Health Homes

A Health Home is a care management service model whereby all of an individual’s caregivers communicate with one another so that all of a patient’s needs are addressed in a comprehensive manner. This is done primarily through a “care manager” who oversees and provides access to all of the services an individual needs to assure that they receive everything necessary to stay healthy, out of the emergency room and out of the hospital.

The Department of Health includes a full web site on Health Homes online here.



12-12-18: Based upon feedback from stakeholders, NYS will be extending the requirement for all 1915c waiver care managers and supervisors for B2H, OMH HCBS, OPWDD CAH and DOH CAH I & II transitioning to HHSC care management to complete CANS-NY in person training to February 28, 2019.  An updated list of training dates will be announced soon.

If 1915c care managers or supervisors transitioning to Health Home care management have not yet been able to attend an In-Person CANS-NY training, care managers and supervisors must at least be CANS-NY certified by December 31, 2018.  If care management staff are not CANS-NY certified by the end of the year, agencies will be unable to transition their children who are currently in waiver services to Health Home care management in the new year during transition activities.  To obtain certification, please go to:  For more information and resources on completing the online CANS-NY certification, please go to and review the” Navigating the Training Site” document and the “FAQ Tip Sheet”.

*As a reminder, the February 28, 2019 deadline is for 1915c waiver care managers and supervisors for B2H, OMH HCBS, OPWDD CAH and DOH CAH I & II programs transitioning to HHSC care managers and does not include current Health Home care managers.  More information will be forthcoming on this requirement as it relates to current Health Home care managers.

If you are a 1915c provider and your staff need in-person training, please e-mail the HHSC Program at with the subject line, “CANS-NY In Person Training for 1915c Providers” by COB December 20, 2018 to ensure training will be scheduled in your area.   In the e-mail, you will need to include the number of staff at your agency that need in person CANS-NY training, whether training needed is general or supervisory and the region your agency is located in.

11-27-18: The Guidance on Background Checks requirements for current 1915c transitioning Home and Community Service (HCBS) providers that serve enrollees under age 21 that needs to be in place by April 1, 2019 can be found at the following link:

10-12-18:  The Health Home program Chronic Condition list has been updated reflective of the developmental disabilities and specific guidance is provided to assist adult and children HH CMA to determine Health Home eligibility and enrollment.

9-27-18:  The 2018 Health Home Measure Specification and Reporting Manual is now available on the Health Home Performance Management webpage, located under Quality and Process Measures:  The manual identifies the quality measures, annual improvement targets, performance goals and reporting requirements for the New York State Department of Health- Health Home Program (NYSDOH-HH).

5-4-18:  Health Home Plus Program Guidance for High-Need Individuals with Serious Mental Illness  and Health Home Care Management Agency Credentials to Serve Health Home Plus (HH+) for Members with Serious Mental Illness

This guidance, effective May 1, 2018, outlines populations considered to have the highest care management needs within the Serious Mental Illness (SMI) population and who qualify for HH+ services. The guidance includes program requirements and care management models that meet those requirements. For other HH+ eligible SMI populations and previously distributed guidance, see also:

Health Home Plus (HH+) Program Guidance for Assisted Outpatient Treatment (AOT) (Revised October 2016);

Health Home Plus Program Guidance New York State Office of Mental Health (OMH) State Psychiatric Center (“State PC”) and Central New York Psychiatric Center and its Corrections-Based Mental Health Units (Located within NYS DOCCS Prison System) (“CNYPC”) Adult Discharges (October 2016)

Prior to May 2018, the ability to serve and bill the HH+ rate code for individuals meeting HH+ eligibility criteria were limited to former Office of Mental Health (OMH) Targeted Case Management (TCM) providers, or OMH Legacy CMAs. Effective May 2018, OMH has established HH+ CMA Credentials that must be met by any non-OMH Legacy CMAs and non-Legacy CMAs who will serve the HH+ population and receive the HH+ reimbursement.

Attestation Process for CMAs to serve HH+ for Members with SMI

Lead Health Homes are responsible for submitting written attestation to Department of Health (DOH)/OMH of all contracted CMAs who will provide HH+ and that meet credentials, staff qualifications and core competencies outlined in the attached Health Home (HH) Care Management Agency (CMA) Credentials to Serve Health Home Plus (HH+) for Members with Serious Mental Illness (SMI) guidance document. Each Health Home will receive an attestation form with their currently identified HH+ CMAs included. The Health Home will update this form with information for additional CMAs who will serve HH+ for members with SMI and attest that they meet the credentials to serve this population.

6-5-17: Health Homes Consent for Children in Foster Care – DOH has issued guidance outlining the process to obtain proper Health Home consents for children in foster care.  This is posted on the DOH HHSC website at

5-14-17: Health Homes Designation list – A new document was released that provides an update on Health Homes Designated to Serve Children as of 5/11/17 as well as their county service areas.  These documents can be found on the Department of Health, Health Homes Serving Children website.

3-24-17: HH Reportable Incidents Policies – The Health Home Monitoring: Reportable Incidents Policies and Reporting Timeframes, guidance and supporting documents are available by clicking this link.  This policy will take effect 4/15/17.  As report submission will be mandatory via the Health Commerce System (HCS), please be sure your accounts are active.

2-21-17: Hospital Referral Letter – New York State Hospitals received notification of a newly developed protocol, “Hospital Requirements for Making Referrals to Health Homes”.  This letter provides an overview of this MRT Initiative, specific regulations and requirements for implementation by Hospitals, and guidance for Hospitals to refer patients who present in an emergency department to Health Homes.  The date for implementation of this protocol is 90 days from the date of the letter.

Along with the letter are two attachments: Attachment A - Hospital Requirements for Making Referrals to Health Homes: Referral Procedures and Determining if a Medicaid Member is Currently Eligible or Enrolled in Health Home, providing guidance to assist Hospitals with the referral process; and, Attachment B – Letter of Attestation, for Hospitals to complete and submit to the Department.

Questions related to this requirement can be submitted to the Health Home BML at: - Subject “Hospital Referral Requirement – Questions”.

1-6-17: MCP Member Assignment – During the January 3 MAPP HHTS Weekly Webinar, DOH presented a process for assigning a member with an MCP assignment to a HH in different situations.  Since presenting this process, DOH discovered a less complicated way to make sure these members are assigned to the correct HH.  Please see slides 4 and 5 of the 1/3/17 MAPP HHTS Weekly Webinar power point presentation for the updated process.

11-9-16: Temporary Health Home Billing Procedures – The procedures will be effective December 1, 2016. The procedures will also be posted on the website under Member Assignment, Tracking System, Billing and Rates – Billing Resources

10-25-16: Health Home Consent Forms – All Health Home Serving Children consent forms have been finalized and are posted to the DOH website.

9-26-16: Briefing available online – The July 25, 2016 briefing:  “Linking Medicaid Members in Hospitals to Health Home Care Management Under the Affordable Care Act ( ACA)”  is now available on the DOH website.

7-5-16:  Health Home Community Referral Guidelines – DOH, OMH, and OASAS has released the most up-to-date guidelines for making community referrals to Health Home Care Coordination.  PROS providers are encouraged to identify individuals who can benefit from Care Coordination and especially HARP enrollees and make referrals to Health Home Care Coordination.

6-29-16: Health Home Re-Designation Standards Checklists & Chart Review Tools Available – The NYS Health Home Standards Review Checklists and the Chart Review Tool used on the Health Home Re-Designation site visits are now available on our NYS Health Homes website.  The State Review Team utilizes these tools to confirm the Health Home’s compliance with Federal and State standards and requirements.

The documents and a brief description of the Re-Designation process can be found on the NYS Health Homes home page under the “Quick Links” section.

3-4-16: Health Home Tracking System – The MAPP HHTS will go-live on Thursday March 23, 2016.    There are a number of steps each organization must complete to ensure their respective staff are ready.  These steps include the following:

  • All staff must be assigned to the appropriate MAPP role.  The MAPP Gatekeeper for each organization can perform this step.
  • All staff must complete the training required for the respective MAPP role.  Each organization is strongly encouraged to work with their respective staff to ensure training has been completed.
    • All staff must complete the overview and navigation web-based courses.
    • Staff assigned to the “Health Home or MCP worker” role must participate in and complete the instructor-led webinar.
    • Staff assigned to the “CMA worker” role are highly encouraged to participate in and complete the instructor-led webinar.
    • MAPP Gatekeepers must complete the Gatekeeper web-based course.
  • Staff who do not complete the required training will be unable to access the MAPP HHTS.

A fundamental feature of the MAPP HHTS is demonstrate the affiliations/relationships between agencies.  Documentation must be submitted to DOH before an affiliation is recorded in the MAPP HHTS.  If your Health Home has not done so already:

  • submit all contracts it has with a Managed Care Plan (MCP).
  • submit all Business Associate Agreements (BAAs) it has with Health Home Care Management Agencies (CMA).

A Health Home will not be able to work together with a MCP or a CMA in the MAPP HHTS until documentation of the contract or BAA is received, approved, and recorded in MAPP HHTS by DOH.

If you have any questions about accessing the MAPP HHTS, please contact the MAPP Customer Care Center at or (518) 649-4335.


Children’s Health Homes

1-4-17: Implementation Webinar – The DOH has released the PowerPoint presentation from its webinar to assist with questions regarding implementation of the HH program for children.

11-1-16: Web site Updates – DOH has updated their Health Homes Serving Children Website to include the following documents:

10-31-16: Updates on Children HH and Early Intervention – the DOH has released an announcement and information regarding the Medicaid Health Home for Children Program and the Early Intervention Program.



The Commonwealth Fund has issued a new brief: Caring for High-Need, High-Cost Patients: What Makes for a Successful Care Management Program?  In the brief, they compared the operational approaches of 18 successful complex care management programs in order to offer guidance to providers, payers, and policymakers on best practices for complex care management.


Seizing the Opportunity: Early Medicaid Health Home Lessons

Medicaid health homes, made possible through the Affordable Care Act, provide states with a mechanism to support better care management for people with complex health needs with the goal of improving health outcomes and curbing costs. States implementing health homes receive enhanced federal support for a limited time period. As of March 2014, 15 states have 22 approved state plan amendments to implement Medicaid health homes. Six “early adopter” states — Iowa, Missouri, New York, North Carolina, Oregon, and Rhode Island — have collectively enrolled more than 875,000 Medicaid beneficiaries in health homes.

This CHCS brief, supported by the New York State Health Foundation and the Missouri Foundation for Health, draws from the experiences of early health home adopter states to outline elements critical to implementation and sustainability of this new model. The brief informs other states looking to develop effective health home programs. See also a fact sheet and infographic that summarize key points in establishing Medicaid health homes.

Read the brief
Read the fact sheet
View the infographic