Eligibility Requirements for Health Home Services and Continued Eligibility in the Health Home Program

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Policy Title: Eligibility Requirements for Health Home Services and Continued Eligibility in the Health Home Program

Policy number: HH0016*
Effective date: April 23, 2014
Last revised: March 3, 2017; August 31, 2018; November 30, 2018; February 2019; April 2019; September 2020; March 2022; October 31, 2023; January 2024

Approved by:

*This number, HH0016, was issued for this policy at the time of revision and implementation on October 31, 2023.

Purpose

This policy outlines the steps that must be taken to ensure every individual, adult and child/youth, meets the required eligibility criteria needed to support Health Home enrollment and continued enrollment in the Health Home program. Part I of this policy provides the steps that must be taken to identify and confirm eligibility for HH enrollment (adults and children/youth). Part II of this policy provides steps that must be taken to identify and confirm eligibility for continued HH enrollment.

This policy supersedes previous policy outlined in the Health Home Eligibility Policy - Updated March 2022 (PDF) and the supplemental document, Eligibility Requirements: Identifying Potential Members for Health Home Services Appropriateness Criteria (HHSA Only) - September 2020 (PDF) and HHSC Eligibility, Appropriateness, Prioritization and 6 Core Services - (PDF) - March 2022

Background

Individuals may be referred to Health Homes (HH) from a number of entities including Medicaid Managed Care Organizations (MCO), physicians and other healthcare and behavioral health providers, emergency departments, schools, community-based providers, criminal justice, supportive housing providers, shelters, family members, self- referrals, and others. Regardless of referral source, the eligibility of the individual and their interest in Health Homes enrollment must be verified.

For Children (ages 0-21 years old) who may be eligible for Health Home services, the State has developed the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) Referral Portal. The Portal requires the referral source to, “Indicate the chronic conditions which, in your best-informed judgement, you believe make the child you are referring eligible for Health Home.” Currently, MCOs, Health Homes, Care Management Agencies, Local Government Units (LGU), Single Point of Access (SPOAs) and Local Department of Social Services (LDSS) and the Administration for Children's Services (ACS)¹ have access to the MAPP HHTS Referral Portal. Other entities that want to make a referral who do not have access to the MAPP HHTS can contact one of these entities or reach out directly to a lead Health Home (Find A Health Home By County (ny.gov)).

NOTE: In the event a member is deemed no longer eligible for continued Health Home Services, Health Homes and Care Management Agencies should refer to the Member Disenrollment From the Health Home Program Policy-HH0007 to ensure appropriate steps are taken to transition members for disenrollment from the Health Home Program.

Policy

Part I: Determining Eligibility for Enrollment into the Health Home Program

Determining eligibility for the Health Home Program has three steps: Step One: Verify Medicaid enrollment and compatibility; Step Two: Verify Qualifying Conditions; and, Step Three: Confirm appropriateness for enrollment. If any of these requirements are not met, the individual may not be enrolled in the Health Home Program. Health Home Care Managers must document each of these eligibility requirements in the member's record.

Step One: Medicaid

Medicaid reimbursement for Health Home services can only be provided for individuals with active Medicaid, whose Medicaid coverage type is compatible with Health Home services, and who do not have any disqualifying Restriction/Exception codes - refer to the Guide To Coverage Codes and Health Home Services and, the Guide To Restriction Exception (RE) Codes and Health Home Services). The Health Home Care Manager (HHCM) must verify Medicaid eligibility at the time of enrollment. A member's Medicaid eligibility may change frequently therefore, the care manager must continue to verify Medicaid eligibility prior to service provision (either directly or through an automated process embedded within the Health Home's Electronic Health Record (EHR)). The HHCM must work with eligible members to assist them in enrolling or renewing their Medicaid benefits as required to continue Health Home enrollment. Medicaid coverage may be granted retroactively.

Step Two: Qualifying Conditions

To be eligible for Health Home services, an individual must have either two chronic conditions (see Appendix A - Health Home Chronic Conditions List) or one single qualifying condition, as follows:

• HIV/AIDS, or
• Serious Mental Illness (SMI) (Adults), or
• Sickle Cell Disease (both Adults and Children), or
• Serious Emotional Disturbance (SED) (Children), or
• Complex Trauma (Children).

Having one chronic condition (other than the single qualifying conditions above) and being at risk of developing another condition does not qualify an individual as Health Home eligible in New York State.

Verification of qualifying conditions is required for enrollment or, if the member's qualifying conditions change any time thereafter. Certain conditions, which are determined based on functioning within the last 12 months such as SED, require annual documentation. Verification of the individual's qualifying condition(s) must be documented in the record. Documentation may be accepted from any one of these sources: MCOs, referrals, medical records or medical assessments, written verification by the individual's treating healthcare provider, the Regional Health Information Organization (RHIO), or the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES).

Qualifying chronic conditions are any of those included in the “Major” categories of the 3MTM Clinical Risk Groups (CRGs) described as follows:

Major Category: Alcohol and Substance Use Disorder

• Alcohol and Liver Disease
• Chronic Alcohol Abuse
• Cocaine Abuse
• Drug Abuse - Cannabis/NOS/NEC
• Substance Abuse
• Opioid Abuse
• Other Significant Drug Abuse

Major Category: Mental Health

• Bi-Polar Disorder
• Conduct, Impulse Control, and Other Disruptive Behavior Disorders
• Dementing Disease
• Depressive and Other Psychoses
• Eating Disorder

Major Personality Disorders

• Psychiatric Disease (Except Schizophrenia)
• Schizophrenia

Major Category: Cardiovascular Disease

• Advanced Coronary Artery Disease
• Cerebrovascular Disease
• Congestive Heart Failure
• Hypertension
• Peripheral Vascular Disease

Major Category: Developmental Disability

• Intellectual Disability
• Cerebral Palsy
• Epilepsy
• Neurological Impairment
• Familial Dysautonomia
• Prader-Willi Syndrome
• Autism

For more information related to Developmental Disability, please see Health Home Program Chronic Condition Update with Developmental Disabilities Conditions

Major Category: Metabolic Disease

• Chronic Renal Failure
• Diabetes

Major Category: Respiratory Disease

• Asthma
• Chronic Obstructive Pulmonary Disease Major Category: Other

Major Category: Other

Step Three: Initial Appropriateness

Determining Initial Appropriateness is the final and key step in the process to determine that an individual meets eligibility for Health Home Program enrollment. It is a two-step process that must be completed for both adults and children/youth. The first part is related to activities that must be completed to confirm Initial Appropriateness (and annual appropriateness for children); the second part is related to the requirement for reporting Appropriateness.

Confirming Initial Appropriateness

Many Medicaid enrollees have Health Home qualifying conditions but simply meeting Medicaid eligibility and qualifying conditions does not make someone eligible for Health Home enrollment. For example, an individual can have two chronic conditions and be managing their own care, health and social care needs effectively thereby not requiring Health Home care management assistance. To qualify for enrollment (and ongoing care management services) in the Health Home program, an individual must be assessed and found to have significant behavioral, medical, physical, or social risk factors that require the intensive level of Care Management services provided by the Health Home program.

Selection of risk factors must be well documented in the member's record and must be related to a requirement for comprehensive care management in order for the member to be effectively served. (It should be noted that even if existing enrolled HH members are triggering some of these historical risk factors, if they are currently managing their condition well with existing services and natural supports they can and should be transitioned to lower levels of care management and disenrolled from the Health Home program).

Requirement for Reporting Initial Appropriateness

Once Initial Appropriateness has been confirmed, enrollment can proceed and HH consent signed (refer to the Access to/Sharing of Personal Health Information (PHI) and the Use ofHealth Home Consents policy #HH0009). Initial Appropriateness must be recorded in the MAPP HHTS which allows access to HHs, CMAs and the Department to review, analyze and confirm Initial Appropriateness. Effective December 1, 2023, Health Homes (adults and children/youth) must ensure that within thirty days of signed consent, Initial Appropriateness is recorded in the Electronic Health Record (EHR) and, in turn uploaded into the MAPP HHTS via the Consent and Member Program Status Upload file. This process requires the selection of one of the Significant Risk Factors in the Initial Appropriateness Criteria chart (refer to Appendix B) that reflects the significant risk that makes the individual eligible for HH enrollment. If a member meets multiple appropriateness criteria, then when choosing the single criterion for reporting purposes, consideration should be given to the reason that initially supports activities that the HHCM will work on that is also important to the member.

NOTE: Recording of Initial Appropriateness applies only to segments with a begin date on or after December 1, 2023. For active members enrolled prior to December 1, 2023, a system upload of Initial Appropriateness will not be required.

After initial enrollment, any time a new enrollment segment is opened for a member, appropriateness must be recorded in the Health Home's EHR and uploaded into MAPP HHTS via the Consent and Member Program Status Upload file. This includes the new segments opened following Diligent Search Efforts (DSE) or Excluded Setting but does not include transfers of enrolled segments via MAPP.

Requirement for Reporting Annual Appropriateness (Children)

On an annual basis, at the annual review of the Plan of Care, the Health Home Serving Children (HHSC) care managers must verify continued eligibility within the HHSC program through annual documentation of continuing appropriateness. This documentation will not be entered in the MAPP HHTS but is required to be entered in the members case file During the annual verification of appropriateness, the HHCM can select a different significant risk factor for appropriateness that differs from the initial or previous annual appropriateness chosen.

Supporting documentation to validate the chosen appropriateness criteria must be included within the member's case file.

Health Home Billing

Generally, it is the care management agency that determines eligibility for Health Home services. Information may be obtained from the member's health care providers and MCO to support the eligibility determination as such entities often have more detailed information on a member's diagnosis and care utilization. Health Homes, MCOs, and CMAs must have policies and procedures in place for determining and documenting Health Home eligibility.

The Department has built systems into the MAPP HHTS to help HHs ensure that claims do not go through for members who are not eligible for services. The Medicaid biller - the Health Home - remains ultimately responsible for ensuring that only those individuals who are eligible for Health Home services are enrolled into the Health Home program.

Beginning 2/1/2024, if the requirement to upload the Initial Appropriateness via the Consent and Member Program Status Upload file within 30 days of signed consent is not met, the MAPP HHTS will prevent any billing from occurring.

Appropriateness and Eligibility for Continued Health Home Enrollment

CMA/HHCMs, HHs and MCOs must routinely review their enrolled Members, adults and children, to determine whether they remain appropriate and eligible for continued Health Home Program enrollment. Can the member manage their condition(s) using existing services and family/natural supports without evidence of risk that supported their HH enrollment? Can the member be graduated or transitioned to a lower level of care management e.g., provided through their MCO, a Person-Centered Medical Home (PCMH), or Managed Long Term Care (MLTC)? Do they need a more intensive level of care management e.g., HARP, HH+, AOT, or beyond HHCM services? Can they be disenrolled from the HH program entirely? (refer to the Member Disenrollment From the Health Home Program HH0007 policy.

For Health Homes Serving Adults (ONLY)

As part of standard, routine Health Home care management activities, members must be evaluated to identify those eligible for disenrollment, which may occur at any time during a member's enrollment. Even while conducting routine activities, HHCMs may not always be able to assess member eligibility and appropriateness for continued enrollment. Therefore, it is necessary that periodic standardized screenings are conducted by all CMAs through completion of the Continued Eligibility Screening (CES) Tool.

The CES Tool evaluates members based upon active Medicaid (eligible and compatible with HH services), qualifying diagnosis, significant risk factors, other risk factors, and member engagement in HH care management.

The use of the CES Tool was implemented for HHSA effective November 1, 2023, as follows:

• New Members enrolled on/after 11/1/23:
  • Complete CES Tool 12 months post-enrollment and every 6 months thereafter
• Existing Members
  • Complete CES Tool at time the member's next Comprehensive Re-assessment is due, and every 6 months thereafter

NOTE: For members who are Health Home Plus (HH+), HH+ Eligible, or Adult Home Plus (AH+) the CES Tool should NOT be completed. When a member is stepped down from HH+ or AH+, the CES Tool would be due 12 months following the date of step down, regardless of when their re-assessment is due.

The CES Tool must be completed by the CMA Supervisor or Quality Improvement staff, or if completed by the HHCM, the CMA Supervisor must review and confirm the final outcome. Completion of the CES Tool must be documented in the member's record.

Additionally, if there are any concerns related to the completion of the CES Tool, the CMA Supervisor has the discretion to complete a new CES Tool for submission into the MAPP HHTS. This new CES Tool must be completed within the same time period allotted for the first CES Tool. Completion of a second CES Tool must also be documented in the member's record.

Important: Multiple CES Tool submissions cannot be used to extend the due date in order to avoid loss of billing. A periodic query should be run to flag members with multiple CES Tools completed to identify whether this may have occurred.

The date of completion and outcome is recorded in the Electronic Health Record (EHR) and, in turn uploaded into the MAPP HHTS via the Consent and Member Program Status Upload file. MAPP HHTS generates the due date for the next CES Tool based on the completion date and outcome. This is shared with Health Homes via the Consent and Member Program Status Download file. The outcomes are as follows:

• Recommend Continued Services - complete CES Tool at next required timeframe - 6 months
• Recommend Disenrollment- require that disenrollment be completed within 60 calendar days
• More Information Needed -requires further evaluation to include the member and other providers for a conclusive outcome. Another CES Tool must be completed within 60 calendars days (a second ‘More Information Needed' result is not acceptable)

Logic built into the CES Tool results in one of the above outcomes based on responses selected during completion of the tool. HHSAs must ensure that the resulting outcome is followed. If the outcome of the CES Tool recommends Disenrollment from the HH program, HHs and CMA/HHCMs must refer to and follow disenrollment procedures within the Member Disenrollment From the Health Home Program policy HH0007.

HHSAs must ensure that policies and procedures are in place that follow guidance and instructions provided in the Continued Eligibility Screening (CES) Tool Guidance document to include: the timeline for completing the CES Tool, completing the CES Tool, and recording outcomes in the MAPP HHTS.

Training Requirements

HHSA, HHSC and CMA staff must receive training on protocols related to eligibility for enrollment and continued enrollment in the Health Home Program including, but not limited to:

• Initial eligibility requirements and continued eligibility
• Initial and annual eligibility for children, staff responsible for appropriateness assessments
• Appropriateness criteria - selection and timeline requirements
• Reporting Initial Appropriateness and uploading into MAPP HHTS

For HHSAs and CMA staff Only

• Documentation requirements For HHSAs and CMA staff Only
• Completing CES Tool, staff responsible, and timeline requirements
• Reporting CES Tool outcomes and uploading into MAPP HHTS
• Documentation requirements

Quality Assurance

Through its Quality Management Program (QMP), HHs must monitor and evaluate patterns related to member eligibility for enrollment and continued enrollment within its own network and establish quality monitoring activities to evaluate practices and address issues identified.

HHs must work with their network CMAs to assure a method is in place for reviewing activities surrounding enrollment, continued enrollment and disenrollment of members no longer eligible for HH services.

Policies and Resources

Health Home Program Chronic Condition Update with Developmental Disabilities Conditions

Continued Eligibility Screening (CES) Tool (PDF)

Continued Eligibility Screening (CES) Tool Guidance

Member Disenrollment From the Health Home Program policy - HH0007

Access to/Sharing of Personal Health Information (PHI) and the Use of Health Home Consents policy #HH0009

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APPENDIX A - Health Home Chronic Conditions List

APPENDIX B – Categories of Significant Risk Factors

9/23/14 updated 3/2/17, 8/31/18, 11/30/18, 2/2019, 4/2019, 9/2020, 3/2022, 10/2023, 1/2024