Brooklyn Health Home – Care Management Agency (CMA) Application

Brooklyn Health Home – Care Management Agency (CMA) Application
Thank you for your interest in becoming a Care Management Agency (CMA) within the Brooklyn Health Home network. CMAs play a vital role in delivering comprehensive, person-centered care management to Medicaid members with complex medical, behavioral health, and social needs.

As a CMA, your organization will be responsible for core functions including outreach and engagement, comprehensive assessments, individualized care planning, care coordination, and supporting transitions of care. Success in this role requires strong organizational infrastructure, qualified and well-supervised staff, and the ability to meet New York State Health Home standards and performance expectations.

Please complete the application below, ensuring all responses reflect your organization’s current capabilities and readiness to operate as a high-performing CMA.

Please Note: This application must be completed in a single session. Progress cannot be saved, and partially completed applications cannot be resumed later. Please ensure you have all required information and documents available before you begin.
Section 1: Organization Information
Legal Organization Name (as appears on your W-9)
DBA (if applicable)
Primary Business Address
Website
Organizational Identifiers
EIN #
If no NPI or MMIS ID, check box here
NPI #
MMIS #
*Read more about the process to obtain and NPI and/or MMIS ID:
- https://www.emedny.org/info/providerenrollment/enrollguide.aspx#web=step1&webtab=tabstep1
- https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/cma_provider_enrollment_guidance.pdf
Years in Operation
Is the organization registered in NYS as a non-profit or a for-profit entity?
Leadership and Key Contacts:
Primary CMA Contact
Name

First NameLast Name
Title
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Chief Executive Officer (CEO)
Name, Email, Phone
Chief Financial Officer (CFO)
Name, Email, Phone
Compliance / Privacy Officer
Name, Email, Phone
Section 2: CMA
Which population(s) do you intend to serve?
Does the organization plan to serve adults 18-20?
Select the Children’s Populations the organization specializes in serving:
Geographic Area(s) Served (Please list counties, boroughs or zip codes)
Section 3: Services Offered & Organizational Experience
Organizational Mission (Brief description)
How does the organization’s mission align with provision of Health Home services?
Populations Served
Describe target populations, including behavioral health, chronic conditions, SDOH needs, special populations, etc.
Current Services Provided (Select all that apply and/or describe)

Other
If Other, please describe
Experience with Care Management or Similar Models (Describe experience with Health Home, case management, or similar programs)
Is the organization currently a CMA of another Health Home?
If Yes, which Health Home(s)?
Which program models (e.g. Children, Adults, HH+)?
Please explain the organization’s interest in joining another Health Home.
Section 4: Staffing & Organizational Capacity
Current Staffing Structure (Provide number of staff by role, e.g., care managers, supervisors, administrative staff. Please indicate if staff will be full-time, part-time, or contract)
Care Manager Qualifications (Describe credentials, education, and experience requirements)
What is the organization’s Caseload Model? What will be your caseload max and your plan for monitoring caseload counts to ensure you do not enroll more members than you have capacity to serve?
Average caseload per care manager
Approach to caseload assignment (e.g., acuity-based, geographic, population-specific)
Supervisory Structure (Describe supervision ratios and team structure)
Which of the following best describes your organization’s care management workforce model?
Describe how your staffing model supports in-person, community-based care management activities, including home visits, accompaniment to appointments, and engagement in community settings.
If the organization is a CMA in other Health Homes, how do you manage caseloads across Health Homes (e.g. separate, mixed/shared, separate with mixed/shared supervision)
Staffing Growth Capacity (Describe ability to hire/train additional staff as enrollment grows)
Languages Spoken by Staff (List languages and approximate capacity, and any other language services available)
Section 5: Quality & Operational Infrastructure
Compliance Program (Describe compliance policies, oversight structure, and training processes)
Quality Assurance / Performance Improvement (Describe QA processes, audits, performance monitoring, and corrective actions)
24/7 Coverage and Crisis Response (Describe after-hours coverage and crisis intervention protocols)
Care Management Systems / HIT (Describe systems used for documentation, care planning, data exchange, etc.)
Eligible Member Identification & Outreach (Provide the organization’s planned referral sources and describe processes for identifying, engaging, and enrolling eligible members)
Section 6: Attestations
By submitting this application, the organization attests that:
All information provided is accurate and complete to the best of its knowledge.
The organization is willing and able to comply with NYS Health Home requirements.
The organization has the infrastructure or a plan to meet CMA expectations, including staffing, compliance, and reporting.
Authorized Representative Name
Authorized Representative Title
Signature
Date

MonthDayYear
Date
Once completed, a member of the Brooklyn Health Home team will review your submission and follow up regarding next steps.
Should be Empty:

Brooklyn Health Home – Care Management Agency (CMA) Application

Section 1: Organization Information

Organizational Identifiers

Leadership and Key Contacts:

Primary CMA Contact

Section 2: CMA

Section 3: Services Offered & Organizational Experience

Section 4: Staffing & Organizational Capacity

Section 5: Quality & Operational Infrastructure

Section 6: Attestations