UPDATED Announcement

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

Health Home Serving Children Home and Community Based Services (HCBS) Children's Waiver Eligibility Determination Assessment Fee Guidelines

May 31, 2024, Updated August 27, 2024

TO: Health Homes Serving Children (HHSC), Care Management Agencies, Medicaid Managed Care Plans including Mainstream and HIV Special Needs Plans

UPDATE: The purpose of this guidance is to clarify when the Assessment Fee can be claimed. This guidance replaces the previous guidance "Overdue HCBS Level of Care Eligibility Determination" issued in January 2024. HHSCs are no longer restricted from submitting monthly Health Home care management claims for members with overdue Eligibility Determinations or expired K codes. The Assessment Fee cannot be claimed for members whose annual Eligibility Redetermination is not completed timely. Other updates are highlighted in yellow.

New York State Department of Health ("Department") has received State Plan approval from the Centers for Medicare and Medicaid Services (CMS) to pay an Assessment Fee for the initial and annual Children's Waiver Home and Community Based Services (HCBS) eligibility determinations conducted by Health Home Serving Children care managers. This includes approval of retroactive payments for assessments conducted during the Public Health Emergency on or after April 1, 2021.

BILLING:

The HCBS Assessment Fee is a payment of $200 for conducting an initial or annual reassessment. It is not paid for a "Significant Life Event" assessment. The HCBS Eligibility Determination must be conducted annually within 365 days of completion of the previous assessment. The Assessment Fee can only be paid one-time per year per member, regardless of how many HCBS Eligibility Determinations are conducted for the member within the year. The Assessment Fee is billable regardless of the member being determined HCBS eligible or ineligible.

The HCBS Assessment Fee will be added to Medicaid Managed Care Plan (MMCP) capitation rates effective October 1, 2024. MMCPs have 90 days from this announcement to configure their systems to pay the HCBS Assessment Fee. For any assessments completed on or before September 30, 2024, the HCBS Assessment Fee is carved out and must be billed to Medicaid Fee-For-Service (FFS) via eMedNY.

Rate Code	Rate Code Description	Procedure Code	Modifier
1875	Home and Community Based Services Assessment Fee	G0506	U1
1868	Health Home-CANS Assessment (Children)	G0506

The HCBS Eligibility Determination is active for 365 days from the assessment date. Health Homes and C-YES (when available) must use the MAPP transfer process for individuals who transfer to a new care management agency or Health Home. A new HCBS Eligibility Determination is not needed when a member transfers from one care management agency to another or to or from C-YES within the eligibility period.

Assessments that are completed for HCBS re-enrollment within 60 days after the end of a previous eligibility period are considered past due assessments and the Assessment Fee cannot be paid. However, in extenuating circumstances, if the member is disenrolled from the Children's Waiver because they no longer meet eligibility criteria and the child's condition worsens after disenrollment, as outlined in supporting documentation, necessitating re-enrollment at any time, the assessment would be considered an initial HCBS Eligibility Determination, and the Assessment Fee can be paid, even if this occurs within 60 days of the end of the previous eligibility period.

Reassessments for continued enrollment completed on or after January 1, 2024, that are not completed within the 365 days of the previous assessment, are not billable.¹ Health Homes are responsible for ensuring that the Assessment Fee is only billed for timely HCBS assessments.

Please refer to the Eligibility and Enrollment Policy for additional guidance on timely completion of HCBS Assessments.

PROCESS:

After completion of release to the MAPP Health Home Tracking System (HHTS) (anticipated on September 7, 2024), once an initial or annual HCBS Eligibility Determination assessment has been completed and signed in the Uniform Assessment System (UAS), the information will be passed to MAPP HHTS. The Medicaid information in the UAS must match the information in MAPP HHTS for the data to be transferred. A “billing instance” for the assessment fee will be available and the Health Home can submit a claim for the completed HCBS assessment. Prior to the MAPP HHTS update, the Department will provide a list of assessments that are eligible for the Assessment Fee to each Health Home.

Phase 1: The Department will send the lead Health Homes a list of unique children that had an initial or an annual reassessment HCBS Eligibility Determination completed between April 1, 2021, and December 31, 2023. The Health Home will confirm this is an accurate list of members for whom an eligible assessment was completed and bill eMedNY for the Assessment Fee for those assessments.

Phase 2: In September 2024, the Department will send the lead Health Homes another list of annual assessments that were completed timely during the period January 1, 2024, through the end of August 2024. The Health Home will confirm this is an accurate list of members for whom an eligible assessment was completed and bill eMedNY for the Assessment Fee for those assessments.

Phase 3: After the MAPP HHTS release, billing instances will be available for the Assessment Fee. Health Homes will be able to complete a billing instance for the Assessment Fee then follow currently established billing policy for assessment completed on or after the MAPP HHTS release.

Due to the delay in the release of the MAPP HHTS, the Health Homes may utilize the delay reason code for these claims. Additional billing instructions will be provided to the Health Homes with the list of members and during each phase.

Please direct questions to healthhomes@health.ny.gov.

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^{1. HCBS Eligibility Determination Assessment Fee will be paid regardless of timeliness for assessments completed prior to December 31, 2023 1}