IV. Core Services

CCO/HH core services are designed to ensure access to appropriate services, improve health outcomes, reduce preventable hospitalizations and emergency room visits, promote use of Health Information Technology (HIT), and avoid unnecessary care.

Section 1945(i)(4)(b) of the Social Security Act defines Health Home services as “comprehensive and timely high-quality services” and includes the six (6) core services to be provided by designated CCO/HH providers.

New York State CCO/HHs are required to provide core services and have policies and procedures in place to ensure Care Management services meet the core service requirements. CCO/HH providers are required to maintain written documentation that clearly demonstrates how these core requirements are being met.

Core Services include: 

1. Comprehensive Care Management;
2. Care coordination and health promotion;
3. Comprehensive transitional care from inpatient to other settings, including appropriate follow-up;
4. Individual and family support;
5. Referral to community and social support services if relevant; and
6. The use of Health Information Technology (HIT) to link services, as feasible and appropriate

The following sections explain the federal requirements of each Core Service. Further information on the six (6) core services is available in the Medicaid State Plan Amendment – #17–0025. The language below has been updated to reflect person-centered language and clarified to address the operating experience of the NYS CCO/HH program. These enhancements do not change the meaning of the federal requirements.

1. A comprehensive health assessment that identifies medical, mental health, chemical dependency, developmental disability, and culturally and linguistically appropriate social service needs.
2. The creation of the person’s Life Plan which integrates the continuum of medical, behavioral health services, rehabilitative, long-term care, developmental disability, and social service needs and clearly identifies the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s), developmental disability providers, Care Manager and other providers directly involved in the person’s care.
3. The person (or their guardian) plays a central and active role in the development and execution of their Life Plan and should agree with the goals, interventions and time frames contained in the Plan.
4. The person's Life Plan:
   • clearly identifies primary, specialty, behavioral health, developmental disability, and community networks and supports that address their needs.
   • clearly identifies family members and other supports involved in the individual's care. Family and other supports are included in the plan and execution of care as requested by the individual.
   • clearly identifies goals and timeframes for improving the individual’s health and health care status, independence and community integration and the interventions that will produce this effect.
   • must include outreach and engagement activities that will support engaging individuals in care and promoting continuity of care.
   • includes periodic reassessment of the person’s needs and clearly identifies their progress in meeting goals and changes in the life plan based on changes in the person's needs.
   • reflects consideration of the culture and language of the person receiving services in identifying goals, activities, and meaningful outcomes.
5. Each enrollee must be assigned a dedicated Care Manager. The Care Manager must manage, coordinate, update, and monitor an individual’s Life Plan in accordance with the person-centered planning requirements set forth in 14 NYCRR Subpart 636-1 and all other applicable requirements. 

See sections titled Comprehensive Assessment, Person Centered Planning, and the Life Plan for additional requirements. 

1. The CCO/HH provider is accountable for engaging and retaining the person in coordinating and arranging for the provision of person-centered services; supporting adherence to treatment recommendations; monitoring and evaluating the person’s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, developmental disability, long term services and supports, and social and community services where appropriate through the creation of an individualized Life Plan. All pertinent medical documentation, should be collected and uploaded into the CCO/HH providers Electronic Health Record (EHR) systems timely/contemporaneously for Care Managers to review and assist the person and their family in making informed decisions regarding their medical care and the potential outcomes associated with their choices and to provide needed care coordination and health promotion services.
2. The CCO/HH assigns each enrollee a dedicated Care Manager who is responsible for coordinating all aspects of their care and overall management of the Life Plan. Where appropriate, the Care Manager should have the ability to communicate with the person and their family/representative in their primary language of choice and/or have training on how to obtain professional interpretation and translation services to ensure that all oral and written communications are clear. The CCO/HH Care Manager is clearly identified in the person’s record. A person cannot be enrolled in more than one (1) Care Management program funded by the Medicaid program.
3. The CCO/HH provider must describe the relationship and communication between the dedicated Care Manager and the treating clinicians to ensure that the Care Manager can discuss with clinicians on an as needed basis changes in the person’s condition that may necessitate treatment change (i.e., written orders and/or prescriptions).
4. The CCO/HH must document when conflicting care decisions and treatment arises. In situations of conflicting care decisions and treatment it is the Care Managers role to assist the person and their family with informed choice and identify when the clinical team is needed.
5. The CCO/HH has policies, procedures, and an accountability structure (written agreements) in place to support effective collaborations between primary care, specialists, behavioral health and developmental disability providers, referrals, follow-up, and consultations that clearly define roles and responsibilities.
6. The CCO/HH supports continuity of care and health promotion through the development of a treatment relationship between the Care Manager, the person, and their Interdisciplinary Team (IDT), also known as the care planning team. Throughout this document IDT and/or Circle of Support are used interchangeably with Care Planning Team.
7. The CCO/HH supports care coordination and facilitates the establishment of regular case review meetings (i.e., Life Plan review), which includes all members of the Care Planning Team on a schedule determined by the person and the CCO/HH. At a minimum, the schedule for the Life Plan review will, in most cases, follow the person’s established schedule for annual care planning meetings, which requires the plan is reviewed and updated at least twice each year in the primary language the person and their family/representatives can speak, read, and understand. The CCO/HH has the option of utilizing technology conferencing tools including audio, video and/or web deployed solutions when security protocols and precautions are in place to protect Personal Health Information (PHI).
8. The CCO/HH ensures twenty-four (24) hour/seven (7) days a week access to a Care Manager to provide information and connection to emergency consultation services.
9. The CCO/HH ensures enrollees timely access to appointments for medical and behavioral health care services within their CCO/HH provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
10. The CCO/HH promotes evidence-based wellness and prevention by linking people with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services. These services must be provided based on the person’s needs and preferences, and CCO/HHs should include community-based programs that offer culturally and linguistically appropriate resources.
11. The CCO/HH has a system to track outcomes and initiate changes in care, as necessary, to address the person’s needs.

1. The CCO/HH has a system in place with hospitals and residential/rehabilitation facilities in their network that allows them to receive prompt notification of a person’s admission and/or discharge to/from an emergency room, inpatient, residential/rehabilitation, or other institutional settings. CCO/HH providers must have documented efforts to obtain clinical information contemporaneously for Care Manager involvement in discharge planning and care transitions. The CCO/HH must obtain individual consents, as appropriate, for accessing and sharing information related to comprehensive and transitional care.
2. The CCO/HH has policies and procedures in place to support people experiencing transitions from school (including residential schools) to adult services, life changes (employment, retirement, other life events), or when a person is electing to transition to a new CCO/HH provider or to a new Care Manager within the same CCO/HH.
3. The CCO/HH has policies and procedures in place to support agreements and partnerships with local practitioners, health facilities including emergency rooms, hospitals, and residential/habilitation providers and community-based services to help ensure coordinated, safe transitions in care for people who require transfer from one site of care to another. These policies and procedures should include guidance on how Care Managers can assist a person with accessing written translation and oral interpretation services through the transitional provider.
4. The CCO/HH utilizes HIT as feasible, to facilitate interdisciplinary collaboration among all providers, the person and/or their family/representative, and local supports.
5. The CCO/HH has a systematic follow-up protocol in place to ensure timely access to follow-up care post discharge that includes at a minimum, receipt of a summary care record from the discharging entity, medication reconciliation, timely scheduled appointments at recommended outpatient providers, Care Manager verification with outpatient providers that the person attended the appointment, and a plan to reach out and re-engage the person in care if the appointment was missed.
   If the person has unique characteristics that are important for the receiving service/program to know, such as involvement with Social Services, high-risk and/or unstable, periods of non-compliance with recommended treatment, or any other risk status, the CCO must notify the receiving entity of those risks and establish effective communications for collaborating on action planning. 

1. The individualized Life Plan reflects the person’s and their family/representative’s preferences, education and support for self-direction, self-help, and other resources as appropriate.
2. The individualized Life Plan is accessible to the person and their family/representative, either electronically and/or via mail, according to their preference. Additionally, the Life Plan should be available in the person’s primary language to ensure full accessibility and understanding.
3. The CCO/HH provider utilizes peer supports, support groups and self-care programs to increase the person’s and their family/representative’s knowledge of their disability, engagement, and self-management capabilities, and improves adherence to prescribed treatment.
4. The CCO/HH discusses advance directives with enrollees and their family/representative when applicable. The result of the discussion must be documented within the person’s record.
5. The CCO/HH communicates and shares information with people and their family/representatives with appropriate consideration for cultural and linguistic needs and preferences.
6. The CCO/HH gives the person and, if they agree, their family/representative access to the Life Plan and options for accessing clinical information in the primary language the person, family, and/or representative can read and understand.

1. The CCO/HH identifies available community-based resources and actively manages appropriate referrals, access, engagement, follow-up, and coordination of services, ensuring arrangements of interpretation services as needed.
2. The CCO/HH has policies, procedures, and an accountability structure (written agreements), to support effective collaborations with community-based resources, which clearly define roles and responsibilities.
3. The Life Plan should include community-based and other social support services as well as healthcare, long term supports and services, and developmental disability services that respond to the person’s needs and preferences and contribute to achieving the person’s goals.
4. CCO/HH are expected to assist people with maintaining benefits within the communities they reside such as Social Security, Supplemental Security Income (SSI), Medicaid, Medicare, Supplemental Nutrition Assistance Program (SNAP), Home Energy Assistance Program (HEAP), and Section 8. Care Manager responsibilities also include: Monitoring benefits for people whose representative payee is the agency operating their certified residence, and assisting people with their benefits, when the person does not have a representative payee or when the non-residential representative payee requests assistance. Assistance may include, but is not limited to, direct physical assistance in the application process, the compilation of required documentation or advocacy/clarification related to the person’s circumstances as appropriate and as needed by the person based on their circumstances.

CCOs must use HIT to link services and adhere to additional HIT requirements as follows: 

1. Use a Certified EHR that is accessible by designated care team members and other specified entities including OPWDD and DOH. The EHR system helps facilitate the provision of high-quality care management and the achievement of health and person-centered goals and outcomes. It must allow the person’s information and Life Plan to be accessible to the care planning team and allow for population management and identification of gaps in care including preventative services.
2. Provide a singular electronic care plan for any care team member/organization and/or the entire network of service providers consented to by the person and use electronic clinical decision support among all providers.

CCO/HHs must:

• have structured information systems, policies, procedures, and practices to electronically create, document, execute and update a Life Plan for every CCO/HH enrollee.
• have a systemic process to follow-up on tests, treatments, services, and referrals, which is incorporated into the person’s Life Plan.
• share, distribute, or provide the capability for people and/or their family/representative, and providers, to access their Life Plans in accordance with federal and state law requirements and their business needs. CCO/HHs must provide the capability for people and/or their family/representative, and providers to contribute information or materials in support of their Life Plans, including but not limited to, clinical notes, progress notes and other related documentation.
• provide capability for people and/or their family/representative to access, via a secure web-based portal, the Life Plan and to view or upload documents and input information to the Life Plan, is hereby deferred. The requirement will be revisited for discussion and a potential implementation timeline.

3. The CCO/HH’s electronic health record must, at a minimum, include “Care Coordination Data Definitions (CCDD)” elements. The CCDD establishes data standards between OPWDD and comprehensive care coordination providers (CCO/HHs). These standards allow OPWDD to collect uniform, vendor-agnostic, elements across CCO/HHs in order to aggregate statewide data. CCO/HHs are required to provide CCDD elements to OPWDD via a data exchange specified by OPWDD. The current CCDD is a continually evolving document and will progressively advance as the CCO/HH program evolves. CCO/HHs are required to maintain Life Plan elements consistent with CCDD updates and OPWDD regulatory and policy requirements as redefined by the OPWDD from time to time.  

Additional information on the current Care Coordination Data Definitions can be found at the following link: 

CCO Data Definitions

4. State Access to the EHR, Life Plans and Related Documentation: CCO/HHs are required to provide NYS DOH and OPWDD and its designated assessors, access to view or download Life Plans and/or any supporting documentation and view complete electronic health records for the purposes of oversight and/or conducting individual assessments. This access may be provided via a web-based portal or direct system access, or temporary direct system access for the purposes of oversight and must be provided via direct system access for the assessment process. 

CCOs must provide appropriate role-based access and related training to DOH and OPWDD and its contractors on the EHR and electronic Life Plan including access for those entities designated to schedule and conduct assessments.   

5. Participate in Regional Health Information Organization/Qualified Entity (RHIO/QE). RHIO/QE is authorized to securely share health care-related information for individuals with qualified health care delivery organizations.
6. The Statewide Health Information Network of New York (SHIN-NY) is the electronic network for the sharing of data. The RHIOs, or as they are now being referred to, Qualified Entities (QEs), are companies that operate on the SHIN-NY network. The SHIN-NY sets policies etc. that the RHIO/QE must abide by.  

The SHIN-NY is comprised of six (6) RHIO/QEs which support HIPAA-compliant clinical data exchange and use between their participating data providers and consumers. The RHIO/QEs are supported by shared technology, governance, and policy standards led by NYSDOH and facilitated by the New York eHealth Collaborative (NYeC) that oversees the SHIN-NY. Over the past decade, New York State has made major investments in the SHIN-NY and RHIO/QEs to facilitate data exchange between clinicians and Care Managers to support the delivery of high-quality coordinated, preventive, and patient-centered care, resulting in improved patient outcomes, reduction of avoidable tests and procedures, lowered costs, and support of new models of care delivery. 

For more information visit SHIN-NY on the OPWDD website.

7. Health Information Exchange via NYS RHIO/QE: Health information in New York State is exchanged between providers, hospitals, payers, and other authorized stakeholders, via the SHIN-NY, and its component RHIO/QE networks (described in more detail in Section 8.1). Providers, hospitals, CCO/HHs and other stakeholders sign a data sharing agreement to become a participant with a RHIO/QE so they can access and exchange electronic health information with participants in their region and throughout New York State. With limited exceptions, a CCO/HH participating with a RHIO/QE can access an enrollee’s information via the RHIO/QE’s interface only if the enrollee signs a written consent form authorizing such access. 

Enrollees can provide this written consent in a variety of ways. The current DOH-5055 consent form is a single entity RHIO/QE consent, in that it allows the CCO/HH to access the enrollee’s health information through the RHIO/QE named on the consent form (provided the CCO/HH is a participant with that RHIO/QE). If the RHIO/QE can support the use of a multi-entity consent form, such form is permitted. The enrollee must give the CCO/HH permission to directly access their health information at any RHIO/QE accepting their county of residence. In other words, a CCO/HH can access the enrollee’s information via more than one RHIO/QE interface, provided the person consented to be enrolled in the RHIO/QE accepting their county of residence.    

Although the CCO/HH must enroll all the consenting people it serves in a RHIO accepting their county of residence, the CCO/HH is required to participate with at least one (1) RHIO/QE to meet the final HIT requirements. There may be financial considerations to joining a RHIO/QE or using their interface for data exchange. Ultimately, the CCO/HH must be able to transmit and receive data electronically with its associated organizations and providers. 

8. The CCO/HH must use systems provided by the State that are, or may become, necessary for conducting the following business or reporting:  managing CCO/HH eligibility, enroll and tracking of CCO/HH enrollments, capturing the enrollees’ consent, calculating CCO/HH rate tiers, and generating CCO/HH enrollment rosters. The systems currently, or potentially, needed are: CHOICES, TABS, EHRs, CMART, UAS, MAPP HITTS, PSYCKES, HCS and/or others as directed by OPWDD and/or NYSDOH. Additional information on some of these systems are outlined below.
9. The Health Commerce System (HCS) is on the list of New York State systems which CCOs are required to access to conduct business. It is a secure website for web-based interactions with the NYSDOH. It is used by NYSDOH to communicate with New York State healthcare providers, employees, and partner agencies. It is a comprehensive web-based technology that supports, integrates, and secures the electronic exchange of health data and information among partners. Additional information about the Health Commerce System can be found on NYSDOH’s website.
10. The Health Home Care Management Assessment Reporting Tool (HH–CMART) is a tool for the collection of standardized care management data for people in intake or enrolled in a Health Home. The data provides the State with information about care management services to evaluate the volume and type of interventions and the impact care management services have on outcomes for people receiving these services. The data requirements include submission of specified data about care management services provided to members in Health Homes. The submission file includes information for all Medicaid members involved in Health Home care management programs during the reporting period. Additional information about Performance Management is available on the NYS DOH’s website.
11. Each CCO/HH operates a billing system that allows for timely claims submission to the State’s Medicaid Management Information System (MMIS) and payment to Care Managers.
12. Each CCO/HH IT capability must develop and produce reports, where applicable and as described in Section 8 Performance Management and Quality Metrics of the CCO/HH Application.
13. CCO/HH IT capability must maintain interoperability with other defined State systems using NYS ITS approved protocols.
14. CCO/HH IT function or process must allow enrollees and their family/representative to approve, sign, and/or manage the Life Plan as described in ADM #2018-06R2.
15. CCO/HH IT function must capture the enrollee’s consent and allow for changes in the Life Plan when services change.
16. CCO/HHs must adhere to all State and federal legal, statutory, and regulatory requirements.
17. CCO/HHs must have structured interoperable information technology systems, policies, procedures, and practices to support the creation, documentation, execution, and ongoing management of a Life Plan as defined by OPWDD for every CCO/HH enrollee. The CCO/HHs’ system must interact with other systems using industry standards so information can be exchanged efficiently to support care planning and service delivery for enrollees.
18. CCO/HHs must use a health record system that qualifies under the Meaningful Use provisions of the HITECH Act, which allows the individual’s health information and Life Plan to be accessible to the care planning team.
19. CCO/HHs will be required to comply with the current and future version of the SHIN-NY Policy Guidance which includes common information policies, standards and technical approaches governing health information exchange. 

Learn more about the Statewide Policy Guidance on the NYS Department of Health website.

20. CCO/HHs must commit to Life Plan data exchange with EHRs which includes sharing consumable data with all providers participating in a Life Plan.
21. CCO/HHs support the use of evidence-based clinical decision-making tools, consensus guidelines, and best practices to achieve optimal outcomes and cost avoidance, as well as supporting the person’s life goals and valued outcomes.

In addition, CCO/HHs must adhere to all State and federal legal, statutory, and regulatory requirements.