Eligibility for Enrollment in Care Coordination Organization/Health Home (CCO/HH) or Health Homes Serving Children or Adults

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On April 9, 2018 CMS approved the State Plan Amendment authorizing Care Coordination Organization/Health Homes (CCO/HHs) to provide Health Home Care Management to individuals with intellectual and/or developmental disabilities effective on July 1, 2018.

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.

CCO/HH Enrollment Criteria

To be eligible for enrollment in a CCO/HH, Medicaid–enrolled individuals will need to present with a diagnosis of one of the above conditions in the Major Category of Developmental Disabilities, which results in a functional limitation that constitutes a handicap per the New York State Mental Hygiene Law Section 1.03(22), and meet the other criteria outlined in the section as determined by the Office of People With Developmental Disabilities. Individuals who meet these criteria, as determined by the New York State Office for People With Developmental Disabilities, may be eligible to enroll in a CCO/HH.

If an eligible individual chooses to receive OPWDD/HCBS services, the individual will need to enroll in a CCO/HH. If an individual is not eligible, declines, or chooses not to pursue OPWDD services, the individual may enroll in a Health Home Serving Children or Adults provided they meet the Health Home Serving Children or Adults eligibility and appropriateness criteria (see below).

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.

Below is an example of a Medicaid enrollee with a developmental disability eligible for enrollment in a Health Home Serving Children:

A 10–year–old Medicaid enrollee was diagnosed with cerebral palsy but was found by OPWDD to not have a functional limitation that constituted a handicap per MHL 1.03 (22). That individual would not be eligible for CCO/HH. If that individual also had asthma and was otherwise eligible and appropriate for Health Home Care Management, then that individual would be eligible for enrollment in a Health Home Serving Children.

In all instances, prior to enrollment, the individual and/or their family, legally authorized representative, or circle of support should be informed of the different enrollment options, the differences between those options, and what may be most appropriate for the individual based on their needs.

July 30, 2018