Can a person be in both an adult and children's health home with two care managers?
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.
Please visit https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm for more information regarding the VBP Initiative.
Yes, this is planned. Materials will be developed and shared for providers to use for outreach to families and referral sources.
There are multiple examples of pathways into services including:
A Health Home Plan of Care (POC) is a plan for how the care manager helps to arrange for and manage the provision of services by others to assure the various needs of the child are being met.
A Treatment Plan is a document developed by a professional on how they will work with the child and family directly to address their needs based on goals and objectives which are identified by the family, and child, along with the practitioner.
For more information about the differences between treatment/service plans and Plan of Care, see state guidance.
The pediatrician can make a recommendation for a service based on their determination of medical necessity. The specific service provider, which may be a pediatrician in some instances, then develops the detailed treatment plan as it relates to the service they are providing.
It is possible a child may have more than one treatment plan if they are receiving multiple services from various providers. However, one treatment plan can be developed for the provision of multiple services when provided by one agency, if their EHR system supports a coordinated treatment case record.
Yes, there will be outreach and education provided to inform the LDSS including an Administrative Directive.
Yes. Certain individual practitioners will now need to enroll as fee-for-service Medicaid providers to remain in Medicaid Managed Care Networks. If the agency is an enrollable type, it must enroll. As indicated on eMedNY Provider Index, OMH provider types that need to enroll include but are not limited to:
OMH Community Residence OMH Licensed ACT Provider
OMH Licensed Outpatient Provider OMH Licensed PROS Provider
OMH Licensed Residential Treatment Facility.
Enrolling and Billing are separate activities and processes. Not everyone who enrolls bills for services. Reiterating, if you are an enrollable type, you must enroll in Medicaid fee for service.
Yes, you need to receive designation to provide Children and Family Treatment and Support Services (formerly SPA) and/or Children's HCBS before you enroll for a provider number such as the Medicaid Management Information System (MMIS).
Adult BH HCBS is not an enrollable practitioner or agency type.
You can find the forms on the website. Provider Maintenance Forms can be found in the Provider maintenance form section. See the eMedNY Provider Index.
MCOs will receive updated monthly lists from the DOH Office of Health Insurance Programs for providers that need to enroll. It is up to the Managed Care Organization (MCO) to contact these providers to enroll. The public can access this list on Health Data website.
Yes, supervisors and managers can be shared across CFTSS. If you are sharing individuals across CFTSS make sure that staff charges/expenses are appropriately allocated. There are not conflict-free requirements restricting supervisors from being shared across CFTSS providers and care managers (this restriction only applies to HCBS), however this is not a recommended practice.
This is not considered a conflict for CFTSS, however it is recommended that individuals be given a choice and only Licensed Practitioner of the Healing Arts (LPHA) can make a recommendation.
Enrollable types include (partial list):
If the agency is an enrollable type, it must enroll. See eMedNY Provider Index for more information.
Licensed professionals that are enrollable types are required to enroll. This may include but is not limited to
Licensed Master Social Workers and Licensed Mental Health Counselors are not enrollable provider types.
It is possible to do batch uploads daily, however this is not recommended. Your organization should determine how often is worthwhile (cost vs. benefit) based on the error rate you are getting. It is a best practice to check the individual’s Medicaid status prior to service delivery and as close to the appointment as possible (e.g. the morning of the scheduled appointment, night before, etc.).
Both the organization where care is being provided and identified licensed practitioners individually need to be enrolled as Medicaid providers in order to bill Medicaid if the individual is an enrollable provider type.
For more information, we recommend you listen to and review the following webinar, Medicaid Provider Enrollment for CFTSS and Children’s HCBS webinar.
Any individual practitioner can obtain an NPI number, but only certain practitioner types may enroll in Medicaid to obtain an MMIS number.▼ Expand to view more
Providers already enrolled in Medicaid do not need to re-enroll. The State will add the appropriate Category of Service code for the providers who have been designated for children’s services.
The only time an agency would need to complete a Medicaid application is if the agency is brand new and those providers should refer to the webinar at the following link for more information: Medicaid Provider Enrollment for CFTSS and Children’s HCBS webinar.
NP LBHP is specific to those practitioner categories that can provide services under OLP. They can make recommendations for any of these services. LPHA is a broader definition and includes additional treating practitioners (i.e. primary care doctor) who can make a recommendation for one of these services.
Please refer to the CFTSS manual for a list of these practitioner types at:
Yes. Non-licensed providers for CFTSS and HCBS that do not have a NPI can use the OMH unlicensed provider number 02249154 or the OASAS unlicensed provider number 02249145
More information on filling out clean claims can be found on MCTAC Billing tool.
For children who are transitioning from waiver, in most cases the HCI/ICC/care manager is responsible for securing a recommendation for CFTSS. Any HCBS provider working with an HCI/ICC should coordinate how recommendations will be secured for CFTSS to avoid duplication of effort.
This date has changed to 1/31/19. Please refer to the following guidance document for more information: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/cftss_prep_billing.pdf
No. The Health Home Care Manager determines what services are needed, facilitates referrals, and develops a HH Plan of Care. The treatment plan is developed by the treating practitioner who provides the direct services. The Agency/practitioner providing direct services is responsible for maintaining the treatment plan.
For transitioning Waiver children, the Plan of Care can temporarily serve as the required treatment plan until March 31, 2019.
For more information on the differences between treatment/service plans and Plan of Care, see state guidance.
The new OLP services are intended for children who have not or are not well suited for clinic based treatment, and would be better served in their home or community. OLP services only include assessment, treatment planning, psychotherapy and some crisis interventions. OLP can only be billed for children admitted to the service.
Clinics can offer a full array of clinical treatment interventions, including but not limited to medication management and psychiatric evaluation. Clinic services are to be billed for any child enrolled in clinic.
The LPHA should be a treating practitioner to be able verify medical necessity. If the LPHA is not treating them actively, they may need to do an assessment in order to determine medical necessity and write a recommendation. For additional detailed guidance for current 1915c Wavier providers on this issue, please go to: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/docs/cftss_prep_billing.pdf
Yes, eMedNY will be able to determine if a child has SSI on their client file.
Waiver services that crosswalk to 3 CFTSS going live January 1st must be billed as CFTSS as of January 1st. There is a period of time to develop a new treatment plan (March 31) and secure the LPHA recommendation (January 31). Refer to the guidance here.
If the service can be cross-walked to one of the 3 CFTSS going live, then it must be transitioned by 1/31/19. Refer to the guidance here.
Non-licensed staff do not require an NPI. Practitioners who are able and required to enroll in Medicaid will need an NPI to enroll.
Page 91 of the CFTSS Provider Manual outlines which LPHA can make a recommendation for CFTSS:
An individual professional who is licensed as a Registered Professional Nurse, Nurse Practitioner, Psychiatrist, Licensed Psychologist, Licensed Psychoanalyst, Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), Licensed Marriage & Family Therapist, Licensed Mental Health Counselor, Licensed Creative Arts Therapist, or Physician (per OMH 599 regulations) and practicing within the scope of their State license to recommend Rehabilitation services.
Please note: While all listed LPHA can make a recommendation, not all have the ability to diagnose a child independently, if needed, within their scope of practice without being under the supervision of another qualified licensed practitioner or physician.
A family, teacher, or other non-clinician may refer directly to an OLP without first going to another LPHA.
When a non-clinician refers directly to OLP, the OLP provider will determine whether the child meets the medical necessity criteria to continue receiving OLP and/or recommend for other CFTSS.
The admission date is the earliest date the service is delivered.
SED clinics will continue to be designated as such but will be billing Managed Care after their exemption is lifted on 7/1/19.
The effective date of the Article 29i License is now scheduled for 10/1/19.
Service descriptions can be found in the 29i Guidelines posted here under “29i Licensure” tab
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.
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.
Please see the MCTAC Matrix for further information on MCOs in each region.
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.
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.
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.
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.
Medicare recipients and dual eligible clients are currently carved out of the managed care transition.
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.
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.