In 2009, New Mexico unanimously enacted Chapter 143 of the 2009 Laws, intended to provide medical homes for members of the state’s Medicaid, Children’s Health Insurance Program (CHIP), and State Coverage Initiative (SCI) program. SCI is a public-private managed care program in New Mexico that targets low-income adults without insurance working for small employers. The statute directs the New Mexico Human Services Department to apply for a waiver or state plan amendment to implement a medical home program, and to work with managed care contractors to “promote, and if practicable, develop” a medical home program.
Participating SALUD! managed care organizations (MCOs) are providing grants to a small number of primary care practices in the state with the goal of achieving NCQA PCMH certification. Initial estimates indicate that over 45,000 members are participating in PCMH delivery models through the SALUD! medical home pilots.
New Mexico Medicaid is focusing on four main objectives:
Enhance and standardize key components of the SALUD! physical health medical home model;
Implement and integrate a medical home model in the behavioral (mental health and substance abuse) and long term care delivery models;
Leverage new federal funding opportunities, specifically ACA Section 2703 health homes and Medicaid beneficiary incentive programs; and
Develop a consistent and transparent payment methodology.
HB34, introduced in the first session of 2011, would have required that all managed care plans to allocate funds to establish and maintain medical home programs, but the legislation was pocket-vetoed after passage in both the House and the Senate.
Federal Support: New Mexico has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Targeted population: Medicaid, CHIP, and SCI.
Last Updated: April 2014
New Mexico Medicaid plans to develop a workgroup including, but not limited to, the following organizations:
The workgroup will develop collaborative/cooperative protocols to support the goals and needs of medical homes.
New Mexico Medicaid also plans to develop managed care consumer advisory boards to educate enrollees and receive input on what enrollees want from medical homes.
|Defining & Recognizing a Medical Home||
Definition: Chapter 143 of the 2009 Laws defined a medical home as “an integrated care management model that emphasizes primary medical care that is continuous, comprehensive, coordinated, accessible, compassionate and culturally appropriate. Care within the medical home includes primary care, preventive care and care management services and uses quality improvement techniques and information technology for clinical decision support.” The statute [NMSA 1978 27-2-12.15 (1978)] also enumerates 18 specific attributes that may be included in a medical home.
Recognition: Chapter 143 of the 2009 Laws specified that medical doctors, physician assistants, and nurse practitioners are eligible for recognition as offering medical homes. Chapter 43 of the 2010 Laws expanded eligibility to osteopathic physicians, osteopathic physician assistants and pharmacist clinicians.
The SALUD! managed care organizations are funding Medicaid pilots and using contractual definitions based on NCQA PCMH principles and modules for PCMH implementation, including: Electronic Medical Record (EMR); Patient Tracking and Registry Functions; Test Tracking; Referral Tracking; e-Prescribing; Access and Communication; and Performance Reporting and Improvement.
The participating SALUD! Managed Care Organizations (MCOs) are currently funding Medicaid PCMH models and payments to practices through a withhold fund established from capitated payments to the MCOs.
The state has met with the Department of Health to identify and target case mangers to work with the Managed Care Organizations and provider networks to identify and manage care for high-cost, high-risk children/patients.
New Mexico Medicaid plans to adopt a common set of performance measures for quality improvement, possibly drawing from NCQA and Electronic Health Record Meaningful Use requirements. Also, utilization measures and cost data will be included in the performance reporting and feedback process to practices and plans. The state is exploring methods to aggregate performance data to identify pockets of care disparities and high avoidable costs.
Initial quality measures have included monitoring diabetic and asthmatic patients. Annual reviews of PCMH pilots include implementation of a scorecard with cost, quality and satisfaction measures. New Mexico is also monitoring emergency department and inpatient utilization.