Health Home Resources Health Home Resources

Health Homes

Health Homes

What is a Health Home?

The Mount Sinai PPS is working with six Health Home lead partners to provide patients with Health Home services. MSPPS is available to assist partners with checking if a patient is eligible for Health Home services and if your patient is already assigned to a Health Home care manager. MSPPS can also provide additional information to help connect your patients with the appropriate MSPPS Health Home. 

A health home isn’t a place, but a Medicaid State option that provides a comprehensive system of care coordination for Medicaid individuals with chronic conditions. The goal of a Health Home is to provide care coordination for Medicaid beneficiaries with certain chronic conditions and integrate and coordinate primary, acute, behavioral health, and long- term health services.

Eligible patients will be assigned a care manager who is responsible for overseeing and coordinating all the different components of care. A care manager will develop a care plan that will address the patient’s medical, behavioral health, and social service needs.

How do I know if my patient qualifies for Health Home services? Your patient must have:

  • Active Medicaid status including: dual eligible, managed care, Special Needs Plans (SNP), Managed Long Term Care (MLTC), Health and Recovery Plan (HARP), Fully Integrated Duals Advantage (FIDA)
  • Two or more chronic medical conditions OR one single qualifying condition: HIV or Serious Mental Illness for adults; HIV Serious Emotional Disturbance, or Complex Trauma for children
  • Demonstrated need for care management services including, but not limited to:
    • - Inadequate social support
    • - Medication non-adherence
    • - Frequent hospital and ED use
    • - Homelessness

What services are available to my patients through Health Homes?

  • With the assistance of a care manager, your patients will have access to the following services:
    • - Comprehensive Care Management
    • - Care Coordination and Health Promotion
    • - Comprehensive Transitional Care
    • - Patient and Family Support
    • - Referral to Community and Social Support Services

To learn more about these Health Home services, please click here. 


MSPPS works with the following Health Home leads to help partners connect their patients to care management services.

This service is exclusive to MSPPS partners only. To learn more about this program, please contact the MS PPS Command Center at: 1-844-674-7463 or Be sure to check out our resources below: