timely in accordance with the redesignation policy.
• Formally evaluate whether to include baseline data calculations (such as Health Home member circumstances before enrollment) in the Health Home performance measures.
• Review the $19.7 million in payments that lacked proper support in the MAPP System attestations, and make recoveries, as appropriate.
• Ensure that Health Home claims are properly supported in the MAPP System and make recoveries on improper payments, as appropriate.