Frequently Asked Questions

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


Source: Children's System Transformation, Elmira, 4.13.16

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

How will the Value Based Payment system work?

Please visit for more information regarding the VBP Initiative. 

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

If an agency offers Adult Behavioral Health Home and Community Based Services (BH HCBS), are they eligible to enroll as a Medicaid provider?

Adult BH HCBS is not an enrollable practitioner or agency type.

Source: OMH Medicaid Provider Enrollment Webinar 11.8.17

Where are the forms for Medicaid Provider Enrollment?

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.

Source: OMH Medicaid Provider Enrollment Webinar 11.8.17

How will Managed Care Organizations (MCOs) address rostered providers at facilities that need to enroll but have not?

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.

Source: OMH Medicaid Provider Enrollment Webinar 11.8.17

Historically, staff of OMH-licensed programs do not have to register individually to bill within a program. Has the requirement changed due to the 21st Century Cures Act?

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.

Source: OMH Medicaid Provider Enrollment Webinar 11.8.17

What type of licensed organizations/programs are required to enroll as Medicaid providers?

Enrollable types include (partial list):

  • OMH Community Residence 
  • OMH Licensed ACT Provider
  • OMH Licensed Outpatient Provider 
  • OMH Licensed PROS Provider
  • OMH Licensed Residential Treatment Facility 
  • Chemical Dependency Program (CDP)
  • OASAS Part 820 Residential Treatment Program
  • Bridges to Health Waiver Providers
  • Children's System Transformation Providers:
    • Children and Family Treatment and Support Servicces
    • Children's Home and Community Based Services


If the agency is an enrollable type, it must enroll. See eMedNY Provider Index for more information.

Source: OMH Medicaid Provider Enrollment Webinar 11.8.17

What licensed professionals providing care at enrolled organizations are required to enroll as Medicaid providers?

Licensed professionals that are enrollable types are required to enroll. This may include but is not limited to

  • LPNs and RNs
    • They can enroll as OPRA non-billing if in a facility. They will be listed as an Attending provider on the claim. 
    • If the nurse is a billing provider on a private duty nursing case, the nurse must enroll as a fee-for-service billable provider.
  • Physicians 
  • Nurse Practitioners 
  • Physician Assistants
  • Clinical psychologists
  • Licensed Clinical Social Workers

Licensed Master Social Workers and Licensed Mental Health Counselors are not enrollable provider types. 

See eMedNY Provider Index

Source: OMH Medicaid Provider Enrollment Webinar 11.8.17

How often do you recommend doing a batch upload to check Medicaid eligibility?

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.).

Source: July 2018 CFTSS Billing In-Person Training

Is the date that medical necessity is determined considered the “admission date”?

The admission date is the earliest date the service is delivered.

Source: State January Roundtable 2019

Can a child/youth receive CFTSS services after they turn 18 and become eligible for some adult services? Can a 19 year old start to receive adult services and then decide CFTSS would suit them better and return to CFTSS until they age out?

Yes, children ages 0-21 who are in Medicaid are eligible to receive CFTSS (assuming they meet medical necessity). This includes children ages 18-21 who may also be (or have been) involved in adult services as long as there is no duplication of services. For more on allowable service billing combinations see the billing manual pages 15-17. 

Source: YPST Webinar 11.18.19

On the adult side, 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

Are Managed Care Organizations (MCOs) required to contract with all Adult 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

On the Adult side, are Medicare or dual eligible recipients eligible for Managed Care?

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