Criteria for Health Home eligibility:
Health Home eligibility criteria require patients to have one of the following:
- Two or more chronic conditions (such as substance use disorder, asthma, diabetes*)
One single qualifying chronic condition:
Physical and behavioral health criteria alone do not make all patients eligible for a Health Home. Patients must also have one of the following risk factors:
- Determinants of medical, behavioral, and/or social risk including:
- Probable risk for adverse events (such as death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement)
- Lack of or inadequate social, family, housing support or serious disruptions in family relationships
- Lack of or inadequate connectivity with health care system
- Non-adherence to treatments or medications or difficulty managing medications
- Recent release from incarceration, detention, psychiatric hospitalization or placement
- Deficits in activities of daily living, learning or cognition issues
- Or is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home.
How does a patient join a Health Home?
If a patient appears to meet eligibility requirements, a referral is sent to a Health Home that is contracted in the patient’s county. The Health Home will assign the patient to one of its care management agencies (CMA).The CMA will contact the patient to review the services of the Health Home program, determine if the individual meets program criteria, and the patient has the choice of enrolling or may decline.
If the patient enrolls, the Health Home Patient Information Sharing Consent Form is signed. This allows information to be shared among listed providers and the health plan.
Provider tools and resources
- Log in to Availity
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- Learn about Availity
- Precertification lookup tool
- Precertification requirements
- Claims overview
- Member eligibility & pharmacy overview
- Provider manual and guides
- Training Academy
- Pharmacy information
- Electronic Data Interchange (EDI)