Health Home Serving Children Guidance

Health Home Serving Children (HHSC) CANS–NY Algorithms for PMPM Fees and Documentation Guidance (PDF)

HHSC CANS–NY Algorithms for Determining Health Home Per Member Per Month Fees and Documentation Guidance

The attached documents provide information regarding the algorithms applied to the CANS–NY assessments tools (ages 0–5 and ages 6–21) for the purpose of determining the Health Home Per Member, Per Month (PMPM) fee for children under 21 and in a Health Home designated to serve children. The Health Home PMPM for children, i.e., referred to as High, Medium, or Low (HML) Health Home care management acuity is a measure of the level of care management required to serve a child in the Health Home program. Algorithms are provided for High and Medium. Children that do not meet the High or Medium algorithm will be assigned Low Health Home care management acuity.

Health Homes and care management agencies must ensure the care plan and case records for members served include supporting documentation for elements required by the standards for Health Home plans of care, the CANS–NY assessment and the Health Home PMPM care management acuity.

The attached list provides examples of supporting documentation that can be obtained from professionals and providers, including those that assist with completing the CANS–NY. Where providers may not be able provide documentation of a particular situation, then well documented case notes from discussions the care manager has with relevant involved professionals, providers and family members may be acceptable. Example from the CANS–NY assessment of such a circumstance: The child has a sibling who is experiencing some mild developmental or behavioral problems. It may be that the child has at least one healthy sibling.

Health Home Serving Children
Division of Program Development and Management
New York State Department of Health
Office of Health Insurance Programs



Case Record and Plan of Care Supporting Documentation
  • Medical assessment (30–day/recent medical)
  • Review of medical history
  • HIV risk assessment
  • Dental assessment
  • Mental and behavioral health screening(s)
  • Mental and behavioral health assessment(s)
  • Medication review
  • Review of mental health/psychiatric history (past, present, trauma and abuse history)
  • Mental health treatment plan and recommendations
  • Developmental assessment
  • (10+) substance abuse assessment
  • Psychological assessment
  • Assessment of past trauma and presenting trauma symptoms
  • CSEC Rapid Indicator screening tool
  • Domestic violence screening and assessment
  • CONNECTION summary progress note (OCFS)
  • CONNECTION history (OCFS)
  • School records (such as Attendance, IEP, behavioral reports/concerns)
  • Previous Family Assessment and Service Plan (FASPs) (OCFS)
  • Juvenile Justice, Probation and or Diversion program records
  • Records received from other jurisdictions/states
  • Family team conferences (such as Child Safety, Placement Transition meetings and preservation/change conferences) documentation
  • Permanency planning meetings
  • Intra–agency team meetings (with mental health specialist, nurse, placement specialist, etc.)
  • Medicaid application
  • Recent hospital discharge summaries
  • Primary care progress notes
  • Specialist progress notes
  • Psychologist assessment (either school or community): often includes parent scales/rating tools
  • Clinical Documentation (psychosocial, psychological, any clinical rating scales or assessments )
  • Multidisciplinary evaluation records to establish eligibility for the Early Intervention Program (EIP) (inclusive of: assessment of developmental functioning in the areas of cognition, social emotional development, communication development, adaptive development, physical development)
  • Individualized Family Service Plan (IFSP) or Supplemental evaluations included in IFSP (in–depth assessment in a particular area of developmental)
  • Optional Family Assessment where available (family–directed assessment of the families resources, priorities and concerns related to the child´s development and the capacity of the family to enhance the child´s development.)
  • Service coordination/case management log notes
  • Service Provider session/progress notes (including services focused on caregivers, family training, family counseling, family support group, etc.)
  • Physical examine for Pediatrics and Development Neuropsychiatry (PDN)
  • Prior Approval transmittal for PDN
  • Assessments, including PPRI, NCTD, etc.
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New York State Medicaid Health Home Acuity for Children Birth to 5 Years Old

Health Home Acuity (Medium) Health Home Acuity (High)
A child meets "Medium" Acuity if he/she meets:
  • [Criterion (2.1a OR 2.1b OR 2.1c OR 2.1d) AND (Criterion 2.2 OR Criterion 2.3)]
    OR
  • any two of Criterion (2.1a, 2.1b, 2.1c, 2.1d)
A child meets "High" Acuity if he/she meets:
  • [Criterion (3.1a OR 3.1b OR 3.1c OR 3.1d) AND Criterion 3.2 AND Criterion 3.3]
    OR
  • any two of Criteria (3.1a, 3.1b, 3.1c, 3.1d) AND Criterion 3.3
Criterion 2.1a: Trauma Symptoms/Adverse Childhood Experiences
  • Two or more identified Adverse Childhood Experiences
    OR
  • at least one item rated a ´1´ or higher on the Trauma Symptoms module (Module 91) or Behavioral Health module (Module 92)
Criterion 3.1a: Trauma Symptoms
  • At least one item rated a ´3´ on the Trauma Symptoms module (Module 91)
    OR
  • two or more items rated a ´2´ on the Trauma Symptoms module (Module 91) and/or Behavioral Health module (Module 92)
Criterion 2.1b: Behavioral Health
  • At least one item rated a ´2´ or ´3´ on the Behavioral Health module (Module 92)
Criterion 3.1b: Behavioral Health
  • At least one item rated a ´3´ on the Behavioral Health module (Module 92)
    OR
  • two or more items rated a ´2´ on the Behavioral Health module (Module 92)
Criterion 2.1c: Medical Health
  • At least one item rated a ´2´ or ´3´ on the Medical Health module (Module 93)
Criterion 3.1c: Medical Health
  • At least one item rated a ´3´ on the Medical Health module (Module 93)
    OR
  • two or more items rated a ´2´ on the Medical Health module (Module 93)
Criterion 2.1d: Child Development
  • At least one item rated a ´2´ or ´3´ on the Child Development domain (Domain D)
Criterion 3.1d: Child Development
  • At least one item rated a ´3´ on the Child Development domain (Domain D)
    OR
  • two or more items rated a ´2´ on the Child Development domain (Domain D)
Criterion 2.2: Child Needs & Functioning and Child Risk Behaviors
  • A rating of ´2´ on any of the following items:
    • Attachment (Item 36)
    • Living Situation (Item 37)
    • Sleep (Item 39)
    • Physical Limitations (Item 40)
    • Recreational/Play (Item 42)
    • Social Functioning (Item 43)
    • Self–harm (Item 69)
    • Aggressive Behavior (Item 70)
    • Fire Setting (Item 71)
    • Problematic Social Behavior (Item 72)
    • Preschool/Child Care Behavior (Module 94, Item B)
    • Preschool/Child Care Achievement (Module 94, Item C)
Criterion 3.2: Child Needs & Functioning and Child Risk Behaviors
  • Any one of the following Child Needs & Functioning (Domain C) and Child Risk Behavior (Domain F) items rated a ´3´
    OR
  • two or more ratings of ´2´ on any of the following items:
    • Attachment (Item 36)
    • Living Situation (Item 37)
    • Sleep (Item 39)
    • Physical Limitations (Item 40)
    • Recreational/Play (Item 42)
    • Social Functioning (Item 43)
    • Self–harm (Item 69)
    • Aggressive Behavior (Item 70)
    • Fire Setting (Item 71)
    • Problematic Social Behavior (Item 72)
    • Preschool/Child Care Behavior (Module 94, Item B)
    • Preschool/Child Care Achievement (Module 94, Item C)
Criterion 2.3: Caregiver Strengths & Needs
  • At least one Caregiver Strengths & Needs item (Domain A) rated a ´2´ or ´3´:
    • Physical Health (Item 1)
    • Developmental (Item 2)
    • Mental Health (Item 3)
    • Substance Use (Item 4)
    • Partner Relationship (Item 5)
    • Caregiver Adjustment to Trauma (Item 6)
    • Legal (Item 7)
    • Organization (Item 11)
    • Supervision (Item 12)
    • Decision–Making (Item 14)
    • Parenting Stress (Item 15)
    • Informal Supports (Item 20)
    • Knowledge of Condition (Item 23)
    OR
  • the Intensity of Treatment item (Item F) in the Medical Health module (Module 93) is rated a ´2´
Criterion 3.3: Caregiver Strengths & Needs
  • Any one of the following Caregiver Strengths & Needs items (Domain A) rated a ´2´ or ´3´:
    • Physical Health (Item 1)
    • Developmental (Item 2)
    • Mental Health (Item 3)
    • Substance Use (Item 4)
    • Partner Relationship (Item 5)
    • Caregiver Adjustment to Trauma (Item 6)
    • Legal (Item 7)
    • Organization (Item 11)
    • Supervision (Item 12)
    • Decision–Making (Item 14)
    • Parenting Stress (Item 15)
    • Informal Supports (Item 20)
    • Knowledge of Condition (Item 23)
    OR
  • the Intensity of Treatment item (Item F) in the Medical Health module (Module 93) is rated a ´3´
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New York State Medicaid Health Home Acuity for Children 6 to 21 Years Old

Health Home Acuity (Medium) Health Home Acuity (High)
Child meets "Medium" Acuity if he/she meets:
  • Criterion (2.1a OR 2.1b OR 2.1c OR 2.1d OR 2.1e) AND Criterion (2.2 OR 2.3 OR 2.4) AND Criterion 2.5
Child meets "High" Acuity if he/she meets:
  • Criterion (3.1a OR 3.1b OR 3.1c OR 3.1d OR 3.1e) AND Criterion (3.2 OR 3.3 OR 3.4) AND Criterion 3.5
Criterion 2.1a: Trauma Symptoms
  • At least one item rated a ´3´ on the Trauma Symptoms module (Module 84)
    OR
  • two or more items rated a ´2´ on the Trauma Symptoms module (Module 84) and/or Behavioral Health Module (Module 85)
Criterion 3.1a: Trauma Symptoms
  • At least two items rated a ´3´ on the Trauma Symptoms module (Module 84) and/or Behavioral Health module (Module 85)
    OR
  • three or more items rated a ´2´ or ´3´ on the Trauma Symptoms module (Module 84) and/or Behavioral Health module (Module 85)
Criterion 2.1b: Behavioral Health
  • At least one item rated a ´3´ on the Behavioral Health module (Module 85)
    OR
  • two or more items rated a ´2´ on the Behavioral Health module (Module 85)
Criterion 3.1b: Behavioral Health
  • At least two items rated a ´3´ on the Behavioral Health module (Module 85)
    OR
  • three or more items rated a ´2´ or ´3´ on the Behavioral Health module (Module 85)
Criterion 2.1c: Medical Health
  • At least one item rated a ´3´ on the Medical Health module (Module 88)
    OR
  • two or more items rated a ´2´ on the Medical Health module (Module 88)
Criterion 3.1c: Medical Health
  • At least two items rated a ´3´ on the Medical Health module (Module 88)
    OR
  • three or more items rated a ´2´ or ´3´ on the Medical Health module (Module 88)
Criterion 2.1d: Developmental
  • At least one item rated a ´3´ on the Developmental module (Module 87)
    OR
  • two or more items rated a ´2´ on the Developmental module (Module 87)
Criterion 3.1d: Developmental
  • At least two items rated a ´3´ on the Developmental module (Module 87)
    OR
  • three or more items rated a ´2´ or ´3´ on the Developmental module (Module 87)
Criterion 2.1e: Substance Use
  • At least one item rated a ´3´ on the Substance Use module (Module 86)
    OR
  • two or more items rated a ´2´ on the Substance Use module (Module 86)
Criterion 3.1e: Substance Use
  • At least two items rated a ´3´ on the Substance Use module (Module 86)
    OR
  • three or more items rated a ´2´ or ´3´ on the Substance Use module (Module 86)
Criterion 2.2: Impairment in Self Care
  • At least one item rated a ´3´ on the Activities of Daily Living module (Module 89)
    OR
  • two or more items rated a ´2´ on the Activities of Daily Living module (Module 89)

    OR for youth 14 or older,
  • At least one item rated a ´3´ on the Independent Activities of Daily Living module (Module 91)
    OR
  • two or more items rated a ´2´ on the Independent Activities of Daily Living module (Module 91)
Criterion 3.2: Impairment in Self Care
  • At least two items rated a ´3´ on the Activities of Daily Living module (Module 87)
    OR
  • three or more items rated a ´2´ or ´3´ on the Activities of Daily Living module (Module 87)

    OR for youth 14 or older,
  • At least two items rated a ´3´ on the Independent Activities of Daily Living module (Module 91)
    OR
  • three or more items rated a ´2´ or ´3´ on the Independent Activities of Daily Living module (Module 91)
Criterion 2.3: Child Needs & Functioning
  • At least one the following Child Needs & Functioning items rated a ´3´
    OR
  • two or more ratings of ´2´:
    • Living Situation (Item 40)
    • Peer Interactions (Item 42)
    • Decision–Making/Judgment (Item 43)
    • Sleep (Item 44)
    • Physical Limitations (Item 45)
    • Recreational (Item 47)
    • Juvenile Justice/Legal (Item 48)
    • School Behavior (Item 50)
    • School Achievement (Item 51)
    • School Attendance (Item 52)
Criterion 3.3: Child Needs & Functioning
  • At least two the following Child Needs & Functioning items rated a ´3´
    OR
  • three or more ratings of ´2´ or ´3´:
    • Living Situation (Item 40)
    • Peer Interactions (Item 42)
    • Decision–Making/Judgment (Item 43)
    • Sleep (Item 44)
    • Physical Limitations (Item 45)
    • Recreational (Item 47)
    • Juvenile Justice/Legal (Item 48)
    • School Behavior (Item 50)
    • School Achievement (Item 51)
    • School Attendance (Item 52)
Criterion 2.4: Risk Factors & Behaviors
  • At least one Risk Factors & Behaviors item (Domain E) rated a ´3´
    OR
  • two or more Risk Factors & Behaviors items (Domain E) rated a ´2´
Criterion 3.4: Risk Factors & Behaviors
  • Any two Risk Factors & Behavior items (Domain E) rated a ´3´
    OR
  • three or more Risk Factors & Behaviors items (Domain E) rated a ´2´ or ´3´
Criterion 2.5: Caregiver Strengths & Needs
  • At least one of the following Caregiver Strengths & Needs items (Domain A) rated a ´2´ or ´3´:
    • Physical Health (Item 1)
    • Developmental (Item 2)
    • Mental Health (Item 3)
    • Substance Use (Item 4)
    • Legal (Item 7)
    • Organization (Item 11)
    • Supervision (Item 12)
    • Decision–Making (Item 14)
    • Parenting Stress (Item 15)
    • Informal Supports (Item 20)
    • Knowledge of Condition (Item 23)
    OR
  • the Intensity of Treatment item (Item F) in the Medical Health module (Module 88) is rated a ´2´

    OR for youth who do not have a caregiver,
  • a score of 2 or 3 on the Self–Care Management item (Item D) in the Transitions to Adulthood module (Module 90)
Criterion 3.5: Caregiver Strengths & Needs
  • Any one of the following Caregiver Strengths & Needs items (Domain A) rated a ´3´
    OR
  • two or more of the following Caregiver Strengths & Needs items (Domain A) rated a ´2´ or ´3´:
    • Physical Health (Item 1)
    • Developmental (Item 2)
    • Mental Health (Item 3)
    • Substance Use (Item 4)
    • Legal (Item 7)
    • Organization (Item 11)
    • Supervision (Item 12)
    • Decision–Making (Item 14)
    • Parenting Stress (Item 15)
    • Informal Supports (Item 20)
    • Knowledge of Condition (Item 23)
    OR
  • the Intensity of Treatment item (Item F) in the Medical Health module (Module 88) is rated a ´3´

    OR for youth who do not have a caregiver,
  • a score of 3 on the Self–Care Management item (Item D) in the Transitions to Adulthood module (Module 90)
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