Alabama Health Homes Program

Program Location: 
Montgomery, AL
Payer Type: 

Reported Outcomes


Federal approval of Alabama's “health home” program provides extra funding and support needed to improve patients’ health outcomes while reducing overall expenditures to the state. In April 2013 the Centers for Medicare and Medicaid Services (CMS) approved Alabama's request to implement comprehensive care management in its four community networks. On April 1, 2015, the Health Home program expanded coverage statewide. Patients are identified monthly using claims data and referred for services.

Through this program, Alabama's Patient Care Networks are now required to have a behavioral health nurse that will serve as a liaison between mental health and the primary care physicians. The program also includes transitional care services - prior to hospital discharge, patients are visited by a nurse in order to help with medication reconciliation or other needs.

Alabama will use Medicaid claims and eligibility data to track performance of the following program goals:

  1. Improve health outcomes for adults with diabetes
  2. Improve health through reduced BMI for adults
  3. Reduce hospital readmission rates and ambulatory care sensitive admissions
  4. Improve care coordination for asthma patients
  5. Improve care coordination through timely transmission of transition records
  6. Improve preventive care for children
  7. Improve treatment of individuals with clinical depression
Payment Model: 

Federal approval allows the state to receive 90 percent federal matching funds for a two-year period between July 1, 2012, and June 30, 2014. The program also financially supports the efforts of two other state agencies: The Alabama Department of Public Health which will provide case management services and the Alabama Department of Mental Health which will provide targeted case management services. 

According to the National Academy for State Health Policy, physicians who oversee the medical care of participating patients will receive enhanced fees including PMPM and FFS. Health home payments constitute an additional $8.00 PMPM for providers plus $0.50 PMPM to provide care management services under the state's 1915(b) waiver. The Patient Care Networks of Alabama will receive $9.50 PMPM for each health home patient.



Fewer ED / Hospital Visits: 

An analysis of 2014 data indicated lower rates of hospital inpatient stays and emergency department visits

Other Outcomes: 

Alabama's health home program has achieved favorable outcomes with respect to utilization and costs, according to preliminary analyses, and enjoys support from the state Medicaid program and the legislature. An analysis of 2014 data indicated lower rates of hospital inpatient stays and emergency department visits, improving access to care, and decreasing PMPM costs for health home members.

Last updated March 2019
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