For adult BH HCBS clients, under what circumstances does the Plan of Care need to be redone?
The plan of care should be redone if the tier of eligiblity, services and/or goals have changed or may no longer be appropriate based on observation or a major life change. Contact your Health Home Care Manager for more information.
What is the timeframe for adult Behavioral Health Home and Community Based Service (BH HCBS) providers to complete the assessment(s) for frequency, duration, and scope of each individual service?
The initial assessment by the adult BH HCBS provider to determine frequency, duration, and scope must be completed within 14 calendar days from the first visit.
Will each adult Behavioral Health Home and Community Based Service (BH HCBS) provider receive a copy of the individual’s Plan of Care? Will the BH HCBS Individual Service Plans be shared among providers?
The BH HCBS plan of care is completed by the Health Home Care Manager. Once complete, the BH HCBS plan of care must be signed by each of the BH HCBS designated agencies providing a BH HCBS service indicated in the HCBS plan of care.
For the initial 3 assessment visits with an adult individual how will the Behavioral Health Home and Community Based Services (BH HCBS) provider bill for these services? Will these visits have a different rate than the service rate? Will these visits apply to the utilization cap?
BH HCBS providers have up to 3 visits to determine the scope, duration, and frequency for the individual based on their needs, goals and preferences. This is a part of the BH HCBS and should be billed the same way an individual BH HCBS is billed. The time spent during these three visits will count toward the cap on hours.
Is a Plan of Care required if the only BH HCBS the adult is receiving is Non-Medical Transportation (NMT)? What is an example of an appropriate NMT trip for an individual who is not receiving any other BH HCBS?
NMT is considered a BH HCBS, and therefore the HCBS requirements for Plans of Care must be met when NMT is utilized. However, the State does not expect that there will be many individuals for whom it will be appropriate to use NMT and not be engaged in other BH HCBS. An example of an appropriate NMT trip for an individual who is not receiving other BH HCBS is a trip to a job interview for an individual with an employment goal who is engaged in a Personalized Recovery Oriented Services (PROS) program and therefore is not eligible for the BH HCBS employment services.
What if the care manager and the family do not agree on what services are needed for the child?
The child and family has choice of services and service providers. Documentation of this choice must be demonstrated by the Health Home Care Manager or Independent Entity. It is a requirement that the care planning process is person-centered and family driven.
Can children's home and community based services be added, as needed, to a Plan of Care?
Yes. The Plan of Care is a fluid document, so for HCBS-eligible children, services can be added as needed based on an identified need and capacity.
Who is responsible for verifying the first service date for a child's Plan of Care?
It is the responsibility of the children's HCBS provider who is delivering the service to notify the Medicaid Managed Care Plan of the first appointment.
Who is responsible for the child's HCBS service plan/goals, the HH Care Manager or the HCBS service provider?
A child/family’s service plan and goals are developed by the HH Care Manager or the IE in conjunction with the family. The HH Care Manager or IE then works with the HCBS service provider to determine which components of the service would help the person best and define scope, duration and frequency of services which is reflected in that provider’s HCBS service plan.
Prior to October 1, 2019, HCBS will be billed Fee for Service (FFS), so the Medicaid Managed Care Plan is not involved. As of October 1, 2019, when HCBS transitions to Managed Care, then there must be communication between the care manager/IE and the Medicaid Managed Care Plan about ongoing authorization for children in a plan.
Please provide more information about how frequency, scope and duration of children's HCBS are determined.
The child's HCBS service provider will make frequency, scope, and duration recommendations and report back to the HH Care Manager/IE so they can update the Plan of Care as appropriate.
The Home and Community Based Service provider will work with the child and family to identify the goals in order to develop the plan around frequency, scope, durations/ the activities they will be engaging in.
Will there be a standardized children's HCBS Plan of Care template released by the state that can/will be used across Medicaid Managed Care Plans for October 1, 2019?
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.
Are the elements that are listed for the Children's HCBS Plan of Care (POC) required to pay claims or should the Medicaid Managed Care Plan (MMCP) pass the claim through even if they do not have all of those elements?
If the MMCP has the minimum information required for HCBS payment as per the remedial POC policy, the MMCP can pay the claim. Otherwise, the MMCP may pend the claim and work with the provider to obtain the missing information.
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 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.
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.