Clarification

Children's Waiver Home and Community Based Services (HCBS) Recipient Restriction/Exemption (R/RE) K-Codes for Eligibility and Enrollment

• Clarification also available in Portable Document Format (PDF)

March 28, 2025

To: Health Homes Serving Children, Care Management Agencies, Children and Youth Evaluation Services (C-YES), Medicaid Managed Care Plans (MMCPs) including Mainstream Managed Care and HIV Special Needs Plans, and Children's Home and Community Based Service (HCBS) Providers

HCBS providers must verify the participant's eligibility and enrollment within the Children's Waiver prior to delivering and billing HCB Services, through the established R/RE K-Codes and annual HCBS Eligibility Determination. HCBS providers are expected to check the Incident Reporting and Management System (IRAMS) Referral and Authorization Portal and eMedNY/ePACES prior to service delivery to ensure that the participant's HCBS eligibility determination is up-to-date, and that K-codes are active. HCBS cannot be provided to a participant with an expired HCBS eligibility determination or K-code¹

As announced October 11, 2024, the Department updated how the Children's Waiver R/RE K-Codes are added to an HCBS participant's file. As a result of this update, HCBS K-codes (K1 & K3-K6) associated with Children's HCBS eligibility determinations completed on or after September 16, 2024, will automatically "end date" 365-days after the date of the finalized HCBS Eligibility Determination. The HCBS eligibility determination, once finalized remains valid for 365 days. If HCBS is needed beyond 365 days, a re-assessment must be completed by the Health Home/C-YES care manager. If the HCBS eligibility determination expires, no further HCBS can be provided until another eligibility determination is completed that results in an eligible outcome or a noted pending Fair Hearing with Aid to Continue. Claims for HCBS with dates of service on or after October 11, 2024 provided to a participant with an expired HCBS eligibility determination must be voided.

If a participant is disenrolled from the Waiver prior to the 365-day timeframe, the care manager must contact their Lead Health Home to notify the Department's Capacity Management team to request the K-codes be removed from the participant's file. HCBS cannot be provided to a participant who does not have an active K1 plus K3-6 code on the date of service.

All HCBS participants are required to receive care management either through a Health Home or C - YES. It is the responsibility of the care manager to establish and monitor HCBS eligibility and notify all care team members of updates. HCBS providers and care managers are required to communicate regularly regarding HCBS participants. If an HCBS participant is disenrolled from care management, HCBS can no longer be provided.

Questions related to this announcement can be sent to BH.Transition@health.ny.gov.

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^{1. Note, participants who have been deemed ineligible for HCBS during the annual HCBS re-assessment may request a Fair Hearing and be granted Aid to Continue. If granted Aid to Continue, HCBS provision can continue until the time of the Fair Hearing Decision. If granted Aid to Continue, the participant will appear "eligible" for HCBS in IRAMS. Care Managers must communicate updates about Fair Hearing status to HCBS providers. 1}