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 2021 with accompanying detail on data movements during January - December 2021.
- 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.
Care Management Enrollment
Figure 1: People Receiving Care Management Services by Program Type (as of December 31, 2021)

A total of 23,673 individuals new to OPWDD care management enrolled in CCOs since the July 2018 implementation (6,613 of these individuals enrolled in the 2021 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, 2021)
Advance Care Alliance | Care Design NY | Life Plan | Person Centered Services | Prime Care Coordination | Southern Tier Connect | Tri-County Care | Total | |
---|---|---|---|---|---|---|---|---|
Health Home Services | 23,158 | 26,671 | 18,158 | 16,689 | 8,088 | 1,215 | 15,563 | 109,542 |
HCBS Basic Plan Support Services | 1,052 | 796 | 476 | 525 | 136 | 34 | 232 | 3,251 |
Total | 24,210 | 27,467 | 18,634 | 17,214 | 8,224 | 1,249 | 15,795 | 112,793 |
Figure 3: People Receiving Care Management Services by Care Coordination Organization (as of December 31, 2021)

Figure 4: People New to Receiving Care Management Services [1]
Care Coordination Organization | New to CM (August 2018 – December 2019) | New to CM (January 2020 – December 2020) | New to CM (January 2021-December 2021) | Total |
---|---|---|---|---|
Advance Care Alliance | 1,312 | 885 | 802 | 2,999 |
Care Design NY | 2,653 | 1,381 | 1,362 | 5,396 |
Life Plan | 1,296 | 948 | 858 | 3,102 |
Person Centered Services | 827 | 724 | 668 | 2,219 |
Prime Care Coordination | 1,068 | 737 | 556 | 2,361 |
Southern Tier Connect | 144 | 124 | 75 | 343 |
Tri-County Care | 2,459 | 2,502 | 2,292 | 7,253 |
Total | 9,759 | 7,301 | 6,613 | 23,673 |
[1] Since January 1 through December 31, 2021, an additional 6,613 people enrolled in CCOs. On average only 1% of new enrollees select Basic HCBS Plan Support Services.
CCO Disenrollment
Figure 5: Total People Disenrolled from a CCO (2021) [2]
Total Enrollments (as of December 31, 2021) |
Total Disenrolled 2021 January – December |
Percentage of Disenrolled compared to Total Enrollments | |
---|---|---|---|
Advance Care Alliance | 24,210 | 1,357 | 5.61% |
Care Design NY | 27,467 | 1,123 | 4.09% |
Life Plan | 18,634 | 825 | 4.43% |
Person Centered Services | 17,214 | 764 | 4.44% |
Prime Care Coordination | 8,224 | 442 | 5.37% |
Southern Tier Connect | 1,249 | 63 | 5.04% |
Tri-County Care | 15,795 | 558 | 3.53% |
Grand Total | 112,793 | 5,132 | 4.55% |
[2] 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 (2021) [3]
Reason for Disenrollment | Jan-Dec 2021 Count |
Jan-Dec 2021 % of Total Disenrollment |
ACA | CDNY | LP | PCS | PCC | STC | TCC |
---|---|---|---|---|---|---|---|---|---|
Enrolled in Another Comprehensive Care Management Program Not Delivered Through a CCO | 180 | 3.51% | 38 | 58 | 21 | 24 | 20 | 0 | 19 |
Ineligible for Medicaid | 59 | 1.15% | 23 | 10 | 7 | 8 | 7 | 0 | 4 |
Moved Out of State | 1,040 | 20.27% | 279 | 241 | 140 | 116 | 72 | 9 | 183 |
Not Residing in a CCO Eligible Setting | 661 | 12.88% | 162 | 142 | 107 | 121 | 37 | 11 | 81 |
Passed Away | 1,333 | 25.97% | 239 | 327 | 301 | 286 | 95 | 16 | 69 |
Requirements Not Met for Level of Care | 55 | 1.07% | 17 | 21 | 2 | 3 | 5 | 1 | 6 |
Transferred to Another CCO [4] | 892 | 17.38% | 345 | 145 | 120 | 81 | 88 | 8 | 105 |
Voluntary Withdrawal from CCO | 912 | 17.77% | 254 | 179 | 127 | 125 | 118 | 18 | 91 |
Grand Total | 5,132 | 1,357 | 1,123 | 825 | 764 | 442 | 63 | 558 |
[3] Data Source = Roster, CCO2 Forms Completed in CHOICES by CCOs.
[4] The Reason for Disenrollment “Transferred to another CCO” also includes people who moved out of the CCO’s catchment area.
Care Planning
Figure 7: Completion of Life Plans for New Enrollees (2021) [5]
CCO Name | % of Life Plans Completed for Individuals New to CCO Services- 90 Days | % of Life Plans Completed for Individuals New to CCO Services- 120 Days |
---|---|---|
Advance Care Alliance | 83% | 94% |
Care Design NY | 72% | 89% |
Life Plan | 83% | 93% |
Person Centered Services | 78% | 89% |
Prime Care Coordination | 70% | 81% |
Southern Tier Connect | 94% | 99% |
Tri-County Care | 83% | 89% |
Statewide Average | 79% | 89% |
[5] Typically, CCOs have 90 days from CCO enrollment to finalize an initial Life Plan for individuals new to CCO services. During the COVID-19 health emergency timelines were extended. As such, Figure 7 includes metrics based on 90 and 120 days for Life Plan completion. Only enrollees new to care management who enrolled between November 2020 and October 2021 were included in the data analysis as these individuals would have a Life Plan due in the year 2021.
Figure 8: Completion of Annual Life Plans for All Enrollees (2021) [6]
CCO Name | Percent of Annual Life Plans Completed Timely |
---|---|
Advance Care Alliance | 93% |
Care Design NY | 98% |
Life Plan | 98% |
Person Centered Services | 98% |
Prime Care Coordination | 97% |
Southern Tier Connect | 99% |
Tri-County Care | 88% |
Statewide Average | 96% |
[6] CCOs perform assessments for all enrollees to inform the review and revision of Health Home and Basic Plan Support Life Plans annually. Figure 8 depicts the percent of total enrollee annual Life Plans finalized.