Care Management Referral Form

In order to be eligible for Health Home services, the individual must be enrolled in Medicaid and have:

• ONE qualifying chronic condition from Group A

OR

• TWO OR MORE qualifying chronic conditions from Group B
  
  *Please Note — Substance use disorders (SUDS) are considered chronic conditions, but do not by themselves qualify an individual for Health Home services. Individuals with SUDS must have another chronic condition to qualify.

Make sure to specify your diagnosis.
E.g. Serious Mental Illness – 296.8 Bipolar Disorder NOS
E.g. Other Chronic Conditions – COPD