Chronic Condition Health Home (for Providers)

Chronic Condition Health Home Overview:

Chronic Condition Health Home is an Iowa Medicaid program. The goal is to target members with chronic conditions, engage them in their health, coordinate their care and show improved health outcomes. The Chronic Condition Health Home program provides primary care delivered through a patient-centered medical home (PCMH) model.   



A list of 2023 topics for learning collaborative webinars can be found here.



  • Providers can practice more proactive, coordinated care, because of a new reimbursement structure.
  • More opportunities to track and engage with patients.
  • Improved communication and coordination for better patient outcomes.
  • Improved utilization of health information technology.


  • Better coordination and management of their often complicated and complex care.
  • Help navigating multiple systems.
  • More engagement in their own care.
  • Access to a wider range of services.


  • Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.


Enroll as a Chronic Condition Health Home Provider

We are excited to have you as part of our Health Home Program. A potential participation call is available for clinics that are interested. Contact the program manager at or call 515-974-3050. To enroll complete the forms below and email them to Once the forms are processed there will be a call with your team to assist with the success of the program.

Providers must meet standards outlined by the State and seek patient centered medical home (PCMH) Recognition or Accreditation within 12 months of enrolling in the program. To facilitate a team-based, community focused approach, providers participating as a Health Home must connect to the Iowa Health Information Network (IHIN). 


Chronic Condition Health Home Standards:

There are requirements to be met, called Health Home Standards, to be able to participate in the Health Home Program. Minimum requirements listed below:

  • Use some form of a Patient Registry.
  • Electronic Health Record (EHR).
  • Agree to participate in the Iowa Health Information Network.
  • Dedicated care coordinators.
  • Expanded hours for access.
  • Alternative means to communicate with patients and get them engaged, such as email, personal health records, reminders, etc.
  • On the path to PCMH recognition or certification.


Chronic Condition Health Home Tools for Providers: 

Tools were created by MCOs and IME.


Patient Tier Assignment Tool (PTAT)

Expanded Diagnosis Clusters (EDCs) are groupings of diagnostic codes that describe the same or related condition. This payment methodology from Johns Hopkins is used as a disease/condition marker to identify patients that are in need of health home services and the severity based on a tiering system. 

Iowa Medicaid Portal Access (IMPA)


Learning Collaborative Webinar Archive:

Webinars were created by MCOs and IME.

February 2022:

December 2021:

November 2021:

  • Health Home Learning Collaborative: Grievance, Appeals, Member Rights, and Guardianship




Provider Services Contact Information

800-338-7909 Toll Free 
515-256-4609 (Des Moines area) 
(Monday to Friday from 8:00 a.m. to 5:00 p.m. Central Time)
515-725-1155 (Fax) 
Provider Services 
P.O. Box 36450 
Des Moines, IA  IA 50315

Managed Care Organization

Provider-Specific Contact Information

Amerigroup Iowa, Inc.
Phone: 1-800-454-3730
Iowa Total Care Phone: 1-833-404-1061

To view member-specific contact information, please go to MCO Member-Specific Contact Information.