Will Managed Care Organizations know who the designated adult Home and Community Based Services (HCBS) providers are? How do providers find out who the adult HCBS providers are?
Yes, Plans are provided this information and when available the list of the adult designated providers is also publicly available on the OMH website, and can be accessed here.
How do associations, agencies, and non-Medicaid providers get designated to provide adult Home and Community Based Services?
All agencies wishing to provide BH HCBS must apply to be designated for each service they would like to provide. Applicants may apply at any time for a designation; however the state will only update the designation lists quarterly for each area on a periodic basis.
How do agencies identify if an adult client is HARP/HCBS eligible?
HARP/HCBS eligiblity information is available using ePaces.
What is the difference between the Health Home Plan of Care (HHPC) and the child's HCBS Service Plan?
The Health Home Plan of Care (HHPC) is the document created by the Health Home Care Manager (HHCM) that lists the full array of services (medical, dental, behavioral, social, etc.) that a child is receiving. The HHPC describes, at a high level, what those services should look like including scope, frequency and duration. Each HCBS provider will identify goals and objectives of the specific service they provide. They will discern appropriate frequency, scope and duration. They will share this, in the form of a HCBS Service Plan, with HHCM for inclusion in the HHPC.
For Children's HCBS modification and/or equipment services, do Medicaid Managed Care Plans need to ascertain whether a member has exceeded their yearly benefit for these services, and to do this they may work with the health home care manager, C-YES coordinator or LDSS?
The plan should make reasonable efforts to ascertain what services have been provided in the calendar year through review of the Plan of Care, discussion with the care manager, and any other information available, such as the State monthly FFS services report for the enrollee.
Plans are reminded that the limit may be exceeded if medically necessary. The MMCP’s medical director may determine when it is medically necessary for the yearly limit on AT/V-Mods/E-Mods to be exceeded.
Should the Medicaid Managed Care Plan (MMCP) obtain the assessment outcome for children who are receiving Community Habilitation as part of children's HCBS?
Providers may routinely share the HCBS Service Plan with care managers, but MMCPs are not required to obtain the assessment tool/outcomes for children in receipt of HCBS. Note that HCBS are provided in accordance with the Children’s HCBS Manual, which does not mandate a specific assessment tool. When monitoring access to care, MMCPs should remain consistent with the Children’s HCBS Manual requirements.
The State training document from June 6, 2019 describes the authorization process for AT, V-Mods and E-Mods (as part of Children's HCBS), but it does not specifically state that the bid process is not applicable to Medicaid Managed Care Plans (MMCPs). Can you confirm that that the bid process does not apply to MMCPs for the HCBS children’s carve-in effective 10/1/19? What is the MMCP’s role in the authorization process if child is in a Health Home?
MMCPs should generally follow the authorization process as provided in the training materials and the service authorization guidelines, and cover services in accordance with the Children’s Home and Community Based Services Provider Manual.
All of the following steps are required before an MMCP authorizes work to begin: identification of the need for an AT/V-Mod/E-Mod pursuant to a person centered plan; a physician’s order; a clinical justification/evaluation; a cost projection/scope of work document; and MMCP medical director approval for projects in excess of the annual limit.
However, MMCPs are NOT required to obtain bids, and may have alternate financial arrangements with vendors that include plan-specific requirements for description of work/cost proposals and invoicing/billing.
As a best practice, where the enrollee has a Health Home Care Manager (and the authorization process is not being carried out by the plan’s care manager), the MMCP should assist the Health Home Care Manager to complete the necessary steps of the care manager role.
This assistance should include but is not limited to: providing clear information about the plan’s process for authorization; accepting standard forms, e.g., Description and Cost Projection Form and Final Cost Form; identifying clinician/evaluators and available vendors; as required by the plan, obtaining bids or scope of work descriptions, and confirmation of service delivery/project completion.
What steps should Care Management Agencies take when there are no designated Children's HCBS providers for Palliative Care or Respite services in a child’s MMCP network/service area?
The State is exploring ways to address provider capacity issues and also to make provider capacity information available for those making referrals to services. Where a provider is unavailable, there should be documentation of efforts made to locate a provider or to identify alternate services that may assist the family. The MMCP may also assist in accessing alternate services. HHCMs who cannot locate providers for HCBS or CFTSS should report the issue to the lead Health Home.
What is other documentation and/or reporting requirements that need to be shared with Medicaid Managed Care Plans (MMCPs), outside of the Plan of Care (POC) for children in receipt of HCBS?
The MMCP must be notified of the first appointment. Upon receipt of the HCBS Authorization and Care Manager Notification Form, the MMCP may ask HCBS providers for additional information regarding the services being provided to the child/youth. The MMCP should be notified of any significant change. The contract between the MMCP and the Health Home or the MMCP and the provider may require additional reports to support oversight of the services delivered to enrollees and/or meet state reporting requirements.
Must Medicaid Managed Care Plans (MMCPs) accept a Plan of Care (POC) that lists a child’s needed HCBS, but does not include providers or frequency, scope, and duration (F/S/D) of services due to the absence/lack of designated providers within the child’s network/area?
Yes. The Plan of Care is a living document and should identify person centered goals of the child and family. Under the children's HCBS workflow, F/S/D may not be available at the time the plan of care is first shared with the MMCP. The provider’s request for authorization of services will provide this information to the MMCP and the Health Home Care Manager (HHCM).
The State is working with providers and MMCPs to improve provider access and availability. Where a provider is unavailable, there should be documentation of efforts made to locate a provider or to identify alternate services that may assist the family. The MMCP may also assist in accessing alternate services. HHCMs who cannot locate providers for children's HCBS or CFTSS should report the issue to the lead Health Home.
Should a Plan of Care (POC) be submitted to the Medicaid Managed Care Plan (MMCP), even if the Children's HCBS provider(s) has not yet been identified?
Yes. The POC for a child participating in the Children’s Waiver should be updated with the identified services, why the service(s) is needed with initial goals and a title of the service as well as the provider (if known). It is not necessary to immediately identify the specific providers prior to submitting the POC if the child/family has yet to choose a provider or if the referral has been made to an HCBS provider but the provider has yet to determine if they have availability to accept the referral.
POCs are to be submitted to the MMCP within 30 days from the HCBS Eligibility Determination regardless of whether the name of the HCBS provider is known to complete all fields. POCs can be updated as more information is known and gathered. The POC should indicate if a referral to provider(s) was made. HCBS providers should be specified in the POC once the HCBS provider is identified.
How often should the Plan of Care (POC) for a child in receipt of HCBS be updated and submitted to the Medicaid Managed Care Plan (MMCP)?
For children, the POC should be reviewed, at minimum: during the 6-month HH CANS-NY assessment; annually during the annual HCBS/LOC re-determination (if different time frame); and when there is a significant life event.
The POC should be updated, at minimum, annually and any time there is a change to the POC of services, providers and or needs of the member. When there is a change to the POC that is specific to services, providers and or needs of the member; the POC must be sent to the MMCP.
Examples of significant changes include admission to a higher level of care or being discharged from a higher level of care. Significant changes in a child’s functioning can include increase or decrease of symptoms, and/or a new diagnosis. Further information can be located on page 5 here.
What is the process for Medicaid Managed Care Plans (MMCPs) to communicate with C-YES (independent entity) about Children's HCBS? How do MMCPs know who at C-YES to communicate with regarding Plan of Care (POC) updates?
C-YES and the MMCPs have developed communication pathways to share POCs and other information in a secure environment, similar to the processes used between Health Homes and MMCPs.
If the Children's HCBS provider has their own referral form can that be used instead of the State’s form?
No, the Referral for Home and Community Based Services (HCBS) to HCBS Provider form must be used. The form as a fillable PDF can be located here.
Does the Freedom of Choice (DOH 5276) need to be completed with the Children's HCBS referral form?
No, the Freedom of Choice (DOH 5276) does not accompany the POC referral form as the form can be completed during the referral process for HCBS or any time after the HCBS LOC has been completed and DOH Capacity Management Team has informed the Care Manager the member has received a HCBS slot.
What is the time frame for children's HCBS codes to be reflected in eMedNY or ePACES once a waiver slot has been confirmed?
Once the capacity management team notifies the care manager that a slot has been assigned, a team member will start the code assignment process. Please allow 2-3 days for the process to be completed. Once entered, codes update almost immediately in eMedNY and in approximately 24 hours for ePACES. If for some reason this does not occur, please contact DOH capacity management.