Health Home Care Management Services for Members Admitted to Inpatient/Excluded Settings and Voluntary Foster Care Agency (VFCA) Residential Treatment Centers (RTCs)

Please be advised that the September 15, 2017 date cited below has been extended to no later than October 16, 2017

Effective Date As Of August 7, 2017

  • Guidance is also available in Portable Document Format (PDF)

During the initial months of the expansion of the Health Home program to serve children, there has been confusion among Voluntary Foster Care Agencies (VFCAs), care managers, LDSS, and Health Homes when children/youth in a VFCA Residential Treatment Centers (RTCs) may be enrolled in the Health Home program and when they can receive billable Health Home care management services. The purpose of this guidance is to clarify the role of the Health Home Program in relationship to RTCs.

The key points are as follows:

  • RTCs are defined by the child welfare community as an institutional level of care.
  • The Health Home model and Health Home care management services are intended to be provided in the community. Health Home care management requires the development and implementation of an integrated care plan that involves a network of providers and services, including currently available community and social supports, and will include the expanded package of Home and Community Based Services being implemented next year as part of the Children's Medicaid Redesign plan. These HCBS may not be provided in inpatient/excluded settings.
  • Institutions are inpatient/excluded settings for the purposes of the Health Home Program.
  • Health Home care management services provided in inpatient/excluded settings may only be provided and billed for in accordance with State guidance.
Current Health Home Policy:
  • Health Home services may only be billed for Medicaid eligible children in an inpatient/excluded setting, including RTCs, in the month of admission and discharge, and
  • If the member is anticipated to be discharged from the RTC within 180 days, and
  • At least one billable Health Home core service is provided in the month of admission to the RTC and discharge from the RTC.
  • The ability to bill upon the first month of admission is allowed only if the child/youth is already enrolled in Health Home and transitioning to an inpatient/excluded setting (i.e. RTC).
VFCAs and Health Homes must work together to take the following actions by no later than September 15, 2017.
  • A child/youth is in an RTC, is enrolled in Health Home and the care manager anticipates the child will be discharged from the RTC within 180 days:
    • ✓ The enrollment segment for the child must be pended in MAPP with a reason of Other (RTC inpatient). The begin date of the pended enrollment segment is the first of the month following the admission to the RTC;
    • ✓ When the child/youth transitions to a setting in which Health Home services may be provided, the pended enrollment segment for the child may be changed to active for the month in which the child/youth is discharged from the RTC,
    • ✓ Health Home care management services can be billed in the months of admission or discharge from the RTC provided a billable Health Home core service has been performed.
  • A child/youth is in an RTC, is enrolled in a Health Home and the care manager anticipates the length of stay to be more than 180 days the child/youth should be dis–enrolled from the Health Home

Billing may not occur for members in pended status or members dis-enrolled from the Health Home program.

Referrals to Health Home for Children/Youth in RTCs:
  • LDSS are encouraged to engage with the Health Home VFCAs to identify children/youth in RTCs who would benefit from Health Home care management services in the community upon discharge;
  • Referrals are encouraged to be made 90 days in advance of the anticipated discharge date from the RTC.
  • Allows the VFCA Health Home to enroll the member in the Health Home and provide core services related to discharge planning during the thirty days prior to discharge.

*Please note, the Health Home Managed Care Organization (HH/MCO) Workgroup is working on guidance regarding billing for members in excluded settings. The draft guidance was distributed for review and comment to stakeholders.

If you have any questions regarding the information above, please contact DOH Health Home Serving Children at or 518.473.5569.

August 7, 2017