Yearly Appropriateness (YA) Codes and Criteria

August 2025

This chart lists the codes and criteria used for Yearly Appropriateness for children/youth enrolled in the Health Homes Serving Children (HHSC) program. Documentation supporting the Yearly criterion selected for HHSC members is to be retained in the member's electronic health record (EHR). Please refer to policy HH0016 Eligibility Requirements for Health Home Services and Continued Eligibility for requirements that outline the steps to be taken to ensure members meet criteria for continued eligibility in the Health Home program.

The effective date for implementation of this chart is December 1, 2025.

Appropriateness Code Appropriateness Criteria Program Comments Required (Y/N)?
50 ADVERSE EVENTS RISK: Current K1-code in EMEDNY (Children's Waiver Enrolled) Children N
51 ADVERSE EVENTS RISK: Eligible and or Enrolled in High Fidelity Wraparound (HFW) Children N
52 ADVERSE EVENTS RISK: Eligible and Enrolled in the Children's Waiver Home and Community Based Services (HCBS) Children N
53 ADVERSE EVENTS RISK: Managed Care Organization (MCO), Local Government Units (LGU), Single Point of Access (SPOA), school system, or county Local Department of Social Services recommends child/youth continue Care Management involvement due to continued involvement/lack of stability with mandated preventive services, Child Protective Services/Preventive Services Program, Special Education Program, Schools (e.g., children suspension, truancy, grade failure/repeat grade or summer school). Must specify provider of service, documentation of request and rationale for the recommendation to remain in HHCM Children Y
54 ADVERSE EVENTS RISK: Within the last six months, a significant life advent or recent traumatic experience occurred that affects the member's functioning whereas a new CANS-NY was conducted AND additional services were sought. Specify the event and date of event Children Y
55 HEALTHCARE RISK: Member diagnosed within the last 6 months with a terminal illness/condition and or life expectancy of a year or less. Must specify condition, and date diagnosed Children Y
56 HEALTHCARE RISK: Member is currently waitlisted for services or not connected for diagnostic assessment/services (psychological, neurological, developmental, specialist, etc.) which was referred by the treating provider regarding their chronic condition/diagnosis. Must specify who the treating providers and date last seen, the date of referral, describe the waitlist or date of the scheduled appointment, and with whom Children Y
57 HEALTHCARE RISK: Member has an established relationship with a provider but has not seen them in the 3 months for required appointment(s): Applicable to Primary Care Provider, mental health provider, substance use provider, or provider to treat their Single Qualifying Condition (Complex Trauma, Sickle Cell Disease, Serious Emotional Disturbance/Serious Mental Illness, or HIV) or physical disability related to a neurologic, muscular, or neuromuscular condition.{This code can only be used if there has been a new diagnosis or provider since the previous initial or yearly appropriateness} Must specify new diagnosis/providers and date Children Y
58 READMISSION/RECIDIVISM RISK: Member recent inpatient/Emergency Department/psychiatric hospital/Detox/Skilled Nursing/Crisis Stabilization within the last 6 months. Must specify name of institution and date of release Children Y
59 READMISSION/RECIDIVISM RISK: Member recent out of home placement (foster care, relative, Residential Treatment Facility (RTF), Residential Treatment Center (RTC), Qualified Residential Treatment Program (QRTP), Community Residence, Residential Crisis, etc.) within the last 6 months. Must specify name of institution and date of release Children Y
60 READMISSION/RECIDIVISM RISK: Released from Jail/Prison/Juvenile detention, or involved with Probation, PINS, Family Court, Alternatives to Incarceration, Diversion programs within the last 6 months. Must specify name program and date of release/court/probation Children Y
61 SOCIAL DETERMINANTS RISK: Parent/guardian/primary caretaker cannot maintain ongoing connection with child's/youth's providers and services (i.e. food, needed entitlements, safety, etc.) due to their own barriers (i.e. mental health, maintaining employment, etc.) requiring care management assistance. Specify the caregiver and the listed barrier.
(Examples:
Food insecurity such as:
  • Emergency Food Assistance: Supplemental Nutrition Assistance Program (SNAP), Food Pantries, and Meals on Wheels
  • Women Infants and Children (WIC) for children under age 6 and pregnant/postpartum individuals
Safety: Intimate Partner Violence/Current Family Violence in the home of the member Does not have one (1) of the following needed entitlements:
  • Medicaid Transportation/Access-a-Ride
  • Housing Supports (Section 8, Empire State Supportive Housing Initiative (ESSHI), New York Health Equity Reform (NYHER) Housing Supports)
  • Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Temporary Assistance for Needy Families (TANF)
  • Home Energy Assistance Program (HEAP)
  • Medical Entitlements (Medicare/Medicaid support)
  • Child Care Supports (for caregiver of enrolled children only)
  • Early Intervention (Head Start or Special Education)
NOTE: Members who have access to a needed benefit due to current enrollment in a plan, program, or waiver do not meet this criterion. For example, members who are enrolled in a Medicaid Managed Long-Term Care (MLTC) Plan have access to Access-a-Ride through their MLTC benefit package and therefore do not meet the threshold for Health Home Appropriateness if their only need is Access-a-Ride)		 Children Y
62 SOCIAL DETERMINANTS RISK: For the last three (3) months, unstable housing or homeless (HUD 1, 2, or 4) (inclusive of Transitional Age Youth living with different friends/family). Note how long the member has had unstable housing Children Y
63 SOCIAL DETERMINANTS RISK: Member has had a change in guardianship/caregiver within the last six (6) months Children N
64 SOCIAL DETERMINANTS RISK: Transitional age youth (ages 18- 20) ongoing support needed to prepare for the adult system transition. Transitional plan documentation needed and date of projected transition Children Y
65 SOCIAL DETERMINANTS RISK: Currently navigating a transition to a different level/system of care and must continue services until fully transitioned (OPWDD, EI/CPSE, etc.). Must specify name and Children Y
  program transitioning to and projected date of transition    
66 TREATMENT NON-ADHERENCE RISK: Member/care team member report of non-adherence with a clinician's written treatment plan or prescription within the last three (3) months…Must specify the clinician(s) and medication(s) and/or treatment(s) involved Children Y
67 TREATMENT NON-ADHERENCE RISK: PSYCKES flag related to non-adherence or equivalent from RHIO or MCO Children N