Process for Transferring Health Home Enrolled Members to Another Health Home and/or Health Home Care Management Agency #HH0018

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Policy Title: Process for Transferring Health Home or Children's Waiver Enrolled Members to Another Health Home and/or Health Home Care Management Agency Policy Number: HH0018

Issue Date: November 25, 2024 Effective Date: February 1, 2025

Last Revised:

Approved by:

Applicable to: Health Homes Serving Adults (HHSA), Health Homes Serving Children/Youth (HHSC), Care Management Agencies (CMA), and Children and Youth Evaluation Service (C-Yes).

Purpose : To establish standards and clear guidance which will inform Health Homes and Children and Youth Evaluation Service (C-YES) of requirements for the transfer of enrolled members to a new Health Home and/or Care Management Agency or Children and Youth Evaluation Service (C-YES).

Content

Definitions

Definitions

Administrative Transfer

The process followed by a Health Home and/or Care Management Agency to appropriately transfer Health Home enrolled members as a result of a closure/merger/acquisition.

Member or Participant

The individual (both adult and children/youth) enrolled in the Health Home program or Children and Youth Evaluation Service (C-YES) for the purpose of the Children's Waiver. The term includes the Parent, Guardian, and Legally Authorized of the member, as applicable. These terms are interchangeable.

Member-DrivenTransfer

The process followed when a Health Home enrolled member requests transfer to a new Health Home and/or Care Management Agency.

In relation to the Children's Waiver, this is the choice of the member to have their care coordination with Children and Youth Evaluation Service (C-YES) for their HCBS only or the Health Home program for comprehensive care management.

Warm Handoff

A three-way communication that includes the current entity, new entity, and the member (family as appropriate) as a means to introduce the member and explain next steps in the transition process. Such communication can occur through phone call, telehealth, or in-person meeting to prevent any potential disengagement as the member is transitioning between entities. For example, current Health Home to new Health Home ORcurrent Care Management Agency to new Care Management Agency.
I. Policy

This document outlines the steps that are required for a Health Home (HH) and Care Management Agency (CMA) or Children and Youth Evaluation Service (C-YES) to take when transferring an enrolled member, whether adult or child, to a new Health Home (HH) and/or Care Management Agency (CMA) or Children and Youth Evaluation Services (C- YES). Additional steps required for children/youth enrolled in Home and Community Based Services (HCBS) are included.

Note Regarding Children and Youth Evaluation Services (C-YES) : Children and Youth Evaluation Service (C-YES) will adhere to the steps and requirements in the Transfer Referral Process between the Children and Youth Evaluation Service (C-YES) and Health Home Serving Children (HHSC) policy #CW0007 and the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) release 4.5.1.

Member transfers to another Health Home (HH), Care Management Agency (CMA), or Children and Youth Evaluation Service (C-YES) will occur for various reasons e.g., member requests a change, Care Management Agency (CMA) closure, Health Home (HH) closure, merger, or acquisition, etc. Proper procedures must be in place that outline the steps to be taken by the Health Home (HH), Care Management Agency (CMA), or Children and Youth Evaluation Service (C-YES) to ensure that a warm handoff occurs for the member from the current entity to the receiving entity, to include conducting regular reviews of the status of each member involved in the transfer process. Open communication and coordination between all entities is imperative to support a smooth, safe, and timely transfer for the member. This includes proper notification to the member about the reason for the transition and the member's selection, to include the member's choice not to transfer rather to disenroll from the Health Home (HH) program, if this is their desire.

Health Homes (HH) and Children and Youth Evaluation Service (C-YES) ensure that clear information about the change and choice is provided to each member and documented in the member's record.

NOTE : The Child and Adolescent Needs and Strengths - NY (CANS-NY) and the Home and Community Based Services (HCBS) Eligibility Determination is in the Uniform Assessment System (UAS) and follows the member regardless of transfer.
II. Procedure

When an Administrative Transfer is indicated, the Health Home Care Manager (HHCM) distributes to the member a letter written on Care Management Agency (CMA) agency letterhead clearly explaining the purpose for the transfer (e.g., Care Management Agency (CMA) closure, Health Home (HH) closure, merger, acquisition, or other reason(s), and include all available options depending on the nature of the situation, for example:

  • Remain with current Health Home (HH), but change to another Care Management Agency (CMA)
  • Remain with current Care Management Agency (CMA), but change to another Health Home (HH)
  • Change to another Health Home (HH) and Care Management Agency (CMA)
  • Enroll in Children and Youth Evaluation Service (C-YES) from Health Home (HH)
  • Disenroll from the Health Home (HH) Program (member choice to disenroll or member identified for graduation/step down)
Note: For Member-Driven Transfers, the above letter would not be required by the Care Management Agency (CMA)/Children and Youth Evaluation Services (C-YES); however, the Health Home/C-YES Care Manager (HHCM) documents every step of the transition process until successful completion, including warm hand off, has occurred.

For all transfers, the Health Home Care Manager (HHCM):

  1. Ascertains the member's informed choice to transfer and obtains permission to contact the receiving Health Home (HH)/Care Management Agency (CMA)/Children and Youth Evaluation Service (C-YES) to initiate and complete the transfer.
  2. The current and receiving entities maintain ongoing communication throughout the process to include the member, member's parent/guardian/legally authorized representative. All pertinent information to support the transfer is provided from the transferring entity(s) to the receiving entity(s).
  3. Establishes a date for disenrollment or transfer via the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS). Disenrollments occur on the last day of the month while transfers occur on the first day of the month.
  4. Informs and follows up with the member to ensure updates to their Health Home (HH)/C-YES consent are completed, as needed.
  5. Informs and follows up with member regarding completion and signing of other documents needed (e.g. DOH 5204, etc.).
  6. Documents in the member's record all transfer activities that occurred throughout the transition process.
  7. Ensures transfer of member's record, Plan of Care (POC), Assessments, Safety Plan, Child Adolescent Needs and Strengths-NY (CANS-NY), etc. to receiving Health Home (HH)/Care Management Agency (CMA)/Children and Youth Evaluation Service (C-YES) are completed within five (5) business days after the receiving entity has accepted the case.
III. Guidance for the Transfer of Documents Required for Transition for Health Homes Serving Adults and Health Homes Serving Children (administrative only)

Depending on whether a member's Care Management Agency (CMA) remains the same or changes as a result of a transition, certain rules apply regarding transfer of the Health Home consent, Plan of Care, Assessments, Educational Records, Care Management documentation, and clinical documentation, as follows:

  • If the member's Care Management Agency (CMA) will remain the same under a new Health Home (HH):
    • (For Adults)
      • The currently signed Health Home (HH) consent is valid and will continue to be used until the time the member's Plan of Care (POC) is due.
      • The Continued Eligibility for Services (CES) Tool does not transfer with the member. Upon opening a new segment, the Continued Eligibility for Services (CES) Tool clock is restarted based on the date of transfer. Refer to Connection Between Continued Eligibility for Services (CES) Tool and Billing Instances in the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) v.4 for the member's new segment's Continued Eligibility for Services (CES) Tool due date.
  • (For Children/Youth)
    • The currently signed Health Home (HH) consent is valid and will continue to be used until the time the member's Plan of Care (POC) is due.
    • The Children's Home and Community Based Services (HCBS) Eligibility Determination, Child Adolescent Needs and Strengths - NY (CANS-NY) and, Comprehensive Assessment (CA) will be done at the time the next review is due, based off the dates the prior Children's Home and Community Based Services (HCBS) Eligibility Determination, Child Adolescent Needs and Strengths - NY (CANS-NY) and, Comprehensive Assessment (CA) were signed/finalized.
    • The receiving Health Home (HH) uses the member's current Plan of Care (POC), Children's Home and Community Based Services (HCBS) Eligibility Determination, Child Adolescent Needs and Strengths - NY (CANS-NY), and Comprehensive Assessment (CA) due dates to establish the timeline for the next review and update.
  • (For Adults and Children/Youth)
    • When the transfer function is used, the most current Initial Appropriateness determination transfers with the new segment. In all other instances when a new segment is started (e.g., when the Transfer Function is not used), a new Initial Appropriateness determination is to be submitted within twenty-eight (28) days.
  • If the member's Care Management Agency (CMA) is changing but the member remains within the current Health Home (HH) network as a result of a transition:
    • The currently signed Health Home (HH) consent remains valid for up to ninety (90) calendar days (or the equivalent of three (3) segment months) of the member's transition date in order for needed updates to be made in the CMA and any other providers. Members of the Care Team listed in the consent are made aware of the new Care Management Agency (CMA) and are offered and provided with a copy of the updated new consent.
    • The receiving Care Management Agency (CMA) uses the member's current Plan of Care (POC), Child Adolescent Needs and Strengths - NY (CANS-NY) and Comprehensive Assessment (CA) due date to establish the timeline for the next review and update. For the Children's Home and Community Based Services (HCBS) Eligibility Determination, the due date is determined based on when it was last signed/finalized.

      NOTE : For Health Homes Serving Children, if the transfer is to occur within sixty (60) days of when the Children's Home and Community Based Services (HCBS) Eligibility Determination is due, the assessment is completed prior to the transfer. The assessment can be started two (2) months prior to the due date.
  • If the member's Health Home (HH) AND Care Management Agency (CMA) are both changing:
    • A new consent is obtained by the receiving Health Home (HH) within ninety (90) calendar days (or the equivalent of three (3) segment months) of the member's transition date. This includes consents such as the DOH 5055, DOH 5201, DOH 5203, etc.
    • The receiving Health Home uses the member's current Plan of Care (POC), Children's Home and Community Based Services (HCBS) Eligibility Determination, Child Adolescent Needs and Strengths- NY (CANS-NY), and Comprehensive Assessment (CA) due dates to establish the timeline for the next review and update.
    • The Health Home monitors the transfer of information for all members involved in a transition including Health Home consent, current Comprehensive Assessment and other recent assessments, and the most current Plan of Care accessed through the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) transfer function.
    • The transferring Health Homes Serving Children (HHSC) ensures that the Assessments, Child Adolescent Needs and Strengths - New York (CANS- NY) Acuity Score, and the Home and Community Based Services (HCBS) Eligibility Determination have been appropriately transmitted under the member's new Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) segment or other efficient means possible.
    NOTE : For Health Homes Serving Children, if the transfer is to occur within sixty (60) days of when the Children's Home and Community Based Services (HCBS) Eligibility Determination is due, the assessment is completed prior to the transfer. The assessment can be started two (2) months prior to the due date.
IV. Requirement for Transferring Members via Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS)

To support a successful transfer process, the transferring and receiving entity(s) establish arrangements outside the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) on how communication will occur throughout the entire process. The Health Home (HH) / Children and Youth Evaluation Service (C-YES) that is transferring a member(s) obtains verbal agreement from the Health Home (HH) / Children and Youth Evaluation Service (C-YES) that has agreed to accept the member(s) from the transferring Health Home (HH)/ Children and Youth Evaluation Services (C-YES), including any limitations on the number of members they can accept when conducting an administrative transfer. The transferring Health Home (HH) / Children and Youth Evaluation Service (C-YES) moves the member(s) using the transfer functionality within the system. This process can be completed in bulk using files or one member at a time, on screen. The members eligible for transfer will require review and response from the receiving Health Home (HH) Children and Youth Evaluation Service (C-YES) as to whether they accept or decline each member and communicate why. If a receiving Health Home (HH) /Children and Youth Evaluation Service (C-YES) does not accept members, the transferring Health Home (HH) maintains responsibility for these members and proceeds to locate another Health Home (HH) willing and able to accept these members, following the process outlined in the File Specifications documents1.

As part of the transfer planning process, Health Homes (HH) and or Care Management Agencies (CMA) ensure that the members being transferred are still eligible and appropriate for Health Home Services if applicable. This can be done through pre-existing processes Health Homes (HH) have in place or though completion of the CES Tool (as done by Health Homes (HH) and Care Management Agencies (CMA) prior to release of this policy). If a member is not eligible and appropriate for continued enrollment, they should not be transferred rather should be moved through the discharge planning process according to the Member Disenrollment From the Health Home Program policy #HH0007.

For Health Home Serving Children and Children and Youth Evaluation Service (C-YES) transfers should not occur prior to Home and Community Based Services (HCBS) Eligibility Determination re-assessment. If the transfer is to occur within sixty (60) days of when the Home and Community Based Services (HCBS) Eligibility Determination is due, the assessment must be completed prior to the transfer. The assessment can be started two (2) months prior to the due date. Additionally, the timeline for transfer must follow the Transfer Referral Process between the Children and Youth Evaluation Service (C-YES) and Health Home Serving Children (HHSC) policy #CW0007.

V. Training

Health Homes (HH), Care Management Agencies (CMA)/Care Managers (CM) and Children and Youth Evaluation Service (C-YES) must receive training on protocols related to the requirements for the transfer of enrolled members to a new Health Home (HH) and/or Care Management Agency (CMA) or, Children and Youth Evaluation Services (C-YES) including but not limited to: reason(s) for transfer; responsibilities of each entity involved in the transfer process; notification to the member(s) and obtaining choice; transfer of documentation and associated timelines; communication and coordination between entities throughout transfer process, including warm handoff of members; and, MAPP HHTS requirements.

VI. Quality Monitoring

As part of its structured transfer plan, Health Homes (HH) and Children and Youth Evaluation Service (C-YES) provide oversight and monitoring activities to ensure the transfer of its member(s) occurs in accordance with the requirements and timelines of this policy.

Quality monitoring activities must include, but are not limited to:

  1. type of transfer/purpose
  2. member(s) involved in the transfer request
  3. regular reviews of the status of each member involved (including identification of members disengaged from care, refusal to participate, eligible for disenrollment, etc.)
  4. completion of required documents (e.g., HCBS Eligibility Determination) to support the member's transfer
  5. access to required data and documents by receiving entity(s)
  6. completing transfers in MAPP HHTS
VII. Policies and Resources