Lead Health Home Resource Center

Who is required to complete an eMedNY application for Medicaid category of service (COS) 0265 Health Home/Care Management?

Organizations serving as lead Health Homes (e.g. that have received an approval letter from the New York State Department of Health identifying them as a ""Designated Provider–lead Health Home" ") and any care management agencies that provide health home services must be enrolled in Medicaid for category of service (COS) 0265, Health Home/Care Management.

The eMedNY application and instructions for Health Home enrollment can be found on the eMedNY website (Provider Enrollment). Under the "How do I?" section select Health Homes.

NOTE: Under the Provider Enrollment tab, see information regarding Application Fee.

REMINDER: NPI is required prior to applying for COS 0265 https://www.emedny.org/info/ProviderEnrollment/enrollguide.aspx

Completed applications should be sent to:

Computer Science Corporation (CSC) P.O Box 4603, Rensselaer, N.Y. 12144

Questions regarding the provider enrollment application can be directed to CSC at: 1–800–343–9000.

Care management organizations that appear on the Case Management Provider Names list do not need to submit a Medicaid Provider Enrollment application. The DOH has an expedited process for these enrollments.

Provider Enrollment for Health Home Care Management Agencies Walkthrough (PDF)

The Notification of Change (NOC) Form (PDF) is used by the lead Health Home and Managed Care Plan to inform the NYS Department of Health of any of the following changes:

Health Home Changes
  • Program Name (Changing Designated Corporate Name or DBA)
  • Corporate Structure (Merger, Separation, or Closure)
  • New/Change to Health Home or CMA MMIS/NPI
  • Designated Service Counties (Expansion, Withdrawal)
  • Billing Vendor
  • RHIO Connectivity
  • Care Management Platform/ Electronic Health Record
  • CMA Relationship
  • Partner/Network Provider

Requirements and Instructions For Using the Notification of Change Form (PDF) must be followed when completing the NOC form.

The Health Home must submit the completed NOC form via the Health Home BML "NYS Health Home Email" under: Organizational Changes.

    NOTE: If the NYSDOH Health Home Program receives a phone call regarding a potential change, the HH will be directed to complete and submit the NOC as required via the Health Home BML.
For additional assistance, Health Homes may submit questions electronically to the Health Home BML "NYS Health Home Email" under the Subject: Provider Enrollment/Provider and Network Partner Name Changes/NPI, or call the NYSDOH Health Home Program at (518) 473–5569.

Reminder! Lead Health Homes that hold certifications as clinics or hospital–based providers under Article(s) 28, 31 and/or 32 that change their name and/or apply for new NPI#s after receipt of their New York State Approved Health Home Letter, are encouraged to contact their affiliated State agency respectively, for any additional guidance that may be needed.

Article 28 – Bureau of Project Management, NYS Department of Health, (518) 402–0911

Article 31 – Bureau of Inspection and Certification, NYS Office of Mental Health, (518) 474–5570

Article 32 – Bureau of Certification and Systems Management, NYS Office of Alcoholism and Substance Abuse Services, (518) 485–2250

Lead Health Homes

New York State Department of Health has updated the Data Exchange Application and Agreements (DEAA) to a Data Use Agreement (DUA). DEAAs or DEAA amendments will no longer be accepted. The Department requires that all HHs submit and receive acceptance of the Medicaid Confidential Data Use Agreement (DUA) from the Department’s Office of Health Insurance Programs, Division of Operations and Systems, Security and Privacy Bureau in order to access Medicaid Confidential Data (MCD). Completed DUAs should be sent to: doh.sm.Medicaid.Data.Exchange@health.ny.gov

The purpose of the DUA is to assure the Department that the HH will maintain the security and privacy of MCD that the Department releases to the HH.

The DUA, once accepted by the Department, establishes a legally binding agreement between the HH and the Department by defining the terms and conditions of the MCD release. The sensitivity of MCD cannot be over-emphasized. MCD includes all personal information about Medicaid members, including Protected Health Information (PHI).

A DUA must be completed and accepted prior to the Department granting a HH access to the Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS), whichcontains MCD and PHI.

HHs who work with subcontractors/business associates that will also access MCD and the MAPP HHTS are required to complete and submit a DUA Addendum along with the Business Associate Agreement (BAA). The BAA is an agreement between the HH and their subcontractors/business associates regarding the release of MCD/PHI. BAAs must be sent to and acknowledged by the Security and Privacy Bureau before any MCD/PHI can be shared with the HH’s business partners. The Department must acknowledge security requirements imposed by the HH on subcontractors/business associates which should take into account the risk presented by the type and volume of the data being shared by the HH with the subcontractor/business associates in the DUA Addendum and BAA before the subcontractor/business associate may access MCD.

The HH is responsible for complying with all federal and state laws and regulations regarding the privacy, protection and security of MCD. The HH must ensure that any BAA with a subcontractor/business associate reasonably protects the HH from liability in the event of a breach attributable to the subcontractor/business associate.

All questions regarding the DUA and/or BAA should be directed to the New York State Department of Health, Office of Health Insurance Programs, Division of Operations and Systems, Security and Privacy Bureau at: Doh.sm.Medicaid.Data.Exchange@health.ny.gov

General Instructions

When completing any form with an individual/member, the care manager should:

  1. Give consideration to the member´s level of understanding and comfort. Legal representation (e.g., guardian) must be involved as appropriate;
  2. Use the form in the language most suitable for the member. If the form is not available in the individual´s chosen language, assure the presence of an interpreter;
  3. Complete all sections of the form as indicated, using full name of Health Home, other entities, phone numbers, etc.;
  4. Review the completed form in full with member and assure understanding prior to signing;
  5. Provide a copy of the completed and signed form to the member; and,
  6. Maintain the original signed form in the member´s record.

NOTE: DOH numbered forms such as the DOH 5055, DOH 5058, and DOH 5059 may not be altered in any way (e.g., use of agency logo, changing original content, attaching other types of forms or documents, altering DOH form numbers or date, adding bar codes, etc. are prohibited).

UPDATED 6/18

The signing of the DOH 5055 Health Home Patient Information Sharing Consent is directly tied to Health Home enrollment therefore, for an individual to be enrolled in the Health Home Program, consent must be signed. The individual must be informed that without signed consent enrollment cannot occur. By completing the DOH 5055 consent form, a member is agreeing to allow his/her health information to be shared among the consented Health Home partners and for the Designated Health Home to access the RHIO and PSYCKES for information. At a minimum, page 3 of the DOH 5055 must include the name of the Care Management Agency, the name of the Medicaid Managed Care Plan (if applicable), and the Primary Care Physician and/or the healthcare provider most frequently used by the member (e.g., Mental Health Practitioner, etc.).

2A: Additional Guidance to Completing the Health Home Patient Information Sharing Consent Form (DOH 5055)

In addition to instructions for completing Member forms provided in Section 1, one of the following options must be used when completing page 3 of the Health Home Patient Information Sharing Consent (DOH 5055).

Options may include:

  • Option 1 – Write in the names of only those downstream providers and other entities approved by the member;
  • Option 2 – List all of the Health Home's downstream partners and add any other entities approved by the member. Use check marks to clearly identify only those providers and others approved by the member. Have the member initial next to each selection; or
  • Option 3 – List all of the Health Home's downstream partners and add any other entities as approved by the member. Cross out all entities the member does not want involved in his/her care. Have the member initial next to all those crossed out.

NOTE: An additional assurance would be to have the Health Home Care Manager initial next to each entry initialed by the member.

2B: Making Changes to the Health Home Patient Information Sharing Consent (DOH 5055) after it has been completed and signed

A Health Home member may request to add/remove and/or limit access to information at any time. The care manager must assure that:

  1. Any changes or limitations specified by the member are clearly noted in the DOH 5055;
  2. All page 3´s should be completed in the same format to avoid confusion (e.g. if original uses cross out method, then any updates should use same method);
  3. Each change is initialed by the member and dated; and,
  4. Each change is also initialed by the care manager and dated

If the member limits access to an entity, the HHCM must assure a separate consent form is used to follow the member’s request and minimize potential of error.

This form is used for a member who is enrolled in the Health Home program and has signed the DOH 5055.

3A: Additional Guidance to Complete the Health Home Patient Information Sharing – Withdrawal of Consent (DOH 5058)

In addition to instructions for completing Member forms provided in Section 1, the care manager must;

  1. Assure all Health Home partners and others approved by the Member on page 3 of the signed DOH 5055 consent are notified of the Member´s disenrollment and the effective date to end information sharing;
  2. Document a member´s refusal to sign the DOH 5058 and notify all Health Home partners and others approved by the Member on page 3 of the signed DOH 5055 consent of member´s request to disenroll and end information sharing.

UPDATED 6/18

The DOH 5059 form is used ONLY during outreach activities to document when an eligible individual has been approached about the Health Home Program but choses NOT to be enrolled. The form is completed by the Health Home eligible Medicaid client (or their Parent, Guardian, or Legally Authorized Representative, if applicable), or by the Health Home Care Manager (HHCM), and must include the reason for Opting Out given by the individual. If the individual refuses to complete/sign the form, the HHCM must document this on the form.

The Health Home Opt–Out form (DOH 5059) is not used to disenroll an enrolled HH member. Once an individual has enrolled in the Health Home Program and signed the appropriate consent (DOH 5055 or DOH 5200 and DOH 5201 for HHSC), the appropriate Withdrawal of Consent form must be completed (DOH 5058 or DOH 5202 for HHSC).

If an enrolled Health Home member requests transfer to another Health Home, proper procedures must be followed to withdraw consent and complete new consent documents with the new Health Home.

4A: Additional Guidance to Complete the DOH 5059

In addition to instructions for completing Member forms provided in Section 1, the care manager must ensure assure the DOH 5059 is completed as follows:

  1. The appropriate Attestation Statement box is checked indicating whether the care manager met with the individual in person, or talked with the individual on the phone.
  2. The individual´s reason(s) for opting out are documented;
  3. The form must be signed and dated by the individual (Parent, Guardian, or Legally Authorized Representative, if applicable) and the care manager.
  4. If the individual is unable or refuses to sign the form, the care manager must document this on the form.
  • Information exchange is a critical component of care coordination provided by the Health Home program. By completing the consent form, a member is agreeing to allow his/her Personal Health Information (PHI) to be shared among the consented Health Home partners and, for the Designated Health Home to access information from the Regional Health Information Organization (RHIO) and The Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES). With a signed consent, all providers and others involved in the member´s care has access to the same information to better serve the member.
  • Please note that Health Home Patient Information Sharing Consent form (DOH 5055) must remain up to date to reflect any changes in service providers. If Health Home service providers have changed, Health Homes/care managers must add or delete provider names on page 3 of the DOH 5055 form. The revisions must be initialed and dated by the Health Home/care manager and the Health Home member.
  • Health Home Patient Information Sharing Consent Forms:
  • Policy for Sharing Protected Health Information between HH and MCO (PDF)

If a member chooses to disenroll from the Health Home program s/he must sign a Health Home Patient Information Sharing Withdrawal of Consent Form (DOH 5058). Signing this form indicates not only the member´s intent to disenroll from the program, but also withdraw his/her consent to share health information effective on the date the form was signed. All Health Home partners and others approved by the member on page 3 of the Patient Information Sharing Consent (DOH 5055) must be notified if a member withdraws their consent, and the effective date of withdrawal. If attempts to complete and sign the DOH 5058 are unsuccessful, the care manager must document the member´s request to disenroll from the Health Home program and refusal to complete the DOH 5058.

Health Home Patient Information Sharing Withdrawal of Consent Forms:

The Health Home program is voluntary. For members who choose not to enroll in the Health Home program, the Health Home Opt–out Form (DOH 5059) must be completed and signed either by the member or the care manager.

Health Home Opt–Out Forms:

When the Health Home enrolls a new member, the DOH-5234 should be completed and mailed with the welcome letter.

Health Home Notice of Determination for Enrollment (DOH 5234) Forms:

When a member is disenrolled, the DOH-5235 must be completed and mailed at least 10 days prior to the date upon which the Health Home proposed action is to take place.

Notice of Determination for Disenrollment in the New York State Health Home Program (DOH 5235) Forms:

If an individual is found ineligible for Health Home services, the DOH-5236 must be mailed to the individual informing them they did not meet the Health Home eligibility criteria.

Notice of Determination for Denial of Enrollment in the New York State Health Home Program (DOH 5236) Forms:

The Centers for Medicare and Medicaid Services (CMS) approved a State Plan Amendment (SPA) authorizing the State to distribute $190.6 million dollars of Health Home Development Funds authorized in the MRT 1115 Waiver Amendment. Funds were distributed through a temporary rate add–on to per member per month (PMPM) Health Home claims and was be paid to lead designated Health Homes in quarterly increments from March 2015 through December 2016.

Spending/Reporting Period Report Due Date
October 2019 – December 2019 1/31/20
January 2020 – March 2020 4/30/20
April 2020 – June 2020 7/31/20

For information on Health Home Implementation Funds and Workforce Training Initiative, click here.

Click here to view

    Previous Webinar Materials for both Health Home Serving Adults and Health Homes Serving Children
    Upcoming Health Home Trainings and Webinars
    Presentation Date Time Description/Topic Presenter Target Audience
    2020
        Future webinars will be listed here as they are scheduled    

  • Click here to view information on Health Information Technology (HIT) Implementation and Standards for Health Homes
  • Click here to view all Partner Resources information
  • Click here to view information on Reportable Incidents

Sub Work Groups: Completed 2013

Assignment and Referral
Behavioral Health Transition
Clinical Risk Group Analysis
Contracting
Criminal justice
Financial Feasibility
Implementation Grants

Other Meetings

2013 Meetings
2012 Meetings