Children's Waiver Home and Community Based Services (HCBS) Workflow FAQs

Updated May 1, 2022

• FAQs also available in Portable Document Format (PDF)

#	Topic	Question	State Response
1	General Requirements / Guideline Clarifications	Will the referral process need to be restarted if the Referral for Home and Community Based Services to HCBS Provider Form (Referral Form) is not sent within four (4) calendar days of the HCBS referral request?	It is the goal of the State for HCBS providers and HH CM to build relationships to establish referrals and the first appointment (though phone calls, with the family on the phone, etc.) as soon as possible with the follow up of the Referral Form as outlined in the policy. Therefore, if the referral form is later than 4 days, there would not be a need to re-start the process over again and delay the child/family access to services. The care manager should confirm that a first appointment is still available for the child.
2	General Requirements / Guideline Clarifications	How are Medicaid Managed Care Plans (MMCPs) notified of the first HCBS appointment date?	As outlined in the policy, the first appointment is established with the HCBS provider. The HCBS provider reports the date of the first appointment to the MMCP through the means established between the two entities – can be by phone, secure email, or other.
3	General Requirements / Guideline Clarifications	Will DOH add an area on the referral form to put in the child's address?	The Referral Form has been updated to include the address.
4	POC Requirements / Guideline Clarifications	Do I still need to submit a plan of care (POC) to the MMCP, even if the provider has not yet been identified?	Yes. The POC for a child participating in the Children's Waiver should be updated with the identified services, why the service(s) is needed with initial goals and a title of the service as well as the provider (if known). It is not necessary to immediately identify the specific providers prior to submitting the POC if the child/family has yet to choose a provider or if the referral has been made to an HCBS provider but the provider has yet to determine if they have availability to accept the referral. POCs are to be submitted to the MMCP within 30 days from the HCBS Eligibility Determination regardless of whether the name of the HCBS provider is known to complete all fields. POCs can be updated as more information is known and gathered. The POC should indicate if a referral to provider(s) was made. HCBS providers should be specified in the POC once the HCBS provider is identified.
5	POC Requirements / Guideline Clarifications	Are POC with HCBS -Federal Requirements the same for children as they are for adults?	Yes. Please reference the Person Centered Service Planning Guidelines located here.
6	POC Requirements / Guideline Clarifications	What are the guidelines for authorization of HCBS included in the POC?	Guidelines regarding authorization for units / days of service for HCBS service type can be located in Appendix C of the Children's Home and Community Based Services Provider Manual.
7	POC Requirements / Guideline Clarifications	Should POCs be sent to MMCPs for all Health Home enrollees, or just those in receipt of Children's HCBS?	POCs for children/youth who are enrolled in HCBS need to be sent to the MMCP. POCs for Health Home-only enrollees are typically sent to the MMCP upon the MMCP's request.
8	POC Requirements / Guideline Clarifications	How often should the POC for a child in in receipt of HCBS be updated and submitted to the MMCPs?	For children, the POC must be reviewed and updated, at minimum: during the annual HH CANS-NY assessment and HCBS/LOC re-determination (if different time frame); and when there is a significant life event. The POC must be updated, at minimum, annually and any time there is a change to the POC services, providers and/or needs of the member. When there is a change to the POC that is specific to services, providers and/or needs of the member, the POC must be sent to the MMCP.
9	POC Requirements / Guideline Clarifications	What constitutes a 'significant change' that would warrant an update to the POC outside of the 6-month timeframe?	Examples of significant changes include admission to a higher level of care or being discharged from a higher level of care. Significant changes in a child's functioning can include increase or decrease of symptoms, and/or a new diagnosis. Further information can be located on page 5 here
10	POC Requirements / Guideline Clarifications	What is other documentation and/or reporting requirements that need to be shared with MMCPs, outside of the POC for children in receipt of HCBS?	The MMCP must be notified of the first appointment. Upon receipt of the HCBS Authorization and Care Manager Notification Form, the MMCP may ask HCBS providers for additional information regarding the services being provided to the child/youth. The MMCP should be notified of any significant change. The contract between the MMCP and the HH or the MMCP and the provider may require additional reports to support oversight of the services delivered to enrollees and/or meet state reporting requirements.
11	POC Requirements / Guideline Clarifications	Is the State/MMCP tracking POCs as complete once they are submitted, even if the POC is partially incomplete (i.e. missing provider information, required signatures).	For the 10/1/19 transition, the State is tracking to ensure POCs are obtained by the MMCP. Additional guidance has been given to HHCM, MMCP and HCBS providers to ensure provider and service information is shared for 10/1/19. However, as outlined in the HCBS POC Workflow, there may be times when the POC is waiting for f/s/d and HCBS provider acceptance of a referral, so some information will not be in the POC at the time the POC is sent to MMCPs. POCs must have a signature from the child/ parent/guardian/legally authorized representative. It is the role of the HH and MMCP to have oversight and monitoring of the of the quality of the POC and enrollees' access to services.
12	Referrals	Are services placed on hold until all necessary approvals are received from the MMCPs? What is the process to handle delays in MMCP approvals?	Services should not be delayed for child/youth in need of and eligible for HCBS. Providers are encouraged to request continued coverage of HCBS at least 14 days in advance of the current authorization's expiration to avoid delays. HCBS providers should serve a Medicaid covered child/family, especially during the first180 days as services will be covered without MMCP utilization management (clinical review). An enrollee has the right to request an appeal from the plan regarding a delay in approval, denial or reduction in services. With written consent, the provider may appeal on behalf of the enrollee. The enrollee also has fair hearing rights, once the plan's appeal process is exhausted. The provider or the enrollee may also file a complaint at any time with the Department at managedcarecomplaint@health.ny.gov
13	Authorization Requirements / Guideline Clarifications	Will MMCPs use the POC for utilization management? What is the MMCP timeframe for authorization? How is authorization impacted if a child is hospitalized during the current service plan?	MMCPs may not conduct utilization management on Children's Waiver HCBS, CFTSS or LTSS included in the POC for 180 days after October 1, 2019, however the MMCP will respond to a request for continued services with a written decision regarding the authorization. MMCPs will use the POC to confirm a person centered plan was conducted that identified the child's needs and goals/objectives, and the HCBS chosen to address these. This information will be combined with the provider's information regarding the first appointment and any subsequent Children's HCBS Authorization and Care Manager Notification Form (located here) to ensure that the provider is appropriately included on the plan's claims systems (for initial 96 units/24 hours/60 days) and to make a determination regarding continued HCBS coverage. The MMCP must make a determination regarding a request for continued services within the timeframes indicated in the right-hand column of this table and send a written decision notice. For a child/youth receiving HCBS that is hospitalized, The HCBS waiver slot with pended services occurs for 90 days prior to discharge from the Children's Waiver. The HHCM can work with higher level of care facilities to determine the discharge expected date for the child/youth and 30 days prior to discharge, the HHCM can assist with transition back to community services. The MMCP's HCBS authorization may or may not be suspended based on the anticipated length of stay. MMCP authorization of continued services may be re-determined as part of the discharge planning process.
14	Access to Care	How do families choose an HCBS provider? What happens if there is no HCBS provider within the surrounding area?	It is the role of the HH or C-YES care manager to provide the family with the options for HCBS providers and to work with the family to choose the provider(s) that will best fit the needs of the child/family. While the care manager may provide guidance, the types of service(s) and provider(s) is ultimately the family's choice, which is documented by the child/family signing the Freedom of Choice form. Care managers should work with the family to identify providers that can service them and have capacity. Due to the high needs of this population, children/youth that are enrolled in the Children's Waiver cannot be placed on a provider waitlist for their identified and referred HCBS.
15	Workforce Issues	As of what date will the child/youth become mandated to enroll in managed care and be auto enrolled if they have not yet chosen a MMCP?	Mandated enrollment starts October 1, 2019. Transitioning children/youth and their families will have at least 60 days to choose a MMCP. No child/youth will be auto-enrolled prior to January 1, 2020. After that date, a child/youth required to enroll will receive reminders and notification if they are to be auto- enrolled.
16	Care Management Communications	What is the process for MMCPs to communicate with C-YES? How do MMCPs know who at C-YES communicate with regarding POC updates?	C-YES and the MMCPs have developed communication pathways to share POCs and other information in a secure environment, similar to the processes used between HHs and MMCPs.
17	Request for distribution list	Is there a list of MMCPs and HCBS Providers who are in that network?	All network providers are available on the MMCP websites. However, the HHCMs may refer to MCTAC matrix. and contact the MMCP if assistance in identifying a provider is needed.
18	Documentation	If the HCBS provider has their own referral form can we use that instead of the State's form?	No, the Referral for Home and Community Based Services (HCBS) to HCBS Provider form must be used. The form is a fillable PDF can be located here.
19	Documentation	Is there a specific POC template that should be used?	No, each Health Home may have their own template as long as it meets the HH and HCBS required elements. Health Home Plan of Care Policy #HH0008 (PDF)
20	Documentation	Can the HCBS provider referral form be created and disseminated as a writable form in order to assist care managers when having to fill out multiple forms for the same youth?	There is a fillable PDF HCBS provider referral form that can be found on the Children's Behavioral Health website.
21	Documentation	Does the DOH 5276 need to be completed with the referral form?	No, the Freedom of Choice (DOH 5276) does not accompany the POC referral form as the form can be completed during the referral process for HCBS or any time after the HCBS LOC has been completed and DOH Capacity Management Team has informed the CM the member has received a HCBS slot.
22	Guidance	The MMCP is to ensure HCBS in POCs are accessible for the 60 days, or 96 units/24 hours. Can you advise where this guidance appeared previously?	See the HCBS service manual: Children's Home and Community Based Services Provider Manual (PDF)