Frequently Asked Questions

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When will Children's Health Homes go live?

Existing Children's 1915(c) Care Coordination will transition to Health Home for NYC/LI jUly 2017 and rest of state January 2018.

Source: Children's System Transformation, Albany, 4.1.16

What is the designation process for children's SPA?

This is currently being finalized and more information should be available in late 2016/ early 2017.

Source: Children's System Transformation, Albany, 4.1.16

Can children be eligible for Medicaid but not Medicaid managed care? How can this information be determined for each child?

To determine if a child is Medicaid eligible, consult ePaces or call district.  Determination of whether that child can be enrolled in a Plan can be assisted by an Enrollment Broker at the county offices.

Source: Children's System Transformation, Buffalo, 4.12.16

Does an individual have to be connected to an agency to provide SPA to children?

Yes. Must be connected to an agency that is licensed, certified, designated or funded by OMH, OASAS, OCFS or DOH.

Source: Children's System Transformation, Elmira, 4.13.16

Can a person be in both an adult and children's health home with two care managers?

No.

Source: Children's System Transformation, Elmira, 4.13.16

Do children need to be Medicaid eligible to receive SPA services?

Yes. The six State Plan Amendment (SPA) services will be available to any child eligible for Medicaid who meets relevant medical necessity criteria

Where can the children's SPA manual be accessed?

The SPA Manual is available here.

Does eligibility for children's services end with someone's 21st birthday or through their 21st year?

Eligibility of children's services continues, if they meet eligibility criteria, until a young person's 21st birthday. At 21, transition to the adult system is necessary if need is present and eligibility criteria is met. 

Source: Children's System Transformation, North Country, 4.19.16

Where does NYS stand with CMS around conflict free case management for children?

Under the CMS HCBS Rule for 1915c waivers, you cannot have the same agency providing care management also provide HCBS services to the same child. However, CMS has not provided guidance on how the HCBS Rule applies to Health Homes. Therefore, NYS has inquired whether under Health Homes we can adhere to conflict free case management, which allows for agencies to provide both, but with firewalls and mitigation strategies. 

Source: Children's System Transformation, NYC, 3.22.16

This whole redesign is based on the premise that things are very inefficient. How did NYS compare so poorly to the rest of the country? What are we supposed to be improving on?

NYS is ranked very low among US states in terms of the cost of healthcare and quality outcomes. This coupled with our extremely high rate of inpatient admissions has prompted a statewide change for healthcare management and utilization. The issue is not with individual providers and agencies but with the larger system. Also, compared to other states, New York has added more services under its Medicaid program which has driven costs higher without the greater level of coordination.

Source: Children's System Transformation, NYC, 3.22.16

Will there be legacy slots and funds?

All five waivers will be transitioning into managed care without slot limits. The 1115 authority gives NYS the ability to serve more children than  the 1915c authority does currently.

Source: Children's System Transformation, NYC, 3.22.16

Is Medicaid a managed care system already?

Medicaid for primary care is currently managed care. Behavioral Health is being transitioned and will no longer be carved-out from Medicaid recipient's Managed Care Plans and billed Fee-for-Service.

Source: Children's System Transformation, Poughkeepsie, 3.31.16

What is "Other Licensed Practitioner" in the children's State Plan Amendment service list? Will they be allowed to provide billable services in clinic settings?

OLP is a reimbursement authority that allows you to have social workers and other non-physician licensed clinicians to provide certain services. It helps to operationalize CPST and allows treatment to occur outside of clinic walls. According to the SPA manual regarding settings: "Services should be offered in the setting best suited for desired outcomes, including home, or other community- based setting in compliance with State practice law, including telemedicine as per New York State requirements." If a service is delivered in a clinic and it is a clinic-defined service, then it will not be billable under the new OLP reimbursement authority.

Source: Children's System Transformation, Poughkeepsie, 3.31.16

When SPA goes live, will children not yet in managed care be eligible?

With current timeline, anyone who is Medicaid eligible but not yet in managed care will be eligible for SPA services under Fee for Service. 

Source: Children's System Transformation, Poughkeepsie, 3.31.16

Will OMH Community Residences be moving into Managed Care? Why or why not?

Kids in Community Residences are eligible for managed care and services. The Community Residence setting itself is not moving into managed care and will continue to be billed fee-for-service. There are complex rules as to where services can be delivered. Also excluded on the adult side. May be something for state to revisit in the future. 

Source: Children's System Transformation, Syracuse, 4.14.16

Are children placed in Voluntary Foster Care Agencies through local school districts' Committees on Special Education (the CSE population), eligible for Managed Care?

Children placed in Voluntary Foster Care Agencies through local school districts' Committees on Special Education (CSE)  are not categorically eligible for Medicaid.  As such, New York State is still assessing the impact of the Medicaid Redesign on this population, including eligibility for Managed Care.

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

As children who have become Medicaid eligible through spend down are excluded from Managed Care, will they still be able to access Medicaid? How will they access coordinated care?

For those who become eligible for Medicaid and are excluded from Managed Care, the services for which they are eligible will be available on a fee for service basis. 

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

How will children with private insurance fit in? Will they have access to these services?

For children who meet the Level of Care criteria in the current 1915c waivers and have Medicaid without regard to parental income, the State will maintain the rules for the transition. The state is hopeful that at least two of the six new Medicaid State Plan services will be eligible under the parity legislation to be covered by commercial insurance.  More information to be determined. 

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

Once the child redesign goes live and Residential Treatment Facilities are impacted will individuals between 18 and 21 be able to be referred to RTF's?

RTFs will transition to Medicaid Managed Care. Children between the ages of 18 and 21 who are not already in RTF will most likely not be referred to RTF as the service of choice for them.  The goal is for each person to get the service that is most appropriate for them. If children are already in an RTF setting and are 18-21 years of age then they will continue to be eligible for that service. More information will be forthcoming as the transition progresses.

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

For children who are in residential treatment foster care or community residence (OMH), will they transition to Fee for Service Medicaid?

For the Foster Care population, their services will be transitioned into Managed Care, and the Voluntary Foster Care Agencies will continue to play a role in the oversight of the child's health care.

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

How will Children's Day Treatment fit into the system transformation?

OMH is working to redesign Children's Day Treatment. Hopefully the State will be able to help providers implement the six new State Plan services so that those services can be incorporated into various settings. More information will be forthcoming but hopefully these services will facilitate the more efficient treatment of children.

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

Has there been a decision regarding the referral process for children (i.e. sending a referral to CSPOA versus directly to the H/H provider)?

There are several past webinars available on the NYS DOH Health Home website that review how referrals for children can be made. 

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

Who can provide children's services? What training does a person need to have to supply those services?

Service components and staff qualifications for SPA are available through the manual. For HCBS services, the state hopes to provide more in-depth information soon.

Source: Transforming the Children's Medicaid System Webinar Part 1, 1.27.16

Does the grandfathering of 1915c service providers refer specifically to provider agencies, or to the individual staff? If a person qualified to provide specific services under a current waiver program, would that person continue to qualify to provide the equivalent service in the future?

Grandfathering of providers refers specifically to the agency designated and approved to provide the individual HCBS benefit.

Source: Transforming the Children's Medicaid System Webinar Part 2, 2.11.16

Foster care children in B2H services will not be eligible for Health Home enrollment in Sept 2016. With this program changing in Jan 2017, who will be doing care coordination for these children at that point? Should they then be enrolled in a Health Home?

NYS will be issuing guidance around the transition into Health Home Care Management and children enrolled in current 1915c waivers, including B2H, the OMH Waiver, and Care at Home Waivers.  Federal CMS will provide direction to NYS to ensure all rights and responsibilities intrinsic within all waivers are maintained before and during any transition out of existing waivers.

Source: Transforming the Children's Medicaid System Webinar Part 2, 2.11.16

Have the roles of Health Homes and the Health Home Care Manager been determined for children?

For children enrolled in Health Homes, the care managers will complete a comprehensive assessment and develop the service plan with the child and their family, including involved service providers.  The amount, duration and scope of services will be recommended in the Plan and authorized by the managed care plans. The care manager's role will be to coordinate and monitor access of services .

Source: Transforming the Children's Medicaid System Webinar Part 2, 2.11.16

How is the state working to ensure the MCOs agree to embrace the new services in HCBS? Why would MCOs approve a broad range of extensive and expensive HCBS for children that mirrors current B2H services?

It is the State's vision that the expanded array of benefits, both in the State Plan and through the 1115 authority, will be a benefit to all Medicaid eligible children so that we can best meet their needs. NYS has had positive outcomes for children involved in the 1915c Waivers and that is why the transformation is being built on the existing foundation of that learning.  We do anticipate that we will be partnering with the Plans to increase understanding of how beneficial these services can be for children and families. NYS and the provider community know that provision of HCBS is less expensive than the alternative, an institutional level of care. 

Source: Transforming the Children's Medicaid System Webinar Part 2, 2.11.16

How do fee for service agencies fit into the children's system preparation schedule?

Current providers that bill Medicaid services through the fee for service payment system will transition to Managed Care. These providers are a critical part of the preparation schedule. 

Source: Transforming the Children's Medicaid System Webinar Part 3, 2.25.16

How will the Value Based Payment system work?

There is information on the Department of Health's website regarding DSRIP and the VBP initiative. Visit http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/

Source: Transforming the Children's Medicaid System Webinar Part 3, 2.25.16

Will children's care management implementation have different enrollment phases (ex. Foster Care population then prevention population then general population)?

The current timeline is as follows: 

March 1, 2017

- Statewide: SPA OLP FFS 

October 1, 2017 

- NYC and Nassua, Suffolk and Westchester counties:

-1915(c) Care Coordination transitions to Health Homes 

-HCBS and certain BH services, including but not limited to new SPA services are carved in to MMMC 

-Statewide: Five Rehab Services to State PLan FFS

-Children in receipt of HCBS will be mandatorily enrolled in MMMC

January 1, 2018

- ROS:

-1915(c) Care Coordination transitions to Health Homes 

-HCBS and certain BH services, including but not limited to new SPA services are  carved in to MMMC 

-Children in receipt of HCBS will be mandatorily enrolled in MMMC

July 1, 2018

- LON Community Medicaid Eligible HCBS group begins to receive HCBS/SPA

January 1, 2019

- LON Family of One eligibility group begins to receive HCBS/SPA

- Children in VFCA mandatorily enrolled in MMMC

As of November 2016

Source: Transforming the Children's Medicaid System Webinar Part 3, 2.25.16

Who's included, or carved-in, and who's excluded, or carved out?

Some of the adult clients who are carved-in include those who utilize Personalized Recovery Oriented Services (PROS), mental health / substance use disorder clinics, Assertive Community Treatment (ACT), Home and Community Based Services (HCBS) and opioid treatment programs.

Some of the clients who are carved out include individuals who are 18 - 20 years old and those who participate in Medicaid buy-in, commercial Medicaid or spend down. In addition, dual eligible clients are also carved out.

Source: MCTAC Kick-Off Forum, 1.23.14

How will providers transition from the Fee-For-Service(FFS) system to the value based system?

The transition to a value based system is still in development. Be sure to listen to State and Federal government guidance as well as your managed care plans. Currently, by the 5th and final year of the DSRIP program (2019), all managed care organizations must employ value based payment systems for at least 80-90% of their provider payments.

Additional information provided by the New York State Department of Health can be found here.

Source: RCM/UM/Outcomes Event: Albany 5.29.15

Is there a list of Managed Care Organizations (MCOs) in each region?

Please see the MCTAC Matrix for further information on MCOs in each region.

Source: Contracting

With multiple payers and multiple contracts how can small organizations survive and even thrive?

Small providers should start with where they are and what resources they have. Utilize board members to help with certain tasks or get further financial commitment from the board to help with the process of contracting and preparing for managed care services. In other states, nonprofits have formed affiliations, partnerships or collaborations to use shared infrastructure to help with tracking outcomes, billing, etc.

Source: Contracting

What is the definition of "recovery-based"?

A recovery-based mental health system embraces the following values: self-determination, empowering relationships based on trust, understanding and respect, meaningful roles in society, and elimination of stigma and discrimination.

The Substance Abuse Mental Health Services Administration, or SAMHSA, offers additional information here.

Source: Managed Care 101 7.22.15

What's the most recent implementation timeline and deadline to enter into networks?

For the most recent information on implementation, please consult this timeline, which is published on MCTAC's website.

Additional information can also be found on the OMH, OASAS and Department of Health websites.

Source: Contracting

What is the recommended website/reading for providers to get briefed about the transition to managed care?

We recommend that providers use CTACNY.org to be briefed about the transition to managed care. Up-to-date presentations can be found there under Tools and Resources as well as information about all upcoming events. In addition, more specific information about individual services can be obtained through OASAS' FAQs or by directly contacting OASAS and OMH.

Source: HCBS Rehabilitation/Habilitation, 7.31.15

Are Managed Care Organizations (MCOs) required to contract with providers?

An MCO (both mainstream and Health and Recovery Plans, or HARP) is required to offer contracts to behavioral health programs serving 5 or more of its enrollees. Plans may also offer contracts to providers who serve less than 5 of their enrollees.  For programs licensed by OMH, the requirement is program specific (i.e., contracts must be offered to all of an agency's mental health clinics, but NOT necessarily its Personalized Recovery Oriented Services (PROS) and Continuing Day Treatment (CDT) programs unless each of them also serve 5 or more of its enrollees). An MCO can contract with all of an agency's MH programs even if one or more of its programs did NOT serve 5 or more of the MCO's enrollees. In addition, an MCO is required to put all of an agency's OASAS programs in its network if that same agency has one or more licenses from OASAS and at least one program serving 5 or more enrollees of that MCO.

Additional information on this can be found here, here and here.

Source: Managed Care 101, 7.21.15

What about Medicare or dual eligible recipients?

Medicare recipients and dual eligible clients are currently carved out of the managed care transition.

Source: Managed Care 101 Webinar, 7.21.15

What is Level of Care for Alcohol and Drug Treatment (LOCADTR)?

LOCADTR is the patient placement criteria system that must be used in making substance use disorder (SUD) level of care decisions in New York State (NYS). LOCADTR assesses the intensity and need of services for an individual with an SUD. All OASAS providers and Medicaid plans will be required to use this tool.

Additional information can be found on OASAS' website.

Source: MCTAC Kick-Off Forum, 1.23.14

What is a Medical Loss Ratio (MLR)?

In New York, the state has imposed an MLR of 89% for its Medicaid Managed Care program. This means that 89 cents of every dollar that flows from the state to the MCOs must be used to pay providers for services and not MCO administrative or marketing costs. If this figure is not met, funds return to the state and a legal process follows. The goal of this standard is to get behavioral health dollars out to providers.

Source: UM for OASAS Programs, 10.5.15 AM Session