New York State Child Health Plus (CHPlus) Program Home and Community Based Services (HCBS) Benefit Enhancement

  • FAQs also available in Portable Document Format (PDF)

Question and Answers

March 2025

Note: guidance has been updated from 11/2024 Q/A and new questions added.

HCBS CHPlus Eligibility Assessment

1. What is the volume of CHPlus enrollees expected to be eligible for HCBS services under CHPlus?

It is anticipated that the CHPlus population eligible for Home and Community Based Services (HCBS) under CHPlus will be extremely limited, as most children that qualify for HCBS will be Medicaid eligible, unless they qualify for HCBS but do not meet Medicaid requirements.

CHPlus Managed Care Organizations (CHPlus MCOs) must continue to refer CHPlus enrollees seeking HCBS and who may be Medicaid eligible to C-YES to complete the HCBS Eligibility Assessment. If a CHPlus enrollee is referred to C-YES and determined to be Medicaid eligible, they will no longer be eligible for CHPlus and would receive HCBS under the Medicaid 1915c Children's Waiver. These enrollees will be systematically terminated from CHPlus.

CHPlus MCOs are responsible for referring a CHPlus enrollee who is not Medicaid eligible to a Health Home (HH) Entity, with whom they contract, to complete the HCBS Eligibility Assessment.

CHPlus MCOs should contact CHPlus@health.ny.gov with case specific assistance if they cannot determine if an enrollee should be referred to C-YES or the HH Entity, with whom they contract, for the HCBS Eligibility Assessment.

Please note, children who qualify for HCBS under Medicaid who become Medicaid eligible will no longer be CHPlus eligible and cannot opt to remain in CHPlus.

2. How will the HCBS Eligibility Assessment be completed for CHPlus enrollees?

If a CHPlus enrollee is not eligible for Medicaid the CHPlus MCO should refer the enrollee to a contracted HH Entity to complete the HCBS Eligibility Assessment.

The HCBS Eligibility Assessment for CHPlus will follow the same process as the Medicaid 1915c Children's Waiver Program. The CHPlus enrollee must be at risk of institution or leaving an institution level of care for the HCBS Eligibility Assessment to be conducted. In-person requirements are the same in CHPlus as Medicaid.

Once there is a determined risk of institution, the assessor would collect information and documentation to support a Target Population of Serious Emotional Disturbance, Medically Fragile, Medically Fragile Developmental Disability, or Developmental Disability and in Foster Care, risk factors, and functional criteria.

The CHPlus HCBS eligibility worksheets must be utilized by the HH Entity contracted with the CHPlus MCO to conduct the HCBS Eligibility Assessment.

In addition to the instructions on the scoring sheets, information regarding the HCBS Eligibility Assessment process can be found here: Children's Home and Community Based Services (HCBS) Waiver Eligibility and Enrollment Policy.

Once a CHPlus enrollee is determined eligible for HCBS, the CHPlus MCO can provide Case Management/Care Coordination internally, or they can contract with the HH Entity for this service.

HCBS Eligibility Assessment Process for CHPlus Enrollees who are not eligible for Medicaid:

  1. CHPlus MCO refers a CHPlus enrollee who is not otherwise eligible for Medicaid to a HH Entity, with whom they contract, to complete the HCBS Eligibility Assessment.
    • Please note, CHPlus MCOs are responsible for distributing the CHPlus HCBS eligibility worksheets, and associated forms, and the CHPlus HCBS Licensed Practitioner of the Healing Arts Attestation to any HH Entity with whom they have a contract.
  2. HH Entity will complete the following:
    1. Initial HCBS Eligibility Assessment using the assessment tools and forms provided by the CHPlus MCO and any information provided by the CHPlus MCO and/or the CHPlus enrollee's providers.
      • The HH Entity may delegate this task to Care Management Agencies in their network if included in the negotiated contract with CHPlus MCO.
    2. Compile documentation of the HCBS Eligibility Assessment outcome and need for HCBS to be sent back to CHPlus MCO.
    3. Refer child to HCBS provider(s) once the child/youth is found eligible for HCBS.
      • The CHPlus HCBS Referral Form should be completed to make a referral.
      • The entity responsible for filling out the CHPlus HCBS Referral Form depends on the contract agreement between the CHPlus MCO and the HH Entity. Although HCBS providers who are designated by the Department of Health (DOH) under the Children's Waiver are eligible to contract with the CHPlus MCOs to provide HCBS to CHPlus enrollees, they will not use IRAMS to receive referrals for CHPlus enrollees.
    4. Provide Case Management or Care Coordination for the CHPlus enrollee receiving HCBS.
      • HH Entity will only provide this service if included in the negotiated agreement between the CHPlus MCO and the HH Entity for CHPlus HCBS.
    5. Annual HCBS Eligibility Assessment
      • If CHPlus enrollee is not being case managed by a HH Entity, the CHPlus MCO will need to contact the HH Entity three months prior to annual HCBS Eligibility Assessment due date, to begin the HCBS Eligibility Assessment, if applicable due to child's continued risk of institution, need for HCBS, and choice of the child/youth/family.
3. Are CHPlus enrolled children now eligible for HH Care Management (HHCM)? Will CHPlus kids be eligible for HH enrollment? Will the members be able to be served by HH?

HH Care Management is not being added to the CHPlus benefit package. CHPlus children are not eligible to be enrolled in the HH.

HH Entity MCO HCBS Contracts

4. Are there any guidelines HHs and MCOs should follow for adding CHPlus HCBS to their contracts?
  1. Amended ASA is to specify that the CHPlus MCO is contracting with the entity that operates the HH and that the services are to be provided by that entity.
    1. HHs may not enroll CHPlus members into HHs, but they may use their expertise and infrastructure to provide HCBS Eligibility Assessment and associated Care Coordination services for CHPlus members referred to them from a CHPlus MCO, covered under the contract.
  2. MCOs and HH Entities are to negotiate reimbursement rates for the completion of the HCBS Eligibility Assessment and associated Care Coordination services (if the MCO elects to contract for associated Care Coordination services). Associated Care Coordination services include:
    1. Sharing results of the initial HCBS Eligibility Assessment (and subsequent annual reassessments) with the MCO
    2. Linking the Child/Youth to the HCB services that the CHPlus MCO has approved.
  3. MCOs and HH Entities are to develop workflows for information transfer and payment
  4. The content and integrity of the HCBS Eligibility Assessment process used for CHPlus should be consistent across the CHPlus and Medicaid line of business.
5. Is the HH Statement and Certification DOH 5060 Form required to be submitted with the CHPlus ASA?

Yes.

6. How should the 5060 Form be completed as some of the sections of the DOH 5060 Form are not applicable for the CHPlus HCBS services.

The DOH Bureau of Managed Care Certification and Surveillance (BMCCS) suggests the following when completing the 5060 Form:

  • Section A.1. Check one applicable box, "Amendment of existing contract" or "Template" may be the most applicable.
  • Section C1.If the agreement is an amendment, the Key Contract Provisions should already be incorporated within the MCO's original HH ASA, therefore Key Contract Provisions are not required to be submitted again. Additionally, many of the Contract Provisions are not applicable to the CHPlus/HCBS Eligibility Assessment criteria.
  • Section C. 2.Complete only sections applicable.
  • Section C. 3. Identify location of the additional clauses below if included in Agreement: #22. Additional provisions or appendices are also an option if the MCO's ASA includes an appendix or addendum with the ASA.
  • Section D. Financial Arrangements between MCO and HH Entity Category may be modified as applicable.
7. What is the HH ASA submission process?

The agreement and DOH 5060 Form should be submitted to the BMCCS mailbox at contract@health.ny.gov. Upon receipt, the agreement will be catalogued and reviewed for approval with agency partners.

8.Are Standard Clauses required with the HH CHPlus ASA template?

No. The MCO agreement that is being agreed upon with the HH Entity is NOT considered a Provider Agreement. It is an Administrative HH Entity Services Agreement and as such, the provider standard clauses are not applicable.

9. Are there designated rates for the performance of the CHPlus HCBS Eligibility Assessment?

The CHPlus MCO and HH Entity shoulf negotiate rates or any other provisions within the MCO's template.

The HCBS provided under CHPlus by HCBS providers shall be reimbursed in accordance with government rate-setting methodology (Children's Waiver Rates posted here).

HCBS Providers

10. Do CHPlus MCOs need to have a separate contract for CHPlus HCBS services, if they are already contracted with the MCO under Medicaid for HCBS?

Per the CHPlus contract, CHPlus MCOs shall provide all health care services to CHPlus enrollees through provider agreements in accordance with the terms of the CHPlus contract. Providers who already contract with an MCO for the Medicaid line of business should reach out to the MCO if they wish to participate with CHPlus.

11. HCBS providers are designated to provide these services in Medicaid, is CHPlus to identify HCBS providers?

CHPlus will rely on the Medicaid designation to identify qualified in good standing providers delivering HCBS.

HCBS providers who are designated and in good standing under the Children's Waiver are eligible to contract with CHPlus MCOs to provide HCBS to CHPlus enrollees.

Designated providers can be found here: Children and Family Treatment and Support Services/Home and Community Based Services (ny.gov)

The CHPlus MCOs should verify with the HCBS designated provider if they are in good standing and not on a Corrective Action Plan and or Referral Hold with DOH, prior to contracting with HCBS providers. If the CHPlus MCO has any questions about an HCBS provider designation or standing, please reach out to BH.Transition@health.ny.gov.

12. What notifications have been provided to the field (providers of service) regarding the CHPlus enrolled children being eligible for HCBS?

CHPlus MCOs are responsible for providing guidance and instructions to their contracted providers in their networks on the administration of the CHPlus HCBS benefit.

Billing for HCBS

13. Is the state going to utilize the same R/RE (K)-Codes to indicate that the

child/youth is eligible for HCBS or enrolled in the Children's Waiver? How will the MCO receive the RRE K codes for CHPlus? If RRE codes aren't utilized, is there an alternative billing/coding methodology that will be utilized to indicate HCBS or how a child is enrolled in the Children's Waiver?

CHPlus does not use RR/E K-codes. CHPlus MCOs must provide billing instructions to their contracted HCBS providers. HCBS provided under CHPlus shall be reimbursed in accordance with government rate-setting methodology (Children's Waiver Rates posted here).

For CHPlus enrollees who are not eligible for Medicaid, HCBS benefits will be provided through the CHPlus MCOs, not under the Medicaid 1915c Children's Waiver. Children who may be Medicaid eligible should continue to be referred to C-YES. Please see additional information in question 1.

14. If child is with a HH, who pays for HH services?

HH Care Management is not being added to the CHPlus benefit package as it is a Medicaid service and children/youth who are eligible for Medicaid cannot remain in CHPlus.

15. Please confirm if HCBS will be billed back to the State via eMedNY billing? If yes, what ID# should be utilized, since CHPlus members do not have a Medicaid ID/CIN (which is a required field for pass through billing)?

No, these services will not be billed back to eMedNY as pass-through payments for CHPlus enrollees. CHPlus capitation payments were previously adjusted to reflect the expanded scope of benefits.

16. How will HCBS Eligibility Assessments be billed by the HH for CHPlus? Does DOH intend to publish a rate, or will this be left up to each MCO/HH to negotiate? Is the rate of reimbursement to HH or designated providers for completing the assessments going to mirror the rate currently being paid for by the Medicaid line of business?

DOH will not be providing specific instructions to CHPlus MCOs on how to configure their billing systems for HCBS Eligibility Assessments. CHPlus MCOs are to negotiate with the HH Entity for agreed upon rates for HCBS Eligibility Assessments and associated Care Coordination (if CHPlus MCO is contracting for Care Coordination).

CHPlus MCOs should communicate billing instructions to their contracted providers and any HH Entity with whom they contract.

17. HH and HCBS providers are concerned about billing as they would need to set up new billing systems/processes to claim services outside of Medicaid/EMEDY.

For CHPlus enrollees who are not eligible for Medicaid, HCBS benefits must be provided through the CHPlus MCOs and their contracts with HH Entities and designated HCBS providers. CHPlus MCOs are responsible for communicating billing processes to the HH Entities, with whom they contract, and HCBS providers.

HCBS Benefit Coordination

18. Can CHPl u s MCOs require authorizations instead of notifications for CHPlus HCBS? Will MCOs be allowed to implement prior authorization or other forms/paperwork? Will the requirements on the number of units that MCOs are required to approve apply to CHPlus if MCOs are not permitted to do initial authorizations based on medical necessity.

DOH will not be providing specific instructions to MCOs on how to configure their systems related to utilization management.

To the extent that MCOs also have a Medicaid line of business and are covering these services for Medicaid-enrolled children, it would be appropriate and acceptable for MCOs to configure CHPlus utilization management in a similar way.

CHPlus MCOs should work with providers to help them understand the CHPlus MCO's requirements for prior authorization and other requirements for each service.

19. Is any benefit excluded?

The CHPlus HCBS benefit will mirror what is approved for coverage in Medicaid under the 1915c Children's Waiver, without exclusions. Please note, Environmental and Vehicle Modifications and Adaptive and Assistive Technology will remain in the CHPlus benefit matrix even after they are carved out of the Medicaid Managed Care benefit package. Systems regarding the 1915c Children's Waiver will not be utilized for CHPlus enrollees receiving HCBS, such as but not limited to: IRAMS HCBS Referral Portal, the Uniform Assessment System (UAS), or the Financial Management Service (FMS) for modifications.

20. Can you advise if Environmental Modifications, Vehicle Modifications, and Adaptive and Assistive Technology will be arranged by Children's HH of Upstate New York (CHUNNY) and paid for by Financial Management Services (FMS) for CHPlus effective 1/1/25 like Medicaid?

CHPlus MCOs will be responsible for the administration of Environmental and Vehicle

Modifications and Adaptive and Assistive Technology services. This will notbe arranged by the FMS and will not be paid for by FMS for CHPlus.

21. Can you provide clarification specifically related to the Non-Medical Transportation services under HCBS for CHPlus. For Medicaid members, The MMCP is responsible for approving the Person-Centered POC and for forwarding the completed Grid to DOH's Medicaid Transportation Manager. These services will be paid fee-for-service for eligible children/youth, regardless of whether the child/youth is enrolled in Medicaid Managed Care. Can the Department provide guidance in relation to this benefit and the MMCP's responsibilities for CHPlus members?

CHPlus MCOs will be responsible for the administration of Non-Medical Transportation.

22. Under the CHPlus Benefit Matrix effective January 1, 2025, shared by CHPlus on November 1, 2024, the 3rd column under Level of Coverage, it states in the sentence, "Home Health Aides, Personal care, Chores", which under Medicaid, this is Personal Care Services. In the bulleted list of HCBS services, we do not see Personal Care mentioned at all, please clarify.

This is clarified in CHPlus benefit matrix distributed 3/72025.

23. How will MCOs identify CHPlus members eligible for HCBS? Is there a mechanism to identify a CHPlus member receiving HCBS services on a transaction using specific codes, like Medicaid today (RRE codes)?

CHPlus MCOs should contact CHPlus@health.ny.gov with case specific assistance if they cannot determine if an enrollee should be referred to C-YES or the HH Entity with whom they contract for the HCBS Eligibility Assessment.

24. What is the best approach for MCOs to update their CHPlus Subscriber Agreements? There have been several benefit updates since last revised.

As previously indicated, the DOH CHPlus Program will be issuing a model Member Handbook to MCOs shortly which will incorporate the HCBS benefit.

25. Can DOH please clarify whether children/youth who have CHPlus should have always been referred to Children and Youth Evaluation Services (C-YES) for LOC assessment if they needed HCBS to go through the Family of One process and obtain Medicaid to then receive waiver/HCBS services?

CHPlus enrollees who are at risk of institutionalization and who may be Medicaid eligible must continue to be referred to C-YES for the HCBS Eligibility Assessment and the Medicaid determination. This process is not changing.

If a CHPlus enrollee is determined to be Medicaid eligible after being referred to C-YES, they will no longer be eligible for CHPlus, and will be systematically terminated from CHPlus, and would receive HCBS under the Medicaid 1915c Children's Waiver.

For CHPlus enrollees who are not eligible for Medicaid, and need an HCBS Eligibility Assessment under CHPlus, the CHPlus MCO will refer these enrollees to an HH Entity, with whom they contract, to complete the HCBS Eligibility Assessment.

The HH Entity should only be completing an HCBS Eligibility Assessment for a CHPlus enrollee who has been referred to them by a CHPlus MCO.

If the HH Entity has a question regarding the CHPlus enrollee's eligibility for HCBS under the Medicaid 1915c Children's Waiver or CHPlus, they should contact the CHPlus MCO in which the child is enrolled. The CHPlus MCO will be able to advise if the child should be referred to C-YES or if the HH Entity should complete the HCBS Eligibility Assessment.

26. How does this impact children who are currently enrolled in Medicaid under "Family of One" budgeting, after having been determined eligible for Children's Waiver enrollment.

An expansion to the CHPlus benefits package does not have a bearing on a child's Medicaid eligibility.

Not all CHPlus enrollees will be eligible for HCBS under CHPlus: only those CHPlus enrollees meeting HCBS eligibility criteria who are not eligible for Medicaid are eligible for HCBS under the CHPlus program.

Children who are eligible for Medicaid (including under "Family of One" criteria) are not eligible for CHPlus and cannot opt to remain in CHPlus.

27. On what platform are the HH or designated providers going to utilize to provide the assessments to the MCOs?

HH Entities will not use the Uniform Assessment System (UAS) to conduct the HCBS Eligibility Assessment or IRAMS to send HCBS referrals for CHPlus enrollees. The CHPlus HCBS Eligibility Worksheets, and associated forms, the LPHA Attestation Form, and CHPlus HCBS referral forms to HCBS providers have been shared with the CHPlus MCOs who are responsible for sharing and communicating this information with any HH Entity with whom they contract.

28. CHPlus families have indicated they do not want to be directed to C-YES and then enroll in Medicaid as they want to remain in CHPlus and keep their same providers.

CHPlus enrollees who need HCBS who may be eligible for Medicaid must continue to be referred to C-YES for the HCBS Eligibility Assessment and Medicaid determination. This process is not changing. If a CHPlus enrollee is determined to be Medicaid eligible after being referred to C-YES, they will no longer be eligible for CHPlus and would receive HCBS under the Medicaid 1915c Children's Waiver.

Families cannot not opt to keep their child enrolled in CHPlus if the child becomes Medicaid eligible. Medicaid eligibility makes the child ineligible for CHPlus.

29. What is the process for disenrolling a CHPlus enrollee from HCBS if they are no longer determined to meet HCBS Eligibility requirements at the Annual Eligibility Assessment?

Upon annual HCBS Eligibility Assessment if a CHPlus enrollee no longer meets criteria for eligibility for HCBS, the HH Entity would submit documentation to the CHPlus MCO, as described in the process outlined in number 2. The CHPlus MCO would communicate this information to the CHPlus enrollee using the appropriate CHPlus Service Authorizations Request Template, pursuant to ADM 73. The CHPlus MCO or HH Entity would then inform the HCBS providers, and other involved providers, as appropriate of the disenrollment from HCBS.

CHPlus HCBS Q/A 3.2025