Children's Waiver Home and Community Based Services (HCBS) Medicaid Managed Care Plan (MMCP) Transfer Continuity of Care Requirements

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Overdue Home and Community Based Services (HCBS) Level of Care (LOC) Eligibility Determinations

January 26, 2024

Applicable to: Health Homes Serving Children (HHSCs), Care Management Agencies (CMAs), Children and Youth Evaluation Services (C-YES), Children's Home and Community Based Service Providers, and Medicaid Managed Care Plans (MMCPs) including HIV Special Needs Plans

In January 2023, the Department of Health issued a notice to Health Homes that the Public Health Emergency flexibility waiving the annual HCBS eligibility determination ended and that all Children's Waiver members MUST have an annual HCBS Eligibility Determination to remain enrolled in the Children's Waiver. As outlined in the Children's Waiver Eligibility and Enrollment policy, federal rules require an annual eligibility determination for all members and therefore, the previously issued HCBS Reassessment Eligibility Extension guidance has been rescinded. The HCBS Eligibility reassessment must be completed annually (365 days).

As a result, by February 15, 2024, all overdue HCBS Eligibility Determinations for members enrolled in the Children's Waiver must be completed and a Notice of Decision (NOD) must be issued. Care managers must alert HCBS providers and MMCPs of children/youth being disenrolled from the Waiver and K-codes must be removed from the members' files.

HCBS providers cannot bill for services provided to HCBS members whose eligibility has not been renewed.

Health Homes are not permitted to bill for the monthly per member per month (PMPM) rate (PMPM) for members that have expired HCBS Eligibility Determinations on or after February 15, 2024. For every month, on the first day of the month, the Health Home PMPM cannot be billed for members with an expired HCBS Eligibility Determination for the previous month.

Example: March 14th the annual HCBS Eligibility Reassessment was due. On April 1st there was not a completed HCBS Eligibility Determination, then the March PMPM cannot be billed.

Additionally, the HCBS Restriction K-Code must be removed from the member's file. No later than 30 days of the determination that a member is no longer eligible for the Children's Waiver, the K-code must be removed from the member's file, otherwise the Health Home PMPM cannot be billed.

Example: The member was determined ineligible for the Children's Waiver in February, the K-code must be removed from the member's file no later than March 31st, otherwise the February PMPM cannot be billed.

Care managers must begin the HCBS Eligibility Determination two months prior to the annual reassessment due date, to work with the family and involved professionals to gather the documentation and information necessary to complete the HCBS Eligibility Determination. Care managers must also ensure the child/youth/family and all involved professionals are aware of the HCBS Eligibility Determination requirements and reassessment due date. The multi- disciplinary team should work collaboratively to ensure that the child/youth have a current HCBS Eligibility Determination with all required supporting documentation to remain in the Children's Waiver, if the child continues to be at risk of institutionalization.

If a member is determined ineligible and has filed a request for a Fair Hearing with aid to continue, the care manager's supervisor must enter that information within the Uniform Assessment System (UAS), to ensure that HCBS providers and MMCPs are aware that services and payment for services can continue. The MAPP Health Home Tracking System (HHTS) has the information necessary to view if the child/youth has a current Eligibility Determination, the outcome of such assessment, and if the child/youth filed a request for or has a pending Fair Hearing (if entered in the UAS). HCBS providers are encouraged to work with care managers to verify HCBS eligibility, continuous enrollment, and current HCBS reassessment status.

It is the responsibility of the lead Health Homes to monitor, oversee, and manage the multi- disciplinary HCBS reassessment process, ensure timely Notices of Decision (NOD) and that the UAS is updated. Compliance with the timeframes outlined in this guidance will be reviewed by the State through annual case reviews. Health Home redesignation may be impacted based on the outcomes of these reviews.