19ADM-01 - Community First Choice Option (Attachment 4)

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Placement and Maintenance of CFCO RR/E Code – LDSS

Scope

The intent of the job aid is to provide the Local Departments of Social Services (LDSSs) with detailed system instructions to be utilized when assisting an individual with Community First Choice Option (CFCO) eligibility determination, determining service authorization pathway, and placement of the CFCO Recipient Restriction Exception (RR/E) code for the mandatory CFCO services. The job aid also contains general information about CFCO system instructions.

Note: This job aid is not intended for assistance with an individual enrolled in a Managed Care Organization (MCO). As stated in 19 OHIP/ADM–01, the LDSS is responsible for referring MCO enrollees to their respective MCO for CFCO eligibility determination and CFCO service authorization.

Two (2) unique identifiers (Recipient Restriction Exception (RR/E) codes) for individuals determined to meet the CFCO eligibility criteria have been added to the eMedNY system. The new Client Restriction Codes are "CF" and "CO" and contain the following system attributes:

CF: Community First Choice Option (Non–OPWDD)

  • Short Description: "CFCO"
  • Long Description: COMMUNITY FIRST CHOICE OPTION (Non–OPWDD)

CO: Community First Choice Option (OPWDD)

  • Short Description: "CFCO–OPWDD"
  • Long Description: COMMUNITY FIRST CHOICE OPTION (OPWDD)

With the addition of the CF and CO RR/E codes, eMedNY system edits were created based on CFCO criteria. These edits include:

  • Specific RR/E codes cannot co–exist with a "CF" or "CO" (RR/E to RR/E Conflict);
  • Specific RR/E codes can only exist with a "CF" or a "CO" based on populations;
  • Only specific Medicaid Eligibility Coverage Codes that meet the CFCO Medicaid eligibility are allowed to co–exist with a CFCO RR/E code; and
  • Begin Date for CFCO RR/E code cannot be prior to April 1, 2018.

The LDSS is responsible for the identification of CFCO eligible individuals (not enrolled in MCOs) and placement and maintenance of the CF RR/E in eMedNY for their respective populations, which also includes Medicaid Advantage enrollees. The process for the LDSS to have the CF RR/E code added or updated to an individual´s eligibility file is completed in eMedNY.

Individuals seeking enrollment in the Nursing Home Transition and Diversion (NHTD) or Traumatic Brain Injury (TBI) waivers must meet the nursing facility level of care to qualify for enrollment into the waiver. Upon receipt of the Notice of Decision (NOD) Authorization from the Regional Resource Development Center (RRDC), the LDSS is responsible for placing the waiver RR/E code of 60 or 81 on the client´s file. In addition, the LDSS will now add the CF RR/E code if the waiver recipient meets the CFCO eligibility criteria.

For recipients already established in the NHTD and TBI waivers (RR/E 60/81 code), the LDSS is responsible for determining the CFCO eligibility and assigning the CF RR/E code to identify the waiver participant as eligible for CFCO services.

Once the waiver recipient´s file has been updated with the correct waiver and CFCO RR/E code, the individual should be directed back to the RRDC for service authorization, unless they are requesting a State Plan service that is not included in the NHTD/TBI waiver programs.

For Office for People With Developmental Disabilities (OPWDD) individuals (CO RR/E), the LDSS is responsible for utilizing this job aid to identify and appropriately refer the individual to the applicable contact entity. Individuals are coded CO when determined to meet the Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) level of care criteria, meet all other CFCO eligibility criteria, and are approved to receive at least some CFCO services from providers overseen by OPWDD. Individuals coded CO may also receive some CFCO services from Department of Health (DOH) providers e.g. Personal Care Services (PCS) or Consumer Directed Personal Assistance Program (CDPAP). OPWDD performs a CO RR/E upload on a monthly basis.

Additionally, MCOs and 1915 (c) waiver programs will contact the LDSSs regarding Nursing Home (N1 – N9) RR/E to CFCO RR/E conflicts. The LDSS will be responsible for reviewing N1 – N9 RR/E codes that conflict with CFCO RR/E codes and make the final determination regarding the existing N1 – N9 RR/E code.

Contents

Scope
Activity Steps: CFCO Eligibility Criteria Determination
Activity Steps: Does Meet CFCO Eligibility Requirements – FFS Only Individual
Activity Steps: Does Meet CFCO Eligibility Requirements – OPWDD
Activity Steps: Does Meet CFCO Eligibility Requirements – Waiver – Non OPWDD Individual
Activity Steps: CF RR/E upload (CFCO Eligible) – Non OPWDD Individual
Activity Steps: Does Not Meet CFCO Eligibility Requirements
Activity Steps: CFCO RR/E Maintenance (CFCO Ineligible)

Activity Steps: CFCO Eligibility Criteria Determination

When an individual (not enrolled in a MCO) contacts the LDSS seeking CFCO services, these Activity Steps are required for determining and re–assessing for CFCO eligibility, referring the individual to the appropriate contact entity for CFCO assessment, and CFCO service authorization.

Reminder: The LDSS will refer all individuals enrolled in MMC or MLTC to their respective MCO for CFCO eligibility determination and CFCO service authorization.

  1. Review the individual´s Medicaid eligibility and compare to the table below.
    Note: The Department of Health (DOH) made the determination that "06" Provisional Coverage does not meet the CFCO Medicaid Eligibility criterion. However, "06" will be systemically allowed with a "CF" or "CO" RR/E code to eliminate the additional burden of repetitive maintenance for this code. The LDSS will not have to end date a "CF" RR/E code during the individual´s provisional coverage.
    1. If the individual does not have active Medicaid, proceed to Step 2.
    2. If the individual has active Medicaid, and their coverage code is listed within the table below, proceed to Step 3.
    3. If the individual has active Medicaid, but their Medicaid coverage code is not listed within the table below, proceed to Activity Steps: Does Not Meet CFCO Eligibility Requirements.
    Medicaid Coverage Code Medicaid Coverage Code Name
    01 Full Coverage
    02 Outpatient Coverage
    06 Provisional Coverage
    10 All Services Except Nursing Facility Services
    11 Aliessa Aliens
    16 Safety Net
    19 Community Coverage with CBLTC
    21 Outpatient Coverage with CBLTC
    23 Outpatient Coverage with no Nursing Facility Services
  2. Determine individual´s enrollment path (No active Medicaid).
    1. If the individual is seeking CFCO and MLTC enrollment, refer the individual to the Conflict Free Evaluation and Enrollment Center (CFEEC) at 1–855–222– 8350. The LDSS will continue to determine Medicaid eligibility. No further action is needed at this time.
    2. If it appears the individual might benefit from OPWDD services, the LDSS will refer the individual to the Developmental Disabilities Regional Office (DDRO). If there are indications of a potential mental health diagnosis, the LDSS will refer the individual to the Office of Mental Health (OMH). The LDSS will continue with Medicaid eligibility determination. Once a determination has been, return to Step 1.
    3. If the individual is seeking a CFCO service only, determine Medicaid eligibility. Once Medicaid eligibility is determined, return to Step 1.
  3. Determine if the individual"s Medicaid eligibility was determined using Spousal Impoverishment post–eligibility rules, a Special Income Standard for Housing Expenses, or Family of One budgeting for a child participating in a Home Community–Based Services (HCBS) waiver.
    1. If the individual´s Medicaid eligibility was determined without the use of Spousal Impoverishment post–eligibility rules, a Special Income Standard for Housing Expenses, or Family of One budgeting for a child participating in a HCBS waiver, proceed to Step 4.
    2. If the individual´s Medicaid eligibility was determined with the use of Spousal Impoverishment post–eligibility rules, a Special Income Standard for Housing Expenses, or Family of One budgeting for a child participating in a HCBS waiver, proceed to Activity Steps: Does Not Meet CFCO Eligibility Criteria.
  4. Determine the individual´s enrollment path (CFCO Medicaid Eligible).
    1. If the individual is on the mandatory path for enrollment in Managed Care and non–dual, refer them to New York Medicaid Choice (NYMC) at 1–800–505– 5678 to enroll in a MCO. No further action is needed.
      Note: The MCO is responsible for the CFCO eligibility determination of its enrollees.
    2. If the individual is on the mandatory path for enrollment in Managed Care and dual, refer the individual to the NYMC Enrollment Broker at 1–888–401–6582. No further action is required.
      Note: The MCO is responsible for the CFCO eligibility determination of its enrollees.
    3. If the individual is not on the mandatory path for enrollment in Managed Care, proceed to Step 5.
  5. Determine if the individual meets the CFCO residential requirement as specified in 19 OHIP/ADM–01.
    1. If the individual meets the CFCO residential requirement, proceed to Step 6.
    2. If the individual does not meet the CFCO residential requirement, proceed to Activity Steps: Does Not Meet CFCO Eligibility Requirements.
  6. Review the individual´s eligibility file for active N1 – N9 RR/E code during the applicable time frame.
    Note: CFCO RR/E codes cannot systematically co–exist with a current N1 – N9 RR/E code. An individual residing in a nursing home does not meet the CFCO residential requirement. The LDSS must follow their existing process for the review and determination of the existing N RR/E codes.
    1. If the N RR/E code is active and during the applicable timeframe, the code will need to be reviewed and a determination made.
      1. If the individual has been discharged from the nursing facility, the LDSS must follow their existing process to end date the N RR/E code in eMedNY. Proceed to Step 7.
        Note: The removal of the N RR/E code MUST not delay CFCO service authorization if the consumer is found eligible for CFCO services.
      2. If the N RR/E code was inappropriately placed on the individual´s file, the N RR/E code must be inactivated. Proceed to Step 7.
      3. If the determination is made that the individual does reside in a nursing home, the individual does not meet the CFCO residential requirement. Proceed to Activity Steps: Does Not Meet CFCO Eligibility Requirements.
    2. If no active N RR/E code is identified on the individual´s eligibility file during the applicable time frame, proceed to Step 7.
    Conflict RR/E Code RR/E Description RR/E Conflict Review
    N1 REGULAR SNF RATE – MC ENROLLEE Does NOT
    Meet CFCO
    Residential
    Requirement
    N2 SNF AIDS – MC ENROLLEE
    N3 SNF NEURO–BEHAVIORAL – MC ENROLLEE
    N4 SNF TRAUMATIC BRAIN INJURY
    N5 SNF VENTILATOR DEPENDENT – MC ENROLLEE
    N6 MLTC ENROLLEE PLACED IN SNF
    N7 NH BUDGET APPROVED
    N8 TRANSFER PENALTY PERIOD DHPCO
    N9 NH RESIDENT PENDING NH ELIGIBILITY DETERMINATION
  7. Review the individual´s eligibility file for an active 38, 48, or 49 RR/E code during the applicable timeframe.
    Note: A CF or CO code cannot systematically co–exist with an existing 38, 48, or 49 RR/E codes.
    1. If the 38, 48, or 49 RR/E code is active and during the applicable timeframe, contact the OPWDD´s Revenue Support Field Office (RSFO) to determine if the coding is accurate.
      1. If the RSFO determines the 38,48, or 49 is not accurate, the RSFO updates the applicable RR/E code and informs the LDSS. Once completed, proceed to Step 8.
        Note: The removal of the RR/E code MUST not delay CFCO service authorization if the consumer is found eligible for CFCO services.
      2. If the RSFO determines the 38,48, or 49 is accurate, the person is not eligible for CFCO. Proceed to Activity Step: Does Not Meet CFCO Eligibility Requirements.
    2. If no active 38, 48, or 49 RR/E code is identified on the individual´s eligibility file during the applicable time frame, proceed to Step 8.
    Conflict RR/E Code RR/E Description RR/E Conflict Review
    38 ICF/DD RESIDENT Does NOT
    Meet CFCO
    Residential
    Requirement
    48 SUPPORTIVE IRA´S AND CR´S
    49 SUPERVISED IRA AND CR
  8. Review the individual´s eligibility file to determine if the individual´s ICF/IID level of care (LOC) has already been determined by OPWDD, or if the individual should be referred to OPWDD for a LOC determination.
    Note: For Medicaid FFS individuals identified as OPWDD, the LDSS will not be responsible for the LOC determination, notifying the individual of the CFCO determination, and the placement of the CO RR/E code on the individual´s eligibility file in eMedNY.
    1. If the individual has an active RR/E code of 95 during the applicable timeframe, proceed to Activity Steps: Does Meet CFCO Eligibility Requirements – OPWDD
    2. If the individual does not have an active 95 RR/E code and you suspect the individual may benefit or qualify for OPWDD services, contact (telephone call) the applicable DDRO.
      1. https://opwdd.ny.gov/opwdd_contacts/ddro
    3. If the individual does not meet the criteria listed in 8.a – 8.b, proceed to Step 9.
  9. Review the individual´s eligibility file to determine if the individual is enrolled in a waiver program.
    1. If the individual has an active RR/E code (within the current date range) in the table below, contact the appropriate waiver program to determine if the individual meets the CFCO eligibility requirements.
      1. If the waiver program states that the individual meets the CFCO LOC requirement, proceed to Activity Steps: Does Meet CFCO Eligibility Requirements – Waiver – Non OPWDD Individual.
      2. If the waiver program states that the individual does not meet the CFCO LOC eligibility requirement, proceed to Activity Steps: Does Not Meet CFCO Eligibility Requirements.
    2. If the individual does not have an active RR/E code in the table below, proceed to Step 10.
    RR/E Code RR/E Description CF / CO Contact Entity
    60 NH TRANSITION & DIVERSION WAIVER CF Regional Resource Development Centers (RRDC)
    62 CAH I CLIENT CF LDSS
    63 CAH II CLIENT CF LDSS
    72 BRIDGES TO HEALTH SERIOUSLY EMOTIONALLY DISTURBED (B2H) CF Office of Children and Family Services (OCFS)
    73 BRIDGES TO HEALTH DEVELOPMENTALLY DISABLED (B2H DD) CF Office of Children and Family Services (OCFS)
    74 BRIDGES TO HEALTH MEDICALLY FRAGILE (B2H MEDF) CF Office of Children and Family Services (OCFS)
    81 TBI ELIGIBLE CF Regional Resource Development Centers (RRDC)
  10. Determine if a LOC determination has been completed within the last six months.
    1. If a LOC assessment has been completed within the last six months, and the LOC score on the Community Assessment within the Uniform Assessment System for New York (UAS–NY) is five or greater, the individual meets the CFCO LOC requirement. Proceed to Activity Steps: Does Meet CFCO Eligibility Requirements – FFS Only Individual.
    2. If a LOC assessment has been completed within the last six months, and the LOC score on the Community Assessment within the UAS–NY is not five or greater, the individual does not meet the CFCO LOC requirement. Proceed to Activity Steps: Does Not Meet CFCO Eligibility Requirements.
      Note: In the event of a change in the consumer´s condition, a new LOC determination may be needed prior to the six–month reassessment date.
    3. If a current LOC assessment does NOT exist, or has not been completed within the last six months, refer the individual to the CFEEC for a LOC determination.
      1. If CFEEC determines the LOC score on the Community Assessment within the UAS–NY to be a five or greater, the individual meets the CFCO LOC requirement. Proceed to Activity Steps: Does Meet CFCO Eligibility Requirements – FFS Only Individual.
      2. If CFEEC determines the LOC score on the Community Assessment within the UAS–NY is not five or greater, the individual does NOT meet the CFCO LOC requirement. Proceed to Activity Steps: Does Not Meet CFCO Eligibility Requirements.
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Activity Steps: Does Meet CFCO Eligibility Requirements – FFS Only Individual

The Activity Steps in this section are for individuals determined to meet all CFCO eligibility criteria. The information presented is at a very high level. The LDSS must refer to 19 OHIP/ADM–01 for complete details.

  1. Inform the individual that CFCO requires a LOC reassessment bi–annually (unless the FFS case has been authorized for annual reassessment).
  2. Determine the CFCO service authorization path. Follow existing LDSS process.
  3. Update the plan of care to include the CFCO eligibility determination.
  4. Determine that a Physician´s Order is on file and active, if applicable.
  5. Proceed to Activity Steps: CF RR/E upload (CFCO Eligible) – Non OPWDD Individual.
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Activity Steps: Does Meet CFCO Eligibility Requirements – OPWDD

Reminder: OPWDD will upload the CO RR/E code to the individual´s file based upon the information available via an OPWDD monthly report. CFCO service authorization MUST not be delayed due to placement of the CO RR/E code.

  1. Review the individual´s eligibility file to determine if the individual is enrolled in a Care Coordination Organization/Health Home (CCO/HH).
    1. If the individual has an active I5 to I9 RR/E code, s/he is enrolled in a CCO/Health Home. The following steps must be completed:
      1. For CFCO services not authorized by the DDRO (e.g., Personal Care), the LDSS is responsible for service authorization.
        Note: For individuals enrolled in a CCO/Health Home, the CCO/Health Home maintains the individual´s Plan of Care. The LDSS must consult and collaborate with the CCO/Health Home where appropriate.
      2. For CFCO services authorized by the DDRO, the LDSS must make a referral to the DDRO for service authorization.
        Note: OPWDD authorization of CFCO services will commence July 1, 2019.
  2. If the individual has an active 95 RR/E code and does not have an active A1 or A2, I5 – I9 or 73 RR/E code, s/he is not enrolled in a CCO/Health Home. Contact (telephone call) the DDRO to refer the individual to a CCO/Health Home, which will screen for the appropriateness of CFCO services, begin the service/care planning process, and coordinate with appropriate service authorizing entities.
    1. https://opwdd.ny.gov/opwdd_contacts/ddro
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Activity Steps: Does Meet CFCO Eligibility Requirements – Waiver – Non OPWDD Individual

  1. Follow existing process(es) to authorize the CFCO services that are not included in the Waiver Program (e.g., Personal Care).
  2. For CFCO services authorized by the Waiver Program, the LDSS must make a referral to the appropriate contact entity for service authorization.
  3. Proceed to Activity Steps: CF RR/E upload (CFCO Eligible) – Non OPWDD Individual.
RR/E Code RR/E Description CF / CO Contact Entity
60 NH TRANSITION & DIVERSION WAIVER CF Regional Resource Development Centers (RRDC)
62 CAH I CLIENT CF LDSS
63 CAH II CLIENT CF LDSS
72 BRIDGES TO HEALTH SERIOUSLY EMOTIONALLY DISTURBED (B2H) CF Office of Children and Family Services (OCFS)
73 BRIDGES TO HEALTH DEVELOPMENTALLY DISABLED (B2H DD) CF  
74 BRIDGES TO HEALTH MEDICALLY FRAGILE (B2H MEDF) CF  
81 TBI ELIGIBLE CF Regional Resource Development Centers (RRDC)
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Activity Steps: CF RR/E upload (CFCO Eligible) – Non OPWDD Individual

Prior to placement of the ´CF´ RR/E code, the LDSS is required to review an individual´s eligibility file. The LDSSs will follow their existing process to review an individual´s eligibility file.

  1. Determine if a CO RR/E code is on the individual´s eligibility file in eMedNY.
    1. If a CO RR/E code is on file and needs to be end dated or inactivated prior to placement of a CF, contact the RSFO for review of the CO RR/E code.
      1. If the RSFO responds that the CO RR/E code is correct, no further action is needed.
      2. If the RSFO responds that the CO RR/E is incorrect, the RSFO will end date or inactivate the CO RR/E code as appropriate. Proceed to Step 2.
    2. If a CF is active on the individual´s eligibility file, review the "From Date" and "Thru Date" in eMedNY to determine if information is valid. Update as necessary.
    3. If a CF is not on file, proceed to Step 2.
  2. Upload the CF code to an individual´s eligibility file through the "Add Exceptions" process in eMedNY.
    1. Change Date: Pre–populates
    2. RR/EXC: Select CF– CFCO from the dropdown
    3. Provider ID: Leave Blank
    4. From Date: Enter the date (00/00/0000) the individual was eligible for CFCO.
      Note: Cannot be prior to 04/01/2018
    5. Thru Date: Enter 12/31/9999
    6. Status: 1–Active
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Activity Steps: Does Not Meet CFCO Eligibility Requirements

  1. Discuss with the individual alternative services to meet his/her needs. Services available under an alternate State Plan or waiver authority should be initiated as appropriate, for the individual using existing processes.
  2. Review the individual´s eligibility file for CF or CO RR/E code.
    1. If there is an active CF RR/E code on the individual´s eligibility file, proceed to Activity Steps: CFCO RR/E Maintenance (CFCO Ineligible).
    2. If there is an active CO RR/E code on the individual´s eligibility file, contact RSFO for review of CO RR/E Code. The following information will be needed for the telephone call:
      1. Individuals Name
      2. Date of Birth (DOB)
      3. Client Identification Number (CIN)
      4. Contact information (including authorized representative´s information)
      5. Reason for ineligibility
      RSFO
    3. If there is no active CO or CF RR/E code on the individual´s eligibility file, no further action needed.
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Activity Steps: CFCO RR/E Maintenance (CFCO Ineligible)

It is the responsibility of the LDSS to maintain the CF RR/E codes for their respective population. When it has been identified that an individual is ineligible for CFCO, or no longer eligible for CFCO, the CF RR/E code on the individual´s eligibility file will need to be end dated or inactivated.

  1. Review the "From Date" and the "Thru Date" on the CF RR/E code.
  2. Determine if the CF RR/E code needs to be updated or inactivated.
  3. Update or inactivate the CF RR/E code, as necessary, based on the date the individual was no longer eligible for CFCO services (i.e. date individual entered nursing home).
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