Transfer Process between the Children and Youth Evaluation Services (C-YES) and Health Home Serving Children (HHSC)

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

Policy Title: Transfer Process betweenthe Children and Youth Evaluation Services (C-YES) and Health Home Serving Children (HHSC)
Policy number: CW0007
Effective date: February 1, 2021; updated July 15, 2025
Last revised: July 15, 2025

Applicability

This policy pertains to C-YES and HHSC, including Care Management Agencies (CMAs), that provide care management to children and youth who are or will be enrolled in the 1915(c) Children's Waiver for Home and Community Based Services (HCBS).

Purpose

The purpose of this policy is to establish a transfer process for C-YES to refer children/youth who are eligible and enrolled in the Children's Waiver and choose to receive comprehensive Health Home (HH) care management. The policy also establishes procedures for conducting a transfer from HHSC to C-YES for children/youth who opt-out of HH care management but choose to continue receiving HCBS through enrollment in the Children's Waiver.

Background

Effective April 1, 2019, the 1915(c) Children's Waiver became operational across New York State. This waiver allows children/youth to access an aligned array of HCBS to address their needs, goals, and preferences as detailed in their person-centered Plan of Care (POC).

All 1915 (c) Children's Waiver participants must receive care management services as part of waiverservices. Children's Waiver Medicaid participants are eligible for HHSC. If the child/family elects to receive care management from a HHSC, the Health Home Care Manager (HHCM) determines a child/youth's eligibility for HCBS waiver participation by conducting the annual HCBS Eligibility Determination1. If the child/youth is found HCBS eligible, the HHCM conducts person-centered care planning to develop a comprehensive Plan of Care (POC) and ensures the POC supports the child/youth's functional development within the community.

Contents

Applicability
Purpose
Background
C-YES Steps to HCBS and Medicaid Eligibility:
Transfer Process
C-YES to HHSC/CMA
    HHSC/CMA to C-YES
Additional Resources

Eligibility and Documentation

For children/youth who at the time of requesting HCBS do not have Medicaid or who opt out of HH, the State's Independent Entity (IE), C-YES, conducts the annual HCBS Eligibility Determination to determine a child/youth's eligibility for HCBS waiver participation and develops a person-centered POC for HCBS only. C-YES provides care coordination and maintains the POC for HCBS eligible waiver children/youth . C-YES coordinates at least quarterly contacts with the MMCP (if applicable), the HCBS provider, and the participant/family regarding the child/youth's HCBS POC.

Once enrolled in Medicaid, children/youth have a choice to transfer to HH care management or stay with C-YES for HCBS only care coordination. C-YES is responsible for providing education to children/youth/families about Health Home during the Medicaid/HCBS enrollment process. By the time HCBS/Medicaid eligibility is established, the child/youth/family should have determined whether they'd like to opt-in or opt-out of Health Home.

If a child/youth/family indicates they would like to transfer to HH comprehensive care management, after being initially enrolled in the Children's Waiver by C-YES, C-YES will not be responsible for developing a POC or generating HCBS referrals for the participant. C-YES will focus on the immediate transfer and warm hand-off of the child/youth to the participant's choice of HH/CMA. The transfer to the HH/CMA must include the complete HCBS eligibility supporting documentation, to ensure proper HCBS eligibility determination, inclusive of proper consent from those who supplied the supporting eligibility documentation.

If during initial enrollment into the Children's Waiver with C-YES, a child/youth/family opts-out of HH, C-YES will be responsible for developing a Plan of Care and managing HCBS referrals for the participant. If a child/youth/family initially opts-out of HH but later opts-in to HH, C-YES would be expected to provide all available documentation with the most recent HCBS eligibility supporting documentation, to ensure proper HCBS eligibility determination, inclusive of proper consent f rom those who supplied the supporting eligibility documentation at the time of transfer to HH, including applicable POCs and HCBS referrals. The transfer process within the MAPP HHTS must also be followed.

Additional information about Children's Waiver Eligibility and Enrollment can be found in the Children's HCBS Waiver Eligibility and Enrollment Policy.

C-YES Steps to HCBS and Medicaid Eligibility:

C-YES serves children/youth 1) who are enrolled in Medicaid and opt-out of Health Home2 comprehensive care management or 2) who are not already enrolled in Medicaid and identified by a referral source (i.e. parent/doctor/school/service provider) as potentially needing HCBS.

  1. In either circumstance, C-YES will educate the child/youth/family about HH care management, C-YES care coordination, and HCBS eligibility requirements and process, and services. For children/youth already enrolled in Medicaid, the child/youth/family may choose if they would like to proceed with the HCBS eligibility process with C-YES or be connected to a HH to be enrolled so the HH care manager can conduct the HCBS eligibility determination.
  2. C-YES will provide education and resources on other available supports related to the child/youth's needs (i.e. Children and Family Treatment and Support Services, etc.), as appropriate during the C-YES referral process. C-YES will also complete an appropriate screening with the child/youth/family to determine appropriateness for HCBS prior to pursuing HCBS/Medicaid eligibility.
  3. C-YES will work with the child/youth/family to complete the HCBS Eligibility Determination and, if determined HCBS eligible and the child/youth/family wants to proceed, then C- YES will assist the family with the process of applying for Medicaid.
  4. During the HCBS/Medicaid enrollment process, C-YES will continue to educate the child/youth/family about HH care management, C-YES, and HCBS eligibility and services, so the child/youth/family may make an informed choice regarding if HH or C-YES will provide care management once eligibility is established.
  5. C-YES will make an appropriate referral to a Lead HHSC/CMA as chosen by the child/youth/family. If the child/youth/family does not want to be referred to a HHSC/CMA, then C-YES will provide HCBS only care coordination.
  6. For a child/youth/family who has opted-out of HH, the child/youth/family can reverse their initial decision at any time, and the child/youth/family may request areferral to HH. C-YES must educate the child/youth/family about the availability of this option3.

Transfer Process

C-YES to HHSC/CMA

Transfer Types from C-YES to HH/CMA:

  1. Transfer from C-YES to HH/CMA and the child/youth already has Medicaid–
    • C-YES educates the child/youth/family about HCBS, C-YES, and HH, as well as State Plan Services, to determine how best to meet the child/youth/family needs. At any time, the child/youth/family can determine that they want to transfer to HH care management services. C-YES staff will complete the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” to indicate to the HH/care management agency where in the process / service the child/youth/family are, so the HH/CMA is aware.
    • C-YES must send all relevant information as outlined in the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” within seven (7) business days from learning of the child/youth/family's choice. Additionally, obtaining the participant's signature on the C-YES “Opt-in to Health Home form” constitutes the participant/family agreement to be transferred and enrollment in the Health Home program.
    • NOTE: C-YES and the Health Home consent forms provide language which allows for the transfer any Personal Health Information (PHI) between C-YES and Health Home without additional signatures or forms
    Please note: If the child/youth/family was referred to C-YES and determines they want to transfer to HH/CMA prior tothe HCBS eligibility determination being completed or other information being obtained, then C-YES would only need to complete the “Opt-in to Health Home form” and not the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” as they would not have enough information to complete this form, nor could the HH/CMA immediately enroll the child/youth in the HH program. The HH/CMA should consider this as a new member referral. *C-YES may take verbal consent to refer the consumer to HH in this type of scenario and make the referral within seven (7) business days from learning of the child/youth/family's choice.
  2. Transfer from C-YES to HH/CMA and the child/youth does not already have Medicaid -

    C-YES will follow their process as outlined above. Once C-YES has secured Medicaid enrollment for the child/youth who is eligible for HCBS and if the child/youth/family chooses HH, then C-YES will complete the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” and “Opt-in to Health Home form”. The “Transfer Form for C-YES, Health Homes, and Care Management Agencies” must be completed in full, including required supporting documentation as outlined, inclusive of the most recent HCBS eligibility supporting documentation, to ensure proper HCBS eligibility determination, and proper consent f rom those who supplied the supporting eligibility documentation. If the child/youth/family opts-in to HH immediately during the initial HCBS/Medicaid enrollment process, C-YES will not be providing a POC or HCBS provider referrals during the transfer to HH to allow for a focus on a quick and smooth transition to the HH program. The transfer should be initiated within seven (7) business days from learning of the child/youth/family's choice.

Transfer Steps:
It is imperative that all information necessary for the HH/CMA to serve the child/youth/family is given at the time of transfer with the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” via secure email or secure file transfer in the Health Commerce System (HCS).

  1. Review and Acceptance Period: The lead HH/CMA will receive, review, and respond to the referral in no more than three (3) business days with the details of the identified CMA/CM that will be assigned to the case.
  2. Communication between C-YES and HH/CMA: There must be communication between C-YES and the HH/CMA to discuss the case, ensure all the documents have been exchanged, and discuss setting adate and time for a warm hand off call with the child/youth/family
    1. Should the HH/CMA not have the information, or the support needed for HCBS Eligibility, the HH/CMA must communicate this to C-YES and to the Department.
  3. Warm Hand off call: C-YES must schedule a three-way warm hand off call with the HH/CMA and the family to introduce the new entity/care manager and explain the next steps to the family. Only in limited circumstances should the warm hand-off not occur. The participant/family must be told that this is a required part of the transfer process to ensure a smooth transition to the HH program and that their needs are identified, and for the HH/CMA to identify the next steps that will occur with the family and the timeline to do such. Documentation of the warm hand off transfer call must be completed by both C-YES and the receiving HH/CMA.
  4. Date of Transfer: C-YES and HH/CMA will officially determine the date on which the HH/CMAwill assume the case. This period of time of transfer acceptance should be no longer than three (3) weeks fromthe time of Review and Acceptance Period (letter “a” above) determination for the transfer. The transfer must be completed within MAPP HHTS.
    1. HH/CMA can enroll the child/youth based upon the HCBSeligibility and the HH signed Opted-in form as consent by the child/youth/family agreement to be enrolled or through verbal consent during the warm hand-off meeting.
    2. HHCMs who are accepting a transfer from C-YES, must complete the steps above prior to the transfer occurring in MAPP HHTS. HH/HHCMAs will then accept the transfer within MAPP that will create a new active enrollment segment so the Restriction Exception (R/RE) A-codes are on the members file and C-YES can close their case.

HHSC/CMA to C-YES

Transfer Types from HH/CMA to C-YES:

  1. Transfer from HH/CMA to C-YES and the child/youth does not have Medicaid -
    • HH/CMA educates the child/youth/family about HCBS, C-YES, and HH and other community resources. The child/youth/family can determine that they want to transfer to C- YES to receive an HCBS Eligibility Determination and assistance with obtaining Medicaid. The HH/CMA links the child/youth/family and/or referring provider to the C-YES referral form and contact information. More information can be found in the C-YES Referral Form Instructions.
      • ❖ The HH/CMA can request or have the child/youth/family request, if they choose, to be referredback to the HH/CMA if the child/youth is found HCBSeligible and obtains Medicaid eligibility.
      • ➣ This DOES NOT apply for children/youth served by the HHCM who lose their Medicaid. The HHCM is responsible for assisting children/youth in this situation re-enroll in Medicaid, as appropriate.
  2. Transfer from HH/CMA to C-YES for the purpose of receiving HCBS and the child/youth does have Medicaid –
    • Children/youth who are not enrolled in HH or who are HH enrolled with active Medicaid may want to transfer to C-YES to receive an HCBS Eligibility Determination and care coordination of HCBS. The HH/CMA will educate the child/youth/family about HCBS, C-YES, and HH, as well as State Plan Services, to determine how best to meet the child/youth/family needs. The HH/CMA will complete the C-YES referral form with contact information for the child/youth/family not already enrolled in HH. More information can be found in the C-YES Referral Form Instructions.
    • If already enrolled with HH/CMA but not yet determined HCBS eligible, the HHCM must conduct the HCBS Eligibility due to already working with the family, having knowledge of their story and service providers, to then be able to transfer to C-YES utilizing the process below.
  3. Transfer from HH/CMA to C-YES for children/youth currently receiving HCBS and HH care management -
    • At any time, the child/youth/family can determine that they want to opt-out of HH care management services and be transferred to C-YES. It is necessary to ensure the child/youth/family are properly educated about the difference of C- YES and HH to ensure that the child/youth/family obtain the appropriate level of care coordination and are not passed back and forth between HH and C-YES, as a delay or loss of services could occur.
    • The HH/CMA will complete the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” to indicate to C-YES where in the process / service the child/youth/family are, so that C-YES is aware. The HH/CMA is not required to obtain additional consent to transfer any PHI and relevant information. Consent to share this information is captured in the Health Home 5201 consent form. The “Transfer Form for C-YES, Health Homes, and Care Management Agencies” must be completed in full, including the required supporting documentation as outlined, inclusive of the most recent HCBS eligibility supporting documentation, to ensure proper HCBS eligibility determination, and proper consent from those who supplied the supporting eligibility documentation.

Transfer Steps:
It is imperative that all information necessary for C-YES to serve the child/youth/family is given at the time of transfer with the “Transfer Form for C-YES, Health Homes, and Care Management Agencies” via secure email or secure file transfer in HCS.

  1. Review and Acceptance Period: C-YES will receive, review, and respond to the referral no more than three (3) business days with the details of the identified Family Support Coordinator (FSC) that will be assigned to the case.
  2. Communication between HH/CMA and C-YES: There must be communication between the HH/CMA and C-YES to discuss the case, ensure all the documents have been exchanged, and discuss setting adate and time for a warm hand off call with the child/youth/family
    1. Should C-YES not have the information or the support needed for HCBS Eligibility, C-YES must communicate this to the HH/CMA and to the Department.
  3. Warm Hand off call: HH/CMA must schedule athree-way warm hand off call with the C-YES and the family to introduce the new entity/care manager and explain the next steps to the family. Only in limited circumstances should the warm hand-off not occur. The participant/family must be told that this is a required part of the transfer process to ensure a smooth transition to the C-YES and that their needs are identified, and for C-YES to identify the next steps that will occur with the family and the timeline to do such. Documentation of the warm hand off transfer call must be completed by both HH/CMA and C-YES.
  4. Date of Transfer: C-YES and HH/CMA will officially determine the date on which the C-YES will assume the case. This period of time of transfer acceptance should be no longer than three (3) weeks fromthe time of Review and Acceptance Period (letter “a” above) determination for the transfer. The transfer must be completed within MAPP HHTS.
    1. C-YES can enroll the child/youth based upon the HCBS eligibility.
    2. When C-YES is accepting a transfer from HHCM, the steps above must occur prior to the transfer through the MAPP HHTS. C-YES will then accept the transfer within MAPP HHTS and start providing Care Management within this timeframe.

Care Management Requirements

  • Children/youth who meet the Children's Waiver HCBS eligibility criteria due to Medicaid Family of One budgeting and receive HH care management as their required monthly HCBS, may not transfer to C-YES. Please refer to the Children'sHCBS Manualfor additional information on care management requirements and Family of One budgeting.
  • HCBS enrolled children/youth receiving HH care management who lose or may lose their Medicaid should not be referred to C-YES for assistance with re-establishing Medicaid. It is the responsibility of the HHCM to assist in restoring active Medicaid status, if possible, by working with the Local Department of Social Services (LDSS). In addition to ensuring the Restriction Exception (R/RE) K-codes are in place, HHCMs can share a print-out of the UAS HCBS eligibility if this will assist/verify for the LDSS that the child/youth is in the Children's Waiver.
  • Children/youth who are receiving only HH care management services and are requesting Children's Waiver HCBS, must not be transferred to C- YES until HCBS eligibility has been determined. The HHCM must conduct the HCBS Eligibility Determination to determine if the child/youth is HCBS eligible. If HCBS eligible, the child/youth/family choose to go to C- YES for HCBS care coordination, then the HHCM can conduct the transfer at this time following the transfer process outline above.

Requirements for Transfer

  • The HCBS Eligibility Determination must be current and valid at the time of transfer. If the HCBS will expire in the next 60-days, the transferring entity must complete the HCBS re-assessment prior to transfer so the receiving entity can receive the most up-to-date information.
  • The HCBS Eligibility Determination is active for 365 days, so at the time of transfer a new HCBS is not necessary to be completed by the receiving entity.
  • Verification of proper recipient Restriction Exception (R/RE): K-codes must be active on the child/youth's file prior to transfer. If C-YES transfers to HH/CMA, the A-code must be active on the child/youth's file prior to C-YES closing the case.
  • All involved providers and care teammembers, including HCBS provider(s) and Medicaid Managed Care Plan (if applicable) must be notified of the transfer of care management services and continued HCBS eligibility.

If applicable, POC and outstanding referrals to HCBS providers MUST be provided as outlined in the transfer form. HCBS referral information will be viewable within the Referral and Authorization Portal by the receiving entity once the transfer has been finalized.

  • C-YES and the Health Home consent forms provide additional language which allows the transfer any Personal Health Information (PHI) between C-YES and Health Home without additional signatures or consent forms. Additionally, the Opt-in Health Home form allow the Health Home/Care Management Agency to accept the MAPP HHTS transfer and enroll the participant immediately, after the outlined steps above are completed.

All required transfer documentation is noted on the "Transfer for C-YES, Health Homes, and Care Management Agencies" form.

Additional Resources

Required Annual HCBS LOC Eligibility Determination

HCBS POC Workflow Policy

C-YES Website

Children's HCBS Manual

____________________________________________

1. Refer to the Children's HCBS Waiver Eligibility and Enrollment Policy for additional information. 1
2. Children/youth referred to C-YES and already enrolled in HH will be directed to contact their HH to request an HCBS Eligibility Determination. Children/youth referred to C-YES and already enrolled in Medicaid but notenrolled in HH may choose to be referred to a HH for their initial HCBS Eligibility Determination. 2
3. C-YES personnel are trained to provide familieswith education regarding the benefits of HH care management; it is expected that most children/youth/families will choose the HH option. 3