Health Home Initial Appropriateness and Continued Eligibility for Services (CES) Tool: Frequently Asked Questions (FAQ)

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New York State Department of Health

November 2023

Table of Contents

The New York State Department of Health (DOH) created this document to answer frequently asked questions that the Health Home Network within New York State had following the webinar NYS DOH provided on Initial Appropriateness and The Continued Eligibility for Services (CES) Tool. Please use this document to help you answer any questions that come up during your implementation of both Initial Appropriateness and the CES Tool.

  1. Will the initial appropriateness have to be submitted every time a client comes out of DSE or Pended status?
    DOH Answer: Every time a new enrollment segment begins an Initial Appropriateness will need to be completed.
  1. Can Health Home enrollment occur before the Initial Assessment is complete?
    DOH Answer: We would expect Initial Appropriateness to be determined at the time of enrollment. If there is no Initial Appropriateness criterion that the individual meets, then they should not be enrolled.
  2. Is Initial Appropriateness needed for only newly enrolled member after 12/1?
    DOH Answer: Effective 12/1/23, Initial Appropriateness will need to be entered for all newly enrolled youth and adults within 30 days of signed consent, and upon creation of any new subsequent segment.
  3. If the consent date is prior to the segment start date, how will the 30 days count?
    Example: A consent is signed on 8/30/23, but for whatever reason the segment start date is 10/1/23. Would the Initial Appropriateness be due immediately when reporting the 10/1/23 segment or could it be reported up any time within the month of October 2023 (to be able to bill for October 2023)?
    DOH Answer: Initial Appropriateness is due 30 days from signed consent.
  1. We would like to see 14, 15, 16, 17 changed to last 12 months instead of 6 months. Often there can be barriers or long-term placements that may prevent the 6-month timeframe.
    DOH Answer: The six-month interval lookback will remain as-is.
  2. Assuming 20 refers to BH or medical providers?
    DOH Answer: Yes, this item refers to medical providers and specialists, including those associated with Behavioral Health treatment.
  3. Is there any flexibility in 25 with the word "cannot" access? Some of our families can access unhealthy options or some but not enough or rely on food pantries but is that good enough and wouldn't warrant additional help from us?
    DOH Answer: The standard for this criterion is firm. Providers can make this determination by ascertaining if members' available/accessible food sources are adequate to sustain themselves.
  4. For 28, it just states "recent" as the timeframe. Will the state scrutinize interpretation of "recent"?
    DOH Answer: Thank you for identifying this ambiguity. DOH will define "Recent" as "within the last 6 months". We will make this clarification known to the community and will update information on the DOH website and associated with the MAPP system at the earliest opportunity.
  5. For 29, we don't believe it is appropriate to add a parent's name to the child's record and identify them as being enrolled in a HH (which indicates they have a diagnosis qualifying them for HH). We plan to have the CM put the appropriateness criteria justification within the enrollment note and these notes are discoverable during audits. Is there another way this should be identified? Seems like a PHI concern when putting that information in the chart.
    DOH Answer: We will explore this question with DLA. Until such time as the matter is clarified, the CM may enter the full name of the HH and CMA in which the caregiver is enrolled, and append the Health Home - enrolled caregiver's initials, instead of full name.
  1. Will Initial Appropriateness have to be submitted every time a client comes out of DSE or Pended status?
    DOH Answer: Every time a new enrollment segment begins an Initial Appropriateness will need to be completed.
  1. Will this replace the Health Home Eligibility Form, or is that also still required in addition to this?
    DOH Answer: Initial Appropriateness will be collected on all members as described in this training. DOH encourages HH's to explore opportunities to reduce duplication effort that may arise.
  1. There is not one mention of education/school barriers in the SDOH reasons. We have over 60% of our kids coming into this program that experience barriers to attending school and feel this, along with their diagnostic criteria, should make them appropriate for the program. Schools do not always follow through on IEPs, they can't accommodate high needs behaviors, nursing and medical care are barriers, etc. and families need assistance navigating this system. For many families, this can lead to PINS or justice issues due to non-adherence.
    DOH Answer: We anticipate that difficulties with school will be secondary to the Initial Appropriateness criteria that would justify enrollment in HH, and we would direct the CM to select the primary applicable criterion. Difficulties with school have not been among appropriateness criteria to this point and DOH is not going to expand criteria at this time.
  2. We don't see much related to our Med Frag kids who utilize HCBS/Waiver as a means of accessing Medicaid for medical fragility... these "could" be the case without the Medicaid but are we using a masking concept here? Also, if they are utilizing the program for EMOD/VMOD but none of the other criteria are true, at the moment, we aren't sure where they would fit.
    DOH Answer: The Medically Fragile Family of One HCBS children still need to meet risk and would minimally fall under items 14, 16, 17. The criteria are not being expanded further at this time. The Department will monitor feedback on whether there are individuals are being inappropriately excluded from the HHSC program.
  3. Given the changes in OPWDD and young children not being able to access services, we would recommend another criterion such as "Has deficits in activities of daily living, learning, or cognition issues" be added.
    DOH Answer: We've reviewed this with the HHSC team and have concluded that this recommendation would be captured under item 17. The criteria are not being expanded further at this time. The Department will monitor feedback on whether there are individuals are being inappropriately excluded from the HHSC program.
  1. Is MAPP updating the children's referral portal by December to reflect these changes?
    DOH Answer: The MAPP referral portal is not being changed at this time. The information provided through the portal must always be validated and it is expected that during the enrollment process the CM would obtain sufficient information to determine whether or not at least one Initial Appropriateness criterion applies subsequent to receipt of the referral through the portal.
  2. How will Initial Appropriateness go into MAPP?
    DOH Answer: Health Homes must start recording Initial Appropriateness in their EHRs effective 12/1/23. The MAPP tracking system will start accepting Initial Appropriateness via the Consent and Member Program Status Upload file on 12/9/23. MAPP HHTS December 2023 4.4 release contains this information.
  1. Will billing be affected if the six-month reassessment is not completed?
    DOH Answer: Per the slide deck, at present there is no billing block associated with the CES Tool. There will likely be one in the future.
  2. Will the CES Tool be replacing the HML?
    DOH Answer: The CES Tool will not replace the HML. Please see policy.
  3. Are we able to bill if a billable service has been provided within the 60-day period that the CES Tool recommended disenrollment?
    DOH Answer: Yes, in the 60 days you are working towards disenrollment, as long as a core service is provided, you are able to continue to bill.
  4. If it recommends disenrollment, and the POC expires that month, are we not able to bill during the 60 days we have to disenroll?
    DOH Answer: You will be able to bill within the 60 days you are working towards disenrollment, as long as a core service is provided. CMAs are still required to follow the current POC policy.
  1. Were stakeholders from CMA's and health home members allowed to provide input in the development of the CEST?
    DOH Answer: Representatives from the Health Home Coalition, the Care Management Coalition, iHealth, MCOs, HIV SNPs, DOH, and OMH met for 6- weeks to come to consensus on the design of the CES Tool.
  1. Are the responses to the CES Tool "yes", "no"?
    DOH Answer: The answers to the CES Tool questions are Yes/No/Unclear/NA.
  2. Would the CES tool be completed by the CM and reviewed by Supervisor before being submitted to the Health Home? Or does it have to be uploaded into the Netsmart files?
    DOH Answer: If a Care Manager is the individual completing the CES Tool a supervisor must review the Tool prior to submission. Please refer back to your Lead Health Home for clarification on how they are working with their EHR vendors on building the CES Tool.
  3. With the CES tool, will members have to sign off on it as well? That way they are aware as well?
    DOH Answer: No, the member does not need to sign off on the CES Tool. However, the outcome must be discussed with member and documented in the members' record.
  4. Does the client need to participate in the CES? Or can the CM do it on their own?
    DOH Answer: The client does not need to participate in the completion of the CES Tool. However, the outcome must be discussed with the member.
  5. Who completes the CES tool? Care Managers? Supervisors?
    DOH Answer: The CMA Supervisor or Quality Assurance staff must complete this tool. However, if the tool is completed by the Care Manager it must be reviewed and approved by the CMA Supervisor prior to submission.
  1. When a member is in diligent search and you are reengaging them, by creating a new segment. Are we required to create a new CES?
    DOH Answer: If a member is re-engaged following a DSE, the CES Tool would be completed 6 months following the start of a new segment.
  2. Will DSE be eliminated based on the new CES Tool?
    DOH Answer: Please refer to the Continuity of Care and Re-engagement for Enrolled Health Home Members policy HH0006 which describes steps to be taken when a member is deemed disengaged from HHCM services. Diligent Search Efforts (DSE) will not be eliminated based on the new CES Tool.
  3. Would you complete the CES Tool on a member that is in DSE?
    DOH Answer: Please refer to the Continuity of Care and Re-engagement for Enrolled Health Home Members policy HH0006 which describes steps to be taken when a member is deemed disengaged from HHCM services. If a member is in Diligent Search Efforts (DSE), the CES Tool would only be completed if the member is re-engaged.
  1. If someone is pended and then a new segment is done, do I do the CES tool then (upon creation of the new segment) or when their next reassessment is due?
    DOH Answer: Every time a new enrollment segment begins an Initial Appropriateness will need to be completed.
  2. Would the tool be completed on members who are HH+ eligible but rather stay as HH?
    DOH Answer: If a member is HH+ eligible or enrolled, the CES Tool should not be completed.
  3. How would the CES Tool address clients in Adult Homes who have in-house providers and are stable, but would become unstable without Health Home CM interventions?
    DOH Answer: If you are referring to Adult Home Plus or Health Home Plus members, the CES Tool is not required.

    If you are referring to a member living in a Community Residence, please refer to the Health Home Eligibility Requirements policy. The member needs to meet Eligibility and Appropriateness Criteria in order to be enrolled in services.
  4. What if the client has no risk factors at the time of enrollment? Are we still do the CES Tool?
    DOH Answer: Please refer to the Health Home Eligibility Requirements policy. The member needs to meet Eligibility and Appropriateness Criteria in order to be enrolled in services.
  1. Is there an operational definition for 'engagement'?
    DOH Answer: Per the CES Tool, a member is not actively engaged if they are only in touch with the HHCM to say they are busy, or will call them back, or if regularly, Core Services being provided are only being provided through the Care Team because the member is unavailable.

    A member is not working with the HHCM on their HH POC Goals and Tasks if during their contacts they are solely updating the HHCM on their life or persistently addressing something not on the POC.
  2. What would happen if the patient became disengaged within the 60 days?
    DOH Answer: If you received a "Recommend Disenrollment" result you would continue to follow the CES Tool recommendation and proceed with disenrollment.

    If you received a "More Information Needed" result Please refer to the Continuity of Care and Re-engagement for Enrolled Health Home Members policy HH0006 which describes steps to be taken when a member is deemed disengaged from HHCM services.
  3. Does this take into account individuals who may have cognition issues or severe mental health symptoms which may prevent them to be engaged in care - according to your definition?
    DOH Answer: We encourage CMAs to utilize engagement skills to connect the members to HHCM services. However, it is ultimately the members decision if they want to participate in the program.
  1. When will it be required for enrolled members?
    DOH Answer: Yes, the CES Tool will be required for all members who are not Health Home Plus or Adult Home Plus.
  1. Will there be any type of follow up with how everyone is doing?
    DOH Answer: Per the slide deck, follow up with members will be determined by the outcome of the CES Tool.
  1. Is there a separate consent form for this service?
    DOH Answer: There is no consent form needed to complete the CES Tool.
  2. Will DOH Form 5235 be updated to include "you are no longer engaged in care management" as a reason for disenrollment?
    DOH Answer: We will explore whether this addition is necessary. In the meantime, utilize the "other" option and insert "Member is no longer engaged in Health Home Care Management Services as defined in the CES Tool."
  1. HH+ "eligible" and HH+ "enrolled" do not have to have CES, correct?
    DOH Answer: HH+, HH+ eligible, and Adult Home + do not have to have a CES tool completed. The tool is being built into systems which will give cues to ensure folks remember that.
  2. If client steps down from HH+ on 11/1. When is CEST tool due. Next year or 11/1 as well?
    DOH Answer: If a member is stepping down from Health Home Plus on 11/1/2023, the CES Tool would be due 11/1/2024.
  3. If a member steps down from HH+, do they need to do a CES Tool right away or at the annual assessment after HH+ ends?
    DOH Answer: If a member is stepping down from Health Home Plus, the CES Tool would be due at their annual assessment.
  4. DOH does not require HH+ eligible, HH+ enrolled, AH+ members to complete CEST. Is DOH planning on doing any data reconciliation on this? If so, what will your reference data be? We want to ensure that our CMAs have transparency on any future planning so that they are not held accountable for missing CEST data if our information on special populations differs from DOH's.
    DOH Answer: At this time, we do not plan on doing data reconciliation. If DOH engages in data reconciliation project, we will provide ample notification.
  1. Is a CES completed for children in HH?
    DOH Answer: A CES Tool is only for Health Homes Serving Adults. Additionally, HH+, HH+ eligible, and AH+ are excluded.
  2. What is the operational method for the supervisor review of the CES Tool?
    DOH Answer: Please refer back to your Lead Health Home for clarification on how they are working with their EHR vendors on building the CES Tool.
  1. Will the form be available on the DOH website or emailed to our agency? Will it be available on the program we use, such as Netsmart?
    DOH Answer: The tool and training will be available on the DOH website. Lead HH's are currently working to build the CES Tool in their EHR's.
  1. If after the 60 days, it says more information needed again, how long can we keep the case?
    DOH Answer: A second "More Information Needed" result is not an acceptable end point. The team needs to collect enough information to yield a result of either Recommend Disenrollment or Recommend Continued Enrollment.
  2. When you receive a More Information Needed Outcome, a new CES Tool is due 60 days from when outcome was provided correct? 60 Calendar or business days?
    DOH Answer: The CES Tool is completed within 60 calendar days.
  3. If the CES tool results are unclear and then we obtain additional information that confirms continued eligibility, would another CES tool need to be completed?
    DOH Answer: Yes, once a More Information Needed outcome is determined and additional information is obtained that supports continued enrollment, a new CES Tool must be completed within 60 days.
  1. Can the completing of this tool result in updating the Plan of Care? Example: The Plan of Care has maintenance goals but needs to be updated to reflect other/additional needs.
    DOH Answer: Please refer to the Plan of Care policy HH0008 which describes steps to be taken when additional needs are identified for a member.
  2. Are the risks that are part of the CES and Initial Appropriateness going to be standardized with those that are selected/entered with the care plan?
    DOH Answer: While in most cases goals ought to be closely aligned with the significant risk factors that justify enrollment. Goal setting in the context of the Plan of Care is a highly individualized and person-centered process and therefore, DOH is not mandating the verbiage that must be included when goals are developed with the member.
  3. Will the target date for the care plan be every 6 months, since the CES Tool will be due every 6 months after the initial?
    DOH Answer: Please refer to the Plan of Care policy HH0008 which describes steps to be taken when additional needs are identified for a member.
  4. Will the Plan of Care and Comprehensive Assessment still only be due annually?
    DOH Answer: See policy. We are exploring with the HH Community whether efficiencies can be generated related to the comp assessment.
  1. Can clients continue to have maintenance goals in addition to the actionable goal they may have? For example, a housing goal may be in limbo, meaning, the (SPOA housing, section 8, etc.) application is in so this goal so may not be worked on every month.
    DOH Answer: Yes, as long as there are actionable non-maintenance goals in the POC as well.
  2. From what I read in the visual aid, does this mean that for all members that CES tool identifies as eligible to continue enrollment, will they need to have a new CES tool completed every six months if it continues to report as eligible?
    DOH Answer: For New Members, that are enrolled on/after 11/1/23 the CES Tool will be completed 12 months post-enrollment and completed every 6 months thereafter.
    For Existing Members, the CES Tool will be completed at time the member's next annual Reassessment and completed every 6 months thereafter.
  1. If at the annual mark, the member is noted as "disenroll", will there be flexibility with the POC / Comp Assessment completion so that unnecessary work is not ALSO being completed while getting the member set for post-disenrollment services?
    DOH Answer: DOH is taking under consideration any changes to policy to address your question regarding Comprehensive Assessment and Plan of Care. In the interim, CMAs are required to follow Plan of Care and Comprehensive Assessment policies, as written.
  2. Can the CES tool provide a due date for disenrollment?
    DOH Answer: For each outcome to a CES Tool submitted to MAPP, the MAPP system will assign an end date appropriate to the outcome. Health Homes will be able to download those end dates from MAPP.

    In the excel document that is posted on the NYS DOH website, once the date of the assessment is input, the tool will output the disenrollment date.
  3. What if a member tries to re-enroll with CMA or another CMA within a certain frame? Do receiving CMA's have to screen referrals from being discharged from other CMAs
    DOH Answer: HHs and CMAs are required to screen all individuals for eligibility and appropriateness per Health Home Eligibility policy, currently under revision to include Initial Appropriateness.
  4. Will "Disengagement" be elaborated further? Many high-risk enrollees can be understandably difficult to engage due to MH Dx or Homelessness. These members may be intermittently engaged, perhaps engaging around events such as ED/Inpatient encounters. Simply making a decision to disenrollment, sending an NOD for Disenrollment due to disengagement, and closing the case. This could leave high-risk members without a connection to HH during a crises MH episodes, SU treatment, ER visits for SU, Overdoses, losing housing, etc.
    DOH Answer: If you are referring to Disengagement as it related to Diligent Search Efforts, please refer to the Continuity of Care and Re-engagement for Enrolled Health Home Members Policy, HH0006.
    If you are referring to Engagement as defined in the CES Tool, please refer to the three questions within the Member Engagement section of the CES Tool.
  5. What if the client does not agree with graduation? There are a lot of clients that have had support for a long time... it will be very difficult to make them understand that they will not have the support, especially since no step down is available.
    DOH Answer: It is understood that at times the outcome of the CES Tool will lead to involuntary discharges from the HH program. Per the Member Disenrollment from the Health Home Program policy HH0007, steps are outlined to support proper involvement of the member and care team to develop and implement an appropriate discharge plan for members and to connect members to less intensive support structures and the resources needed. Policy also includes steps to inform members how to request consideration for HH program re-enrollment if needed after disenrollment.
  6. What happens when they decompensate after disenrollment and need to be re referred in a few months?
    DOH Answer: Per the Member Disenrollment from the Health Home Program policy HH0007, there are steps to inform members how to request consideration for HH program re-enrollment if needed after disenrollment.
  7. If the member disagrees, when should the fair hearing process start? During the 2 months or after they have to disenroll?
    DOH Answer: Please follow steps per the Health Home Notices of Determination and Fair Hearing Policy HH0004, for issuing the Notice of Determination to members being disenrolled from the HH Program.
  8. If you can't engage a client in 60 days, then the client isn't engaging in the program, and you would disenroll correct?
    DOH Answer: Please refer to the Continuity of Care and Re-engagement for Enrolled Health Home Members policy HH0006 which describes steps to be taken when a member is deemed disengaged from HHCM services.
  9. If someone who must disenroll due to the outcome of the CES Tool and has a set back within a month of not having HHCM support, is there a rapid process to re- enroll and get started on services again?
    DOH Answer: While currently there is no 'rapid' process to re-enroll an individual, as per the Member Disenrollment from the Health Home Program policy HH0007 steps must be taken to inform members of the process to request consideration for re-enrollment in the HH program.
  10. What if, during disenrollment, the care team determines client needs program? Or a new risk has been identified?
    DOH Answer: Yes, once a Recommend Disenrollment outcome is determined and additional information is obtained that supports continued enrollment, a new CES Tool must be completed within 60 days.
  11. Does the member stay enrolled while doing the fair hearing or services are terminated completely while fair hearing is being process? If the member is not enrolled during the fair hearing process, will we be liable if something happens to member as a result of services not being provided during that period?
    DOH Answer: The fair hearing notice would be given following steps per the Health Home Notices of Determination and Fair Hearing Policy HH0004.
  12. If disenrollment is recommended, what is the reason step-up would be an appropriate decision?
    DOH Answer: Please refer to the Member Disenrollment from the Health Home Policy HH0007 for guidance on step-up.
  1. What if a member has more than 1 active risk factor and is HH+?
    DOH Answer: The CES Tool is not completed on HH+, HH+ eligible, or AH+.
  2. Do we have to have documented "proof" in the EHR for the significant Risk factors?
    DOH Answer: The significant risk factor(s) should be documented in the member's record.
  3. What about unable to navigate the healthcare system? Is that considered a significant risk factor?
    DOH Answer: Yes, this is under Healthcare Risk and states a "member (or guardian) is unable to appropriately navigate the healthcare system for the member's chronic conditions."
  4. How do we reconcile risk factors with scarce resources? Do members still remain enrolled?
    DOH Answer: HHCM should hold a case review with member and care team including MMCP, to discuss disenrollment and establish a post disenrollment plan/safety plan, including any referral(s) or contact information for new provider(s) and/or service(s) to support member's care and safety post discharge, as appropriate to the disenrollment reason. Please refer to the Member Disenrollment from the Health Home Program policy HH0007.
  5. If a person loses their Medicaid, do we go right to discharge over 2 months, or can we work with the individual to get the Medicaid back (if they are appropriate)?
    DOH Answer: Medicaid is required to be enrolled in the HHCM program. Care Managers should be aware of the members recertification date and should be actively working to ensure coverage.
  6. Will there be a list of Additional Risk factors provided, or is at the discretion of the CMA?
    DOH Answer: No, the required risk factors are listed within the tool and must be used.
  7. I haven't see anything about excessive/unnecessary medical ED visits as a risk factor?? This is a huge thing for many of our clients. Maybe I missed it…
    DOH Answer: Under the General Risk Factors section of the CES Tool it addresses ED utilization.
  1. Do we have to complete all of the questions, if we KNOW they continue to qualify/engage can we "skip" the >20 Questions?
    DOH Answer: Each section in the CES Tool must be completed in order and the SKIP logic will determine the need to answer additional questions.
  1. How long can we back date a CES tool?
    DOH Answer: Back dating is not an acceptable practice.
  2. What happens to the clients who have been enrolled prior to 11/1/23? When should they be assessed?
    DOH Answer: Current enrolled members should be assessed at the time of their annual assessment.
  3. Would this be effective for new clients enrolled in December or does this apply for current enrolled clients?
    DOH Answer: For New Members, that are enrolled on/after 11/1/23 the CES Tool will be completed 12 months post-enrollment and completed every 6 months thereafter.
    For Existing Members, the CES Tool will be completed at time the member's next annual Reassessment and completed every 6 months thereafter.
  1. A number of questions were asked regarding the impact of this addition on Health Home Care Management workload.
    DOH Answer: Representatives from the Health Home Coalition, the Care Management Coalition, iHealth, MCOs, HIV SNPs, DOH, and OMH are working to address issues regarding administrative burden.