Understanding the Data
- It is important to note that the COVID-19 health emergency has had a significant impact on all CCOs’ operations, therefore, the data presented in this report may not be representative of timelines or demographical information during a typical year.
- The Care Coordination Organization/Health Home Care Management Profile provides an overview of enrollment and care planning information for individuals with intellectual and/or developmental disabilities receiving OPWDD services.
- The data displayed in this report represents statistics as of the end of calendar year 2020 with accompanying detail on data movements during January - December 2020.
- The data is compiled from CCO roster data as well as self-reported information from the CCOs that is submitted to OPWDD.
- Health Home Care Management is also known as Care Coordination, which are services provided by Care Coordination Organizations (CCOs). There are seven CCOs operating across New York State.
CCO/Health Home Care Management Enrollment
Figure 1: People Receiving Care Management Services by Program Type (2020)
A total of 17,060 individuals new to OPWDD care management enrolled in CCOs since the July 2018 implementation (7,301 of these individuals enrolled in the 2020 calendar year).
Individuals have a choice of two service options. The number of people receiving either Health Home or Home and Community Based Services (HCBS) Basic Plan Support has remained constant at 97% and 3% respectively, since the implementation of CCOs (see Figure1).
Figure 2: People Receiving Care Management Services by Program Type and Care Coordination Organization (as of December 31, 2020)
|Advance Care Alliance||Care Design NY||Life Plan||Person Centered Services||Prime Care Coordination||Southern Tier Connect||Tri-County Care||Total|
|Health Home Services||23,577||26,143||17,992||16,621||7,795||1,168||13,442||106,738|
|HCBS Basic Plan Support Services||1,056||767||442||499||146||36||234||3,180|
Figure 3: People Receiving Care Management Services by Care Coordination Organization (2020)
Figure 4: People New to Receiving Care Management Services 
|Care Coordination Organization||New to CM (August 2018 – December 2019)||New to CM (January 2020 – December 2020)||Total|
|Advance Care Alliance||1,312||885||2,197|
|Care Design NY||2,653||1,381||4,034|
|Person Centered Services||827||724||1,551|
|Prime Care Coordination||1,068||737||1,805|
|Southern Tier Connect||144||124||268|
 Since January 1 through December 31, 2020, an additional 7,301 people enrolled in CCOs. On average only 1% of new enrollees select Basic HCBS Plan Support Services.
Figure 5: Total People Disenrolled from a CCO (2020) 
(as of December 31, 2020)
|Total Disenrolled 2020
January – December
|Percentage of Disenrolled compared to Total Enrollments|
|Advance Care Alliance||24,633||1,245||5.05%|
|Care Design NY||26,910||1,471||5.47%|
|Person Centered Services||17,120||734||4.29%|
|Prime Care Coordination||7,941||450||5.67%|
|Southern Tier Connect||1,204||78||6.48%|
 This data includes people who transferred from one CCO to another but who are still enrolled in a CCO (see figure 6).
Figure 6: Disenrollment Count by Reason (2020) 
|Reason for Disenrollment||Jan-Dec 2020
% of Total
|Enrolled in Another Comprehensive Care Management Program Not Delivered Through a CCO||369||6.92%||45||247||15||16||17||0||29|
|Ineligible for Medicaid||141||2.65%||14||19||24||45||19||1||19|
|Moved Out of State||716||13.43%||149||176||120||89||59||14||109|
|Not Residing in a CCO Eligible Setting||570||10.69%||100||129||114||119||49||8||51|
|Requirements Not Met for Level of Care||279||5.23%||68||38||59||30||31||0||53|
|Transferred to Another CCO ||940||17.64%||401||153||114||65||84||29||94|
|Voluntary Withdrawal from CCO||792||14.86%||155||202||100||141||109||14||71|
 Data Source = Roster, CCO2 Forms Completed in CHOICES by CCOs.
 The Reason for Disenrollment “Transferred to another CCO” also includes 70 people (or 7% of the category total) who moved out of the CCO’s catchment area.
CCO/Health Home Care Management Care Planning
Figure 7: Completion of Life Plans for New Enrollees (Q1-Q3 2020) 
|CCO Name||90 Days Q1-3||120 Days q1-3||180 Days Q1-3|
|Advance Care Alliance||46%||62%||76%|
|Care Design NY||69%||87%||97%|
|Person Centered Services||53%||77%||90%|
|Prime Care Coordination||38%||53%||71%|
|Southern Tier Connect||45%||58%||66%|
|Statewide Weighted Average||68%||81%||89%|
 Typically, CCOs have 90 days from CCO enrollment (or HCBS Waiver enrollment, whichever comes first) to finalize an initial Life Plan for individuals new to CCO services. During the COVID-19 health emergency timelines were extended. As such, calculations in Figure 7 were based on 120 days and 180 days instead of 90 days for Life Plan completion. Only enrollees new to care management who enrolled between January 1 and September 1, 2020 (Q1-Q3) were included in the data analysis as the majority of individuals enrolling in Q4 (October 1-December 1) have until on or after January 1, 2021 to finalize an initial Life Plan.
Figure 8: Completion of Annual Life Plans for All Enrollees (2020) 
|CCO Name||Percent of Annual Life Plans Completed
(January – December 2020)
|Advance Care Alliance||88%|
|Care Design NY||93%|
|Person Centered Services||93%|
|Prime Care Coordination||93%|
|Southern Tier Connect||95%|
|Statewide Weighted Average||93%|
 CCOs perform annual assessments to inform the review and revision of Health Home and Basic Plan Support Life Plans annually for all enrollees. Figure 8 depicts the percent of total enrollee annual Life Plans finalized.