New York State’s Health Home eligibility criteria are as follows:
- Medicaid eligible/active Medicaid; and
- Two (2) or more chronic conditions; or
- One (1) single qualifying condition of either HIV/AIDS or a Serious Mental Illness (SMI)
Qualifying chronic conditions are defined in the State Plan Amendment as any of those included in the “Major” categories of the 3MTM Clinical Risk Groups (CRGs). A table of qualifying conditions contained in these categories has been compiled and is shown below. Substance use disorders (SUDS) are in the list of qualifying chronic diseases but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition (chronic medical or mental health) to qualify. A chronic disease in the context of determining eligibility for Health Homes implies a health condition that requires ongoing monitoring and care. The state should not be incidental to the care of the member but have a significant impact on their health and well-being.
In addition to having a qualifying condition, an individual must be appropriate for Health Home services. Individuals who are Medicaid eligible and have active Medicaid and meet diagnostic eligibility criteria may not necessarily be appropriate for Health Home care management. Individuals that meet the eligibility criteria for Health Homes and manage their care effectively do not need the level of care management provided by Health Homes.
An individual must be assessed and found to have significant behavioral, medical, or social risk factors to deem them appropriate for Health Home services. An assessment must be performed for all presumptively eligible individuals to evaluate whether the person has significant risk factors and is suitable for Health Home care management services. Determinants of medical, behavioral, and social risk can include:
- The probable risk for adverse events (e.g., death, disability, inpatient or nursing home admission);
- Lack of or inadequate social/family/housing support;
- Lack of sparse connectivity with the healthcare system;
- Non-adherence to treatments or medication(s) or difficulty managing medications;
- The recent release from incarceration or psychiatric hospitalization;
- Deficits in activities of daily living such as dressing or eating; and
- Learning or cognition issues.