New MN DHS Benefit, Behavioral Health Homes: Resources for MA Beneficiaries with Severe and Complex Conditions

Psychologists and other mental health professionals who serve people with more complex and challenging problems may want to refer them to a new DHS service, Behavioral Health Homes. (BHH).  BHH services can increase support and treatment resources for the person, and can help the mental health professional better respond to the person’s needs. 

The Patient Protection and Affordable Care Act (ACA) created a “health home” benefit to help states better coordinate care for Medicaid enrollees with chronic medical conditions. This program focuses on populations that traditionally face serious barriers to accessing medical care, and end up being underserved by our medical and mental health system.  They also have reduced quality of life and increased mortality, and frequently are high utilizers of expensive urgent care services.

Patient-centered medical homes have the goals of improving access, usually to multiple providers due to their complex medical problems, and to improve coordination of care among their providers.  This program is administered by the Centers for Medicare and Medicaid Services (CMS) and provides new funding for specialized interdisciplinary teams with a strong connection to the patient’s primary care provider.

Minnesota has developed a version of this program which has more of a focus on mental health treatment needs, Behavioral Health Homes (BHHs).  We are one of only three states with this version of patient-centered medical homes, which required special approval by CMS. BHH services are a new benefit, as of July 1, 2016, for persons on Minnesota Medicaid (MA). These services are voluntary, and are benefits for people enrolled in Medicaid fee-for-service (“straight MA”) and Pre-Paid Medical Assistance Plans (“PMAP”).    BHHs specifically target adult Medicaid recipients experiencing serious mental illness and children with a serious emotional disturbance.  More specific information about BHH, including eligibility criteria is available at: People cannot receive both BHH and Targeted Case Management services at the same time.

While BHH services became a covered Medicaid benefit as of July 1, 2016, the State’s certification of new BHH providers is still in process. Currently, 21 organizations have been certified statewide.  A list of certified BHH providers is available at:, and it will be updated as other BHH providers are certified.

Certified BHHs are mandated to assess and respect the consumer’s cultural values and strengths. They also are required to provide a holistic, coordinated “health action plan” (HAP) and to re-assess the HAP every six months.  The goals for BHH services are to:

  • Improve health outcomes (more preventative care, better continuity of care with providers, better coordination of care among providers, few ER visits and hospitalizations)
  • Improve the consumer’s experience with care across the system 
  • Improve the consumer’s quality of life and wellness
  • Reduce unnecessary utilization and costs, including visits to emergency departments and hospital admissions.

BHH teams provide six “core services,” with the mix of services provided tailored to the patient’s unique needs and situation. At least one of six core services are provided to the BHH consumer every month.  The core services are: 

  • Comprehensive care management
  • Care coordination
  • Health and wellness promotion
  • Comprehensive transitional care
  • Individual and family support
  • Referral to community and social services

Finally, in December, 2016, the Substance Abuse Mental Health Services Administration (SAMHSA) announced that Minnesota had been awarded additional grant money to continue and expand the MN BHH program in 2017.  Minnesota is one of only eight states to receive this funding, and is viewed a one of the leaders in developing effective BHH and similar community health care programs. More information about this award is available at:

If you have patients/clients who need help with accessing medical and mental health services, who need support for participating in their care, and who have difficulty managing all their medical and mental health services, and who have MA, referring them to a BHH team may both improve their life and also reduce their stress.  These people are often the ones that we worry about the most and need more help than we can provide on our own.  They would benefit from services provided by a multidisciplinary team of caring professionals who view the patient/client as part of the team, and all work together to get better outcomes.  

Richard Sethre, Psy.D., LP, is in independent practice and is the Behavioral Health Home Team Supervisor for the Natalis Outcomes BHH program. 

Jeffrey Wigren, MPH, MHA, is the Director of Operations at Natalis Outcomes and is the BHH Team Lead.  

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