A Health Home is a Medicaid program that coordinates all medical, behavioral health, and social services for people with multiple chronic conditions. It is not a physical building or a residential facility. Instead, it’s a team-based care coordination model where a dedicated care manager connects the dots between your doctors, mental health providers, pharmacies, and community resources so nothing falls through the cracks. Authorized under Section 2703 of the Affordable Care Act, the program operates in 19 states and the District of Columbia, with 33 approved models as of March 2024.
How a Health Home Works
The central idea is simple: people with serious chronic illnesses often see multiple providers who don’t communicate with each other. A Health Home assigns you a care manager whose job is to make sure all of your providers are on the same page. That care manager tracks your appointments, follows up on lab results, helps you navigate insurance and social services, and checks in regularly to see how you’re doing.
Health Home services are delivered through a network of organizations, not a single clinic. Your network might include primary care practices, behavioral health agencies, health plans, and community-based organizations. All of these providers share information through electronic health records so your care team can see your full picture, identify gaps, and update your care plan in real time.
The Six Required Services
Every Health Home, regardless of which state runs it, must provide the same six core services:
- Comprehensive care management: Your care manager develops and maintains a detailed plan covering all of your health needs.
- Care coordination: Scheduling, tracking, and connecting your various providers so they work together rather than in isolation.
- Health promotion: Education, coaching, and support to help you manage your conditions and adopt healthier habits.
- Transitional care: Follow-up after hospital stays, emergency room visits, or moves between care settings to prevent setbacks.
- Individual and family support: Guidance for you and your family members on navigating the health system and building self-management skills.
- Referral to community and social services: Connecting you with housing assistance, food programs, transportation, employment support, or other non-medical resources that affect your health.
Who Qualifies
Health Homes are for Medicaid beneficiaries with chronic conditions. The federal statute sets three paths to eligibility: having two or more chronic conditions, having one chronic condition with a risk of developing a second, or having a serious mental illness. The conditions specifically named in the law include serious mental illness, substance use disorder, asthma, diabetes, heart disease, and a BMI over 25.
States have significant flexibility to tailor eligibility beyond that baseline. New York, for example, covers people with HIV/AIDS, sickle cell disease, or complex trauma. Wisconsin targets people living with HIV or substance use disorder who also have at least one other chronic condition. Missouri includes people who are ventilator-dependent or have autism spectrum disorder. North Carolina focuses on serious mental illness, severe substance use disorder, intellectual or developmental disabilities, and traumatic brain injury. The exact qualifying conditions depend entirely on which state you live in and which Health Home model that state has adopted.
How Enrollment Works
States choose between two enrollment approaches. Most use auto-assignment: if your Medicaid claims data show you meet the criteria, you’re placed into a Health Home automatically but can opt out at any time or switch to a different qualified Health Home. A smaller number of states, like Maryland, use an opt-in model where you must actively consent to participate. The opt-in approach builds the process of agreeing to share your health information directly into enrollment, giving you more control over your data from the start.
Either way, participation is voluntary. You won’t lose your Medicaid benefits if you decline, and you can leave the program whenever you choose.
Health Home vs. Medical Home
These two terms sound almost identical but describe different things. A Patient-Centered Medical Home is a physician-led practice model. Your primary care doctor’s office takes extra steps to coordinate your care, manage chronic conditions, and strengthen the doctor-patient relationship. The physician team handles your health care needs and arranges referrals as needed.
A Health Home operates at a broader, community level. Instead of being anchored to one doctor’s office, it’s built around a care manager who works across an entire network of providers and organizations. The focus skews heavily toward people with complex needs, especially those with overlapping physical and behavioral health conditions. Care managers in a Health Home spend significant time linking people to social supports like housing, food assistance, and employment services, areas that a typical medical practice wouldn’t handle directly. Think of a Medical Home as your doctor’s office doing coordination well, and a Health Home as an entire system coordinating around you.
The Role of Technology
Health Homes rely on shared electronic health records to function. Providers in the network use systems that meet federal Meaningful Use standards, which means your care plan, test results, medications, and treatment history are visible to every member of your care team. This prevents the common problem of one doctor not knowing what another prescribed or ordered.
Many states also require Health Home providers to participate in regional health information exchanges, platforms that allow different health systems to securely share patient data. The care team uses evidence-based decision-making tools built into these systems to flag potential issues, like a missed follow-up appointment after a hospital discharge or a gap in preventive screenings.
Funding and Availability
The Affordable Care Act gave states a financial incentive to launch Health Homes: a 90% federal match rate for the first eight quarters of each new program. After that initial two-year period, the federal share drops to the state’s regular Medicaid matching rate, which ranges from 50% to about 83% depending on the state’s per capita income. This structure made it relatively low-risk for states to experiment with the model.
Despite the incentive, adoption has been uneven. Only about 40% of states have active Health Home programs. If you’re on Medicaid and have multiple chronic conditions, whether a Health Home is available to you depends on your state. You can check with your state Medicaid office or search the Medicaid Health Home Information Resource Center to see what programs exist where you live.