X. Eligibility and Referrals

Health Home services are provided to a subset of the Medicaid population with complex chronic health and/or behavioral health needs whose care is often fragmented, uncoordinated, and duplicative. This population includes categorically beneficiaries with high medical needs served by Medicaid Managed Care Plans (MMCP) or Fee-For-Service (FFS) plans as well as Medicare/Medicaid dually eligible beneficiaries who meet Health Home criteria.

People served in a Health Home must have: 

1. Two or more chronic conditions (e.g., Substance Use Disorder, Asthma, Diabetes). Please see Section 1945(i)(2) of the Social Security Act for more information. 

OR

2. One single qualifying chronic condition:
   1. HIV/AIDS or
   2. Serious Mental Illness (SMI), which applies to Adults or
   3. Serious Emotional Disturbance (SED) or Complex Trauma, which applies to Children

Specialized Health Home services for people with I/DD are known are Care Coordination Organization Health Homes (CCO/HHs). People are eligible for enrollment into a CCO/HH if they have one (1) chronic condition in the Developmental Disability category, including:

1. Intellectual Disability;
2. Cerebral Palsy;
3. Epilepsy;
4. Neurological Impairment;
5. Familial Dysautonomia;
6. Prader-Willi Syndrome; or
7. Autism 

AND

Have received OPWDD’s determination that the person’s chronic condition in the Developmental Disability category originated prior to age 22 and results in functional limitations that constitute a substantial handicap as defined by section 1.03(22) of the Mental Hygiene Law. 

Developmental Disability is defined by New York State Mental Hygiene Law Section 1.03(22) as:

1. (1) is attributable to intellectual disability, cerebral palsy, epilepsy, neurological impairment, familial dysautonomia, Prader-Willi syndrome or autism; 
   
   (2) is attributable to any other condition of a person found to be closely related to intellectual disability because such condition results in similar impairment of general intellectual functioning or adaptive behavior to that of intellectually disabled persons or requires treatment and services similar to those required for such person; or 
   
   (3) is attributable to dyslexia resulting from a disability described in subparagraph one (1) or two (2) of this paragraph;
2. originated before such person attains age twenty-two (22);
3. has continued or can be expected to continue indefinitely; and
4. constitutes a substantial handicap to such person’s ability to function normally in society.

To meet CCO/HH chronic condition and eligibility criteria, the person must:

1. Be eligible for Medicaid in New York State that covers the Comprehensive Health Home Care Management Service;
2. Reside in their own home, a family home, or live in an Individualized Residential Alternative (IRA), Community Residence, or Family Care Home, certified by OPWDD;
3. Not be enrolled in another comprehensive care management program (e.g., Fully Integrated Duals Advantage (FIDA) – Intellectual and Developmental Disabilities);
4. Reside in New York State;
5. Meet Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) Level of Care Eligibility Determination (LCED) criteria, and an ongoing annual redetermination completed in the CHOICES system; and
6. Have received OPWDD’s determination that the person is eligible for OPWDD services.  

Please refer to the CCO/HH State Plan Amendment (SPA) for a list of single qualifying Developmental Disability eligibility conditions.          

CCO/HH Referrals

The primary mechanism for referral to CCO/HHs for people with developmental disabilities is OPWDD, through the DDRFOs or designee. CCO/HHs may also directly receive referrals from the community. 

There are at least two (2) CCO/HHs serving each of the five (5) regions of New York State. Please view this coverage chart for a comprehensive list of CCO/HHs, their service area, and contacts for making referrals.

DDRFO (Developmental Disabilities Regional Field Office) Referrals

Through OPWDD’s Front Door Process the DDRFO will share information with the person/family on CCO/HHs serving the person’s geographic region. The person/family will need to make a choice of which CCO/HH they would like to receive care management services from and contact that entity to begin the enrollment and intake process. People/families are encouraged to connect with a CCO/HH as soon as possible to support and assist them in obtaining OPWDD eligibility and Medicaid. Although a person may not be enrolled in a CCO/HH until OPWDD eligibility is determined, the CCO/HH’s role is to assist the person with this process prior to enrollment. 

The CCO/HH will obtain the required eligibility documentation and submit a complete packet to CHOICES and send a notice to the CCO/HH Alert Mailbox. OPWDD, through its Regional Office clinical eligibility staff, determines whether a person has a developmental disability and is eligible for OPWDD services. The process for determining eligibility may involve multiple reviews. 

All referrals from DDRFOs will be accepted by CCO/HHs to provide CCO/HH Care Management. If the DDRFO determines that the person does not meet OPWDD criteria, DDRFO may refer the person to the Department of Health’s (DOH) Health Homes serving adults or children.  

Hospital Referrals

As required by Section 1945(3)(d) of the Social Security Act, all hospitals must have procedures in place for referring any eligible person with chronic conditions seeking or needing treatment in a hospital ER/ED to a NYSDOH Designated Health Home. 

Transitional Services and Facilitating Referrals for People in “Excluded Settings”  

“Excluded settings” are institutional settings that include but are not limited to: 

1. Inpatient Hospital Settings;
2. Intermediate Care Facilities (ICF);
3. Developmental Centers;
4. Residential Schools – with certain exceptions (i.e., Day Residential Programs such as Lexington School for the Deaf);   
5. Correctional Settings (i.e., jail and/or prison);
6. Nursing Homes;
7. Foster Care;
8. Office of Addiction Services and Supports (OASAS) Operated or Certified Facilities; and
9. State-operated psychiatric centers.  

Each OPWDD Regional Office has mechanisms in place to ensure that people are educated on the available CCO/HHs in their area so they can make an informed decision on which CCO/HH they would like to be referred to.  

Each CCO/HH must accept all referrals of people with developmental disabilities who may be eligible for OPWDD services that are either made by an OPWDD Regional Office or another referring entity. 

These referral entities may include, but are not limited to: 

1. Criminal Justice System;
2. Department of Corrections and Community Services;
3. County and City Jails;
4. Hospital Inpatient Settings;
5. State-Operated Psychiatric Centers; and
6. Social Service Providers.  

CCO/HHs must have an identified point of contact and clear processes in place for accepting referrals from these sources and providing necessary supports and services including comprehensive transitional care and comprehensive care management services.  

To ensure people experience a smooth transition and to allow adequate time for service planning, referrals to CCO/HHs will typically occur prior to the person’s discharge from the institutional setting. The CCO/HH should begin working with people at least three months (90 days) prior to their discharge from long-term care facilities, such as Residential Schools and Nursing Homes, and immediately begin working with people in short term settings, such as Emergency Departments. It is the expectation that CCO/HHs will begin assisting people at the time of referral to the CCO/HH even when enrollment into the CCO/HH cannot occur until post discharge from the institutional setting. A CCO/HH staff should be assigned prior to CCO/HH enrollment in order to actively participate in service planning, advocacy, and service enrollment. 

CCO/HHs must establish a process that enables them to respond quickly to people referred who are discharged unexpectedly or with short notice (e.g., a person who signs themselves out of a hospital setting against medical advice) or who are in crisis situations.  

In recognition of the additional workload associated with assisting people with the transition from institutional settings to more independent settings, the CCO/HH is eligible to receive a one-time enhanced transition payment for the provision of Care Management to people in transition who have never before received care coordination services through OPWDD. This enhanced payment is available the first month of enrollment in the CCO/HH and is to accommodate the additional time required to assist the person.  

Per ADM #2023-02, in cooperation with Developmental Disabilities Regional Field Offices (DDRFOs), CCO/HHs are responsible for assisting people seeking services and their families with gathering the required documentation, evaluations, and assessments needed for both OPWDD and ICF Level of Care eligibility determinations and redeterminations.  

To support the eligibility and enrollment process CCO/HHs must:

1. Develop policies and procedures to respond timely to people referred, including those who are discharged from excluded settings unexpectedly, with short notice, or who are in crisis;
2. Develop quality management/improvement processes addressing intake and enrollment into the CCO/HH;
3. Accept all referrals of people with developmental disabilities who may be eligible for OPWDD services and who may meet the criteria for enrollment in a CCO/HH (Please note, citizenship status is not a factor in determining OPWDD eligibility);
4. Begin assisting people at the time of their referral;
5. Assist the person to establish timely enrollment in the CCO/HH taking into consideration their cultural norms and language access needs;
6. Help gather required documentation, evaluations, and assessments needed for both OPWDD eligibility and LCEDs;
7. Provide required language access services for documentation, evaluations and assessments, including oral interpretation and written translation in the person’s primary language as determined by the person and their families/representative;
8. Assist people seeking OPWDD services with applying for and maintaining Medicaid.

CCO/HHs are directly responsible for supporting someone through the OPWDD eligibility and enrollment process. If during this process it is evident that the person does not require comprehensive supports through the waiver or CCO/HH Care Management, the CCO/HH staff supporting eligibility and enrollment activities would assist the person/family as needed with finding appropriate non-waiver services and supports.  

For more detailed information on enrollment processes and requirements see Enrollment.

It is important to determine Medicaid eligibility prior to providing CCO/HH services. This is because people entering CCO/HHs are required to be enrolled in Medicaid, and their Medicaid eligibility is date specific. A person’s Medicaid eligibility may change frequently, and it is incumbent on the CCO/HH to ensure that the person is actively enrolled in the NYS Medicaid program prior to rendering Medicaid-funded CCO/HH services.   

If the CCO/HH does not verify eligibility and the extent of coverage for each enrollee, each time services are requested, the provider may be at risk for non-reimbursement for those services provided. The State cannot compensate a provider for a service rendered to a person who doesn’t have Medicaid that will support CCO/HH billing. In determining Medicaid eligibility, the provider is responsible for reviewing the type of Medicaid coverage authorized, as well as any restrictions that may exist. 

If the person is not eligible for Medicaid or their Medicaid coverage has lapsed, the CCO/HH should work with the NYS Local Departments of Social Services (LDSS), New York City Human Resources Administration (HRA), New York State of Health (NYSoH aka Exchange), or the appropriate local Financial Benefits & Entitlement Assistance Management (FBEAM) office to apply for, or reactivate, Medicaid coverage. In addition, a person who is not eligible for Medicaid should be provided with assistance in finding appropriate health care options. 

Additional information on Medicaid can be located in the Benefit Development Resource Toolkit. 

Medicaid Eligibility Verification Process

Medicaid eligibility information, including covered services, is identified in the Medicaid eligibility verification process. For more information, consult the Medicaid Eligibility Verification System (MEVS) Manual.  

Questions concerning Medicaid eligibility verification may be addressed to eMedNY (800) 343-9000.

Process for Children Who Require Waiver of Parental Deeming

Children under the age of eighteen (18) seeking OPWDD services may require Medicaid eligibility. In some cases, a child may not qualify for Medicaid based on their family’s income and resources. In these cases, the child can ask for the parental income and resources to be disregarded (a waiver of parental deeming) in order to access OPWDD’s home and community-based services (i.e., 1915(c) HCBS Waiver). A complete HCBS Waiver application must be submitted prior to requesting waiver of parental deeming. 

A complete OPWDD 1915(c) HCBS Waiver application (“waiver application”) contains the criteria identified in 23-ADM-06. The CCO must complete the HCBS Waiver application; the Request for Service Authorization (RSA) may be signed by the CCO intake staff, rather than a Care Manager. 

The DDRFO will review the waiver application, including the RSA, and make a determination on whether to enroll the child in the HCBS Waiver. The DDRFO may ask for more information to make its determination. 

If the DDRFO determines the child is eligible for enrollment in the HCBS Waiver, OPWDD will issue a Letter of Introduction requesting the local Department of Social Services (DSS) waive parental deeming for purposes of Medicaid eligibility. The CCO/HH is responsible for assisting the person in the Medicaid process. As a best practice, once Medicaid has been opened, the CCO/HH should confirm the issuance of the Waiver Notice of Decision (NOD).  

If a determination is made that the child is not eligible for enrollment in the HCBS Waiver, the DDRFO will issue a Notice of Decision (NOD.02 Denial of Participation in the OPWDD Medicaid Home and Community Based Services (HCBS) Waiver Program) informing the person and their representative of their due process rights. 

As required by OPWDD’s Liability for Services regulations (14 NYCRR Part 635-12), the Liability Notice(s) must be issued to anyone new to CCO care management (Health Home or HCBS Basic Plan Support) or to the CCO. 

For more information on notices and forms, please see OPWDD’s liability webpage.

Please refer to the Non-Medicaid Care Management section for those potential enrollees that are not eligible for Medicaid but may qualify for enrollment under State Paid Care Management.