July 2015 Special Edition Medicaid Update:

The Official Newsletter of the New York State Medicaid Program
  • Update is also available in Portable Document Format (PDF)

July 2015

Volume 31 | Number 7


New York State Behavioral Health Transition to Managed Care


This Special Edition of the Medicaid Update focuses on several programmatic changes that will affect the delivery of Behavioral Healthcare for adult Medicaid members when Behavioral Health services are transitioned to Medicaid Managed Care. The transition of Medicaid Behavioral Health services from a primarily fee-for-service environment to a managed care environment is an initiative of the State´s Medicaid Redesign Team through partnerships with the State Department of Health (DOH), Office of Mental Health (OMH), Office of Alcoholism and Substance Abuse Services (OASAS), the New York City Department of Health and Mental Hygiene (NYC DOHMH), and stakeholders statewide. This initiative is intended to improve clinical and recovery outcomes for individuals with Serious Mental Illness (SMI) and Substance Use Disorders (SUDs); reduce the growth in costs through a reduction in unnecessary emergency and inpatient care; and increase network capacity to deliver community-based recovery-oriented services and supports.

Andrew M. Cuomo
State of New York

Howard A. Zucker, M.D., J.D.
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs

The Medicaid Update is a monthly publication of the New York State Department of Health.


The State has submitted an amendment to its current 1115 waiver demonstration to enable qualified Managed Care Organizations (MCOs) throughout the State to comprehensively meet the needs of individuals with Behavioral Health needs. These needs will be met in the following ways:

Mainstream Medicaid Managed Care (MMC) Plans: All adult recipients with who are eligible for Medicaid Managed Care (excludes Medicare recipients and certain other populations), will receive the full physical and Behavioral Health benefit through managed care. Beginning October 1, 2015, plans will cover expanded behavioral health benefits. Also effective October 1, 2015, consumers enrolled in a MMC plan whose behavioral health benefit was covered under Fee for Service Medicaid through SSI will begin receiving these benefits through the MCO.

Health and Recovery Plans (HARPs) & HIV Special Needs Plans (SNPs): Adults enrolled in Medicaid and 21 years or older with select Serious Mental Illness (SMI) and Substance Use Disorder (SUD) diagnoses1 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 who meet the HARP eligibility criteria who are already enrolled in HIV Special Needs Plans (SNPs) 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 their 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 of care and provide care management for all services within the care plan, including the HCBS.

The State is in the process of designating mainstream MCOs, HARPs, and SNPs to manage the Behavioral Health benefit in New York City. The State will qualify plans in the rest of the state in the fall of 2015 to ensure that plans meet the requirements for the management of Behavioral Health services

Children in Mainstream MCOs: Children´s Behavioral Health services, including all six HCBS waivers currently operated by OMH, DOH and the Office of Children and Family Services (OCFS), will be included in the Medicaid Managed Care benefit package in in 2017.

Mainstream MCOs, HARPs, and HIV SNPs will manage access to the following services:

  • Medicaid State Plan Services:
  • OASAS Medically Supervised Outpatient Withdrawal
  • OASAS Outpatient Clinic
  • OASAS Opioid Treatment Program (OTP)
  • OASAS Outpatient Rehabilitation Programs
  • OASAS Medically Managed Detoxification
  • OASAS Medically Supervised Inpatient Detoxification
  • OASAS Inpatient Rehabilitation
  • OMH Outpatient Clinic
  • OMH Comprehensive Psychiatric Emergency Program (CPEP)
  • OMH Continuing Day Treatment Program (CDTP)
  • OMH Partial Hospitalization
  • OMH Personalized Recovery Oriented Services (PROS) program
  • OMH Assertive Community Treatment (ACT) program
  • OMH Inpatient Psychiatric Services (except for adults living in Institutes for Mental Disease (IMDs)
  • Health Home Care Coordination and Management

For more information on these services, please visit the following websites:

OMH services

OASAS services:
OASAS Home Page
OASAS Regulations

Mainstream MCOs, HARPs and HIV SNPs will also manage access to the following services that will only be available to managed care enrollees under the State´s 1115 Demonstration Waiver:
  • Residential addiction services
  • Outpatient addiction services (clinic to rehab)
  • Crisis intervention services
  • Community Mental Health Services
    • Licensed Behavioral Health Practitioner Services

In addition to the services above, eligible individuals with serious Behavioral Health issues who are enrolled in HARPs and HIV SNPs will have access to the following Home and Community Based Services:

  • Psychosocial Rehabilitation (PSR)
  • Community Psychiatric Support and Treatment (CPST)
  • Habilitation support services
  • Family support and training
  • Short-term crisis respite
  • Intensive crisis respite
  • Education support services
  • Peer support services
  • Non-medical transportation (as a managed care carve-out)
  • Pre-vocational services
  • Transitional employment
  • Intensive supported employment
  • On-going supported employment
  • Supports for self-directed care (will be available at a later time, pending CMS approval)

For more information on HCBS services, please visit: here.

NYC Implementation

July 2015 - First phase of HARP enrollment notices distributed (see below for an explanation of the initial enrollment process)

  • Enrollment notices will be issued to eligible individuals by NY Medicaid Choice in three phases:
    • Approximately 20,000 issued in July/August for October 1, 2015 enrollment
    • Approximately 20,000 issued in August/September for November 1, 2015 enrollment
    • Approximately 20,000 issued in September/October for December 1, 2015 enrollment

October 1, 2015 - Medicaid Managed Care plans HARPs, and SNPs implement expansion of non-HCBS Behavioral Health services for enrolled members

October 2015-January 2016 - HARP enrollment begins to phase in

January 1, 2016 - HCBS become available for the "assessed and eligible" HARP population

Rest of State Implementation

June 30, 2015 - Request for Qualifications (RFQ) distributed (with expedited application for NYC designated Plans)

October 2015 - Conditional designation of plans

October 2015-March 2016 - Plan readiness review process

April 1, 2016 - First phase of HARP enrollment notices issued

July 1, 2016 - Mainstream plans Behavioral Health management and phased HARP enrollment begins

Explanation of Passive Enrollment Process
  1. Individuals initially identified by NYS as HARP eligible, who are already enrolled in an MCO whose parent company operates a HARP, will be passively enrolled in that plan´s affiliated HARP product after a 30 day opt out period.
  2. Individuals identified for passive enrollment will be contacted by the NYS Enrollment Broker, New York Medicaid Choice.
  3. They will be given 30 days to opt out or choose to enroll in another HARP.
  4. Once enrolled in a HARP, members will be given 90 days to choose another HARP or return to a Mainstream Managed Care plan before they are locked into the HARP for 9 additional months (after which they are free to change plans at any time).
  5. Individuals initially identified as HARP eligible who are already enrolled in a Medicaid Managed Care plan without an affiliated HARP will not be passively enrolled. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to assist with the plan selection and enrollment in the plan that is right for them.
  6. HARP eligible individuals in a SNP will be able to receive HCBS through the SNP. They will also be given the opportunity to enroll in a HARP. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to help them decide which Plan is right for them.

January 1, 2017 - NYC and Long Island Children´s Transition to Managed Care

July 1, 2017 - Rest of State Children´s Transition to Managed Care

HARPs and HIV SNPs will contract with Health Homes to complete HCBS assessments, develop a comprehensive, person-centered plan of care, and provide care management to their eligible members who choose to enroll in a Health Home. The Health Home care manager will complete an initial assessment to determine if the individual is eligible for the new array of HCBS. If determined eligible, the Health Home care manager will conduct a full assessment, using the Community Mental Health Suite of the interRAI assessment tool, to help inform a plan of care for HCBS. The plan of care developed by the Health Home care manager will also include any other Behavioral Health or physical health services that the individual needs.

Health Homes will receive training on how to use the Community Mental Health Suite of the interRAI assessment tool; the new HCBS array; and the new HCBS specific plan of care requirements. More information on the Health Home program and training for Health Homes can be found here.

NYS has multiple efforts to assist providers and ensure a successful Behavioral Health transition to managed care. These efforts consist of the following:

  1. Managed Care Technical Assistance Center (MCTAC)
  2. Health Information Technology (HIT) Support
  3. Start-up Assistance for Designated HCBS Providers

To ensure that providers are well-prepared for the Behavioral Health transition, NYS has partnered with the Managed Care Technical Assistance Center (MCTAC). MCTAC is a partnership between the McSilver Institute for Poverty Policy and Research at New York University (NYU) School of Social Work and the National Center on Addiction and Substance Abuse (CASA) at Columbia University, as well as other community and state partners. It provides tools and trainings that assist providers to improve business and clinical practices as they transition to managed care.

MCTAC is receiving ongoing stakeholder input through a workgroup that includes advocates, provider organizations, and state and city partners.

In the fall of 2014 MCTAC traveled across NYS and hosted a kick-off event for providers to learn about the resources available to them through MCTAC. Accompanying MCTAC were DOH, OMH, and OASAS representatives discussing the Behavioral Health transition to managed care; the new services available to individuals with serious mental illness and substance use disorders; and how this transition impacts providers. This kick-off event can be viewed on the MCTAC website.

Currently MCTAC is offering the following trainings for providers:

  • Contracting
  • Business & Clinical Operations Innovation
  • Overview of Home and Community Based Services
  • Evaluating, Measuring, & Communicating
  • Billing, Finance & Revenue Cycle
  • Utilization Management
  • MCTAC is developing dedicated HCBS provider trainings
    • Specific HCBS services (with Centers for Practice Innovations)
    • Business Practices targeted at small providers

Additionally, NYU´s McSilver Institute is also developing technical assistance specific to Child and Adolescent providers´ needs in preparation for Children´s Managed Care implementation.

For additional information about the trainings and technical assistance MCTAC offers please refer to their website.

NYS is developing a process to assist Behavioral Health providers who do not currently have the technological infrastructure to efficiently transition to a managed care system. Funding will be targeted first to agencies with little or no Medicaid or Medicaid Managed Care experience.

NYS will assist HCBS providers with start-up funds. Providers will need to demonstrate a contractual relationship (or letters of intent) with HARPs. Funding will be targeted first to agencies with little or no Medicaid or Medicaid Managed Care experience.

NYS will release notifications of funding availability in July 2015.

NYS is promoting financial stability through the following payment and claiming requirements:


  • Mainstream MCOs, HARPs, and HIV/SNPs are required to reimburse services delivered by OMH licensed or OASAS certified ambulatory providers at the Medicaid fee-for-service rate for the first 24 months from the effective date for implementation of such service into the contracted benefit package.
  • The HARP capitation rate does not include the HCBS package in first year. The providers will bill the Plan and get paid by the Plan. In turn, the Plan will bill the State for each HCBS on a "non-risk" basis.
  • NYS will establish initial HCBS payment rates. Plans will be required to pay these amounts to providers for at least 24 months.
  • The State is implementing a Medical Loss Ratio (MLR), requiring plans to pay a portion of the capitation rate on medical care:
    • HARPs will have an integrated MLR (HARP MLR percentage in NYC is 89%)
    • Mainstream MCOs will have a Behavioral Health expenditure target (under development)


  • Plans must be able to support the Behavioral Health services claim submission process.
  • Plans must meet timely and accurate payment requirements.
  • Plans must support web and paper based claiming.
  • Plans must offer technical assistance to Behavioral Health network providers on billing, coding, data interface, document requirements, and utilization management requirements.

Additional Protections

  • Plans must use the OASAS Level of Care for Alcohol and Drug Treatment Referral (LOCATDR) 3.0 tool when making SUD level of care determinations.
  • No prior authorization will be required for ambulatory services.
  • Plans cannot include "all products" clauses in their contracts with OASAS and OMH providers.

To ensure that members have access to an adequate network of services that includes a choice of qualified providers, Plans must comply with the following network and contracting requirements:

  • Plans must contract with OMH or OASAS licensed or certified providers serving 5 or more members for a minimum of 24 months
  • Plans must contract with all State operated Behavioral Health ambulatory services (including HCBS)
  • Plans must include in their network:
    • All Opioid Treatment programs in their region to ensure regional access and patient choice where possible
    • Health Homes
  • Plans must allow members to have a choice of each Behavioral Health specialty service and must meet State-defined network requirements
  • Plans must provide sufficient capacity for their populations
  • Plans must contract with crisis service providers for 24/7 coverage
  • Plans contracting with clinics with "integrated licenses" must contract for full range of services available
  • HARPs must have an adequate network of Home and Community Based Services

LOCADTR was developed by the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and is the patient placement criteria system required for use in making SUD level of care decisions. The LOCADTR tool will be used for making prior authorization and continuing care decisions for all SUD services. LOCADTR is designed to assure that a client in need of substance use disorder services is placed in the least restrictive, but most clinically appropriate level of care available. The LOCADTR is to be used in making all level of care decisions (prior authorization and continuing care decisions) in New York State. For additional LOCADTR information please go here.

With the transition of Behavioral Health services into managed care, enhancements related to Behavioral Health will be added to the quality assurance monitoring currently being done for mainstream MCOs. HARPs will have a quality assurance program that is separate and distinct from the mainstream MCO quality assurance program.  It must meet all requirements and conditions of the 1115 Partnership Plan relating to HCBS quality assurance performance measure reporting. HARP reporting will include standardized measures i.e., Quality Assurance Reporting Requirements (QARR), and new recovery outcome measures in areas such as employment, housing, criminal justice status, and functional status. These social outcome measures will be derived using data obtained from HCBS eligibility evaluations and annual re-evaluations as well as from consumer self-report surveys.

The External Quality Review Organization (EQRO) will continue to work with the qualified mainstream plans to oversee and validate Performance Improvement Projects (PIPs). OASAS, OMH, and DOH Plan oversight staff will together determine guidelines for plans and the EQRO regarding PIPs that either focus on a Behavioral Health topic or incorporate an enhanced focus on individuals with Behavioral Health conditions. For example, following integration of specialty Behavioral Health benefits, the mainstream plans may be asked to develop and implement a quality project to increase screening and treatment of Behavioral Health conditions in primary care settings. HARPs will implement a separate PIP focused on topics affecting the Behavioral Health population. Additionally, plans will regularly participate in NYS sponsored focused clinical studies on select topics or initiatives affecting people with Behavioral Health. The HARP will conduct a NYS mandated clinical quality study annually on select topics or initiatives affecting people with Behavioral Health.

OMH and OASAS will work with DOH to enhance existing oversight processes for the provision of Behavioral Health benefits in mainstream managed care plans and HARPs. OMH and OASAS have each modified their internal structures by creating distinct entities for managed care. These new organizational structures will allow the agencies to provide better oversight by centralizing functions related to managed care. Oversight activities include readiness reviews, complaint monitoring, and network adequacy monitoring.

In March 2015, NYS released a billing manual that describes how to bill HCBS and State Plan services. The purpose of this document is to enable providers to submit accurate claims to Plans and to enable Plans to pay accurate fee-for-service rates for Behavioral Health services.

The billing manual includes a coding taxonomy document (Excel file) which provides the required coding construct for billing the government rates services. All OMH licensed and OASAS certified providers must submit claims to Managed Care Plans using the coding contained herein.

NYS also released the HCBS fee schedule and HCBS rate codes. The HCBS fee schedule shows the required coding combinations to bill the Managed Care Plan for the provision of these services, including applicable procedure and modifier codes. The HCBS rates are subject to approval by the Centers for Medicare and Medicaid Services and the NYS Division of Budget. Only HCBS designated providers are eligible to be reimbursed for these services. The billing manual can be found here.

HCBS provider designation confirms that an agency has attested that it will provide HCBS consistent with the criteria articulated in the manual. An agency will only be designated to provide the HCBS that have been applied for and approved by the State. HCBS provider designation does not guarantee that an agency will receive referrals for these services, nor does it commit an agency to provide the service(s) that they are designated to provide.

The designation process for New York City HCBS providers is complete. To view the complete list of HCBS providers and the services they were designated to provide, click here.

The HCBS application process will begin in July 2015 for the rest of the state and be completed in October of 2015. A list of HCBS providers designated for the rest of state will be posted on the NYS OMH website.

In order to become an HCBS provider, an agency must fill out an application located on the NYS OMH website

Questions regarding HCBS applications may be sent to: omh.sm.co.HCBS-Application@omh.ny.gov

In accordance with the timeline referenced in this Special Edition, MCOs will begin covering injectable second generation long acting antipsychotics; e.g., risperidone microspheres (Risperdal® Consta®) and paliperidone palmitate (Invega® Sustenna®), for their SSI and SSI related enrollees. These medications are currently carved out of the Medicaid managed care benefit and covered under the fee-for-service benefit. Additionally, in accordance with the timeline, MCO´s will begin covering naltrexone extended release suspension (Vivitrol®).

Information regarding plan coverage will be made available in the near future through the Medicaid Managed Care Pharmacy Benefit Information Center. This site already provides plan contact information, a "drug look-up" function, and functionality to view coverage for selected therapeutic classes; e.g., 2nd Generation Antipsychotics and Central Nervous Stimulants.

The Children´s MRT Health and Behavioral Health Subcommittee, in conjunction with DOH, OMH, OASAS, and the OCFS, has guided the development of a design to transform the children´s service system for youth birth to 21 years of age. The design focuses on early identification and intervention, expansion of State Plan services and increasing the availability of HCBS to more children and their families.

The intent of the expanded State Plan services is to intervene early in a child or youths trajectory in order to prevent long term health and Behavioral Health problems. By increasing the availability of HCBS to youth who meet level of need as well as level of care criteria we will increase access to support services for children and youth who have experienced trauma; are in the foster care system and have serious emotional disturbance, developmental disabilities or are medically fragile; are diagnosed with serious emotional disturbance, with substance use disorders and/or require significant medical or technological health supports.

First, specific children´s fee-for-service Medicaid State Plan services will transition into the Medicaid Managed Care delivery system in 2017. Services that will be carved into managed care include: per diem payment for the health and Behavioral Health needs of children in foster care, OMH Day Treatment, OMH Residential Treatment Facilities, and OMH Community Residences for Children. From the OASAS system, medically supervised outpatient withdrawal, OASAS outpatient clinic, OASAS opioid treatment program (OTP) ,OASAS outpatient rehabilitation programs, OASAS Residential Rehabilitation Services for Youth programs, OASAS medically managed detoxification, OASAS medically supervised inpatient detoxification, and Demonstration Only Services (services available only through Medicaid Managed Care): Residential addiction services and Outpatient addiction services (clinic to rehab) will also transition.

In order to meet the overall goals of the design, new Medicaid State Plan services are being proposed for all children eligible for Medicaid. These new services include: Crisis Intervention, Community Psychiatric Supports and Treatment, Other Licensed Practitioner, Psychosocial Rehabilitation Services, Family Peer Support Services, and Youth Peer Advocacy and Training. All of the services are expected to be delivered where children and families live, work and go to school by a variety of licensed or unlicensed practitioners and peers. The services will also provide reimbursement methodology for the delivery of approved Evidence Based Practices. These services will be implemented as soon as possible, pending CMS approval. Initially, the services will be available on a fee-for- service basis but in 2017 will transition into Medicaid Managed Care.

The care coordination service imbedded within the six children´s 1915c HCBS Waivers (OMH Serious Emotional Disturbance, DOH Care at Home I/II and OCFS Bridges to Health) will transition to Health Home Serving Children in 2017.

Additionally, NYS will align the existing HCBS that are in the six 1915c children´s Waivers, pending CMS approval, and will transition the service array to Managed Care. As a result, the 1915c Waivers will be discontinued as separate programs once the transition is complete.

The aligned array of HCBS benefits for all target populations will include:

  • Care Coordination (for those ineligible for Health Home or who opt out)
  • Habilitative Skill Building
  • Family and Caregiver Supports and Services
  • Prevocational Services
  • Supported Employment Services
  • Community Advocacy and Support
  • Non-Medical Transportation
  • Day Habilitation
  • Adaptive and Assistive Equipment
  • Accessibility Modifications
  • Palliative Care
  • Respite Services (Crisis & Planned)

In order to identify and assess the Health and Behavioral Health needs of children and adolescents, NYS has endorsed the use of the Child and Adolescent Needs and Strengths (CANS) New York Assessment tool for the children´s design. The CANS-NY is a multi-purpose tool that will support decision making, including level of care/level of need and service planning, facilitate quality improvement initiatives, and allow for the monitoring of outcomes of services. The CANS has been used in New York for twenty years, predominantly with OMH programs and, more recently, the OCFS Bridges to Health Waiver.

New York has created two CANS-NY tools, targeted at the 0-5 and 6-21 age groups. Each tool is supported by two algorithms that will:

  • determine acuity for Health Home Care management and rate assignment;
  • provide information that may help determine if children meet the Health Home eligibility functional criteria for Serious Emotional Disturbance (SED) and Trauma; and
  • determine the need for aligned HCBS within Managed Care.

For eligibility for HCBS benefits, a CANS-NY will be completed to determine if a child meets criteria for:

  • Level of Care - criteria met and determined by assessment that would indicate a child is eligible for or at risk of medical institutional placement in licensed by NYS OMH, Intermediate Care Facility for the Mentally Retarded (ICF/MR), or skilled nursing facility/Hospital. This is the existing criteria for the six current children´s 1915c Waivers.
  • Level of Need - criteria met and determined by an assessment that would indicate a child has needs that cannot be met only by non-medical institutional State Plan Services, but who does not qualify for Level of Care.

The same array of HCBS will be available to both groups of children, but at varying levels of intensity, frequency, and duration.

The Children´s design includes a proposal to evaluate Level of Need and Level of Care eligibility to establish disability and need for HCBS benefits, then follow with determination of Medicaid eligibility without regard to parental income. This maintains availability and expansion of the HCBS benefits to children whose families do not meet traditional Medicaid eligibility limits.

For more information on the children´s managed care design, please register to receive updates from the Children´s Managed Care Listserv here.

Key dates for the Children´s Medicaid Managed Care Transition are:

January 1, 2017 - NYC and Long Island Children´s Transition to Managed Care

July 1, 2017 - Rest of State Children´s Transition to Managed Care

January 1, 2018 - Phase in Children who have Medicaid and meet Level of Need Criteria for HCBS Benefits

July 1, 2018 - Phase in Children who meet Level of Need Criteria for HCBS Benefits and can be determined eligible for Medicaid as a "Family of one", without regard to parental income.

Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit here

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website

Providers wishing to listen to the current week´s check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week´s amount).

Do you have questions about billing and performing MEVS transactions?
Please call the eMedNY Call Center at (800) 343-9000.

Provider Training:
To sign up for a provider seminar in your area, please enroll online here. For individual training requests, call (800) 343-9000 or e-mail: emednyproviderrelations@csc.com.

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites:
Prescriber Education Program
New York State Medicaid Prescriber Education Program

Need to change your address? Does your enrollment file need to be updated because you´ve experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit here and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.).

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance

Comments and Suggestions Regarding This Publication?
Please contact the editor, Amy Siegfried, at medicaidupdate@health.ny.gov


1. HARP eligibility criteria has been determined by the State. HARP eligibles cannot be dual enrolled (receiving both Medicare and Medicaid) or participating in a program with the Office for People With Development Disabilities (OPWDD) 1