Health Home Chronic Conditions and Billing Questionnaire/HML Selection Guidance

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Beginning for service dates on or after July 1, 2018; the Health Home Serving Children and Adult´s Chronic Condition list was updated to include specific mental health conditions of Health Home´s single qualifying condition of Serious Mental Illness (SMI) / Serious Emotional Disturbance (SED). The eligibility criteria for enrolling individuals with Intellectual/Developmental Disabilities (I/DD) in Health Homes is also outlined.

As such, it is necessary to ensure that Health Home care managers have the proper diagnosis and supporting clinical information, from a licensed professional, documented in the member´s case file that demonstrates that the member meets Health Home eligibility for enrollment. The three (3) attachments below outline the definitions and/or processes for obtaining Health Home eligibility for the single qualifying chronic condition of SMI or SED (attachment A and B), as well as the process required to enroll an individual with an I/DD condition (attachment C) as part of the required two (2) chronic conditions in a Health Home Serving Children or Adults.

Additionally, for accurate data collection of SMI, SED, and I/DD populations, it is important that the "Billing Questionnaire/HML" is completed to reflect the documentation that made the member eligible for Health Home enrollment. The purpose of the "Billing Questionnaire/HML" is to document that Health Home eligibility, appropriateness and other Health Home requirements have been met each month to ensure proper billing for services rendered to the specific Health Home outreached or enrolled individual.

For billing instances on or after July 1, 2018, two additional selections are available when responding to the chronic conditions question on the Billing Questionnaire/HML. The additional possible selections are "SED/SMI" and "One or more DD conditions". This question appears on screen as: "Please select the conditions most applicable to the member. Selections should not exceed eight chronic conditions".

Childrens Billing Questionaire

For providers who complete billing instances via the file upload this question is represented in field #5 (Pre–Conditions) on the Billing Support Upload file. Code 20 represents SED/SMI and code 22 represents one or more DD conditions. For more information on codes available on this file please refer to Appendix H of the latest File Specifications document found here.

The system allows for up to eight selections either via screen or via file upload. Selecting more than eight chronic conditions will result in an error when attempting to complete the billing instance. Should a member you are serving have SED/SMI or DD, the ‘SED/SMI´ or ‘DD´ selections must be selected prior toselecting other chronic conditions. Continuing to select "other" and write SED/SMI or DD into the comments section is no longer considered acceptablefor dates of service on or after July 1, 2018.

PLEASE NOTE: SMI/SED should only be selected if the member meetsthe Health Home single qualifying condition as outlined in Attachment A and B. Mental Health should only be selected when the member does not meet the Health Home single qualifying condition of SMI/SED, however the member is Health Home eligible by meeting two (2) chronic conditions of one or more mental health diagnoses or other eligible chronic conditions.

ATTACHMENT A: Serious Emotional Disturbance (SED)

HHSC Serious Emotional Disturbance (SED) Definition and Determination Process:
SED is a single qualifying chronic condition for Health Home and is defined as a child or adolescent (under the age of 21) that has a designated mental illness diagnosis in the following Diagnostic and Statistical Manual (DSM) categories below* as defined by the most recent version of the DSM of Mental Health Disorders ANDhas experienced the following functional limitations due to emotional disturbance over the past 12 months (from the date of assessment) on a continuous or intermittent basis as determined by a licensed mental health professional.

Note: The DSM categories include in the definition of SED used to determine Health Home eligibility is different than the SED definition used to determine eligibility for other Medicaid services (e.g., OMH clinic, inpatient, etc.)

SED Definition for Health Home – DSM Qualifying Mental Health Categories*

  • Anxiety Disorders
  • Bipolar and Related Disorders
  • Depressive Disorders
  • Disruptive, Impulse–Control, and Conduct Disorders
  • Dissociative Disorders
  • Obsessive–Compulsive and Related Disorders
  • Feeding and Eating Disorders
  • Gender Dysphoria
  • Paraphilic Disorders
  • Personality Disorders
  • Schizophrenia Spectrum and Other Psychotic Disorders
  • Somatic Symptom and Related Disorders
  • Trauma– and Stressor–Related Disorders
  • ADHD for children who meet the functional criteria for SED and have utilized any of the following services in the past three years:
    • Psychiatric inpatient
    • Residential Treatment Facility
    • Day treatment
    • Community residence
    • Mental Health HCBS & OCFS B2H Waiver
    • OMH Targeted Case Management

*Any diagnosis in these categories can be used when evaluating a child for SED. However, any diagnosis that is secondary to another medical condition is excluded.

Functional Limitations Requirements for SED Definition of Health Home – The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas as determined by a licensed mental health professional:

  • Ability to care for self (e.g. personal hygiene; obtaining and eating food; dressing; avoiding injuries); or
  • Family life (e.g. capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or
  • Social relationships (e.g. establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or
  • Self–direction/self–control (e.g. ability to sustain focused attention for a long enough period of time to permit completion of age–appropriate tasks; behavioral self–control; appropriate judgment and value systems; decision–making ability); or
  • Ability to learn (e.g. school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

For an SED determination to be utilized as a Health Home single qualifying condition, a mental health diagnosis alone is not sufficient to meet the SED definition for Health Home enrollment. The mental health diagnosis accompanied by documentation from an appropriate assessment outlining the required functional limitation determination is necessary to meet the SED single qualifying condition for enrollment.

Acceptable assessments to determine SED functional limitation are: Psychosocial Assessment, Psychiatric Evaluation, Psychological Assessment, School Information (e.g. IEP/504 Plan), etc. Some mental health providers that work with OMH programs and services will be familiar with the SED determination and can assist HH care managers by actually documenting the child meets SED requirements. Other providers may need to be educated regarding the SED criteria and or be asked to ensure that the functional limitation is clearly documented within the assessment. HH care managers need to document in the members case file how Health Home eligibility and appropriateness was determined. Additionally, all the member´s medical and behavioral health conditions should be documented in the members case file and Plan of Care (if appropriate) and if there are changes in conditions to be clear how the member remains Health Home eligible.

Note: Two mental health diagnosis from the Health Home chronic condition list would meet Health Home enrollment under to the two–chronic condition list.

ATTACHMENT B: Serious Mental Illness (SMI)

In New York State, Medicaid recipients who are determined to have Serious Mental Illness (SMI) are eligible for participation in Health Homes. The designation of SMI allows Health Home services to be delivered to people with mental illness who have difficulty functioning successfully in their relationship, jobs, schools, and other life roles within their chosen community.

According to the DSM 5, a mental disorder is a syndrome characterized by clinically significant disturbance in an individual´s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.1

For the purposes of Health Home eligibility, SMI is determined by both a diagnosis of mental illness and an impairment that impacts social, vocational, and psychological functioning. While SMI meets the Health Home single qualifying condition eligibility criteria, the functional criteria will determine Health Home service appropriateness criteria.

To be considered an individual with a serious mental illness, a person must have at least one of the diagnoses set forth in Section 1 and at least one of the functional impairments set forth in Section 2 resulting from such diagnosis.

Section 1. Qualifying DSM 5/ICD 10 diagnoses:

A DSM–5 diagnosis is usually applied to the individual's current presentation; previous diagnoses from which the individual has recovered should be clearly noted as such. Specifiers indicating course (e.g., in partial remission, in full remission) may be listed after the diagnosis and are indicated in a number of criteria sets. Where available, severity specifiers are provided to guide clinicians in rating the intensity, frequency, duration, symptom count, or other severity indicator of a disorder. Severity specifiers are indicated by the instruction "Specify current severity" in the criteria set and include disorder–specific definitions. Descriptive features specifiers have also been provided in the criteria set and convey additional information that can inform treatment planning (e.g., obsessive–compulsive disorder, with poor insight). Not all disorders include course, severity, and/or descriptive features specifiers.2

Psychotic Disorders: F21, F22, F23, F20.81, F20.9, F25.0, F25.1, F06.2, F06.0, F06.1, F28, F29

Bipolar Disorders: F31.11, F31.12, F31.14, F31.2, F31.73, F31.74, F31.9, F31.0, F31.31, F31.32, F31.4, F31.5, F31.75, F31.76, F31.9, F31.81, F34.0, F06.33, F06.34, F31.89

Obsessive–Compulsive Disorders: F42

Depression: F34.8, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2, F233.3, F33.41, F33.42, F33.9, F34.1, N94.3, F06.31, F06.32, F06.34, F32.8, F32.9, F34, F32.08

Anxiety Disorders: F41.9, F41.0, F41.1, F44.81, F40.0, F43.10

Personality Disorders: F60.0, F60.1, F60.3, F60.04, F60.5, F60.6, F60.9, F60.81, F21

Section 2. Extended impairment in functioning: a recipient is determined to meet one or more of the criteria listed below as a result of their qualifying diagnosis:

  1. Marked difficulties in self–care such as personal hygiene, diet, clothing, avoiding injuries, securing health care, or complying with medical advice; or
  2. Marked restrictions of activities of daily living such as maintaining a residence, getting and maintaining a job, attending school, using transportation, day–to–day money management, or accessing community service; or
  3. Marked difficulties in maintaining social functioning such as establishing and maintaining social relationships, interpersonal interactions with primary partners, children and other family members, friends, or neighbors, social skills, compliance with social norms, or appropriate use of leisure time; or
  4. Frequent deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner in work, home, or school setting. Individuals may exhibit limitations in these areas when they repeatedly are unable to complete simple tasks within an established time period, make frequent errors in task, or require assistance in the completion of tasks.

ATTACHMENT C: Intellectual/Developmental Disabilities (I/DD)

Effective on July 1, 2018. intellectual and/or developmental disabilities conditions were add to the chronic condition list to meet Health Home eligibility.

The State Plan Amendment adds the Major Category of Developmental Disabilities, which includes the following:

  1. Intellectual Disability
  2. Cerebral Palsy
  3. Epilepsy
  4. Neurological Impairment
  5. Familial Dysautonomia
  6. Prader–Willi Syndrome
  7. Autism

The term Autism includes all diagnoses within Autism Spectrum Disorder. The term Neurological Impairment refers to a disease or disorder that results in a neurological impairment or degeneration that affects the integrity of the individual´s musculature and central nervous system. Examples of potentially qualifying neurological impairments include, but are not limited to, Duchenne´s Muscular Dystrophy and traumatic brain injury.

Enrolling Individuals with a Developmental Disability in Health Homes Serving Children or Adults
If an individual has one of the above diagnoses in the Developmental Disabilities Major Category and one or more of the other diagnoses included on the Health Home Chronic Conditions List, the individual may be eligible for enrollment in a Health Home Serving Children or Adults. Specifically, the individual´s developmental disability diagnosis must be in the Developmental Disabilities Category, originate before the age of twenty–two and be expected to continue indefinitely to qualify as a diagnosis in the Developmental Disabilities Category, and the individual must be Medicaid eligible and meet the other appropriateness and enrollment criteria.

For more information on the Health Home Chronic Conditions List and appropriateness, please visit the following link: Eligibility Requirements: Identifying Potential Members for Health Home Services.

All documentation requirements must be met, including but not limited to, documenting the individual´s Medicaid eligibility, diagnosis, and other criteria outlined in this guidance as part of Health Home eligibility.

Guidance surrounding CCO/HH enrollment.

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1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (Arlington: VA, 2013) 20.  1
2. American Psychiatric Association 22  2

August 2018