Guidance on Correction to Yearly Appropriateness Codes and Guidance on Service Provision while a member awaits a Fair Hearing with Aid Continuing

• Guidance also available in Portable Document Format (PDF)

TO: All Health Homes

RE: Guidance on Correction to Yearly Appropriateness Codes and Guidance on Service Provision while a member awaits a Fair Hearing with Aid Continuing

DATE: March 10, 2026

This memo reiterates guidance provided to the Health Homes at the February 4, 2026 and March 4, 2026 Health Home Office Hours Sessions.

Yearly Appropriateness Correction:

Effective immediately, Code 52 on the Yearly Appropriateness Table is not to be used as it is duplicative of Code 50 and by March 31, 2026 it will be deactivated within the MAPP HHTS. Additionally, as requested, Code 57 description will be updated as highlighted - "HEALTHCARE RISK: Member has an established relationship with a provider but has not seen them in the last 3 months for required appointment(s)". Please continue to use all other codes and descriptions as-is.

Fair Hearing with Aid Continuing:

Health Homes and Care Management Agencies must provide services to members in accordance with all policies and procedures that apply when any member is enrolled in a standard enrolled segment, even when the member is continuously enrolled in the Health Home program due to a requested and granted Fair Hearing with Aid Continuing. This includes and is not limited to Initial Appropriateness determination, Initial (and Annual) Comprehensive Assessment, Care Planning, Yearly Appropriateness (children) and Continued Eligibility for Services Tool completion (adults), and annual Children's Waiver HCBS Eligibility Determinations. When a member is receiving Aid Continuing and the associated Fair Hearing has not yet occurred at the time the annual HCBS Eligibility Re-Determination/Re-Assessment is due, the Children's Waiver annual (365 days) HCBS Eligibility Determination must still be conducted timely.

The billing block waiver that the "Pended for Fair Hearing with Aid Continuing" status affords, is not established to waive any service requirements. It is established to allow the Health Homes to continue to provide service and to bill even if a member refuses to engage in some of these required service elements which might otherwise lead to billing block implementations or member disenrollment. Health Homes may not bill if core service requirements for billing are not met when Pended for Fair Hearing with Aid Continuing.

For information on steps required to be taken to determine eligibility and enroll eligible children/youth in the Children's Waiver, please refer to:

Children's Home and Community Based Services (HCBS) Waiver Eligibility and Enrollment Policy - #CW0005