Children's MRT Health and Behavioral Health Subcommittee

Quarterly Meeting
New York City

  • Presentation is also available in Portable Document Format (PDF, 274KB)

October 26, 2015


  • Welcome
  • Children´s Timeline Review
  • Medicaid State Plan Amendment (SPA) Update
  • Operationalization of EBP (discussion and input)
  • Children´s Readiness Resources
  • 1115 Public Process
  • Children´s HCBS Eligibility Flow & Independent Entity
  • MCTAC Children´s Draft Plan
  • Health Home Update
  • Social Determinants of Health Subcommittee Overview

Children´s Leadership Team

  • Donna Bradbury, Associate Commissioner, Division Of Integrated Community Services For Children & Families, NYSOMH
  • Lana I. Earle, Deputy Director, Division of Program Development and Management, Office of Health Insurance Programs, NYS DOH
  • Steve Hanson, Associate Commissioner, Treatment Services, NYS OASAS
  • Laura Velez, Deputy Commissioner, Child Welfare & Community Services, NYS OCFS

State Plan Amendment (SPA) Update

  • Submission to CMS for approval of six new services will be as soon as possible
  • CMS has requested a concept paper prior to SPA and 1115 submissions, to provide NYS´ vision to CMS staff
  • Regulatory development for State Plan services continues
  • Fiscal projections under development

SPA Update: Initial Provider Capacity, Build and Service Utilization Projections

    • Ramp up at 50%, 75% within six months and 100% within one year
    • Maximum projected utilization at mature development 38,560 children/youth
  • Youth Peer Support
    • Ramp up to start at 25%, 25% at six months and 50% within one year
    • Maximum penetration use 14,500 children/youth
  • Family Peer Support
    • Follow youth peer support capacity building
    • Maximum anticipated utilization at 72,500 children/families
  • Crisis Intervention
    • Begin at 75% capacity and grow to 100% within six months
    • Anticipated annual usage 4,350 children

SPA Service Rates

  • Under development
  • Points of reference for build - HARP, HCBS Waivers, APG and other States´ SPA and EBP rates

SPA Update: Proposed Provider Enrollment

  • OCFS Voluntary Foster Care Agencies (18 NYCRR Section 441.22)
  • DOH Care at Home Case Management Agencies and Palliative Care agencies, (Hospice Agency or Certified Home Health Agency - PHL Section 4008; 10 NYCRR Section 791.2 and PHL Sections 3602, 3606)

SPA Update: Proposed Provider Enrollment

OMH providers licensed, certified or designated to provide the following types of programs/services:

  • OMH Residential Treatment Facility (14 NYCRR Part 584)
  • OMH Children´s Community Residences (14 NYCRR Parts 594/593)
  • OMH Children´s Day Treatment (14 NYCRR Parts 587/588)
  • OMH Children´s Outpatient Clinic (14 NYCRR Part 599)
  • OMH Family Peer Support (1650 funded programs or Family Support Services designated through the OMH HCBS Waiver)
  • OMH Youth Peer Support (designated through the OMH HCBS Waiver).

SPA Update: Proposed Provider Enrollment

OASAS providers certified by pursuant to Mental Hygiene Law Articles 19 and 32 to provide the following types of programs/services:

  • Chemical Dependence Inpatient Rehabilitation Services (14 NYCRR 818)
  • Chemical Dependence Residential Rehabilitation Services for Youth (14 NYCRR 817)
  • Residential Services (14 NYCRR 820)
  • Chemical Dependence Withdrawal and Stabilization Services (14 NYCRR Part 816)
  • Chemical Dependence Outpatient and Opioid Treatment Programs (14 NYCRR Part 822)
  • Integrated Outpatient Programs (Statutory Authority Section 365-I (7) of the Social Services Law and Part L of Chapter 56 of the Laws of 2012 and 14 NYCRR Part 825)

SPA Update: Proposed Provider Enrollment

  • Application or State review process of interested providers in development
  • State´s goal is to have an adequate network for SPA benefits
  • Discussion:
    • Other children´s providers that would have experience but not on list?

Operationalization of Evidence Based Practices (EBPs)

  • Application for designation
  • Intended for fidelity models that require ongoing certification, monitoring, data collection and operation as per proprietary models
  • Not intended for individual staff who attend a short term training and achieve certification in a specific practice
  • Rates being developed to incorporate model indirect costs such as ongoing training, monitoring and certification to fidelity model
  • EBP Review Team still in development
  • Anticipated schedule of quarterly submissions

SPA Update: Medical Necessity Review

Draft language suggested by Mercer for CPST, PSR, FPSS, YPST

  • After no more than _______ service encounters to a child and his/her family, the practitioner must submit a treatment (or intervention) plan for the service.
  • The treatment/intervention plan should include the treatment goals and amount, duration and scope of services medically necessary to meet those goals accompanied by documentation to support that the service is medically necessary for the child and family.
  • The treatment plan must be reviewed and approved as medically necessary by (TBD) prior to additional claiming and reimbursement of these services beyond the initial _______ visits.
  • The treatment plan must be reviewed every three months, making necessary edits to amount, duration and scope of services. Utilization of the services will be subject to periodic claims review by NYS DOH or its designees.

SPA Update: Provider Manual

  • Incorporating stakeholder feedback
  • Crosswalk with final SPA
  • Anticipate next revised version complete

Children´s Managed Care Readiness Resources

  • Feedback summary (copy shared prior to meeting)
  • State Team recommendations still in development

Children´s 1115 Amendment Public Process

  • State agency web posting
  • Tribal notice (60 days prior to CMS submission)
  • Public notice in State Register (30 days prior to CMS submission)
  • Statewide Information Webinar
  • Individual agency overview with own stakeholders

Children´s HCBS Eligibility

To be eligible for HCBS benefits, children must meet:

  • target criteria
  • functional criteria and
  • Medicaid financial eligibility

Children´s HCBS Target Populations

Children and youth younger than 21

  • With Serious Emotional Disturbance (SED); or
  • Placed in Foster Care who have SED, are Developmentally Disabled or Medically Fragile, or have experienced trauma; or
  • Who are physically disabled and require significant medical or technological health supports; or
  • With Substance Use Disorders

Children´s HCBS Functional Criteria

Level of Care (LOC)- criteria met and determined by assessment that would indicate a child is eligible for or at risk of medical institutional placement in a facility licensed by NYS OMH, Intermediate Care Facility for the Mentally Retarded (ICF/MR), or skill nursing facility/Hospital. Current criteria for children´s 1915(c) Waivers.

NEW Expansion Population: Level of Need (LON)- criteria met and determined by assessment that would indicate a child has needs that cannot be met only by non-medical institutional State Plan Services, but who does not qualify for Level of Care.

Both levels determined by CANS-NY (Child and Adolescent Needs and Strengths Assessment) and its algorithms.

One Array of Children´s HCBS Benefits

Managed in two ways:

  • Medicaid Managed Care AND
  • Medicaid Fee for Service program

Children with Community Medicaid

  • Will be enrolled in Medicaid Managed Care
  • Can access Health Home Care Management if they meet eligibility criteria
  • Can access the full array SPA services if they meet medical necessity for any of the services
  • Can access HCBS benefits if they meet targeting and LOC or LON criteria (determined by completing the CANS-NY)

Children with Comprehensive TPHI

  • Excluded from Managed Care if they are eligible for Medicaid
  • Comprehensive TPHI (Third Party Health Insurance) includes those with commercial coverage, dual Medicaid/Medicare or Medicaid spend down
  • Children with Comprehensive TPHI have access to HCBS Waiver Services today via targeting and functional criteria (LOC) in the 1915c Waivers (OMH SED, OCFS B2H, DOH CAH I/II)
  • Goal to maintain benefit availability to children meeting LOC criteria and expand to children meeting LON criteria
  • If eligible for HCBS benefits, will access through separate but equal system (Fee for Service) of benefits

HCBS Eligibility Dilemmas and Proposed Solution

New York´s goal is to maintain and expand availability of HCBS benefits for children who need them.

  • Problem: Children without Medicaid cannot enroll in a Health Home, which determines HCBS eligibility
  • Problem: A determination of HCBS targeting and functional criteria must be completed to enable Medicaid financial eligibility determination as a "family of one"
  • Proposal Solution: Development of local Independent Entity function for "family of one" children

Independent Entity (IE) Functions and Responsibilities

  1. Establish a single phone number or physical location for children and families requesting HCBS benefits
  2. The IE will
    • conduct a telephonic or in-person Eligibility Evaluation Screen to determine HCBS presumptive eligibility (target criteria and LON/LOC) for those children without Medicaid;
    • Enter the Screen question data into the Uniform Assessment System (UAS) on the NYS DOH Health Commerce System (HCS);
    • Confirm a LOC/LON algorithm score; and
    • Attest to HCBS Presumptive Eligibility Determination based on target and functional criteria.
  3. The IE will develop a provisional plan of care, to include the immediate HCBS benefits that could meet family needs and/or referral to Health Home
  4. The IE refers the family to file a Medicaid application with LDSS (HRA) with verification of HCBS presumptive eligibility.
  1. The IE should verify Medicaid eligibility for those children screened until which time that Medicaid eligibility has been determined.
  2. Once Medicaid eligibility is established based on family of one financial methodology, the IE should inform the family that they are provisionally eligible for HCBS benefits, the child has been determined Medicaid eligible and ask if they can be referred to Health Home for care coordination services.
  3. If consent is given, the IE enters MAPP via the UAS and completes Health Home referral and transmits the HCBS Presumptive Eligibility verification and Provisional Plan of Care (POC).

Managed Care Technical Assistance Center (MCTAC) - Children´s Draft Training and TA Schedule

Children´s System TA Timeline

More Information

  • Note: Does not include Foster Care Transition Training, Family Peer Support Service, Residential, or clinic specific training
  • Managed Care
    • Webinars - General information. Will lay out state plan surrounding critical topics.
    • Leadership. Event - Professional Development and Value Based Practices. In Albany and geared at executive leadership.
    • System Transformation Update Events - Will be held statewide and entail a 3-4 hour kickoff session
      • Long lsland, NYC (3). Hudson, Albany, Buffalo, Syracuse, Rochester, North Country
    • Contracting - Will be in-person (NYC/LI) and web based and will include workshops and contracting fairs once plans have been identified.
    • RCM, UM, and Outcomes - Will be in NYC/LI.
    • Billing Training, UM guidelines, and credentialing - In NYC/LI after respective plan information has been released.
    • Data and Outcomes Road Map - Will be held yearlong statewide and will cover Understanding Your Population, Key Performance Indicators, Costs and Revenue, Outcomes.
  • HCBS
    • High level overview.
    • Following designation service by se.-vice overview.
    • Plan of care and workflow development and implementation support. Willinclude Health Homes.
  • SPA
    • Designation process, billing, high-level service by service overview.
    • Crisis Intervention, Community Psychiatric Support and Treatment Psychosocial Rehabilitation, Other Licensed Practitioner, Family Peer Support, Youth Peer Training and Support.

Social Determinants of Health Subcommittee Overview -
Kate Breslin, President and CEO, Schuyler Center for Analysis and Advocacy

Health Homes Update

  • Status of Health Home SPA discussions with CMS
  • Readiness activities of contingently designated Health Home Serving Children


Angela Keller, LMSW
Director, Bureau of Children´s Program Design, Policy & Planning
Division of Managed Care
NYS Office of Mental Health