Remedial Process for Provision of Children´s HCBS and Sharing the Plan of Care´s Information in Preparation of October 1, 2019

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This guidance is to clarify information Medicaid Managed Care Plans (MMCP), including mainstream Medicaid managed care and HIV Special Needs Plans, will rely upon to provide Children´s Waiver Home and Community Based Services (HCBS) to their enrollees participating in the Children´s Waiver beginning October 1, 2019.

The State has requested that Health Home care managers; the Children and Youth Evaluation Service; and HCBS providers share necessary information with MMCPs to enable the plans to cover HCBS for eligible and enrolled children/youth on October 1, 2019. MMCPs may accept the following information as sufficient to support coverage of HCBS, with or without the child/youth´s completed plan of care:

  • Child´s Name
  • Child´s Medicaid CIN #
  • Identified Need or Goal
  • The HCBS Being Provided
  • HCBS Provider Name

MMCPs are directed, for the dates of service October 1, 2019 through December 31, 2019, to accept any claim for HCBS that is submitted by a state-designated HCBS provider for a child who is enrolled in the MMCP on the date of service, and:

  • Pay clean claims within statutory timeframes; or
  • Pend the claim for review if the claim may not be immediately paid due to an administrative reason other than the child not covered on date of service, or the child is outside of an appropriate HCBS setting.

MMCPs must make every reasonable effort during this transitional period to resolve administrative barriers to claims payment. Claims should only be denied where the MMCP is not the appropriate payor, the provider is not designated, the child/youth is not in an appropriate HCBS setting, or where the MMCP has confirmation of inappropriate billing practices.

MMCPs must also ensure that children newly enrolled as of October 1, 2019 in receipt of Children and Family Treatment and Support Services (CFTSS) and/or Long Term Services and Supports do not experience delays in coverage of these services in accordance with continuity of care requirements for the Children´s Medicaid Transformation.

Separate guidance will be forthcoming regarding assurance that plans of care and the person-centered planning process include the appropriate required information as outlined in the Health Home policy.

Please direct any questions to OMCmail@health.ny.gov.