Appropriateness Criteria Guidance Notification

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

September 30, 2020

To: NYS Medicaid Health Homes

As part of reforms recommended by the Medicaid Redesign Team II, the NYS Department of Health (Department) is issuing revised guidance to clarify eligibility and appropriateness criteria for enrollment

Health Homes Serving Adults must evaluate enrollment data for each contracted Care Management Agency (CMA) and implement a strategic plan to ensure that adults who are no longer eligible or appropriate for Health Home services be stepped down to a lower intensity care coordination service. The members may include, but are not limited to: members who request disenrollment; members who no longer require the intensive level of Health Home Care Management (HHCM) services; members who have been in pend status due to disengagement from HHCM; and members who can receive care management provided by their Managed Care Plan (MCP), a Managed Long-term Care Plan (MLTCP), Patient-Centered Medical Home (PCMH), or their natural supports. The Department also requires that Health Homes Serving Adults participate in ongoing meetings with MCPs, CMAs and Department liaisons to evaluate and manage member disenrollment.

The Department has issued revised Eligibility guidance that clarifies appropriateness criteria for continued Health Home enrollment. Enrolled Health Home members must be evaluated to determine whether there is a continued need for the intensive level of care management provided by the Health Home Program. If an enrolled member is able to manage their condition(s) well with their current services and family/natural supports, the member could and should be transitioned to a lower level of care management.

Homes and Care Management Agencies should also refer to Policy HH0007 Member Disenrollment From the Health Home Program to ensure appropriate steps are taken to disenroll each member. Attached are step by step instructions for pulling data from the billing support download files, to assist providers in identifying members enrolled under rate code 1873 for potential disenrollment.

Thank you for your ongoing support of our highest risk Medicaid members and for your significant efforts to assure those in need have high quality health home care management. This is especially critical in light of the current pandemic and the difficulty some of our neediest members have with managing their chronic conditions given ongoing issues with service access.

If you have any questions, please contact the Department’s Health Home Bureau Mail Log (BML) at (subject: Policy).

Gregory S. Allen, Director
Division of Program Development & Management
Office of Health Insurance Programs