Are adult Home and Community Based Services (HCBS) only made available for HARP eligible clients?
Yes, HCBS services are only available to clients that are enrolled in a HARP or an HIV SNP after they've undergone assessment and the assessment has indicated that they are eligible and for which services. For more information consult a recent workflow presentation.
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.
Can homeless clients use the Crisis Respite Home and Community Based Service for adults?
If an individual is HARP eligible, yes, but note that Crisis Respite has usage caps outlined in the HCBS manual and MCTAC trainings.
How do agencies identify if an adult client is HARP/HCBS eligible?
HARP/HCBS eligiblity information is available using ePaces.
Are HARPs required to have case managers? How are clients assigned to Health Home Care Managers?
Yes, HARPs are required to have case managers. The expectation is that most face to face care management will be done through the Health Homes. Each Health Home has its own assignment process.
How do adult BH Home and Community Based Services (HCBS) work for those between the ages of 18 and 21?
The adult BH HCBS services are only available to eligible adults ages 21 and over in HARPs or HIV SNPs.
Is there a cap for how many family members or collaterals the person may identify to receive adult Family Support Services?
No. The individual receiving this service is the one who decides which family members and other collaterals may be engaged in the service.
What trips are covered under adult Home and Community Based Services non-medical transportation?
Please refer to MCTAC's non-medical transporation webinar, held on January 9, 2017, which provided guidance on allowable vs. non-allowable trips. Resources from this webinar can be found here.
Can a recipient of adult Home and Community Based Services (HCBS) also receive Health Home Care Coordination without duplication of services?
Yes. All clients receiving adult HCBS are eligible for Health Home Care Coordination.
What are the requirements and expectations regarding supervision of peer support specialists/advocates for adults?
Per state issued guidance, supervision of peer support must be provided by a licensed behavioral health practitioner. The frequency of supervision should be determined as clinically appropriate.
How do adult BH HCBS providers access the manual for ePaces codes?
Providers can access the ePaces manual by clicking on ePaces help. Codes start on page 259.
Will there be any standards concerning choice and conflict of interest (for the service choices the clients are making) for adult clients?
The federal government is very serious about conflict free choice in HCBS. Providers will need to document the choices being offered to the client and the state will collect and monitor that information.
Are Adult HCBS certification and provider qualifications, requirements or guidelines? Do all criteria need to be met? Can staff waivers be obtained and if so how?
New York State HCBS certification and provider qualifications are requirements. All criteria must be met and at this time there are no staff waivers.
For adult BH HCBS clients, what are tiers 1 and 2?
Client tier status is determined by the brief Community Mental Health Assessment. Tier 1 indicates eligibility for select HCBS services including Employment, Education and Peer Supports. Tier 2 indicates eligibility for the full array of HCBS. The brief assessment may also find that an individual is not eligible for HCBS. All HARP enrolled individuals are eligible for short-term crisis respite.
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 HARP?
According to the NY Department of Health, "Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and Substance Use Disorder (SUD) diagnoses having serious behavioral health issues will be eligible to enroll in a new type of health plan, HARP. These specialty lines of business operated by the MCO will be available statewide. Individuals meeting the HARP eligibility criteria who are already enrolled in an HIV Special Needs Plan may remain enrolled in the current plan and receive the enhanced benefits of a HARP. HARPs and SNPs will arrange for access to a benefit package of Home and Community Based Services (HCBS) for members who are determined eligible. HARPs and SNPs will contract with Health Homes, or other State designated entities, to develop a person-centered care plan and provide care management for all services within the care plan, including the HCBS."
How do providers determine who has been designated part of a HARP?
Individual HARP eligibility and enrollment are included in ePaces. Information regarding Managed Care Plans that participate in HARP is available at the MCTAC Plan Matrix.
How many individuals are enrolled in a HARP?
New York State has identified approximately 120,000 individuals throughout NYS.
Who will determine if an adult is HARP eligible?
New York State determines who is HARP eligible. Individuals are eligible if they meet target risk criteria/risk factors or are identified by the service system or a service provider.
Target Criteria: -Eligible for mainstream enrollment and Medicaid enrolled, -21 and older, -Serious Mental Illness/Substance Use Disorder diagnosis, -Not dually eligible for Medicare, -Not participating in OPWDD program
Are adults in HIV SNPs included in HARPS?
Individuals in HIV SNPs are eligible for all services associated with HARP/HCBS under same rules as HARP eligible individuals.
How will managed care plans work with legal mandates (parole supervision, etc.)?
New York State expects managed care plans and providers to continue to follow any legal/court mandated aspects of treatment.
How does confidentiality factor in, when you have calls from Medicaid and managed care organizations needing client information?
If a provider does not have a contract (or is in the middle of contracting) with a managed care plan, how does that provider pay the plan for individual clients?
The provider will have to communicate with the managed care plan to determine how to handle this client. Usually a single case agreement will be reached.
Will the specifics of outlier management for the adult system be shared?
A specific list of outliers will likely not be generated because context is key to determining an outlier. For more guidance around outlier management consult the October 2015 OMH and OASAS UM Implementation presentations, available via the links below.
Are Adult providers required to provide care before authorization from the managed care plan?
Typically no, a provider is not required to provide care before the managed care plan gives authorization. Exceptions include if there is a crisis situation or an organization's own policies and procedures require them to provide care.
Is prior-authorization required for adult clients?
This varies by program and service type. Please refer to MCTAC's guidance on utilization management on our website's resources page, found here.
What are some strategies for providers to use to figure out their costs?
Work with your CFO or budget team to calculate your staffing, administrative and unit of service costs. For a sample model, utilize the CTAC benchmarking tool.
If someone is denied due to medical necessity or if managed care is refusing to pay, is there an appeals process?
Yes. The first step in the appeals process would be to initiate a discussion with the managed care company. If this is unsuccessful, a formal appeals process can then be instituted. Managed care has created external and internal appeals processes. It's important to recognize that the formal appeals process can be lengthy and time-consuming.
Contact information for a specific plan's appeals department can be found on the MCO matrix at matrix.ctacny.org.
What should providers do when clean claims differ across payers?
If a provider were to use a certified peer from an existing program, would it affect the staffing plan of that program, e.g. a peer from a PROS program providing an adult Behavioral Health Home and Community Based Service (BH HCBS). Will peer time for the BH HCBS be subtracted from PROS staffing plan?
Yes. Sharing staff between your adult BH HCBS and other certified programs is allowed; however, the total time (FTE) that an employee spends on BH HCBS must be separated out on the CFR, and the PROS staffing plan must account for this.
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 adult CPST what are the criteria for a “licensed professional,” and does a CASAC (Credentialed Alcoholism and Substance Abuse Counselor) meet these criteria?
CPST must be provided by "Professional Staff",” as defined in the BH HCBS Manual appendix. The manual qualifies that those licenses are issued via NYSED and are focused on the provision of direct services related to the treatment of mental illnesses and SUDs. The CASAC credential is a certificate issued by OASAS, and as such should not be included.
For adults, how is CPST different from outpatient clinic or ACT (Assertive Community Treatment)?
CPST is a Behavioral Health Home and Community Based Service (BH HCBS) available to individuals who are identified as having that need via the NYS Community Mental Health Assessment. It is a stand-alone service providing clinical mental health services to individuals in the community, at the intensity that best meets the individual’s needs. As opposed to outpatient clinic, CPST must be provided off-site, in the individual’s home or a community setting.
ACT is an evidence-based treatment approach targeting people who are resistant to traditional methods of
service delivery or for whom those approaches have not proven effective. There are specific treatment modalities employed, specific staff competencies and trainings proscribed; these are provided by closely monitored consistent teams specializing in a variety of disciplines and life areas, with a focus on ongoing monitoring and communication between all members via their daily Team Meeting. There is no provision in BH HCBS, or specifically CPST, for this intensity of service. The foundation of BH HCBS is that they are consumer-driven and recovery-oriented; they are not intended to address the intense engagement needs that ACT-appropriate consumers have.
Individuals receiving ACT services are not eligible for BH HCBS while they are receiving ACT services.
Can an adult OASAS-Certified Peer provide services to a mental health client and vice-versa?
OMH and OASAS certification programs are separate. The best practice would be for a peer specialist to have the certifications that aligns with the population with which he or she is working. For those working with the dually-diagnosed population, it is recommended that they have both certifications to be fully prepared to serve that population.
Can adult Behavioral Health Home and Community Based Services (BH HCBS) be provided in group settings?
The only BH HCBS that may be provided in groups are Psychosocial Rehabilitation Services and Family Support & Training services. All other BH HCBS must be provided 1:1.
Often times adult peer support specialists provide support through phone, email, and texting. Can these activities be billed under adult Behavioral Health Home and Community Based Services (BH HCBS) Peer Support?
NYS recognizes that peer support specialists provide many valuable activities beyond face-to-face interventions. However, all BH HCBS must be provided face-to-face. Phone, e-mail, and texting would not be considered billable activities.
Who will be responsible for determining if an adult assessed as eligible for Behavioral Health Home and Community Based Services (BH HCBS) lives in a Home and Community Based setting?
This should be determined by the Health Home Care Manager. Further guidance on the HCBS settings requirements is forthcoming.
Can individuals who reside in OMH-licensed Community Residences receive adult Home and Community Based Services (HCBS) in off-site locations?
Community Residences are non-compliant settings for BH HCBS. Individuals residing in community residences are ineligible to receive BH HCBS.
Can Adult Behavioral Health Home and Community Based Services (BH HCBS) be provided in individuals’ homes?
The state encourages Adult BH HCBS providers to provide services in the individuals’ homes and in community locations. Determinations regarding where services will be provided should be made in partnership with the individual. It should be noted that services cannot be provided in residential settings that are not HCBS compliant (such as psychiatric centers or community residences), and individuals who reside in these settings are not eligible to receive BH HCBS.
What are the requirements for Education Specialists for adult HCBS?
All Education Support Staff should have a minimum of two years working in behavioral health. Education Specialists should possess a Bachelor's degree and have two years of experience supporting individuals in pursuing education goals. A supervisor may be unlicensed and requires a minimum of a Bachelor's degree (preferably a Masters in Rehabilitation or a relevant field), a minimum of three years of relevant work experience, preferably as an education specialist.
How will adult HCBS services fit into a community with a PROS (Personalized Recovery Oriented Services) program? When would a client be appropriate for Home and Community Based Services (HCBS) versus PROS?
When choosing when, where, and how to receive services, individuals should be provided with the opportunity to make an informed choice. PROS is a comprehensive and integrated service model that is able to support multiple goals. BH HCBS may be appropriate for individuals who want to work in the community on 1-2 goals, who are averse to attending a program, or who require 1:1 services that a PROS program cannot sustain. The individual, together with his or her Health Home Care Manager and Managed Care Organization (MCO), will determine whether PROS or BH HCBS are more appropriate to help him or her attain or maintain his or her goals. Additionally, there are certain BH HCBS (such as Peer Support and Education Support Services) that can be provided to an individual who is enrolled in PROS.
How will determinations be made regarding settings that are subject to Heightened Scrutiny? Are individuals who reside in Scattered-Site housing considered eligible to receive adult Home and Community Based Services (HCBS)?
The housing settings that currently qualify as HCBS settings include an individual’s own apartment, scattered-site Supported Housing units, or in a family home. BH HCBS designated providers are expected to sign and submit to OMH an BH HCBS Settings Attestation form, declaring site compliance with the BH HCBS settings rule. Therefore, it is the responsibility of the providers to ensure standards are met. Settings under Heightened Scrutiny will not be approved until organizations have submitted a Heightened Scrutiny Self-Survey. Additional details on the survey will be provided. Further guidance regarding HCBS settings compliance is forthcoming.
If an individual has previously failed in an education program, is he or she eligible to receive adult Education Support Services? Is there a minimum number of credits or classes an individual needs to pursue?
If the individual has been assessed as eligible for BH HCBS Education Support Services, has a goal that requires the service, and wants to receive the service, it should be included in the Plan of Care. Failing to complete an educational program in the past does not preclude an individual from receiving this service in the future. There is no minimum number of courses or classes in which an individual must be enrolled. Ongoing Supported Education is provided when an individual has been admitted to an educational or training program.
If an individual is eligible for ACCES-VR, how can adult Behavioral Health Home and Community Based Services (BH HCBS) provide employment and education services?
The BH HCBS Provider Manual stipulates that Education and Employment services may be provided to the extent to which they are not available under a program funded by the IDEA or available for funding by ACCES-VR. BH HCBS services and ACCES-VR services can complement each other, and whenever appropriate, the Health Home Care Manager and provider should ensure coordination with the ACCES-VR Vocational Counselor. It is important that an individual be provided the opportunity to make an informed choice between services and providers. Further guidance is forthcoming.
Are adults who are actively using substances, who have a history of substance use, or who have a history of incarceration eligible for education or employment services?
If the individual has been assessed as eligible for Behavioral Health Home and Community Based Services (BH HCBS), has a goal that requires the service, and wants to receive the service(s), it should be included in the Plan of Care. Substance use and a history of incarceration should not be used an exclusionary criteria for these services.
What would be the typical sequence(s) through which an adult would move between the various services in the Employment cluster?
Behavioral Health Home and Community Based Services (BH HCBS) Employment and Education services are not meant to be sequential. An individualized and person-centered approach should be used to identify the service(s) that are most appropriate to meet the individual’s needs.
Can adult CPST services and PSR services be provided concurrently, and if so, how will two different providers ensure that the combined 500-hour cap is not exceeded?
CPST and PSR may be provided concurrently. It will be important for providers to maintain contact with the Plan and Health Home Care Manager to ensure appropriate utilization management. Following an assessment, each provider will make recommendations regarding scope, duration, and frequency of the service. All BH HCBS are subject to utilization thresholds.
How are adult Psychosocial Rehabilitation (PSR) and adult Habilitation different?
The adult BH HCBS Provider Manual provides definitions of each service. PSR services are designed to assist the individual with compensating for or eliminating functional deficits and interpersonal and/or environmental barriers associated with their behavioral health disorder. Habilitation services are designed to assist individuals in acquiring, retaining, and improving skills necessary to reside successfully in home and community-based settings.
What are the training and experience requirements for adult Family Support staff? Is there a credentialing process?
There is no certification or credentialing process specific to providers of Family Support and Training. This service may be provided by unlicensed staff who have at least a high school diploma or equivalent and 1-3 years of relevant experience working with individuals with behavioral health disorders. OMH-certified Peer Specialists and OASAS-certified Peer Advocates, CASACs, CASAC-T’s, and Certified Psychiatric Rehabilitation Practitioners (CPRPs) may also provide this service.
For adults, can Family Support & Training be offered to the individual alone to review and assess the plan, or does a family member need to be present in order to bill?
Family Support and Training is provided to family members at the individual's request. In order to bill for this service, a family member must be present.
Are adult Intensive Supported Employment and Ongoing Supported Employment subject to the same 250-hour cap that includes Pre-vocational Services and Transitional Employment Services?
Pre-Vocational Services and Transitional Employment are capped together at 250 hours per year. Intensive Supported Employment and Ongoing Supported Employment are each capped individually at 250 hours per year. An assessment by the provider will determine the appropriate frequency, scope, and duration of services. The provider(s) must work with the Plan and the Health Home Care Manager to ensure appropriate utilization management. In addition to the caps on the number of hours, providers should be aware that there are utilization thresholds listed in the Billing Manual that also apply.
Should Health Homes assess only HARP-enrolled individuals, or are we expected to assess all HARP-eligible individuals for Behavioral Health Home and Community Based Services (BH HCBS) eligibility?
Can you explain the group ratios for adult BH HCBS? The fees matrix has rates for groups of 2 or 3, but the HCBS Provider Manual indicates that you can have up to 16 individuals in a group.
Family Support and Training groups are limited to 2 or 3 families at a time, with no more than 16 individuals in any one group.
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.
Can adults who are homeless receive Home and Community Based Services (HCBS)? Does it make a difference if the individual is sheltered or unsheltered?
OMH and OASAS will release further guidance on providing services to individuals who are homeless.
Regarding UM, who organizationally is best situated to handle/manage?
There isn't one path fits all -- depends on an organization's size, how many clients, and how many contracts with MCOs. A recommended approach is to balance centralized vs individual. Consider how well equipped a central staff, social worker or nurse is able to speak to a case just by looking at a chart? On the other side, training 20 people to do UM reduces the amount of time they can spend on other things. Also raises question of supervision.
Can a person be in both an adult and children's health home with two care managers?
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.
If an agency provides services to both children and adults and has been approved for adult BH HCBS, do they receive automatic approval for the children's HCBS?
No, the designation process to provide HCBS services to children is a separate and distinct process from the Adult HCBS designation.
What consideration will there be for complexity and comorbidity in the capitation formula for children's services?
Complexity of co-occurring and chronic conditions for children are being taken into account when determining rates and program design.
How will the Value Based Payment system work?
Please visit https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm for more information regarding the VBP Initiative.
Where is the adult Non-Medical Transportation (NMT) Grid accessed?
Do adult BH HCBS providers bill for Non-Medical Transportation (NMT)?
BH HCBS providers would only provide and bill NMT if they are enrolled Medicaid transportation providers and are assigned transportation by the transportation manager. Transportation is assigned via enrollee choice within the appropriate level of service or rotation when no choice is expressed. When billing for NMT, enrolled Medicaid transportation providers must receive prior authorization from the transportation manager and bill through eMedNY through the same billing process as fee-for-service Non-Emergency Medical Transportation (NEMT).
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.
Can adult BH HCBS providers bill for mileage for staff trips related to an individual’s goal?
Non-Medical Transportation (NMT) is a BH HCBS and is separate from Staff Transportation which is a supplemental rate add-on for some BH HCBS. BH HCBS providers can bill for mileage for staff trips, as long as the mileage is tied to a service that was provided and it is a service that qualifies for Staff Transportation. The services that qualify are essentially all services, except NMT, respite services, and Psychosocial Rehabilitation or Family Support and Training if those services are provided to a group. Information about Staff Transportation is also available in the billing manual here.
What is the timeframe in which the MCO must confirm the proposed adult Non-Medical Transportation (NMT) is appropriate based on the approved POC/Level of Service Determination decision and send the Grid to the Transportation Manager?
If the NMT Grid is received with the level of service determination request, the MCO should forward the Grid to the Transportation Manager at the time of the approval of the level of service. If the Grid is received after the Level of Service approval, the MCO should review and make a decision regarding the appropriateness of the proposed NMT within the timeframe for Service Authorization Requests in Appendix F of the Medicaid Managed Care/Family Health Plus/HIV SNP Model Contract.
Where on ePaces can providers find the adult HCBS codes?
On ePaces, providers should be looking at the section that lists the restriction and exception codes. Providers are looking for the "H codes."
What are eligible settings for Children and Family Treatment and Support Services?
Children and Family Treatement and Support services can be provided in the community, and in Community Residences (OMH). Services can also be provided in any licensed foster care setting, including institutions (e.g. RTC). Services cannot be provided in any hospital, inpatient or Residential Treatment Facility level of care.
Can Other Licensed Practitioner (OLP) be provided under a limited permit license?
Will there be outreach to the medical community, school districts, etc. about the Children and Family Treatment and Support services, referral process and medical necessity?
Yes, this is planned. Materials will be developed and shared for providers to use for outreach to families and referral sources.
From a Workflow perspective, how do you get into these services without going through an Other Licensed Practitioner (OLP)?
There are multiple examples of pathways into services including:
If the child is in clinic receiving therapy, the clinician can make a recommendation for any of the new Children and Family Treatment and Support Services based on their determination of medical necessity.
A pediatrician can directly recommend FPSS as they can support medical necessity.
A school guidance counselor supporting a young man/woman who has come back from a residential setting with a parent who is concerned about positive peer group. The school counselor could refer any agency who providers PSR. The agency can access their own internal licensed practitioner for assessment and determination of medical necessity or work with the parent to identify a treating clinician for documentation of medical necessity to allow the service.
In foster care there is a requirement that youth have a full array of health and behavioral assessments by licensed practitioners, which could result in a recommendation for one or more of these services.
Will Medicaid Managed Care Plans (MMCP) need to approve Treatment Plans for Children and Family Treatment and Support Services?
MMCPs do need to approve scope, frequency and duration, but the goal is not to have plans ‘over manage’. MMCPs are approving services based on their review of the documentation submitted by the provider to substantiate medical necessity. This may include the treatment plan.
Can a pediatrician make a recommendation for Children and Family Treatment and Support Services and develop a treatment plan?
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.
Could a child have more than one treatment plan if they are receiving multiple Children and Family Treatment and Support services?
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.
Is there a process/plan to educate the Local Departments of Social Services (LDSS) on the new and aligned children's services?
Yes, there will be outreach and education provided to inform the LDSS including an Administrative Directive.
What is the difference between a Health Home Plan of Care and a Children and Family Treatment and Support Services Treatment Plan?
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.
Can children's providers continue to provide services on a fee for service basis after the children's system transition?
Yes, services will continue to be provided on a fee for service basis for children who are not enrolled in a Medicaid Managed Care Plan (MMCP). However, services must be billed to the MMCP for children enrolled in managed care.
What types of children will need to remain Fee for Service during the transition?
Many children will remain Fee for Service because they are exempt or excluded from Medicaid managed care for reasons that are not impacted by this transition, such as children with comprehensive Third Party Health Insurance and children who are Native American. Children who will be mandatorily enrolled in Medicaid managed care as part of this transition are children who are only exempt due to 1915c waiver enrollment or who are excluded because they are in the care of a voluntary foster care agency (VFCA).
What is the role of C-YES (Independent Entity)?
The Independent Entity, referred to as C-YES will conduct HCBS Eligibility Determinations for children who are not yet enrolled in Medicaid and assist the child/family with Medicaid enrollment (if eligible).
Additionally, the Independent Entity will conduct HCBS Eligibility Determinations, annual re-determinations, and develop Plans of Care for children who opt out of Health Home Care Management.
Waiver capacity will remain the same upon the initial implementation. Capacity may be expanded beginning July 2019, based on global spending cap allowances.
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.
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:
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.
Do we need to receive designation to provide Children's CFTSS/HCBS before we enroll for a provider number such as the Medicaid Management Information System (MMIS)?
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).
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.
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.
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.
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
Who needs to authorize a child's CFTSS treatment plan, DOH or the Medicaid Managed Care Plans?
Medicaid Managed Care Plans (MMCP) will be authorizing services for children enrolled in managed care. Each MMCP will develop a process by which providers will obtain authorization in line with the State issued utilization management guidelines. Specific MMCP processes for authorization can be found here.
Can you bill for the same family for group and individual in the same day for CFTS service FPSS? If so, can you charge the out of office add-on for both if they are both off-site?
Yes, you can bill for group and individual FPSS on the same day but you cannot charge the off-site twice if both appointments are in the same place back to back. However, if the provider had to travel twice in the same day to deliver services, providers may charge for off-site for both services.
For the CFTSS, OLP Crisis Triage, which has a 15 minute unit, what should be done if the call is less than 15 minutes? Can this be 5 minutes instead?
It is anticipated that Crisis calls usually take more than 15 minutes. Providers will not be able to bill for crisis triage call that are less than 15 minutes.
In CFTSS, how do you bill for more than one OLP evaluation?
There is not a set limit in the billing manual. Providers should follow billing procedures as outlined in the billing manual.
Why in CFTSS is only OLP Crisis Complex Care in 5 min units/max 20 minutes? Was it not agreed that all crisis OLP services would be kept consistent in terms of units and increments?
Crisis Complex Care (Follow Up to Crisis) is meant to be a brief follow up call post crisis services.
Are providers allowed to provide multiple Children and Family Treatment and Support Services in a day?
Yes, multiple CFTSS can be provided on the same day as long as each service is provided at a different time either consecutively or at another point during the day. You cannot bill for OLP, CPST and PSR all during the same interval of time.
In CFTSS, do you need a diagnosis to bill for OLP (Other Licensed Practitioner)?
You do not need a diagnosis to bill for OLP Evaluation. You should use R69 (or for United F99) in field 67 of the paper claim form. If you have seen the individual many times, it is likely a diagnosis would be determined and you would no longer be using R69.
If a field on the claims form is not required and you complete it anyway, what will happen? For example if a field is required for one plan but not others and you set your default to fill it the way it is required for that one plan will the others deny you because you have completed a field that is not required?
Many plans will just ignore it and it will not disrupt the claim, but for some plans, it could lead to a denial.
Claim testing is a great opportunity to determine the appropriate system set up to reduce denials.
How will clinicians know which codes to use?
It can be beneficial to create a Chargemaster that everyone at your organization has access to so that they understand which codes are used for which services as well as who (in terms of licensure) can provide and bill for each service.
Can supervisors be shared across services for Children and Family Treatment and Support Services (CFTSS)? What about case managers?
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.
At an OMH licensed clinic can someone other than the Other Licensed Practitioner (OLP) recommend to the Children and Family Treatment and Support Services (CFTSS) within the same agency or is that a conflict?
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.
When/how are Medicaid Managed Care Plans being informed of designation for children’s services? Are they being informed of specific populations and services?
The State shares updated designation lists with the MMCPs on a monthly basis which includes the services, sites, and populations for which agencies have been designated.
Medicaid Managed Care Plans have begun contacting with providers. However, it is strongly recommended that providers reach out to MMCP directly if MMCPs have not reached out to the provider directly.
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.).
Is there a set timeframe for submitting a CFTSS claim? Are there timeframes for resolving denials or other claims issues (not billed, pending, etc.)?
The state requires providers be given a minimum of 90 days to submit a claim.
It is recommended that providers have a process in place to make sure that every service has been billed in a timely fashion. In addition, the process should include review of remittances (response from MMCP). The goal is to account for every service and its billing status.
How do you become a Medicaid provider as part of an agency?
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.
Do you need authorization for offsite CFTSS, separately from service authorization?
Please discuss with your Managed Care Plan to determine their rules.
What is included in offsite rate for CFTSS? Is it per site or per unit/per client?
The off-site rate supplements the base service rate to account for additional costs associated with off-site billing. The base service rate codes and the off-site rate codes that correspond should be billed for the number of units the service was provided. The rates are billed per client. These rate codes will be billed on separate claims.
How long will CFTSS providers get the transition rate?
Providers will get a transition rate for 24 months from the transition date of 1/1/19. The rate will phase out over these 24 months, with reductions every six months.
If a child has multiple insurances, does a provider have to bill their commercial insurance first or can they just bill Medicaid?
Commercial insurance should be billed first because Medicaid is a payer of last resort.
Even if it is a service that you know the other insurance will most likely not cover you should bill that insurance first and get denied and then bill Medicaid. Talk with your legal and compliance experts.
Please explain the statement, "multiple CFTSS services on same day are to be considered 1 visit.” Is this only for the purpose of counting the 30 visits (as authorized after concurrent review) or is this also for billing i.e. will only one service be paid for per day?
This refers to the counting of 30 visits as authorized after concurrent review. This is not related to billing. Providers may bill for more than one CFTSS in one day, within the daily unit limits outlined in the billing manual.
Is the 30 visit authorization per CFTSS service or is 30 visits inclusive of any services being authorized?
Concurrent review authorizations must be for at least 30 visits for each individual service that the child is receiving. If the child is receiving OLP, CPST, and PSR they get at least 30 visits for each.
Is a behavioral health diagnosis required for concurrent review of OLP, PSR and CPST?
OLP and CPST do not require a diagnosis to begin the service, however it is likely that a diagnosis and/or documentation of medical necessity would be determined before the point at which concurrent review is needed. PSR, on the other hand, does require a diagnosis for receipt of the service.
Since medication management is not a service under OLP, CPST or PSR, is the 30 visit count inclusive of the child’s clinic visits or doctor visits?
Doctor and clinic visits do not count towards the 30 visits that are authorized as part of concurrent review for OLP, CPST, or PSR.
For the 3 visits that are allowed before concurrent review needs to be authorized for CFTSS is that equal to 3 one-hour services or 3 fifteen-minute billing units?
A visit is one interaction with child and family. It could be 15 minutes or 1 hour.
Are you anticipating issues with MMCPs denying coverage if notification of the first 3 visits of OLP, PSR or CPST is not received either on a timely basis or at all?
Since prior authorization is not needed, who is checking that medical necessity is met in order to approve the 30 visits for CFTSS?
Prior authorization is not needed; as a result, the first 3 visits can occur without authorization. After that, concurrent review may be required, based on MMCP specific requirements, so that the MMCP can authorize additional visits. As part of concurrent review, medical necessity must be supported. Please refer to the MMCP specific guidance.
Is the 90 days of service, before authorization is needed for CFTSS, guaranteed for every child who is recommended for a service or only those that are beginning services on day one of the service becoming available (1-1-19)?
For OLP, CPST, and PSR, the State has extended the UM prohibition from 90 days to 180 days. This time period is from January 1, 2019 through June 30, 2019. This is a fixed timeframe, regardless of when the child begins receiving services. The purpose of this is to prevent disruptions in care while MMCPs and providers gain experience with services.
For children currently enrolled in transitioning Waiver services, is there a different authorization period? Is it still the case, that children will be authorized for 6 months after go live for any service they are currently receiving?
The 6 month provision is for the MMCP authorizing existing Plans of Care for children in HCBS and begins when HCBS become part of the managed care benefit package, currently targeted for Oct 1, 2019.
For CFTSS, what is the difference between LPHA and NP-LBHP?
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:
In CFTSS if the youth is enrolled in Health Home Care Management, does the Plan of Care replace the treatment plan?
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.
Is there a deadline for claims testing for children's transformation?
MMCPs were required to open claims testing no later than December 1st 2018 and leave systems open for testing throughout the children’s transition. There is no deadline, but it should be completed before a provider bills for services.
If IT infrastructure is not fully in place for billing on Jan 1 when the 3 CFTSS go live, can claims be backdated for a period of time?
Claims should be submitted with the accurate date of service, and providers have a minimum of 90 days to adhere to timely filing guidelines. Providers can submit paper claims if needed to ensure meets their contracted timely filing guidelines.
Can non-licensed providers for CFTSS and children's HCBS, that do not have a NPI, use the unlicensed provider number?
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
What are the specifics about billing for mileage for an off-site CFTSS visit? If PSR and CPST are provided in the same day can they both bill mileage for that client or is it only one of the services that can bill mileage per day?
There are set off-site rates, not a mileage reimbursement. Providers can only bill for one off-site if two different services were provided during the same trip.
Is there a rate code for CFTSS OLP Complex Care off-site?
Complex Care is provided by telephone, so there is no differentiation needed for offsite vs. on site.
Please clarify how long transitioning waiver children are authorized for CFTSS. Are they authorized to receive the cross-walked services for one year from initial CANS?
CFTSS are Medicaid State Plan services. Any child on Medicaid can receive these services as long as they continue to meet medical necessity. Waiver eligibility is not required for access to CFTSS.
Will there be a standard form for the child's Treatment plan? For the assessments to determine medical necessity for each service?
No specific assessment tool needs to be completed for a child to access CFTSS; all that is needed is for the child to meet medical necessity criteria for the service.
Care Managers can refer directly to a CFTSS provider who is designated for OLP, for the non-physician licensed behavioral health practitioner to determine medical necessity for any CFTSS.
In addition, any licensed practitioner treating the child (such as their doctor) can make a recommendation to CFTSS by completing a written recommendation to document medical necessity based on clinical judgement.
Is there a standard form for notifying MMCP of CFTSS to be provided to children? Should providers anticipate some acknowledgement by the MMCPs that they received the notification? If no form, what does this notification look like?
There is no standard form for notifying plans prior to service delivery. Notification method/process depends on the MMCP.
What is the difference between OLP services and therapeutic services through the Article 31 clinic? How do we distinguish when each is appropriate/when to bill for which?
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.
Will Waiver HCBS Providers who bill Managed Care for cross-walked CFTSS be required to submit Plans of Care to MMCP's?
Plans of Care for Waiver children will need to be submitted to MMCPs beginning 30 days before HCBS become part of the managed care benefit package, currently targeted for July 1, 2019. Plans of Care include a list of all services the child is receiving, including CFTSS.
Plans of Care are separate than the required Treatment Plans for CFTSS. Treatment Plans for CFTSS are not required to be submitted to MMCPs, however, the information necessary to demonstrate medical necessity criteria may need to be submitted to the MMCP for concurrent authorization.
Please refer to MMCP specific authorization requirements at:
Is there a daily unit cap or is it a suggested cap for CFTSS?
The billing manual outlines the daily unit limits. In acknowledgement of the need for checks against fraud and abuse, but to ensure a client's access to services, service utilization in excess of the annual claim limits and "soft" unit limits will be based on medical necessity and subject to post-payment review. Documentation of the medical necessity for extended durations must be kept on file in the client's record. Please refer to UM Guidance for details on annual and daily limits.
What makes a CFTSS service offsite? Is anything beyond administrative site offsite?
Offsite services are intended to be provided in the child’s home or community. All locations, including satellites, are considered on-site.
For CFTSS, is offsite billed separately or as a modifier that increases the rate when an offsite service occurs?
Offsite is billed as a separate claim, using a separate rate code.
For CFTSS, do the base (service) rate and the offsite rate have to be separate claims or can they be multiple lines in one claim?
Because the off-site service requires the use of separate rate codes, they must be submitted on separate claims.
For CFTSS, if offsite is billed with 2 claims: the first using the service rate code and the second using the offsite rate code, and both include the same procedure code will this look like the same services were provided on the same day?
The services are differentiated by the required modifiers. For example,
•OLP Licensed Evaluation: 7900 – 90791 – EP (up to 10 units)
Can individuals providing CFTSS or children's Aligned HCBS who are not licensed practitioners get NPIs?
Non-licensed staff do not require an NPI. Practitioners who are able and required to enroll in Medicaid will need an NPI to enroll.
Does medical necessity need to be signed by a provider with an NPI and a MMIS number? If one number was included but not the other, is that medical necessity form no longer valid?
No, medical necessity can be signed by any LPHA listed in the Children and Family Treatment and Support Services (CFTSS) Provider Manual as long as it is within their scope of practice. If the LPHA does not have an NPI and/or MMIS number, that practitioner may use the NPI and/or MMIS number of their employing agency. There are some LPHAs who can make recommendations/determine medical necessity who may not be eligible to enroll in Medicaid as an individual practitioner. Therefore, those practitioners may not need to obtain an NPI. In these cases, the NPI number of the agency can be used in the Referring Provider field of the claim form.
When should children's providers begin using the CFTSS rate codes?
Providers of waiver services that crosswalk to OLP, CPST, or PSR must begin billing CFTSS codes for children currently enrolled in HCBS waiver programs on February 1, 2019. As of February 1, 2019, current (before Feb) HCBS Waiver services and their rate codes that are transitioning to CFTSS rate codes can no longer be billed. This includes the following services under the OMH HCBS or OCFS B2H Waivers: Skill Building; Crisis Avoidance, Management, and Training; Intensive In-Home Services; Immediate Crisis Response Service; and Crisis Response Services.
For children not enrolled in waivers, billing for CFTSS began on January 1, 2019.
What is within the scope of an LPHA’s practice as related to recommending 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.
Where can claims testing contact information be found for each Medicaid Managed Care Plan?
Providers should contact each MMCP to get instructions on claims testing. The MCTAC Matrix below includes a tab for contacts at each MMCP related to billing: https://matrix.ctacny.org/
Can a child's family or teachers directly refer to an OLP?
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.
Is the date that medical necessity is determined considered the “admission date”?
The admission date is the earliest date the service is delivered.
Once SED is carved in to children's managed care, will clinics no longer be designated as SED clinics? How will the SED checklist be utilized after 07/01/19?
SED clinics will continue to be designated as such but will be billing Managed Care after their exemption is lifted on 7/1/19.
Will the SED rate codes be billed to Medicaid Managed Care, or will standard codes be used after the children's transition is complete?
As of 7/1/19, providers should bill Medicaid Managed Care using standard APG rate codes.
As an Article 31, outpatient mental health clinic, for children that we have been providing clinical services to and that can get to clinic, should we start billing that as OLP service or continue as we have been?
If the child is receiving clinic services, then it should continue to be billed as clinic. OLP is a distinct service, separate and apart from clinic. OMH has issued a guidance memo that addresses the relationship between OLP and clinic services and can be accessed here: https://omh.ny.gov/omhweb/bho/omh_clinic_and_olp.pdf
Who pays for the Other Licensed Practitioner (OLP) service for children in foster care?
OLP will be billed fee-for-service for children residing in a VFCA until the date those children are enrolled in managed care. If the child is already enrolled in managed care, OLP would be billed to the managed care plan (except for SSI children, who will receive CFTSS through managed care beginning 7/1/19.)
Will Youth Peer Support and Crisis Intervention (CI) be billable to the Medicaid Managed Care Plans (MMCPs) on 10/1/19 under the consolidated waiver even though they won’t be CFTSS until January 2020?
Youth Peer Support and Crisis Intervention are part of the Children’s HCBS package until January 2020 when the services become CFTSS.
When the HCBS package moves into Medicaid Managed Care (MMC) on 10/1/2019, all HCBS for children who are enrolled in MMC will be billed to MMC.
Is HCBS Level of Need (LON) still anticipated to roll out following the 3-year level of care expansion?
The HCBS Level of Need (LON) expansion is anticipated to roll-out after the 3-year level of care expansion. It will begin no earlier than July 2022.
When a youth is hospitalized and an FPSS worker was at the home earlier the same day can Family Peer Support Services (FPSS) bill?
A FPSS provider cannot bill Medicaid for services while the child is in the hospital, as the hospital is already billing Medicaid for the child at that time.
However, if the service is provided before the child was admitted to the hospital, the service would be billable and not duplicative of another Medicaid service.
As always, we encourage you to speak with your agency internal compliance officer and/or billing staff to delineate when a staff-person can serve the family.
If a family does not have a child with a substance abuse issue would a Certified Recovery Peer Advocate Family (CRPA-F) be able to work with the parent to provide Family Peer Support Services (FPSS)?
FPSS work to improve the situation of the family in relation to the needs of the child. Family peers have lived experience as a parent of a child with mental health needs or substance use needs and the corresponding certification or credentialing. Therefore, the use of a family peer should take into consideration the needs and diagnosis of the child.
Typically, the CRPA-F would assist the parent or caregiver to address the needs of their child with a substance abuse issue. Whereas, the credentialed FPA would work with a parent or caregiver of a child with a mental health need.
Does the Family Peer Advocate (FPA)/Certified Recovery Peer Advocate Family (CRPA-F) write the treatment plan?
Yes, they create the treatment plan based on the needs of the child and family. The FPSS would engage in a conversation with the child and family and use the information provided by the LPHA to determine what intervention/activities would take place within the scope of the service to support the goals and objectives developed.
Although there is no specific assessment for this, OMH does endorse the use of the Family Assessment of Needs and Strengths (FANS) which will assist FPSS providers in honing-in the on a family’s strengths and needs. This conversation would result in the development and implementation of a treatment plan.
Do all current children's HCBS providers need new fingerprinting and background checks even if they have had them previously?
These checks are not transferable, all HCBS and Care Managers will require CHCR, SCR and SEL checks even if they were performed previously. See Background Check Guidance document for more information.
What category of service are children's HCBS billed under?
Children's HCBS will be billed under 0268. All HCBS designated providers should have that category added to their Medicaid ID number.
How does children's HCBS Caregiver/Family Supports and Services differ from CFTSS Family Peer Support Services (FPSS)?
FPSS is provided by someone with lived experience to help parents and caregivers by empowering them, helping them navigate systems and negotiate services that the child is engaged in. Caregiver/Family Supports and Services is provided by a person with a Bachelor's degree. Their role is to help the family negotiate systems with specialized expertise in schools, education, juvenile justice, etc. A family peer might provide Caregiver/Family Support Services as well if they meet the qualifications.
Does a caregiver or family member have to be present to bill for children's HCBS Community Self-Advocacy Training and Supports or can you work on the goals with just the enrolled youth?
No, the parent/caregiver does not need to be present to bill for Community Self-Advocacy Training and Supports.
The documentation does not say that the LPHA who makes the Family Peer Support Services (FPSS) recommendation "MUST" be involved in the creation/coordination/oversight of the treatment plan and most clinicians (pediatricians/school SW/LPHAs) are not going to want to have more responsibility than is required. What is the protocol in these situations? Can FPSS providers create their own treatment plans with caregivers and submit them to the Medicaid Managed Care Plan (MMCP) without the oversight of any other authority?
The FPSS provider can develop their own treatment plan, with the oversight and approval of the FPA supervisor. The plan, however, should be guided by the needs and functional limitation of the child identified by the recommending LPHA.
Ongoing involvement of the LPHA recommending the CFTS service is not required. However, as with all mental health service provision, coordination of care between service providers or through a multi-disciplinary approach, is most effective.
If the recommending LPHA is also part of the FPSS provider agency, they may play a more active role in the treatment plan and serve as a member of the multi-disciplinary team on an integrated treatment plan.
If the LPHA is not within the same agency, wherever possible, FPSS providers are encouraged to coordinate with external agencies to ensure their work supports the efforts of other treatment providers and helps to inform their own activities.
If a child is determined eligible for HCBS services by a Health Home Care Manager or C-YES, is the child eligible for the entire menu of HCBS services or does the care manager determine which specific services they are eligible for?
If a child is HCBS eligible, then they are eligible for all HCBS services but should only receive the services that are documented in the plan of care as relevant to the child/family’s goals.
Are children that are enrolled in Health Homes that are not transitioning from one of the Waivers, able to access children's HCBS?
Health Home eligible youth are not automatically eligible for HCBS. Children will need to meet target/risk/functional criteria to be determined eligible for HCBS.
Can you provide more detail about the children's HCBS Caregiver/Family Supports and Service limitation regarding special education/IDEA?
Special education and related services that are otherwise available to the individual through a local educational agency, under the provisions of the Individuals with Disabilities Education Act (IDEA) cannot be provided as part of HCBS.
When it is necessary to support a child in HCBS Respite who has medical needs that require a nurse, how can both the Respite provider and the private duty nurse bill without running into a "double billing" problem?
The nurse and the Respite provider are fulfilling different needs of the child, if a child requires a nurse they would seek this service through the State Plan
Can children's HCBS be delivered at two different times of day as long as the amount does not go over the daily rate?
Yes, different HCBS services can be provided on the same day and must be provided at different times in order to bill for both. Additional information on billing can be found here.
Are the children's HCBS pre-service training requirements expected to be completed by staff by 4/1? What happens if these are not completed by then?
Staff members are required to complete Mandated Reporter training prior to delivering HCBS.
Training to be Completed within Six (6) Months of Children’s Waiver Implementation for Existing Staff or within Six (6) Months of Hire for New Staff.
For staff hired before April 1, 2019, the following training must be completed within six (6) months of the 1915(c) Children’s Waiver implementation on April 1, 2019. For staff hired on or after April 1, 2019, the following training must be completed within six (6) months of hire date. • Personal Safety/Safety in the Community • Strength Based Approaches • Suicide Prevention • Domestic Violence Signs and Basic Interventions • Trauma Informed Care
These trainings must be completed by staff providing all HCBS except Youth Peer Support and Training (YPST), Family Peer Support Services (FPSS), and Crisis Intervention (CI).
All training records of staff must be recorded and maintained for auditing purpose.
Will prior training be accepted to meet the children's HCBS pre-service training requirements?
Yes, additional guidance will be provided.
Can care managers refer children to Home and Community Based Services (HCBS) offered at the same agency, but by a different department?
the child/family is given choice
the individual providing the service is not the same person as the care manager
the service provider and the care manager have different supervisors
Does the child’s care manager or the Independent Entity (C-YES) determine eligibility through the CANS?
If the child/family opt in to Health Home, then the care manager determines eligibility. If the child/family opt out of Health Home then C-YES determines their eligibility for HCBS.
When do providers bill Medicaid Managed Care Plans (MMCPs) for Children's HCBS?
Aligned HCBS services transition to Medicaid Managed Care on October 1, 2019. As of October 1, 2019, providers will bill Managed Care for children in plan receiving these services.
Can you clarify the restrictions for children's HCBS Prevocational services? If a child has an IEP or is linked to ACCES-VR are they ineligible?
HCBS eligible children without an IEP or those who are not ACCES-VR eligible, can receive these services.
Children cannot get HCBS Prevocational or Supported Employment services if they should be getting them from school or ACCES-VR.
If there are components of Prevocational or Supported Employment that the child cannot receive through the school or thorough ACCES-VR they should get a letter from the school or ACCES-VR verifying that they cannot be provided or are being denied and then the child can get these services.
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?
Will service planning (not face to face with a client) for children's HCBS be able to be billed?
No, you cannot bill if not face-to-face.
In Children's HCBS, what is the difference between Prevocational and Supported Employment?
Prevocational Employment provides services that are not directly related to a particular job, rather these are geared at developing skills and supporting the child finding a job. Supported Employment provides services to support the child while they perform in a work setting (after they have acquired a job).
Does a child need an IDD/DD diagnosis in order to receive HCBS Community Habilitation (CH) or HCBS Day Habilitation (DH)?
A child does not need an I/DD diagnosis in order to receive Community Habilitation or Day Habilitation, however a child must have an identified developmental delay in order to receive either service. The service need must be described in the Child’s Plan of Care.
Day Habilitation addresses the assistance with acquisition, retention or improvement in self-help, socialization and adaptive skills.
Community Habilitation focuses on the child learning a skill rather than restoring a skill. Community Habilitation is not a rehabilitative service, meaning the provider is not trying to restore functioning.
Typically, Children who have an I/DD diagnosis benefit from Day Habilitation and/or Community Habilitation. Children who meet Level of Care through SED typically benefit from Psychosocial Rehabilitation (PSR) under CFTSS as the service is rehabilitative in nature. PSR DOES require the child to have a behavioral health diagnosis and a child with a developmental disability diagnosis without a co-occurring behavioral health condition is ineligible to receive this rehabilitative service.
Can a child be recommended for HCBS and CFTSS?
Yes, a child may meet criteria for both based on medical necessity for CFTSS and meeting HCBS threshold criteria. The Health Home Plan of Care should identify what goals each service is intended to address. Each service would have its own service or treatment plan.
Can Palliative Care: Bereavement Services continue beyond the death of a child?
No, because services are billed through the child’s Medicaid number.
Can children's HCBS Day Habilitation services be delivered in the community?
Designated Day Habilitation providers are also Certified OPWDD providers. Some activities will take place at the Day Habilitation facility while others may occur in the community based on the goals identified in the Child’s plan of care.
What are the guidelines for authorization of Children's HCBS?
Authorization for continued services will entail a conversation between the MMCP and the HCBS provider, primarily. However, the Health Home Care Manager would notify the MMCP of the services. Continued authorization is between the HCBS provider and the MMCP.
Who writes the Crisis and Safety Plan for the child as part of CFTSS Crisis Intervention?
The Crisis/Safety plan is written by the service provider who is delivering the service. This provider must be a designated entity and meet the necessary qualification as identified in the CFTSS Provider Manual.
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.
Since populations included in the child-carve in for developmental disability population must meet one of the following: developmental disability and medically fragile or developmental disability in foster care and the OPWDD CAH waiver has ended/merged, how will children with just developmental disabilities receive HCBS?
Transitioning children will have access to the Children’s HCBS wavier. If a child/family prefers to utilize services in the OPWDD Comprehensive waiver they would need to meet that eligibility. A comparison of services available with the Children’s HCBS wavier and the OPWDD Comprehensive waiver be found here.
Are YPST and CI interim services in HCBS from April 1, 2019 until YPST and CI are implemented in CFTSS on January 1, 2020?
Yes, between April 1, 2019 and January 1, 2020 YPST and CI services can only be provided to children enrolled in the Children’s HCBS waiver.
January 1, 2020 YPST and CI will be live as part of CFTSS and will be accessible by all Medicaid eligible children that meet medical necessity criteria.
For the time period of 10/1/19-1/1/19, should Medicaid Managed Care Plans (MMCPs) be hard-denying claims for Crisis Intervention (CI) and Youth Peer Support and Training (YPST) (the interim children's HCBS) service for non-waiver children? Are there any scenarios where this would be appropriate?
MMCPs should pend the claim and confirm the waiver status of the child as there may have been a delay in placing the K1 RRE code on the child’s case.
If a Medicaid Managed Care Plan (MMCP) gets a claim from a provider who has been de-designated from children's HCBS, should the plan hard deny, or should they pay and notify the State?
Providers are required to be designated to provide Children’s HCBS. The MMCP can deny the claim if the provider was not designated at the time the service was provided.
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.
Is the Medicaid Managed Care Plan (MMCP) supposed to pay children's HCBS claims that are not submitted properly by the provider, or can they deny these claims?
The remedial Plan of Care (POC) policy includes the significant issues that may be used by the MMCP to determine a children's HCBS claim is invalid and should not be paid. In general, if the claim is valid but cannot be processed for administrative reasons, the plan should pend the claim and work with the provider to correct the claim.
Based upon the four instances listed in state released remedial guidance in which a children's HCBS claim could be denied, can the plan deny claims during the transitional timeframe for non-allowable service combinations?
Medicaid Managed Care Plans may deny for non-allowable service combinations if their claims systems configuration for this process was approved on readiness review. Otherwise, plans should pend the claim and review with the care manager and provider to assure coverage of the most appropriate service for the child.
For Children's HCBS, as part of this transition period from 10/1/19 to 12/31/19, should Medicaid Managed Care Plans reimburse providers whatever is billed on the claim or reimburse the claim in compliance with the State’s posted rates?
Plans should reimburse Children's HCBS providers at the appropriate State rate.
As part of Children's HCBS for E-Mod/V-Mod/Adaptive & Assistive Technology, does the $15,000 limit start as of the 10/1/19 transition to Managed Care?
The service limits apply for the calendar year.
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.
Must all children who are enrolled in Children’s HCBS also enroll in a Medicaid Managed Care Plan (MMCP)?
Children enrolled in the NYS Children’s Waiver (HCBS) who are not otherwise exempt or excluded from Medicaid Managed Care must enroll in an MMCP. The State will not enforce enrollment through auto assignment processes until after 1/1/20.
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.
Can the Medicaid Managed Care Plan deny claims during the children's HCBS transition time period for instances in which the member has exceeded the benefit limit? Would this be permissible if plans denied these types of claims for a medical necessary review?
During the first 90 days, there is to be no utilization review conducted on Children’s HCBS (except for a new request for AT/E-Mods/V-Mods) and transitioning children are provided 180 days continuity of care. The plan should not pend or deny claims for medical necessity review during this period. If it appears the member is exceeding a benefit limit, the MCO should discuss the current HCBS Service Plan with the provider to understand the current goals, and the possibility of other covered services that might benefit the child.
The July 2019 State HCBS billing guidance explains that State designation as a children's HCBS provider is not required for vehicle modification, environmental modification and adaptive and assistive equipment providers. Therefore are these providers and services not applicable to the remedial process?
Consistent with the April 1, 2019, transition, if the FFS authorization process for AT/EMods/ V-Mods has already begun prior to 10/1/19 (meaning the Description and Cost Projection Form has been provided to the LDSS), the process is to be completed through the FFS delivery system.
MCOs are responsible for new requests for these services for eligible enrollees 10/1/19 and forward. New requests for AT/E-Mods/VMods are subject to MCO prior authorization requirements starting 10/1/19, including review for medical necessity of the service.
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.
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.
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.
Are providers allowed to negotiate rates with Medicaid Managed Care Plans (MMCPs) for Children’s HCBS Palliative Care services?
MMCPs are required to pay the government rates for children's HCBS for at least 24 months. By Statute, behavioral health services provided by OMH licensed or OASAS certified agencies are reimbursed at FFS rates through 2023.
How are Medicaid Managed Care Plans (MMCPs) notified of the first appointment date with each Children's HCBS provider?
As outlined in the policy, the first appointment is established with the HCBS provider. The HCBS provider reports the date of the first appointment to the MMCP through the means established between the two entities – can be by phone, secure email, or other.
Should a Plan of Care (POC) be sent to Medicaid Managed Care Plans (MMCPs) for all Health Home enrollees, or just those in receipt of Children’s HCBS?
POCs for children/youth who are enrolled in HCBS need to be sent to the MMCP. POCs for Health Home-only enrollees are typically sent to the MMCP upon the MMCP’s request.
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.
Are Children's HCBS services placed on hold until all necessary approvals are received from the Medicaid Managed Care Plans (MMCPs)? What is the process to handle delays in MMCP approvals?
Services should not be delayed for child/youth in need of and eligible for HCBS. Providers are encouraged to request continued coverage of HCBS at least 14 days in advance of the current authorization’s expiration to avoid delays.
During the first 180 days HCBS services will be covered without MMCP utilization management (clinical review).
An enrollee has the right to request an appeal from the plan regarding a delay in approval, denial or reduction in services. With written consent, the provider may appeal on behalf of the enrollee. The enrollee also has fair hearing rights, once the plan’s appeal process is exhausted. The provider or the enrollee may also file a complaint at any time with the Department of Health at email@example.com
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.
Since a transitioned child (from the previous waiver) keeps their slot until they are discharged, do they still need an HCBS LOC completed in the UAS?
Yes, the federal government requires that the child be assessed annually (at minimum) to confirm they continue to meet the LOC Eligibility requirements to receive HCBS waiver services. This is not a new requirement.
What is the maximum number of individuals that can participate in a CFTSS Family Peer Support Services (FPSS) group session?
The maximum number of individuals that can participate in a group session is 12, regardless of insurance type.
What happens with the children who were transitioned into waiver services (from Care at Home, for example) because they are at risk for a higher level of care but who are using only care management, which used to be a waiver service on its own, and are not using HCBS?
Effective August 2019 via the 1115 Demonstration Waiver, CMS approved Health Home Care Management as a stand-alone service for Family of One Medicaid eligible children determined as HCBS/LOC eligible. The child must be HCBS/LOC eligible with an active LOC determination on file and have obtained a capacity slot. Please see the guidance here.
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.
Does the maximum number of individuals participating in a CFTSS Family Peer Support Services (FPSS) group session include children not actively participating, who happen to be there with their parents?
No, if other children are present due to, for example, lack of babysitting and not actively involved they do not count towards the group number.
Should the agency providing Family Peer Support Services (FPSS) submit one claim per child even if two parents attend the group?
The provider can only submit one claim per child, regardless of, if two parents are in attendance in the group session.
Is a group note required as well as an individual note for each child/youth you bill for in an Family Peer Support Services (FPSS) group session?
There should only be 1 note per client/child per session.
Is Family Peer Support Services (FPSS) technically a collateral service because it works with the parent rather than the child?
The family/caregiver is not a collateral in this instance; others like the school, community members, etc. would be collaterals. Sessions with only collaterals are not allowed for FPSS. Instead, the State encourages FPSS staff to include the family/caregiver in conversations with the school or other collaterals to promote empowerment and skill development.
Family should always be present for the provider to bill for FPSS.
Can a Family Peer Support Service (FPSS) provider bill for collateral visits (e.g. with a teacher, community provider)?
Collateral billing is not allowed for FPSS and not listed as an allowable modality in the CFTSS Provider manual.
Does the maximum number of individuals participating in a CFTSS Family Peer Support Services (FPSS) group session include children participating with parents in a FPSS parenting group?
Yes, it includes all active participants, including children and parents.
What happens with Voluntary Foster Care billing on July 1st 2021?
Voluntary Foster Care Agencies (VFCAs) are required to obtain and maintain Article 29-I licenses to bill for Core Limited Health-Related Services and Other Limited Health Related Services. VFCAs that have not obtained 29-I licensure are not authorized to provide these services. Article 29-I Facilities must bill Medicaid Managed Care Plan (MMCP) for those children enrolled in a MMCP.
Will initial enrollments be retrospective to the first day of the month a child/youth enters foster care? For example, if entry to foster care is 8/10, would the effective month of enrollment be 8/1? How would payment for services rendered by FFS providers between 8/1 and 8/10 be affected?
If a child/youth enters foster care on 8/10, and is not excluded from enrollment, the effective date of the Medicaid Managed Care (MMCP) enrollment is 8/1, as long as the LDSS opened the Medicaid case during the same month. Providers should wait till the enrollment process is completed prior to submitting claims to the MMCP.
Does an Article 29-I Facility need authorization from MMCP to provide Core Limited Health Related Services?
No, Medicaid Managed Care Plan (MMCP) authorization is not required to provide Core Limited Health Related Services.
Do 29-I Facilities follow the same billing rules for CFTSS and children’s HCBS as any other agency or are there differences when these are billed as part of Other Limited Health Related Services?
29-I Facilities must adhere to Children and Family Treatment and Support Services (CFTSS) and children's Home and Community Based Service (HCBS) billing requirements. The appropriate billing manual can be viewed here.
If the plan(s) has a subcontract with Beacon, or another plan for behavioral health, do we, the provider, bill Beacon or the MMCP for Article 29-I Core Services? Other Limited Health Related Services?
Core Limited Health Related Services are always billed directly to the Medicaid Managed Care Plan that you, the provider, are contracted with and not the delegate. For Other Limited Health Related Services, providers need to review their contract and talk with MMCP as this is different across plans.
For Article 29-I Core Limited Health Relates Services, what Diagnosis should I use?
Providers should use an applicable ICD-10 diagnosis. If the youth has more than one diagnosis, the provider only needs to include one on the claim. Providers may only use the ICD-10 code of R69 when the child/youth does not have a diagnosis identified at the time of the claim submission.
Do OPRA requirements apply to Article 29-I Facilities?
Yes. If the individual licensed practitioner is Medicaid enrollable, they must enroll and use their individual NPI number on claims.
If the individual practitioner is unlicensed or not a licensed enrollable Medicaid practitioner the OCFS (05448682) unlicensed practitioner ID may be used.
If a child, covered by a 29-I facility shows up for sick child visit but the doctor is also able to address something unrelated, are 2 bills submitted?
If the office visit covers both issues there would be one claim for the duration of the visit. This would include the additional procedure codes to describe what occurred in the encounter, define the complexity of the visit and support the time that it took. If the child goes into the office visit and there is another BILLABLE encounter that is distinctly different than the reason for the visit and outlined as permissible in the billing manual then there would be two claims.
What are the engagement expectations (e.g. missed appointments)?
Providers should look closely at program specific requirements and contracts with managed care organizations for engagement expectations.
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.
Are Adult Personalized Recovery Oriented Services (PROS) clients, dual eligible clients, etc. designated as Fee-for-Service (FFS) or managed care?
PROS clients are included in, or carved-in to, Medicaid managed care.
Dual eligible clients are now excluded, or carved out, from Medicaid managed care but have an option for managed Medicare. Dual eligible clients who are not in Fully Integrated Dual Advantage (FIDA) programs will remain in FFS. Agencies should not dismantle FFS as clients are still enrolled in it (e.g. non-FIDA dual eligible clients).
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.
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.
How receptive are plans to the negotiation of contracts?
The managed care organization is going to start with its own template agreement for the type of service but contracts are negotiable. For example term and termination are definitely negotiable, assignment can be negotiable. On the other hand compliance with laws is not going to be negotiable. If planning to negotiate a lot of the provisions providers may want to consult with a lawyer. But often plans do not use lawyers in favor of provider contract teams. During negotiation, focus on things that are important from a business perspective. Remember some, like "performance standards," may not be in the main contract; they may be in appendices.
Can providers bill retroactively (i.e., "back bill")?
Plan eligibility is not retroactive. Accordingly, bill Managed Care Organizations (MCOs) fee-for-service (FFS) for 2-3 months. Refer to the guidance found in this presentation.
How will the State measure outcome based performance versus the volume of services provided? Who sets and who measures these goals/outcomes and over what time period?
The State is working on developing social/recovery outcomes to evaluate the quality of services provided.
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.
If managed care organizations are not mandated by NYS to contract with providers, will plans still give other providers contracts?
Plans may offer contracts to providers other than those they are mandated to offer contracts to. Please refer to slide 15 of "Contracting and Credentialing."
Are clinicians mandated to code their own sessions?
Yes, clinicians are mandated to code their own sessions.
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.
Can billing departments or billing systems automate codes based on keywords?
No, billing departments or billing systems cannot automate codes based on keywords.
Is there a way to find out what the Healthcare Effectiveness Data and Information Set (HEDIS) measures are going to be?
HEDIS scores are national quality measures and there are now, through CMS, penalties for not meeting certain HEDIS scores in physical health. Eventually that penalty will affect the behavioral health side as well. Most likely managed care organizations will be interested in behavioral health readmission, 7 and 30 day follow-up, and a medication adherence quality measure.
For more information on HEDIS, please go here. The 2018 HEDIS measures can be found here.
Is there a reason that managed care organizations would not want to contract with a provider?
Managed care organizations may not want to contract with a provider because of geographical coverage, cost, or concerns about quality of care.
Under a value based system, how will authorization work for individuals who struggle with severe mental illness and are doing well but do not demonstrate progress as it is traditionally known?
Symptom reduction may not always be the primary goal. The State will look at functional assessment and how the service that is being provided is creating a functional improvement to the client and their well-being. Managed care organizations will also pay attention, specifically, to how services keep individuals out of the hospital.
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.
Any advice for Adult Home and Community Based Services(HCBS) in terms of contracting with managed care organizations?
There is nothing unique about HCBS from a contracting perspective, but from a quality perspective and an accountability perspective there is a lot of scrutiny over those services. For example, did the member receive what they were supposed to receive (i.e. hours)? Generally it's going to be the same contract template but with some unique features in terms of performance requirements that plans may be focused on. It's important that the providers capture and document the services. The plan also has to ensure that those services are being provided in the home and community based setting.
Are we moving towards a Per-Month-Per-Member (PMPM) environment or a Fee-for-Service (FFS) environment?
We are moving towards a PMPM environment. Managed Care Organizations (MCOs) receive a fixed monthly payment for each member which covers a defined set of services, or benefits. Please refer to slide 16, "How Managed Care is Paid," found here.
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.
How will HARP contracts vary from mainstream managed care contracts?
HARP plans have the same contractual requirements. There is not a separate HARP contract; it is the same as that of a mainstream managed care plan.
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.
What is the definition of medical necessity?
The New York State Department of Health defines medically necessary as: "health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap."
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.
What is the optimal background for the provider point person in the managed care contracting process?
Someone of a high level in the provider organization, who has broad knowledge of the organization and the members that you serve, and who can communicate with high levels within the managed care organization would be optimal.
What can providers expect in terms of potential auditing from the managed care organizations?
This depends on the managed care organization so review your individual contracts. Managed care organizations have the right to audit providers for various reasons. Specifically, reimbursement for services to make sure that there's documentation to support the claims that providers submit as well as for the quality measures that the plans are valuated on. Managed care organizations are entitled to reasonable access to information. Reasonable access presumably means notifying providers in advance, allowing providers to schedule the audit when they do not already have another plan auditing that day, and not interrupting or interfering with provider operations.