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Children and Family Treatment and Support Services Preparation and Billing

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Subject: Children´s Medicaid Waiver Transition Guidance for Providers

To: Transitioning 1915c Children´s Waiver Providers

This document is intended to clarify key points regarding the transition of services for children currently receiving 1915c Home and Community Based Services (HCBS) waiver services by assisting providers with understanding the transition components and provider activities required for a smooth transition for their children/families.

Key Terms:

HCBS Plan of Care (HCBS POC) Document that describes what services the child is receiving by accessing one of the following waivers today:

  • OMH SED HCBS 1915(c) waiver
  • DOH Care at Home (CAH) I/II 1915(c) waiver
  • OPWDD Care at Home 1915(c) waiver
  • OCFS Bridges to Health (B2H) SED 1915(c) waiver
  • OCFS B2H Medically Fragile 1915(c) waiver
  • OCFS B2H DD 1915(c) waiver

The above Waivers today use the following terms synonymously with HCBS Plan of Care: detailed Service Plans (DSP)-completed by the Health Care Integrators, Service Plans-completed by the Individualized Care Coordinator and Individualized Service Plan (ISP)-completed by the Service Coordinator.

HH Comprehensive Plan of Care - Document that a Health Home care manager uses to outline all the services that a child is receiving (Comprehensive inclusive of 360 view of care which identifies health, behavioral health, community and social supports, specialty services, etc.)

CFTSS Treatment Plan - specifies the amount, duration, and scope of Children and Family Treatment and Support Services (CFTSS) in accordance with the treatment/service plan documented. Treatment/service planning is an active process that engages the child/youth, family/caregiver and collaterals in ongoing review of progress toward goals and objectives that incorporates strengths and preferences of the child/youth and family/caregiver.

Key Milestones
Dates Activity
January 1, 2019 through March 31, 2019 Current 1915c Waiver Case Managers (OCFS HCI, OMH ICC, OPWDD/DOH Case Management) transition their children in waiver to Health Home Care Management
Starting January 1, 2019 3 Children and Family Treatment and Support Services (CFTSS) (State Plan Services) become available for ALL children with Medicaid who meet Medical necessity
  • Other Licensed Practitioner (OLP)
  • Psychosocial Rehabilitation (PSR)
  • Community Psychiatric Supports and Treatment (CPST)
By January 31, 2019 Current HCBS Plan of Care needs to be updated to reflect Crosswalk of current services to Children and Family Treatment and Supports Services
  • Skill building = Psychosocial Rehabilitation
  • Crisis Avoidance, Management & Training AND Intensive In-Home Services = Community Psychiatric Support and Treatment (CPST)
  • Immediate Crisis Response Service and Crisis Response Services = CPST AND/OR Other Licensed Practitioner (OLP). Medical Necessity MUST be documented by a Licensed Practitioner of the Healing Arts (LPHA) recommendation.
February 1, 2019 Current HCBS Waiver services and their rate codes that are transitioning to CFTSS rate codes can no longer be billed
By March 31, 2019 All Transitioning children who will receive Children and Family Treatment and Support Services have a required Treatment Plan AND ALL 1915c HCBS waiver children transition to Health Home Care Management
April 1, 2019 All former waiver rate codes will no longer be active using a date of services of April 1, 2019 or later

January 1, 2019 through March 31, 2019
Current Waiver Case Management (OCFS HCI, OMH ICC, OPWDD/DOH Management) transition their children to Health Home Care Management

Provider Action:During the January 1, 2019 - March 31, 2019 transition period, current 1915c waiver case management providers become Health Home Care Managers and transition children currently in HCBS waiver services to Health Home Care management. During this three-month transition period, the now transitioned Health Home care manager will determine which month to transition which children on their case load based upon the transition steps required (as outlined during in-person 1915c waiver transition training).

All waiver transitioning children MUST transition to Health Home care management no later than March 31, 2019 otherwise the child will lose their HCBS. When a child who is receiving HCBS care/case management transitions to HH Care Management, the child´s current HCBS plan of care (HCBS POC) will be transitioned to a Health Home POC and cross walked to the newly aligned HCB Services to reflect HCB Services available as of April 1, 2019 in the consolidated waiver. While converting the HCBS POC, the HH Care Manager will work with all designated HCBS and CFTSS providers involved with the child´s services to convert the POC to the correctly named services, inclusive of the child´s HCBS that transitioned to CFTSS in January 2019. Therefore, no later than March 31, 2019, all POCs should reflect the services - CFTSS and HCBS - the child is receiving and the respective services the providers are billing under the implemented design.

Each provider will need to ensure that all case managers meet the Health Home care management requirements. All children receiving HCI, ICC or Case management through today´s waiver(s) MUST be transitioned to Health Home Care Management by March 31, 2019 to avoid any disruption in their care management services.

Starting January 1, 2019
OLP, PSR and CPST become available and providers are required to transition children receiving existing waiver services according the crosswalk to CFTSS provided by the State

Provider Action: By January 31, 2019 11:59 pm (New Date for Transitioning Wavier Children to CFTSS) providers must revise the HCBS Plan of Care to update the existing 1915c HCBS waiver service names with the new names of CFTSS where appropriate and complete medical necessity via an addendum/progress note citing new names of services and put it in the case file. January 31, 2019, is also the last day to bill HCBS that crosswalk to OLP, CPST, or PSR. The HCBS Plan of Care may be used as the CFTSS Treatment Plan until March 31, 2018. However, the child does not need to transition to Health Home care management by January 31, 2019 even though their HCBS POC has been updated to reflect the new CFTSS.

Existing OCFS B2H Waiver providers and existing OMH SED Waiver providers will transition children from the waiver services today to the corresponding CFTSS outlined below:

Existing OCFS B2H Waiver Existing OMH SED Waiver CFTSS Services Available on January 1, 2019
Skill Building Skill Building Psychosocial Rehabilitation (PSR)
Crisis Avoidance, Management & Training AND Intensive In-Home Services Intensive In-home Community Psychiatric Supports and Services (CPST)
Immediate Crisis Response Service Crisis Response CPST AND/OR Other Licensed Practitioner (OLP)*

*see transitional billing manual for additional details found here.

Once the Current OMH and OCFS HCBS 1915c Waiver Care Management (ICC or HCI) Providers identifies the services each child needs based on the crosswalk from 1915c waiver to CFTSS and will need to establish medical necessity through a recommendation of services from an approved Licensed Practitioner of the Healing Arts (LPHA).

Medical necessity criteria can be found here.

LPHA Recommendations for CFTSS for Current OMH and OCFS HCBS 1915c Waiver Provider Agencies

As a reminder, to be able to begin providing the new CFTSS, Waiver Care Managers or their Waiver care agencies will need to secure a recommendation from a Licensed Practitioner of the Healing Arts (LPHA) prior to service delivery and billing for CPST and/or PSR. The following are various options for securing a recommendation from an LPHA for the receipt of CFTSS, which were previously provided by current OMH/OCFS Waiver Service Providers.

  1. The child is currently engaged in clinical treatment services with a licensed practitioner in another program, such as a clinic, a day treatment program or under the care of a VFCA and receiving clinical services. The treating clinician (LPHA) can make a recommendation, based on their determination of medical necessity from their work with the child, for rehabilitative services to be provided by the designated CPST/PSR (former Waiver Service Provider) agency.
  2. The Waiver Care Management agency employs a LPHA/ or is a designated OLP provider and already employs a Non-Physician-Licensed Behavioral Health Practitioner (NP- LBHP). The LPHA/NB-LBHP can conduct an assessment and determine medical necessity, recommending the service.
  3. The agency does not yet employ an NP-LBHP (OLP) or the child is not actively engaged in mental health treatment elsewhere, the Waiver care coordinator can either:
    1. Refer the child to a licensed mental health practitioner for an assessment, ongoing treatment and recommendation for rehabilitative services.
    2. Contact another identified treating LPHA, such as a Pediatrician/Primary Care Physician who treating the child or may be providing medication management, to secure a recommendation for rehabilitative services.

It is expected that most of the agencies can employ the above options to transition most, if not all, of their HCBS enrolled children to CFTSS by the required deadline of January 31, 2019. However, in order to assure continuity of care and assure all current HCBS enrolled children get access to the necessary CFTSS starting in January, the State is issuing additional guidance specific to current ICC/HCI Agencies only.

If none of the above options work, or the Wavier ICC/HCI provider cannot secure a LPHA recommendation in the allowable timeframe (by January 31, 2019) using one the strategies outlined, a Waiver program supervisor who also is a licensed LPHA may make the recommendation for a HCBS enrolled and transitioning child only using the guidance below.

A HCBS Waiver supervisor who also a currently licensed LPHA, may make a recommendation for CFTSS services for a HCBS enrolled and transitioning child during the transition period ending January 31, 2019. The recommendation can be made in one of the following ways:

  • A face-to-face clinical verification of functional deficits and service needs of the known Wavier child (serves as supervisor to care manager); or
  • A review of written documentation in the EHR/case file and verification of service needs by the treating Wavier care manager and service providers.

If the above approach is employed, the LPHA written recommendation must include the following statement:

"This written recommendation is solely for the purposes of continuity of care and admission to CFTS services for the current HCBS enrolled and transitioning child."

NOTE: Any future recommendation for CFTS services will require a recommendation by a treating or assessing LPHA. After the transition period ending January 31, 2019, no LPHA recommendations may be made based solely on documentation/record review.

Reimbursement for LPHA Assessments in OMH Licensed Clinics

Beginning January 1, 2019, OLP providers will be able to recommend CFTSS. However, we are also encouraging Children´s waiver providers to work with OMH-licensed clinics to provide the LPHA recommendation by way of initial assessments. Clinics can provide initial assessments for the following children:

  • If the child is currently receiving services from a clinic, the clinic may extend the recommendation without providing or billing for an initial assessment; or
  • If the child is currently receiving services from a clinic, the clinic may determine that another assessment is necessary before making a recommendation. For fee-for-service reimbursement, the assessment for determining CFTSS eligibility will not count toward a child´s limit of three initial assessments per episode of care. The claim will be submitted by the clinic using the usual APG rate code and CPT code (90791 or 90792).
  • If the child is not known to the clinic, the clinic may provide an assessment service (90791 or 90792) to determine if the child should be recommended for CFTSS. The claim will be submitted by the clinic using the usual APG rate code and CPT code (90791 or 90792).
  • Specialty Clinics with the SED rate codes assigned to their provider files may use these rate codes to submit claims directly to fee-for-service Medicaid for initial assessments provided to determine eligibility for CFTSS.
Note: This document can be shared with clinics to inform them of these allowances.

Should providers have any questions regarding the above, please contact the OMH HCBS Wavier Unit at DCFS@omh.ny.gov.

Key Links/Additional Resources

For additional resources, please visit the Provider Resources Website.

Child and Family Treatment and Support Services (CFTSS) links:

Services for Medicaid Managed Care Plans - revised June 20, 2018 (PDF)

The 1915c (Consolidated) Waiver links:

Billing and Coding Manual for the CFTSS and 1915c consolidated services can be found here