FAQ Regarding Health Homes & Home and Community Based Services (HCBS)
- FAQs is also available in Portable Document Format (PDF)
Notices of Determination and Fair Hearing Policy #HH0004 November 2024 Updates
Instructions
There is an index below that allows the user to click the category they want to see and will automatically scroll to that section of the spreadsheet. Please reach out to healthhomes@health.ny.gov with questions and/or feedback. NOTE: Reference to page numbers and sections included in questions below may no longer be ap plicable. As adjustments were made to revise this policy, certain page numbers/sections may have been altered.
Revisions have been made to this FAQ as of January 2024. Updates made can be identified by an Asterix * in the update "Made Column".
- Evidence Packet
- Timely & Adequate Notice and Mailing
- Continuing Service
- Home and Community Based Services (HCBS) Waiver
- MAPP and UAS (HHSC)
- * Section VII. & Segment Pend Reason Codes
- Fair Hearing Representative
- * Issuing Notices of Determination/Decision
- Due Dates
- * Decision After Fair Hearing
- Excluded Settings
- * E14 Waiver
- * Fair Hearing Requests Timeline and Process
- Documentation Following Fair Hearing Decision
| Category | Question/Comment | Response | ||
|---|---|---|---|---|
| Evidence Packet | Pg 3. Evidence Packet – Documentation supporting enrollment/disenrollment determinations including, but not limited to, the signed consent form; the updated Plan of Care (POC); care record notes; appropriateness, eligibility assessments, documentation, and medical documentation written summary of the case; the applicable policy governing the program; a copy of the notice being challenged; and an explanation of the action taken and why it was appropriate and in compliance with that policy. As well as the Children's Waiver Eligibility Determination or attempts to complete such Eligibility Determination must be included for children under Home and Community Based Services (HCBS) More documents are required for the FH packet, including appropriateness and eligibility. I don't see an issue with that provided we can note when there is not an eligibility assessment due to enrollment date without being penalized. |
The determination of a member's eligibility and appropriateness is a key piece of evidence that an Administrative Law Judge would need to review. In the case where a Health Home is asserting a member is not eligible on this basis, they need to provide such evidence. The Department edited policy in the Definition section for 'Evidence Packet' describing what documentation is included. When reference to 'Evidence Packet' is seen throughout the policy, refer to the definition. |
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| Evidence Packet | The policy lists "the applicable program policy upon which the decision is based;" as one of the documents to support the determination. Is the requirement here that the applicable policy is shared/ submitted when responding to a fair hearing request? |
A copy of the Health Home policy/s is to be included in the Evidence Packet to support the program's decision. | ||
| Evidence Packet | DOH should add the details regarding submission of the FH packet to NYUpload site and how HHs obtain access. |
Health Homes (HH)/Children and Youth Evaluation Service (C-YES) submit Evidence Packets to Office of Temporary Disability Assistance (OTDA) through Upload.NY.gov, a secured portal for Fair Hearings. Each entity sets up an account. Refer to the Office of Administrative Hearings (OAH) transmittal 22-02 (September 1, 2022- Subject: Secure Evidence Submission Portal- UploadNY) | ||
| Evidence Packet | Please clarify if the evidence packet HAS to be sent to the member/family automatically for each FH or only upon request. | The policy has been changed to clarify that a copy of the Evidence Packet must be provided to the member/family 'upon request' as well as any additional documents requested for the purpose of preparing for the Fair Hearing. | ||
| Timely & Adequate Notice and Mailing | Pg 5. timely and adequate notice of a disenrollment within five (5) calendar days of determination; Policy states that the CMA should issue the appropriate notice of determination as follows: "timely and adequate notice of a disenrollment within 5 calendar days of determination". Where does the "within 5 calendar days of determination" come from? |
The use of five (5) calendars days was included in policy by the Department to provide ample time for Health Homes/C-YES to ensure the Notice of Determination is prepared and mailed out to the member, upon which time the ten (10) day timeframe for the timely notice requirement begins. The five (5) day timeframe begins when the decision is made by the program (HHSA/HHSC) that the member is to be disenrolled. For HCBS, this is when the LOC is completed and identifies that the child is not eligible. |
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| Timely & Adequate Notice and Mailing | Pg 7. The notice is mailed to the member along with the Health Home Welcome Letter within five (5) business days from the Determination for Enrollment into the Health Home Program. Policy states, "the notice is mailed…within 5 Business days from the determination for enrollment". All other forms in policy references "calendar" days. |
Use of five (5) days is adjusted from business to calendar days and will remain in policy to reference the time allotted for preparing and providing the NOD to the member. | ||
| Timely & Adequate Notice and Mailing | Pg 7. at least ten (10) calendar days (based on postmark) Change to "issued" to the member. Sometimes the NOD/welcome letter is physically given to the member, securely emailed, etc. Sometimes the NOD and disenrollment letter are physically given to the member, securely emailed, etc. Also, this appears to imply that we must retain a copy of the postmark to prove timely notice, which seems unreasonable and not how we have been audited. The auditors have been looking at the date on the notice and perhaps a case note documenting when it was issued. I understand that a postmark could be brought to the Fair Hearing to prove un-timely notice, but that's a different scenario than how we have to document things. Replace the word "mailed" with issued as not all forms are mailed. Many are given in person or given to the member in alternative formats. |
Statute only contemplates issuance of NODs through the mail. The ten (10) calendar day requirement is part of the statute. DOH will explore development of guidance for issuance of NODs through other means. In the meantime, the use of the word "mail" will remain in policy. Whatever the Health Homes provide in the Fair Hearing process, it is weighed as evidence along with whatever evidence the record includes from the member, including but not limited to, member's testimony. |
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| Continuing Service | Pg 7. If the ten (10) calendar days carry over into the following month, then the disenrollment date is identified and written as the last day of that following month. Any Health Home Care Management (HHCM) core services conducted during this time are billable. If the 10 calendar days carry over into the following month, is the expectation for the CMA to continue to provide services in the interim, or is this simply for administrative purposes? |
An NOD may be provided to the member at any point during the month, which may mean that the ten (10) calendar day period carries over into the next month. The member may not be disenrolled until after the required ten (10) day period has elapsed. | ||
| Continuing Service | What if the member is being disenrolled due to Medicaid ineligibility, how do we reenroll or allow for billing while waiting for the FH if aid continuing is granted? | The program must adhere to the requirement of Aid Continuing regarding continuing to serve the member regardless of Medicaid status. | ||
| Continuing Service | What if the aid continuing notice comes a couple months after NOD submission and the CMA no longer has capacity. Are they required to take the member or can we reassign to a new agency in aid continuing status? | Aid Continuing pertains to the continuation of the service but does not specify that the service must be performed by the same provider. If necessary, the member may be reassigned to a new agency to receive the same services. | ||
| *Continuing Service | Pg 9. When a Notice of Determination/Decision is issued to the member, the member has the right to determine whether they want to request a Fair Hearing and whether the selection of Aid Continuing is right for them. If Office of Temporary and Disability Assistance (OTDA) orders Aid Continuing before the effective date stated in the notice, the member continues to receive Health Home Care Management services and/or Children's Waiver Home and Community Based Services until the final outcome of the Fair Hearing is determined. This sections states, "if OTDA orders aid continuing before the effective date stated in the notice…" but often times that notice comes well after the 10 days effective date and then we are tasked with reenrolling the member by undoing the discharge in MAPP and documenting a note about this in the chart. Are we to be putting them into a Pended for Aid Continue status at this point and will it be a billable status (we don't currently use this)? |
The Department has re-issued this policy to include Section VII, Maintaining Members' Status in the Tracking System for Health Homes and Home and Community Based Services, which addresses this question. Please refer to page nine through twelve (9-12) of the Health Homes & Home and Community Based Services (HCBS) Notices and Fair Hearings Policy HH0004 | ||
| Home and Community Based Services (HCBS) Waiver | Pg 8. The Children's Waiver Home and Community Based Services (HCBS) Eligibility Determination is valid for one (1) year (three-hundred and sixty-five (365) days). If the child/youth no longer meets the Home and Community Based Services (HCBS) eligibility criteria or found ineligible during the annual HCBS Eligibility Determination, then Health Home (HH) /Children and Youth Evaluation Services (C-YES) sends a Notice of Decision (NOD) for Discontinuance in the New York State Children's Waiver (DOH 5288) within five (5) business calendar days from the ineligibility determination to the child/family and (10) calendar days (based on postmark) prior to the action of disenrollment from the Children's Waiver. What is the difference? Are you saying that an NOD for discontinuance can be issued without doing the LOC? Like just because the HHCM thinks they won't be eligible when the time for the LOC comes?Recommend changing this to say: If the child/family requests disenrollment from the waiver or the child/youth is found ineligible during the annual HCBS Eligibility Determination. We don't want HHCMs deciding whether someone is eligible or not without doing the LOC. |
The Health Home Care Manager must follow the protocol to obtain needed documentation. An NOD can be issued without a Level of Care being finalized if the Health Home Care Manager attempted to get all documentation required but did not receive it. Reference to postmark has been revised to state, "date mailed." | ||
| Home and Community Based Services (HCBS) Waiver | Pg 9. Once a slot becomes available, the Department of Health (DOH) Capacity Management will notify the Health Home (HH)/ Children and Youth Evaluation Services (C-YES) care manager and then the Health Home Care Manager (HHCM)/ Children and Youth Evaluation Services (C-YES) will issue an updated DOH 5287 to the child/family indicating that a slot is available or will need to conduct a new Home and Community Based Services (HCBS) Eligibility Determination if the family wishes to pursue Home and Community Based Services (HCBS) and the Eligibility Determination is over six (6) months. Recommended edit "was signed/finalized over 6 months ago." |
Policy has been adjusted to include this recommended language. |
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| Home and Community Based Services (HCBS) Waiver | To confirm, if a child is in aid continue status and their annual HCBS LOC is due, we should do the LOC again if even if we know it will be ineligible and then do we have to provide a NOD for that LOC as well? | If the child is in aid continuing status they need to remain as such until the final Fair Hearing decision is made. If the decision is in favor of the child/family, the Level of Care will be due 365 days from the determination date on the most recently completed Level of Care. | ||
| Home and Community Based Services (HCBS) Waiver | Pg 13. If a Fair Hearing is requested, the Health Home (HH) will compile the evidence packet as directed by the Health and Recovery Plans (HARP) or Special Needs Plans (SNP) in support of the determination; the Health and Recovery Plans (HARP) or Special Needs Plans (SNP) have ten (10) calendar days from the date of the notice to forward the evidentiary packet. Is the notice of the outcome of the HCBS EA, or the Fair Hearing notice from OTDA? To whom are they forwarding the evidentiary packet? |
The Department has revised this section to remove all contents except the following: "The Health and Recovery Plans (HARP) or Special Needs Plans (SNP) are responsible for issuing the determination regarding eligibility for Home and Community Based Services (Adults). Health Homes are to comply with requests from Health and Recovery Plans (HARP) or Special Needs Plans (SNP) to participate in the Fair Hearing." | ||
| Home and Community Based Services (HCBS) Waiver | The Health and Recovery Plans (HARP) or Special Needs Plans (SNP) may request that the Health Home (HH) participate in the Fair Hearing Process, but the Health and Recovery Plans (HARP) or Special Needs Plans (SNP) will be issuing the determination regarding eligibility for Home and Community Based Services (HCBS).' | It will be required that the NOD is issued to the member, which will show the 365 days of eligibility. | ||
| *Home and Community Based Services (HCBS) Waiver | Can the Department explain language stating Health and Recovery Plans (HARP) or Special Needs Plans (SNP) are responsible for issuing the determination regarding eligibility for adult HCBS? Is the Managed Care Plan (MCP) responsible? |
Level of Service Determinations (LOSD) for Home and Community Based Services (HCBS) for adult Health Home members are provided by Health and Recovery Plans (HARP) and Special Needs Plans (SNP). Accordingly, if a Plan deems someone ineligible to receive these services, it is the Plan's responsibility to issue the Notice. Health Homes will provide support at the Fair Hearing, if requested by the Plan. | ||
| *Home and Community Based Services (HCBS) Waiver | During the Fair Hearing process, does HCBS continue upon parental request? | Home and Community Based Services (HCBS) continue if and when the Office of Temporary and Disability Assistance (OTDA) grants Aid Continuing following receipt of a request for Fair Hearing with Aid Continuing. | ||
| *Home and Community Based Services (HCBS) Waiver | If the participant and/or family request another HCBS Level of Care (LOC) eligibility assessment after losing a Fair Hearing, and the care manager does not think they are appropriate, what steps should be taken? | It is the care manager's responsibility to evaluate and determine whether the participant is at risk of institutionalization. Care managers should consider what changed since the Fair Hearing and why Home and Community Based Services (HCBS) are appropriate. Refer to the Children's Home and Community Based Services (HCBS) Waiver Eligibility and Enrollment Policy | ||
| MAPP and UAS (HHSC) | Pg 9. NOTE: If an annual Home and Community Based Services Eligibility Determination cannot be completed due to lack of documentation, a DOH 5288 is sent at least ten (10) calendar days prior to the annual reassessment due date. Aren't we still supposed to do the HCBS LOC but indicate that there aren't the required forms/documents by leaving the LPHA date field blank, and then it will give an ineligible result? |
The UAS doesn't allow for a Level of Care to be completed for some target populations. The LPHA is only for the SED target population. | ||
| MAPP and UAS (HHSC) | Pg 13. Reviews the number of Fair Hearings filed against the Health Home (HH)/Care Management Agency (CMA): Will there be a report from MAPP or UASNY that we can pull to show this information? Or are we expected to track and analyze the data by hand, increasing administrative burden. Also, since CMAs are in multiple Health Homes, isn't DOH in the better position to do this kind of analysis at the CMA level? |
The Department will explore the possibility for using MAPP and UAS for tracking and trending. | ||
| *MAPP and UAS (HHSC) | If a LOC assessment cannot be completed due to a lack of documentation, is it expected that a LOC is completed in UAS and marked 'no' to having the needed documentation to get an ineligible outcome? Or is nothing entered in the UAS and a NOD is issued with the 10 day notice? | Without documentation, the Level of Care (LOC) in the Uniform Assessment System (UAS) cannot be completed. The Notice would be issued ten (10) days prior to the Level of Care due date. Refer to slide #15, second bullet in the slide deck provided for the *Section VII. & Segment Pend Reason Codes |
Pg 9. SECTION UNDER REVISION. NEW CONTENT TO BE RELEASED PRIOR TO THE RELEASE OF MAPP HHTS UPDATE 4.7 DECEMBER 2024. Given Section VII. Is missing, can the state wait to implement the policy until that guidance is added so we don't have to revise policies multiple times within a 2 month period? |
The Department re-issued this policy to include Section VII Maintaining Members' Status in the Tracking System for Health Homes and Home and Community Based Services in December 2024 for implementation November 22, 2024. |
| *Section VII. & Segment Pend Reason Codes | *Section VII. & Segment Pend Reason Codes | Will segments also be pended for HCBS Fair Hearings? | Home and Community Based Service providers and Health Homes will be able to see all Fair Hearings in Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS), but segments will only be pended for Health Home requests for Fair Hearings with Aid Continuing. | |
| *Section VII. & Segment Pend Reason Codes | Seeking direction on members who have been Pended for Fair Hearings, are awaiting their hearings and go into Diligent Search. Are we to update the Pended segment to reflect DSE for the applicable months and then re-Pend for Fair Hearing, as the members have been re-engaged but are still awaiting their hearings? I'm not sure if MAPP will allow this many changes to back-to-back Pended segments, so I have a request into them, as well, regarding the functionality. | The segment for members who have been 'Pended for HH Fair Hearing Aid Continuing' that then go into diligent search are not to be changed and remain in place until an outcome of the Fair Hearing is determined. For further information on this and other case scenarios, refer to Appendix A of the Health Homes & Home and Community Based Services (HCBS) Notices and Fair Hearings Policy HH0004 For Diligent Search Efforts (DSE), Health Homes and Care Management Agencies are responsible for following the Continuity of Care #HH0006. |
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| *Section VII. & Segment Pend Reason Codes | It was stated in the overview that there would be new pend reason codes to call out the fair hearing status, but I didn't see any new pend reason codes related to this in the specs that were released. Is this an oversight? | Appendix C: Segment Pend Reason Codes (p. 158) of the Medicaid Analytics Performance Portal File Specifications Document version 4.7.1 has a chart with the pend reason codes for Fair Hearing and can be found here. | ||
| Fair Hearing Representative | Please confirm the CMA can represent the HH at the Fair Hearing as they are more equipped to explain the case and findings than the HH. If the CMA cannot attend, then the HH can but we require the CMA. The policy states HH (reminder, CMA is the one being paid the monthly PMPM to do these activities, not the HH). We do manage the process and confirm the packets are submitted and the CMA is prepared for the FH but we expect them to attend it. | Policy is adjusted to include citation regarding who may be present at the fair hearing – refer to 18 NYCRR 358-5.7. Health Homes/C-YES are responsible to ensure that an appropriate representative is selected to attend and present at the Fair Hearing. | ||
| *Fair Hearing Representative | Is a member of the CMA required to attend a Fair Hearing? | No. The Care Management Agency is not required to attend the Fair Hearing. The Health Home may identify an appropriate representative who is in a position to act on their behalf. This representative could be the Care Management Agency. The Health Home's policy will drive this decision. | ||
| Issuing Notices of Determination/Decision | Pg 6. If a determination is made to disenroll a Health Home (HH) member or upon a member's successful completion of the Health Home (HH) program, timely and adequate notice by means of Form DOH-5235 is required before the Health Home (HH) can take any action. Please confirm if DOH includes graduation from the HH program as a disenrollment reason requiring a NOD. Page 6, under B. indicates "upon a members' successful completion of the HH program" as a reason but we consider that a voluntary disenrollment if they are in agreement that they have met their goals and choose to disenroll. |
Successful completion could be through agreement of the member and therefore, is a voluntary disenrollment. In these cases, an NOD would not be issued. However, if the member does not agree with the program's determination of successful completion, then an NOD would be issued to member. | ||
| *Issuing Notices of Determination/Decision | Is the Denial of Enrollment into the Health Home (HH) program Notice of Determination (NOD), DOH-5236, required to be issued for members in outreach who are found ineligible, or just for those enrolled who are found ineligible? | If an individual approached the Health Home seeking enrollment but was denied because they were found ineligible, then a DOH-5236 (Denial of Enrollment) would be required. The DOH-5236 would not be required if the member did not request enrollment. The DOH-5235 (Disenrollment) is issued to an enrolled member who is deemed no longer eligible for continued Health Home enrollment. |
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| *Issuing Notices of Determination/Decision | Will NOD forms be published in multiple languages? | The Notices (NOD) are posted on the website in English. The Notices will be translated into other languages and upon completion, will be posted on the Department's website with notification to Health Homes. | ||
| *Issuing Notices of Determination/Decision | Is the NOD necessary for voluntary disenrollment? | Per the Health Homes & Home and Community Based Services (HCBS) Notices and Fair Hearings Policy #HH0004, if a member voluntarily requests disenrollment, then a Notice (NOD) would not be issued. For children under the Home and Community Based Services Waiver, the Freedom of Choice form is signed indicating decision to no longer pursue continued eligibility in the waiver. |
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| *Issuing Notices of Determination/Decision | Who sends the NOD? The Health Home (e.g., Collaborative for Children) or the CMA (e.g., WellLife network)? | The Health Home determines which entity, Health Home or Care Management Agency, distributes the Notices. Care Management Agencies should follow guidance provided by their lead Health Home. | ||
| Due Dates | Pg 12. If the previous Plan of Care was completed within the last three hundred and sixty-five (365) days, it is still active. Initial appropriateness must be recorded within twenty-eight calendar (28) days of the new active segment (adults and children/youth). But it would still need an updated signature within 60 days to be billable right? |
An update to the Plan of Care with signature, is not due until the current Plan of Care's 365 day's expiration date. For example: a Plan of Care was signed on October 15th 2024. The member was moved toward disenrollment and in response, requested a Fair Hearing without Aid Continuing. The final Fair Hearing determination was issued on February 2, 2025, in favor of the member. Therefore, Health Home Care Management services must resume. Initial Appropriateness is due within twenty-eight (28) days. Plan of Care remains in effect until October 2025. |
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| Decision After Fair Hearing | If the decision is in favor of the member and we are required to start a new segment for the member and complete the initial appropriateness criteria, what are we selecting if not meeting the appropriateness criteria was the reason we disenrolled them in the first place? | The Health Home and Care Management Agency are to select the most appropriate option from existing Initial Appropriateness criteria. If no applicable criteria can be identified, the Health Home must contact the Department for guidance via the HH BML – subject: Health Home Policy. | ||
| *Decision After Fair Hearing | Is there any guidance if a member "loses" a Fair Hearing but requests a new referral shortly after? Is it acceptable to re-enroll if there is eligibility and appropriateness? | All individuals seeking Health Home enrollment must meet all eligibility criteria to be enrolled. For more information regarding Health Home enrollment and eligibility, please refer to the Eligibility Requirements for Health Home Services and Continued Eligibility in the Health Home Program Policy number #HH0016 | ||
| Excluded Settings | Pg 8. Individual currently resides in an excluded setting (Residential Treatment Facility, Nursing Home, Incarceration etc.) Regarding individuals in excluded settings, the addition of "with no plan for discharge/release to the community within 30 days" is suggested. |
The Department has edited this section of the policy to better define the reasons for denial of enrollment, providing the link to the Appropriateness Codes and Criteria chart, which includes the timelines associated with each appropriateness code. | ||
| *E14 Waiver | If the NOD language will not change to reflect temporary changes in the E14 Waiver, can the Department please confirm that the E14 Waiver's pause on recoupment does, in fact, apply to all Aid To Continue for Fair Hearings with OTDA, including Fair Hearings regarding Children's HCBS Waiver enrollment, Children's HCBS Waiver services, Health Home program enrollment, and Health Home program services? | The E14 Waiver's pause in recoupment will continue to apply whenever Aid to Continue is awarded by OTDA in connection with a Request for a Fair Hearing for as long as that Waiver is in effect (currently approved through June 2025). Aid to Continue generally is not available for enrollment determinations. For more information on the, please refer to the E14 Waiver Letter linked here. For more information on the waiver's effective timeframe, please refer to the GIS 24 MA/07 linked here. |
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| *Fair Hearing Requests Timeline and Process | If a participant is going through the Fair Hearing process, but it was rescheduled and the parent/family is unaware of their next steps, is there a contact number to contact someone in regard to the HCBS appeal? | The member, parent or family should be directed to the information listed on page 2 of the Notices regarding the location and phone numbers for Office of Temporary and Disability Assistance (OTDA). | ||
| *Fair Hearing Requests Timeline and Process | Can the member have a three-day request with expedited review? What is the timeframe for Aid to Continue and Fair Hearings? |
For more information related to the timing and scheduling of Fair Hearings, please refer to the AH-22-03 - OAH Transmittal - Expedited Medicaid Hearings Additionally, for more information regarding the Fair Hearing process, please refer to the Frequently Asked Questions | Fair Hearings | Office of Temporary and Disability Assistance. |
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| *Documentation Following Fair Hearing Decision | How do Care Management Agencies (CMA) document in the record if the case is closed? | Health Homes must have policies and procedures on how Care Management Agencies should handle this. Please contact your lead Health Home for guidance. |
