Restriction Exception (R/E) Code Compatibility with the Health Home Program

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GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES
RE CODE RE CODE DESCRIPTION COMPATIBLE WITH ADULT HEALTH HOME SERVICES POLICY NOTES
02 RRP Podiatry YES
(See notes)		 Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care Manager should work with the recipient and contact their Managed Care Plan, if applicable, to ensure compliance with any restrictions.
These are codes to restrict recipient to specific podiatric providers.
03 RRP Dental YES
(See notes)
These are codes to restrict recipient to specific dental providers.
04 RRP Durable Medical Equipment YES
(See notes)
These are codes to restrict recipient to specific durable medical equipment providers.
05 RRP Pharmacy YES
(See notes)
These are codes to restrict recipient to specific pharmacy providers.
06 RRP Physician YES
(See notes)
These are codes to restrict recipient to specific physicians.
08 RRP Clinic YES
(See notes)
These are codes to restrict recipient to specific clinics.
09 RRP In-Patient Hospital YES
(See notes)
These are codes to restrict recipient to specific hospitals for inpatient services.
10 RRP Dental Clinic YES
(See notes)
These are codes to restrict recipient to specific dental clinics.
11 RRP Physician Group YES
(See notes)
These are codes to restrict recipient to specific physician groups.
12 RRP Physician Assistant/Nurse Practitioner YES
(See notes)
These are codes to restrict recipient to specific PA/NP providers.
13 RRP Alternative Pharmacy YES
(See notes)
These are codes to restrict recipient to specific alternative pharmacy providers.
20 Enrollee in Special Needs MC Plan (HIV SNP) YES
(See notes)		 Like mainstream plans, recipients can be members of HIV SNP and enrolled in a Health Home program.
This code is used to identify enrollees in Special Needs Plans.
21 Enrollee in Special Needs MC Plan (HIV SNP) YES
(See notes)
This code is used to identify enrollees in Special Needs Plans.
23 OMH Children´s Waiver NO
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides individual care management services. Care managers should work with individuals to determine which service best meets their needs.
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
25 OPWDD - Sub-Chapter A Exception NO  
This code is for individuals receiving OPWDD for a limited period of time with no local shares.
30 LTHHCP - Long Term Home Health Care Program (Lombardi Waiver) NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Code used for individuals authorized for long term care services who are eligible for nursing home level of care and are residing in the community. Services provided through a certified LTHHCP provider.
35 Case Management Program; Medicaid Service Coordination/Case Management Program (Medicaid OMH, COBRA, AI TCM, OPWDD) YES
(See notes)		 Children receiving OMH TCM services are being transitioned and adults receiving HIV COBRA and OMH TCM care management have transitioned into Health Homes. Individuals receiving OPWDD and EI TCM services will transition to Health Home enrollment at a later date. First Time Mothers/Newborns will not transition.
Comprehensive case management program.
38 Utilization Threshold Exempt NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Recipient is a resident of an ICF-DD Facility.
39 Aid Continuing YES
(See notes)		 The care managers must work within the individuals established UT. Limitations on services may apply.
Recipient is subject to Utilization Threshold (UT) and exempt from copay.
44 vHCBS at Home Non-Intensive Residential Habilitation NO
(See notes)		 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Recipient is in a HCBS Non-Intensive AHRH to better serve consumers in their own homes and reduce demand for more costly residential placement.
45 HCBS at Home Intensive Residential Habilitation NO
(See notes)		 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Recipient is in a HCBS IBS to better serve consumers in their own homes and reduce demand for more costly residential placement.
46 OPWDD Home & Community Based Services Waiver - HCB (Pure Waiver) NO
(See notes)
Identifies a recipient in home & community based services waiver program (HCBS).
47 OPWDD HCBS Community Habilitation Phase 2 NO
(See notes)		 At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish to receive care management through a Health Home they must dis-enroll from the waiver. Health Home care managers and OPWDD Medicaid Service Coordinator (MSC) managers should work with individuals to determine whether the waiver or Health Homes can best meet their needs.
Identifies a recipient in home & community based services waiver supervised CR or supervised IRA.
48 OPWDD HCBS Supportive IRAs and CRs NO
(See notes)
Identifies a recipient in home & community based services waiver supportive IRA & CR.
49 OPWDD HCBS Supervised IRA NO
(See notes)
Identifies a recipient in home & community based services waiver supervised IRA & CR.
55 MCC Pharmacy YES Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
An HR recipient enrolled in the MCCP and receiving pharmacy services from the primary pharmacy.
56 MCC Physician YES Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
An HR recipient enrolled in the MCCP and assigned to a primary physician or a preferred provider. Non-emergent transportation must be ordered by a primary provider only. Ancillary services (pharmacy, DME & lab) must be ordered by primary or referred provider.
58 MCC Clinic YES
(See notes)		 Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
An HR recipient enrolled in the MCCP and assigned to a primary clinic where s/he must receive care or be referred for care. Ancillary services (pharmacy, DME & lab) must be ordered by primary only.
59 MCC Hospital YES
(See notes)		 Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care manager should work with the recipient and contact their Managed Care Plan to ensure compliance with any restrictions.
A recipient enrolled in the MCCP and assigned to a primary inpatient provider where s/he must receive care.
60 Nursing Home Transition and Diversion Waiver NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Recipient enrolled in Nursing Home Transition & Nursing Home Diversion waiver
62 Care at Home (CAH) I (Administered by DOH) NO
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) NO
(See notes)
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
64 Care at Home (CAH) III (OPWDD NO
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) NO
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
67 Care at Home (CAH) VI (OPWDD) NO
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) NO
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled NO
(See notes)
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) NO
(See notes)
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
75 LTC D/D Asset Protection YES  
Recipients are those who receive resource exemptions in the amount of LTC insurance benefit dollars paid to date. The amount determines the amount of resources disregarded in the Medicaid Budget Logic (MBL) budget.
76 LTC Total Asset Protection YES  
Recipients are those who have complete disregard of resources in Medicaid Budget Logic (MBL).
77 LTC Insurance-Non-Partnership YES  
Recipients have LTC insurance but not through the Partnership for LTC.
81 Traumatic Brain Injury (TBI) NO
(See notes)		 Individuals receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
HCBS/TBI waiver services include: service coordination, independent living skills training and development (ILST), structured day program services, substance abuse program services, positive behavioral interventions and support services (PBIS), community integration counseling (CIC), home and community support services (HCSS), environmental modifications (emods), respite services, assistive technology (AT), waiver transportation, and community transitional services (CTS).
82 Non-MMIS ID RRP Provider YES
(See notes)		 Individuals can be in a Restricted Recipient Program (RRP) and enrolled in Health Home, but the Care Managers should work with the individual and contact their Managed Care Plan to ensure compliance with any restrictions.
This code returns an eligible message "Restricted recipient contact MC plan for provider information"
83 Alcohol & Substance Abuse (ASA) YES
(See notes)		 The care manager should coordinate services within existing Fee-For-Services and Managed Care Plan eligibility requirements.
Recipient has been mandated to receive ASA services FFS in some instances. The recipient may also be in PCP where the plan is responsible for payment of some services.
84 OMH Base/Community Rehab & Support (CRS) with Clinical Treatment YES  
Recipient is enrolled in an outpatient rehab program for mentally ill adults (OMH). Recipients are exempt from UT.
85 OMH Base/Community Rehab & Support (CRS) without Clinical Treatmentv YES  
Recipient is enrolled in an outpatient rehab program for mentally ill adults (OMH). Recipients are exempt from UT.
86 OMH Intensive Rehab & Ongoing Rehab Services (IR/OR) YES  
Recipient is enrolled in an outpatient rehab program for mentally ill adults (OMH). Recipients are exempt from UT.
89 Money Follows the Person YES  
 
90 Managed Care Excluded YES  
Recipient is excluded from mandated managed care auto assignment of a plan
91 Managed Care Exempt YES  
Recipient is exempt from managed care enrollment
92 DOH/ Managed Care Exempt YES  
Recipient is exempt from managed care enrollment
93 Managed LTC YES
(See notes)		 Individuals can be in both a Health Home and a MLTC plan. The Health Home and MLTC plan must have an administrative services agreement outlining their respective responsibilities.
Recipients are marked who are required to enroll in a managed LTC program
94 OMH Exempt YES  
Recipient exempt from managed care enrollment
95 OPWDD Waivered Services Look-Alikes YES
(See notes)		 Care Managers must check with OPWDD to ensure an individual is not receiving Care Management from OPWDD before they can be outreached or enrolled in the Health Home Program. The following steps MUST be taken to ensure there is not duplication of services:
  • Step 1 - Enter Member´s Name, Date of Birth, and CIN number in an excel file.
  • Step 2 - Encrypt with password the excel file.
  • Step 3 - Send excel file with subject line "RRE Code 95 Check" to OPWDD´s BML at: fida-idd@opwdd.ny.gov
  • Step 4 - Send the password to the same BML with the same subject line.
Recipient exempt from managed care enrollment
96 Seriously & Persistently Mentally Ill Adults (SPMI) & Seriously Emotionally Disturbed Children (SED) YES
(See notes)		 Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver, but cannot be in both as each provides care management services. Care managers should work with individuals to determine which service best meets their needs.
Recipient exempt from managed care enrollment
A1 Health Home Program - Care Management Agency YES Tentative date of release is March 2017.
Member is assigned, in outreach, or enrolled with a Care Management Agency
A2 Health Home Program - Health Home YES Tentative date of release is March 2017.
Member is assigned, in outreach, or enrolled with a Health Home
AL Assisted Living NO  
System generated based on claims for assisted living.
B7 Non EP BHP Aliessa YES  
 
C1 Copay Exempt (Hospice) YES  
 
CO Community First Choice Option NO  
 
CF Community First Choice Option OPWDD NO  
 
G1 Transgender Male to Female YES  
 
G2 Transgender Female to Male YES  
 
H1 HARP Enrolled without HCBS Eligibility YES  
 
H2 HARP Enrolled with Tier 1 HCBS Eligibility YES  
 
H3 HARP Enrolled with Tier 2 HCBS Eligibility YES  
 
H4 HIV SNP HARP Eligible without HCBS Eligibility YES  
 
H5 HIV SNP HARP Eligible with Tier 1 HCBS Eligibility YES  
 
H6 HIV SNP HARP Eligible with Tier 2 HCBS Eligibility YES  
 
H7 Opted out of HARP YES  
 
H8 State-Identified for HARP Assessment YES  
 
H9 HARP Eligible- Pending Enrollment YES  
 
I1 OPWDD MC Class 1 NO  
 
I2 OPWDD MC Class 2 NO  
 
I3 OPWDD MC Class 3 NO  
 
I4 OPWDD MC Willowbrook NO  
 
M1 MAGI Remains in WMS YES  
 
N1 Regular SNF Rate - MC Enrollee NO  
 
N2 SNF AIDS - MC Enrollee NO  
 
N3 SNF Neuro-Behavioral - MC Enrollee NO  
 
N4 SNF Traumatic Brain Injury - MC Enrollee NO  
 
N5 SNF Ventilator Dependent - MC Enrollee NO  
 
N6 Partial Cap 21+ Nursing Home Certifiable NO  
 
N7 NH Budgeting Approved NO  
 
N8 Transfer Penalty Period DHPCO NO  
 
N9 NH Resident Pending NH Eligibility Determination NO  
 
NH Nursing Home NO  
System generated based on claims for nursing home.
S1 Surplus Client Not Eligible for Medicaid MC or Medicaid Advantage (NYC ONLY) YES
(See Note)		 Care manager should work with the individual to maintain their Medicaid eligibility.
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
95 OPWDD Waivered Services Look-Alikes The Health Home Compatibility Changed from No to Yes with stipulations. Please see above.
Recipient exempt from managed care enrollment
A1 Health Home Program - Care Management Agency Added
Member is assigned, in outreach, or enrolled with a Care Management Agency
A2 Health Home Program - Health Home Added
Member is assigned, in outreach, or enrolled with a Health Home
AL Assisted Living Added
System generated based on claims for assisted living.
B7 Non EP BHP Aliessa Added
 
C1 Copay Exempt (Hospice) Added
 
G1 Transgender Male to Female Added
 
G2 Transgender Female to Male Added
 
TR Transgender Individual Deleted as more specific codes were added. Please see G1 and G2.
 
Updated 1/25/2017
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
23 OMH Children´s Waiver Changed policy notes to delete " (once Health Homes have been designated to serve children)"
This code is used to identify recipients in the OMH Home & Community Based Services (HCBS) waiver for seriously emotionally disturbed (SED) children.
35 Case Management Program; Medicaid Service Coordination/Case Management Program Changed policy notes to account for adults completion of transition and children transitioning into Health Homes.
Comprehensive case management program.
62 Care at Home (CAH) I (Administered by DOH) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH I program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
63 Care at Home (CAH) II (Administered by DOH) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH II program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
64 Care at Home (CAH) III (OPWDD) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH III program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
65 Care at Home (CAH) IV (OPWDD) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
67 Care at Home (CAH) VI (OPWDD) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
The Medicaid-waiver CAH IV program provides community-based services to physically disabled children who require hospital or skilled nursing home level of care, and allows the child to be at home instead of in an institutional setting.
72 Bridges to Health (B2H) Seriously Emotionally Disturbed (SED) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
73 Bridges to Health (B2H) Developmentally Disabled Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
74 Bridges to Health (B2H) Medically Fragile (MedF) Changed policy notes to delete " (once Health Homes have been designated to serve children)"
Bridges to Health (B2H) Waiver services are tailored to meet the child´s specific, presenting health care needs, and are not available through other programs these children attend.
92 DOH/ Managed Care Exempt Added
Recipient is exempt from managed care enrollment
CO Community First Choice Option Added
 
CF Community First Choice Option OPWDD Added
 
I1 OPWDD MC Class 1 Added
 
I2 OPWDD MC Class 2 Added
 
I3 OPWDD MC Class 3 Added
 
I4 OPWDD MC Willowbrook Added
 
M1 MAGI Remains in WMS Added
 
N8 Transfer Penalty Period DHPCO Added
 
N9 NH Resident Pending NH Eligibility Determination Added
 
Updated 2/21/2017
CHANGE LOG
CODE CODE DESCRIPTION WHAT CHANGED
95 OPWDD Waivered Services Look-Alikes DELETED: To find a Developmental Disability Regional Office copy and paste the following link in your web browser: https://opwdd.ny.gov/sites/default/files/documents/OPWDD-DDRO-Eligibilty-Coordinators.pdf ADDED: new instructions for inquiries.
Recipient exempt from managed care enrollment
Updated 5/9/17