Transition of Children placed in Foster care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care

  • Presentation - is also available in Portable Document Format (PDF)

Question and Answer Session for Local Districts of Social Services

June 15, 2021

Welcome

  • Questions and Answers Session on the Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care
  • All lines muted upon entry
  • Please use Q&A feature for comments and questions

Agenda

  • Overview of the Foster Care Transition to Medicaid Managed Care (MMC)
  • Frequently Asked Questions
  • Open Floor
  • Next Steps

Overview

2021 Foster Care Transition to MMC

Population change - Effective July 1, 2021

  • Children/youth placed in foster care statewide are mandatory for Mainstream Medicaid Managed Care enrollment unless otherwise exempt or excluded
    • Removes MMC exclusion for children/youth in direct placement foster care in New York City and for children/youth in foster care placed with a Voluntary Foster Care Agency (VFCA) statewide
    • All other MMC exemptions and exclusions will remain in place
    • Eligible children/youth may enroll in HIV Special Needs Plans (HIV SNP)
  • No other population’s exemptions or exclusions change as part of this transition

Benefit Change - Effective July 1, 2021

  • Most VFCAs will be licensed as a Public Health Law Article 29-I Health Facility
    • Provide per diem Core Limited Health-Related Services (CLHRS) to all placed children/youth
    • Provide and claim for Other Limited Health-Related Services (OLHRS)
    • CLHRS and OLHRS are covered by FFS and included in the Mainstream MMC Plan and HIV SNP Benefit Packages
  • 29-I Health Facilities can provide Medicaid covered services to:
    • Children/youth placed in foster care
    • 8D Babies
    • Pre-dispositional placed youth
    • Committee on Special Education (CSE) children
    • Children/youth and adults who have been discharged from foster care but are still receiving some services from the 29-I Health Facility
    • Any other children as identified per State Plan Amendment (SPA) and the New York Medicaid Program 29-I Health Facility Billing Guidance
  • Licensing as 29-I Health Facility fundamentally changes reimbursement structure for these VFCAs
    • ending cost-based, roster per diem
    • 29-I Health Facilities will claim to Medicaid FFS or the MMC plan for all services they provide, both the CLHRS (residual per diem) and the OLHRS
    • 29-I Health Facilities will not have funding in new standard statewide rates to cover the cost of services provided by community providers to children/youth in their care
  • Community providers, including pharmacies, will claim for all Medicaid covered services provided to children/youth in foster care directly to Medicaid FFS or the MMC plan
  • Medicaid claiming cannot occur until Medicaid case is opened for the child/youth
  • LDSS must establish the Medicaid case immediately upon the child/youth's removal from home and being placed into foster care

FAQs

What action should LDSS take to remove RRE K8 and K9?
  • LDSS should not take action on RRE K8. The State will use a bulk system process to void RRE K8 and will ensure districts are aware of when this occurs.
  • As for RRE K9, some should remain on the child/youth's file and others must be end dated. The RRE K9 is valid and should remain on the case when the child/youth is in the Children's Waiver and also in foster care. More information will be provided to districts on when to load the K9, and the process for removal of invalid K9.
29-I Health Facilities are contacting LDSS about children not yet enrolled- should the LDSS process these enrollments?
  • The pre-implementation process is not yet complete.
  • LDSS and 29-I Health Facilities are requested to wait until June 19, 2021, before processing enrollments for children/youth in foster care.
How do we know what plan to choose for a child in when we have more than one plan choice?
  • MMC plan selection considerations include:
    • choice of child/youth and parent/guardians, where appropriate
    • evaluation of the provider networks
    • service locations;
    • identification of the child's current primary care provider (PCP); and
    • county and other placement arrangements for the child
Is NYMC or the LDSS enrolling the child/youth?
  • The pre-implementation process is conducted statewide by NYMC
  • For ongoing enrollments, outside of New York City, the Maximus field representatives do not currently enroll children/youth in foster care. LDSS should follow their regular process for enrolling children/youth in foster care
  • NYMC will enroll children/youth in NYC whose case is opened through the SERMA process
  • NYMC will also process 29-I Health Facility requests to disenroll or changes plans for children/youth placed with the 29-I Health Facilities. 29-I Health Facilities may also work directly with the LDSS to request these changes.
Does NYMC have to evaluate 'good cause' for disenrollment?
  • Any child/youth in foster care can change/transfer Managed Care Plans or disenroll from Plan at any time (no lock-in)
  • The LDSS or 29-I Health Facility may determine the good cause reason (as per 18 NYCRR 360-10.6) or that the change is the best interest of the child
  • The reason must be documented in the child/youth's case record
What if child has active case on HBE prior to placement?
  • When activating a foster care child who is active on HBE, contact hxfacility@health.ny.govto coordinate takeover of the coverage
How does LDSS address downgrade in Coverage from 01 to 30?
  • If child was previously FFS and new to placement in foster care, effectuating MMC enrollment retrospective to first of the month may create downgrade of coverage from 01 to 30.
    • Enrollment is retrospective for new placements only
    • Coverage change is made as system allows, which may be prospective to first of the month after the following month
    0591 - DOWNGRADE OF MA COVERAGE CODES HAS OCCURRED
    MA Coverage Code may only be changed according to Table #591. (F, E, U). This Edit is not Overridable.
    1776 - DOWNGRADE OF MA COV CD 01 TO 30 HAS OCCURRED
    MA Coverage Code 01 to 30 may only be changed according to Table #591. (F, E, U). This Edit is Overridable.

Transmittal Form

Does LDSS have to use statewide form? Who completes the transmittal- the Medicaid worker or the Foster care worker?
  • All LDSS and 29-I Health Facilities must now use the new statewide standard Transmittal Form. This does not preclude the LDSS or 29-I Health Facility from coordinating or agreeing with a managed care plan to provide additional information with the Transmittal Form
  • The LDSS may determine who best at the county should complete the form.

General Information Requests

DOH will make this information available to LDSS:

  • Current 29-I Health Facility MMIS ID Number list
  • List of the 29-I Health Facilities and what the plans they participate in broken down by county
  • List of foster care liaisons by County with contact information
How will plan ID cards be sent? How is PCP information added to ID cards?
  • All cards and notices for children in the care of a 29-i Health Facility should be sent to the 29-I Health Facility. If child is in direct care, the ID card is to be sent to the LDSS. LDSS may report any misdirected cards to mcsys@health.ny.gov
  • If in the care of 29-I Health Facility, the Facility should communicate to the plan the choice of PCP, and the plan will update the ID card. The LDSS should communicate PCP information to the plan for children in direct care.
Will all plans participate with all 29-I Health Facilities?
  • All Mainstream Medicaid Managed Care Plans and HIV Special Needs Plans must accept claims from any 29-I Health Facility providing covered services to their enrollees, whether or not the 29-I Health Facility is contracted with that managed care plan.
  • Transitional care rules apply. In addition, the managed care plan must facilitate or arrange for continued access to requested services without interruption and without conducting utilization review for LTSS, HCBS, or OLHRS at least 180 days from the effective date of enrollment
  • See also the Transition of Children Placed in Foster Care and New York State public Health Law Article 29-I Health Facility Services into Medicaid Managed Care, 2021policy paper

Open Floor

Next Steps

Upcoming Webinars

  • Foster Care Services Stakeholder Workgroup
    • June 22, 2021, 11:00am-1:00pm
    • Register here

Contact Us:

BH.Transition@health.ny.gov
Hope.Goldhaber@health.ny.gov
April.Hamilton@health.ny.gov
Mimi.Weber@ocfs.ny.gov

Appendix

References

Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care Policy Paper.

VFCA Health Facility License Guidelines

Article 29-I Health Facility Billing Guidance

State Plan Amendment 21-0003

Mandatory Article 29-I Health Facility Services

Core Limited Health-Related Services (residual per diem)*
  • Skill Building Services
  • Nursing Supports and Medication Management
  • Medicaid Treatment Planning and Discharge Planning
  • Clinical Consultation and Supervision
  • Managed Care Liaison/Administration

Note: All Licensed Article 29-I Health Facilities must provide these services to children in their care

*not covered after 21st birthday

Optional Article 29-I Health Facility Services

  • Other Limited Health-Related Services (OLHRS) are provided in accordance with the 29-I Health Facility's license and designation, and are reimbursed according to a 29-I OLHRS Fee Schedule
  • Physical and Behavioral Health screening, diagnosis, and treatment services, including but not limited to:
    • Ongoing treatment of chronic conditions as specific in treatment plans
    • Diagnosis and treatment related to episodic care for minor ailments, illness or injuries, including sick visits
    • Psychiatric consultation, assessment and treatment
    • Psychotropic medication treatment
    • Developmental screening, testing and treatment
    • Psychological screening, testing and treatment
    • Smoking Cessation treatment
    • Alcohol and/or drug screening and intervention
    • Laboratory Services
    • Children and Family Treatment and Support Services*
    • Children's Home and Community Based Services*

* Not covered for adults over age 21

Article 29-I Health Facility Services DO NOT INCLUDE

  • Surgical Services
  • Dental Services or Orthodontic Care
  • General hospital services including emergency care
  • Birth center services
  • Emergency intervention for major trauma
  • Treatment of life-threatening or potentially disabling conditions
  • Non-Routine Transportation

Resolving Gaps in Coverage - Scope of Problem

  • Children who enter foster care without existing health insurance coverage, or whose coverage status is unknown, for whom the local district has not established Medicaid coverage before the child needs medical services, appear to have a "gap" in coverage. Likely to be a very small number of children and limited set of benefits.
    • Only occurs when kids don't have coverage. Most kids come into the foster care system with existing coverage.
    • Primarily prescriptions and equipment, etc. Provider types that aren't willing to wait for MA to be established
  • The community provider of the critical medical services requires payment at the time of service.
  • Medicaid cannot pay for those services at the time they are delivered during this "gap" period.
  • If Medicaid is activated retroactively to cover the dates of service, whomever covers the cost of the services in the first instance can be reimbursed.

Resolving Gaps in Coverage

Option A - Identify/Establish Coverage

LDSS or VFCA identifies existing health insurance coverage

LDSS establishes MA Case before the child/youth needs medical services

Option B - Request that Community Provider holds billing until Coverage is established

  • Use if Option A is not available
  • LDSS and VFCAs should conduct outreach to community providers to establish working relationships and provide documentation of foster care status in these cases.
  • Coverage information must be provided to community providers when established to allow the provider to bill the appropriate payor
  • Note retro coverage rules already covered during this presentation

If Options A & B are not feasible, use Option C or D

Option C - Community Provider bills VFCA

  • VFCA covers the cost of the service at the time of delivery
    • C.1 - VFCA submits request for reimbursement to the LDSS for reimbursement under MA FFS when the coverage is established
    • C. 2 - VFCA submits request for reimbursement to MMC plan when the coverage is established

Option D - Community Provider bills LDSS

  • LDSS covers the cost of the service and bills MA FFS when the coverage is established using Schedule E

Notes

  • Medicaid cannot cover the cost of health services, until the Medicaid case is established. Once established, the VFCA or LDSS can be reimbursed by Medicaid.
  • The VFCA and LDSS must coordinate to determine who will be the payor in these circumstances to ensure access to necessary service

RESOLVING GAPS IN COVERAGE FOR CHILDREN ENTERING FOSTER CARE

Medicaid Case Coding for Children/Youth in Foster Care

  • As of April 1, 2021, LDSS should discontinue
    • use of Recipient Restriction Exception (RRE) code K8 to indicate children/youth placed in foster care in care of a VFCA on any cases in eMedNY going forward
    • use of RR/E code K9 to indicate children/youth placed in foster care on any cases in eMedNY
      • K9 should only be utilized to indicate 1915(c) participation AND placed in foster care.
  • As of April 20, 2021, RRE 90 should no longer be used solely to prevent MMC enrollment for children/youth placed in foster care
  • However, LDSS should continue to use system codes (e.g. RRE 90) to prevent MMC enrollment when enrollment is not appropriate due to an:
    • Exemption/exclusion
    • Good Cause reason
    • When determined in the best interest of the child/youth to remain in FFS
    • When child/youth is placed out-of-state (applies to both IV-E and non-IV-E children/youth)
  • For children/youth placed with a 29-I Health Facility, the LDSS must continue to enter and maintain the accurate Principal Provider code 10 and corresponding 29-I Health Facility Provider MMIS ID number in eMedNY.
    • New York Medicaid CHOICE (NYMC) and the MMC Plans will use the PP10/MMIS ID number to appropriately communicate with 29-I Health Facilities, process enrollment changes, and direct enrollee notices and materials.
  • There are only four VFCAs that are not licensed under Article 29-I, and these VFCAs do not use Principal Provider 10 and do not have MMIS ID numbers:
    • Behavioral Health Services North
    • Catholic Family Center
    • St. Colman's
    • St. John's Bosco

MMC Plan Enrollment - Ongoing

New York City

  • Starting May 24, 2021, NYMC began daily process to automatically passively enroll eligible* children placed in foster care and 8D Babies whose case opens in eMedNY on and after May 15, 2021, through the NYC SERMA system
    • For cases opened in eMedNY between May 15, 2021 to June 30, 2021, enrollment will be effective July 1, 2021.
    • Starting July 1, 2021, new MMCP enrollments are retrospective to the first of the month the case is opened in eMedNY based on the case transaction date.
    • Retrospective MMCP enrollment is not greater than 30 days, regardless of the effective date of Medicaid coverage
  • NYMC sends a 'supplemental' file of children/youth enrolled to 29-I Health Facilities and MMC plans
  • NYMC sends enrollee enrollment notices in care of the 29-I Health Facility

*All other Medicaid Managed Care exclusions still apply

Outside of New York City

  • LDSS will continue to enroll children/youth newly placed in foster care and 8D Babies in MMCP (as is done today)
    • starting June 19, 2021, LDSS will no longer exclude those children placed in VFCAs, enrollments effective July 1, 2021
    • all other Medicaid managed care exclusions still apply
  • Starting July 1, 2021, new MMCP enrollments are retrospective to the first of the month the case is opened in eMedNY based on the case transaction date.
    • Retrospective MMCP enrollment is not greater than 30 days, regardless of the effective date of Medicaid coverage

Retrospective MMC Enrollment Example

  • Date of placement in foster care is July 21, 2021 = Medicaid effective date back to 1st of month
  • Child/Youth is not enrolled in MMC at the time of placement
  • Case opens on eMedNY August 6, 2021, and child/youth is enrolled in MMC = enrollment transaction date
  • MMC enrollment is effective August 1, 2021
  • Child/youth is covered by Medicaid FFS July 1, 2021 through July 31, 2021.

Putting It All Together - Expected Information Flow

Outside of NYC:

  • Child enrolled in MMC plan effective January 1, 2021, is placed in foster care with 29-I Health Facility on July 15, 2021 (same County/DFR)
  • LDSS updates/creates Medicaid case and maintains the enrollment in same MMC plan
  • LDSS notifies 29-I Health Facility that child is placed with them, and enrollment is in MMC plan
  • 29-I Health Facility sends Transmittal Form to MMC Plan with placement and care needs information
  • MMC Plan and 29-I Health Facility foster care liaisons continue to communicate regarding ongoing care needs for the child/youth Child/youth is in direct care foster care placement beginning July 3, 2021, and enrolled in MMC plan.
  • On July 27, 2021, LDSS transfers enrollment to new MMC plan effective first of the following month- August 1, 2021
  • LDSS to send enrollee notice to child/youth and parent/guardian as appropriate
  • 834 from eMedNY is sent to old plan confirming disenrollment, effective last day of current month -July 31, 2021
  • 834 from eMedNY is sent to new plan confirming new enrollment date, effective first day of following month - August 1, 2021
  • LDSS sends Transmittal Form to new MMC Plan with placement and care needs information
  • LDSS Foster Care Liaison and new MMC Plan foster care liaison continue to communicate regarding ongoing care needs for the child/youth

Statewide:

Child/youth is in foster care and placed with 29-I Health Facility beginning July 3, 2021, and enrolled in MMC plan.

  • On July 27, 2021, 29-I Health Facility contacts NYMC to request transfer to new MMC plan
  • NYMC processes enrollment transactions, transfers to new MMC plan effective first of the following month- August 1, 2021
  • NYMC sends supplemental file to 29-I Health Facility with enrollment and MMC plan with placement; sends enrollee notice in care of 29-I Health Facility
  • 834 from eMedNY is sent to old plan confirming disenrollment, effective last day of current month -July 31, 2021
  • 834 from eMedNY is sent to new plan confirming new enrollment date, effective first day of following month - August 1, 2021
  • 29-I Health Facility sends Transmittal Form to new MMC Plan with placement and care needs information
  • New MMC Plan and 29-I Health Facility foster care liaisons continue to communicate regarding ongoing care needs for the child/youth

Sources to Confirm Enrollment and Placements

Outside of New York City Scenario 1A

  • A child is enrolled in MMCP1, and is newly placed in foster care and placed with 29-I Health Facility
    • LDSS updates case and maintains the enrollment in that same plan
    • LDSS notifies 29-I Health Facility that child is placed and is in MMCP1
    • 29-I can also confirm MMCP1 enrollment through ePACES
    • 29-I Health Facility sends Transmittal Form to MMCP1
  • MMCP1 will receive:
    • if there is change in case eligibility or demographic information, 834 change transaction confirming enrollment from eMedNY
    • Transmittal form to plan by 29-I Health Facility, confirming placement
  • Source of Truth for enrollment: Most recent 834
  • Source of Truth for placement: Most recent Transmittal Form

Outside of New York City Scenario 1B

  • A child is enrolled in MMCP1, and is newly placed in foster care and placed with 29-I Health Facility
    • LDSS updates case and changes enrollment to new MMCP2, effective the first of the following month
    • LDSS notifies 29-I Health Facility that child is placed and is in MMCP2
    • 29-I can also confirm MMCP2 enrollment through ePACES
    • 29-I Health Facility sends Transmittal Form to MMCP2
  • MMCP1 will receive:
    • 834 from eMedNY confirming disenrollment, effective last day of current month
  • MMCP2 will receive:
    • 834 from eMedNY confirming enrollment date, effective first day of following month,
    • Transmittal Form from 29-I Health Facility, confirming placement
  • Source of Truth for enrollment: Most recent 834
  • Source of Truth for placement: Most recent Transmittal Form
New York City Scenario 2A

New York City Scenario 2A

  • A child is newly placed in foster care and placed with 29-I Health Facility
    • SERMA process opens in eMedNY
    • NYMC processes enrollment in MMCP1, retrospective to first of current month
    • 29-I Health Facility receives VF file from NYMC indicating MMCP1
    • 29-I Health Facility sends Transmittal Form to MMCP1
  • MMCP will receive:
    • 834 from eMedNY confirming enrollment
    • Supplement VF file from NYMC
    • Transmittal Form from 29-I Health Facility, confirming placement
  • Source of Truth for enrollment: Most recent 834
  • Source of Truth for placement: Most recent Transmittal Form

New York City Scenario 2B

  • A child is enrolled in MMCP1, and 29-I Health Facility requests NYMC transfer to MMCP2
    • NYMC processes transfer, effective first of the following month
    • 29-I Health Facility receives VF file from NYMC indicating MMCP2
    • 29-I Health Facility sends Transmittal Form to MMCP2
  • MMCP1 will receive:
    • 834 from eMedNY confirming disenrollment, effective last day of current month
  • MMCP2 will receive:
    • 834 from eMedNY confirming enrollment date, effective first day of following month,
    • Supplement VF file from NYMC
    • Transmittal Form from 29-I Health Facility, confirming placement
  • Source of Truth for enrollment: Most recent 834
  • Source of Truth for placement: Most recent Transmittal Form
New York City Scenario 2B