Guidance for Use of the Continued Eligibility for Services (CES) Tool

  • Document is also available in Portable Document Format (PDF)

Background:

Health Home Care Management is a voluntary program that should be provided to members only for as long as they continue to want the service and continue to need the service.

There are several obvious ways that a CMA will know someone is appropriate for disenrollment. For example:

  • Member asks to close their case
  • Member disengages from care and cannot be found despite Diligent Search
  • Member is in or is expected to be in an excluded setting for more than six months
  • Member dies
  • Member is no longer eligible for Medicaid
  • Member moves out of state and/or service area
  • Etc.

This guidance is meant to address situations where the member may be appropriate for disenrollment, but it is not obvious and may appear (at a surface level) that the member is participating in and benefiting from the program.

These cases can be identified with periodic screening for Continued Eligibility.

Definitions:

Continued Eligibility for Services Tool - The NYS DOH- approved Health Homes screening tool. It prompts the user to answer the minimum number of questions required to determine whether the member should continue in the Health Home program or be disenrolled. Completion of the tool generates a recommendation of “Recommend Continued Services”, “Recommend Disenrollment” or “More Information Needed”.

Voluntary Disenrollment: Member knowingly and voluntarily leaves the program.

Involuntarily Disenrollment: Member either does not know about or does not agree with the CMA’s decision to disenroll the member. The Notice of Determination for Disenrollment in the New York State Health Home Program form (DOH-5235) is used to provide fair hearing rights.

Graduation: A member no longer needs any care management support. They may still use other supports like family, friends, Home Attendants, etc.

Step-Down: A member needs a lower-level intensity of care management support (MCO/MLTC Telephonic Case Manager, Housing Case Manager, Patient Centered Medical Home Case Manager, etc.)

Step-Up: A member needs a higher-level intensity of care management support (AOT Case Management, Health Home Plus Case Management, ACT Case Management, Institutional Setting)

Guidance:

The CES Tool is completed for members enrolled in Health Homes Serving Adults (HHSA) ONLY. CMAs must use the CES Tool at least annually and every 6 months thereafter (Month 12, then Month 18, then Month 24…) on all enrolled (non-pended) HHSA members to identify members who no longer want or need the Health Home level of service and take appropriate steps to disenroll such members.

For members who are Health Home Plus (HH+) (SMI and HIV), HH+ Eligible, or Adult Home Plus (AH+) at the time a CES Tool is due, the CES Tool should NOT be completed.

The CMA will endeavor for disenrollments prompted by a CES Review to be Voluntary, but there are certain circumstances where they may be Involuntary.

The use of a CES Tool does not replace the requirement to disenroll members organically as reasons to disenroll present themselves. The CES Tool is not required to be completed prior to all disenrollments, nor should it be. Members do not need to meet the criteria of the CES Tool before graduating. Rather, the tool is to be used at defined timeframes to help identify additional members who are appropriate to graduate, step down, or step up from HHCM management services.

The CES Tool process does not change any requirements in the Disenrollment Policy. It is an additional check point.

Although the tool may recommend “disenrollment”, there are many types of disenrollment. The CMA indicates whether the case was ultimately disenrolled as a graduation, step down, step up, etc. within the chart and in the segment end reason code.

Procedure:

  1. The CMA will complete a CES Tool for enrolled (not pended) adult members that are neither eligible nor enrolled in HH+ or AH+ on the following schedule:
    • At the time of the annual Comprehensive Re-assessment (possibly replacing or built into the Re- assessment). Ideally the CES Tool is done in conjunction with the annual Comprehensive Re- Assessment, but there may be some circumstances where the Re-assessment cannot be done, but the CES Tool can.  Ex. Member is out of the country.
    • Per DOH Assessment Policy, Health Home Eligibility is a required part of the Comprehensive Assessment, therefore the result of the most recent CES Review should be documented in the annual re-assessment. DOH Disenrollment Policy also requires that “evaluation for continued enrollment be supported by thorough documentation in the member’s record, assessments, evaluations, and plan of care updates”.
  2. The CMA may choose to complete a CES Tool for a member off-cycle at any time. This could be prompted by a request from the NYS DOH, the member’s MCO, or other reasons. The Health Home cannot require a more frequent time frame.
  3. The CES Tool can be completed by the Case Manager, Supervisor, or a Quality Assurance staff (QA). It is recommended that it is done by QA staff or supervisors so that it is based solely on the documentation in the chart, and there is no conflict of interest or bias.
    • 3.1 If completed by a Care Manager/Care Coordinator, supervisory review is required. The CMA Supervisor must document the outcome of this review in the member’s record.
  4. Member and Care Team involvement is intentionally not required to complete the CES Tool. The CES Tool should be completed based upon a chart review, provided that all documentation is present in the member’s record. If answers are unclear, yielding a result of “More Information Needed”, the tool must be completed a 2nd time within the following 60 calendar days, during which time the member and/or care team member(s), a supervisor and the Health Home should be consulted about those specific questions. If the tool recommends Disenrollment, the member and Care Team would become involved to discuss and plan for an appropriate disenrollment.
  5. The CES Tool examines whether the member has Risk Factors (Needs HHCM) and is fully Engaged in the Health Home level of service (Wants HHCM).
  6. The CES Tool outcome identifies a member as being in one of three possible categories, as follows
    • Recommend Continued Health Home Services
    • Recommend Disenrollment (with appropriate Transition Planning)
    • More Information Needed
      • Used if there is not enough information in the record to answer a question.
  7. If the recommendation is to Continue Health Home Services, services should continue for the member. All usual processes for assessment, care planning, and ongoing service should be followed.
    • 7.1 The risk factor(s) that contributed to the recommendation on the CES Tool should be incorporated into the Health Home Plan of Care if they are not there already. The tool’s determination may be shared with the member in the course of ongoing Plan of Care development
  8. If the recommendation is to Disenroll, the Care Manager follows the following steps:
    • 8.1 Review the outcome of the CES Tool and the reason disenrollment is recommended with the member and Care Team members as appropriate.
    • 8.2 Determine what type of disenrollment makes sense for the member. The most common disenrollment following a CES Review would be graduation, step down, or withdrawal of consent.
    • 8.3 Identify the most appropriate program for the member.
    • 8.4 Identify whether the member agrees with the disenrollment recommendation (Voluntary) or does not agree (Involuntary).
      • It is recommended that a Transition Goal be added to the Health Home Plan of Care to be worked on over time. This may be appropriate in cases where complex referrals are needed, or where it would be appropriate to use Motivational Interviewing to help the member feel confident and ready for disenrollment.
      • It is also possible that in cases where the disenrollment recommendation was prompted by a lack of engagement, and the member does not agree with the recommendation, the possibility of disenrollment motivates them to begin fully engaging with the Care Manager and their Plan of Care.
    • 8.5 Proceed to disenrollment, following all normal disenrollment processes, including appropriate letters, forms, referrals, and notification to Care Team members.
      • If the member is not in agreement, a DOH-5235 form would be used along with the disenrollment letter.
    • 8.6 The case should be closed within 60 calendar days from the recommendation to disenroll.
    • 8.7 A Disenrollment recommendation on the CES Tool could be the result of poor documentation in the chart, the member not understanding the program, a poor fit with the Care Manager or Care Management Agency, not having all the information about the member, etc.
      • A supervisor’s best judgment may supersede the recommendation on the tool. For example, a supervisor may recommend that the Care Manager add missing documentation to the chart, explore certain areas further with the member, transfer the case to a different Care Manager, etc. to determine the best course of action.
      • In some cases, while working on a disenrollment plan, a new risk factor could present itself that would support remaining in Health Home. Ex. You find out about a previously unknown Intimate Partner Violence event.
      • In this case the reason for not following the recommendation should be documented, and CES Tool should be redone within 60 calendar days, and the recommendation of the second completion must be implemented
      • Failure to complete a follow-up CES Tool within 60 calendar days resulting in a determination of either Recommend Continued Enrollment may lead to suspension of billing for services to the member.
  9. If the recommendation is More Information Needed, the Care Manager will:
    • Review the recommendation with the member
    • Engage in a prompt and concerted effort to collect information to determine more definitively whether a member is still appropriate for Health Home Enrollment or whether the member should be Disenrolled.
    • Case Conferences and consultation with other providers is recommended when any of the questions are answered as “Unclear”. Therefore, the purpose of the Case Conference is to determine the answers to those questions. Sources such as PSYCKES may also be used to obtain information.
    • Following the Case Conference the CMA should complete another CES Tool to generate a recommendation.
    • This process should take no longer than 60 calendar days.
    • Failure to complete a follow-up CES Tool within calendar 60 days resulting in a determination of either Recommend Continued Enrollment or Recommend Disenrollment may lead to suspension of billing for services to the member.
  10. Copies of any CES Tools completed for the member must be available in the case record, either built into the Electronic Health Record, or uploaded as separate documents.
  11. Health Homes are required to provide quality oversight, training, and guidance to their CMAs related to the CES Tool. This could include data analysis as to any outliers within their networks, percentage of cases where a CES Tool Recommendation was not followed, etc.

Attachments:

Additional information related to the CES Tool can be found on the Health Home Policy and Updates webpage

References:

Eligibility Requirements: Identifying Potential Members for Health Home Services and Continued Eligibility in the Health Home Program policy HH0016

Member Disenrollment From the Health Home Program Policy #HH0007 (PDF)

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1. In NYC, Voluntary Foster Care Agencies (VFCA)) that contract with ACS will make referrals on behalf of ACS 1