Medicaid Program – Oversight of Health Homes

DOH did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments, including not completing redesignation reviews for all Health Homes within the required time frames and inconsistent monitoring prior to August 2023 when improvements were implemented.

Health Homes frequently did not comply with Medicaid policies and procedures, such as updating members’ care plans when needed.

Performance measure calculations did not include baseline measurements, hindering evaluation of progress and program effectiveness.

From January 2019 through June 2023, auditors identified $19.7 million in payments across 67,026 claims that lacked proper support in the MAPP System.

Ensure redesignation reviews are conducted timely in accordance with the redesignation policy.

Formally evaluate whether the redesignation process should be improved to ensure that Health Homes (via the plan of care and other actions) are addressing the underlying risk factors members were identified to have upon enrollment in the Health Home program.

Ensure that Health Homes submit Enhanced Oversight Plans timely, when required, and with adequate detail.

Formally evaluate whether to include baseline data calculations (such as Health Home member circumstances before enrollment) in the Health Home performance measures to: More accurately score Domain 2 of Health Home redesignation reviews, and Effectively measure the overall performance of the Program.

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.

Ensure the MCO identified in this report takes corrective actions to prevent erroneously paying voided Health Home claims due to retroactive rate changes.