For Individuals

Care Management

Care Coordination through our Health Home Services

Care coordination team meeting — healthcare partnership

A ‘Health Home’ isn’t a place, it’s a group of health care and service providers working together to make sure you get the care and services you need to stay healthy. Our Health Home provides free care coordination to Medicaid members who have significant medical and/or behavioral health challenges, along with other certain risk factors.  

Once referred and assessed eligible, your enrollment and access to our Health Home services will be guided by your own personal care manager. The care manager will work with you to set up a care plan and appointments and get the services you need to put you on the road to better health. Some of the services may include:

  • health care providers
  • mental health and substance abuse providers
  • medications
  • housing support
  • social services (such as food, benefits, and locating transportation) or
  • other community programs that will support and assist you.

To qualify for Health Home services, you must:

1

Have active Medicaid

If you are not on Medicaid or your enrollment has lapsed, we can help you navigate enrollment and eligibility.

2

Have two or more chronic conditions (e.g., asthma, diabetes, mental health, substance use) OR have a single qualifying condition such as:

HIV/AIDS, Serious Mental Illness (SMI), or Sickle Cell Disease. View the full list of qualifying conditions:
Health Home Chronic Conditions

3

And, have risk factors such as:

No primary care provider, difficulty managing medications, recent incarceration, unstable housing or limited family support, and other challenges with daily living activities.

Want to talk to us about Health Homes?

Call (800)-768-5080 or email Annecy Cruz at acruz@hvcare.net

FAQs

If you are a Medicaid recipient or believe you may qualify for Medicaid, think about the following questions: 

  • Do you have chronic or mental health conditions for which you need regular doctor’s care?
  • Do you have a doctor you can see when you need to?
  • How many times have you been in the emergency room or hospital in the past six months? Twelve months?
  • Do you have a safe place to live?
  • Do you have someone in your life to help you whenever you need help?
  • Do you have difficulty keeping medical appointments?

You can talk to your current service provider, or you can contact us directly [link] at any time to find out if you are eligible to enroll. You may also be referred to a Health Home by Medicaid, based on care and services you have already received. Additionally, you may be referred by your Managed Care plan, doctor, specialist, hospital emergency room, discharge planner, or Social Services.

A care manager is a healthcare professional who coordinates and manages care for individuals with chronic conditions or complex health needs, ensuring they receive all necessary medical, behavioral, and social services.

Your doctor wants to make sure you have the extra support you need to stay healthy. The Health Home program is not a place—it’s a team of doctors, care managers, and community providers who work together to coordinate your care. If you have ongoing health needs, frequent hospital visits, or need help with things like housing, food, or transportation, a Health Home care manager can connect you to the right services, help you keep appointments, and make your care less stressful.

No, there is no fee for this service if you are an active Medicaid member.

No, you can continue to see your current doctor. You can get services from any provider that is part of the Medicaid program. 

No. Enrolling in the Health Home program is your choice. If you decide to enroll in the Health Home program, the Health Home care manager will help you manage all your health care and social service needs. Once you enroll in the Health Home program, you may choose to disenroll at any time. 

Self-Screening Tool