Glossary of Terms
For the purposes of the CCO/HH program and as used in this manual, the following terms are defined.
Aid Continuing: Aid Continuing is the right of a CCO/HH enrollee to have services continue unchanged until a Decision After Fair Hearing is issued. Aid Continuing directives are issued by the Office of Temporary Disability and Assistance (OTDA).
Agency Conference: Agency Conference is defined as an informal meeting that may be requested by the person/family and/or representative, in addition to requesting a Fair Hearing, where the person may submit additional information in support of their disagreement with the determination on enrollment in or disenrollment from the CCO/HH Program
Business Associate Agreement (BAA): An agreement not to use or further disclose PHI, other than what is permitted or required by the agreement or as required by law. This includes using the appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by the agreement. The agreement includes implementing administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of any electronic PHI that it creates receives, maintains, or transmits on behalf of the covered entity.
Care Management: A process of coordinating and arranging for the provision of needed services in accordance with goals contained in an enrollee’s written Life Plan.
Care Planning Team: Also known as the Interdisciplinary Team or Circle of Support. The team of people who participate in the person-centered planning process and the development of an enrollee’s Life Plan. The team must be comprised of the enrollee and/or their family/representative, Care Manager, primary providers of developmental disability services and other providers or individuals either as requested by the enrollee or their family member/representative if the enrollee is unable to make their wishes known.
CCO/HH Service Organizations: The collective list of CCO/HH service providers.
CCO/HH Participant: A Medicaid eligible candidate who agrees to receive CCO/HH services.
Child and Adolescent Needs and Strengths (CANS): OPWDD’s approved and required person-centered, consensus-based functional needs assessment for people ages 17 and younger and their families. The CANS assessment tool was customized for New York State to give a profile of the specific current needs and strengths of the child/adolescent with I/DD and their caregiver(s). The CANS will provide important information to the child’s/adolescent’s Care Manager (CM) and is utilized to inform and maintain the Life Plan. At this time the DDP2 will be the assessment tool used to determine CCO/HH PMPM rates. The DDP2 will only be used for the development of the Life Plan until a CANS assessment can be completed.
Circle of Support: Also known as the Care Planning Team or Interdisciplinary Team. The team of people who participate in the person-centered planning process and the development of an enrollee’s Life Plan. The team must be comprised of the enrollee and/or their family/representative, Care Manager, primary providers of developmental disability services and other providers or either as requested by the enrollee or their family member/representative if the enrollee is unable to make their wishes known.
Claims Payment: A process within eMedNY that generates a payment of all approved claims and prepares a Remittance Statement with each payment cycle which lists the status of all paid, denied, and pended claims.
Client Identification Number (CIN): Medicaid Client Identification Number that is unique to each Medicaid beneficiary.
Clinical Team: Dedicated clinical staff, either employed or accessible through a contract, available to consult with Care Managers when needed and monitors that the appropriate interventions and action plans are put in place to meet the person’s needs. The clinical team, when determined to be clinically necessary, should also contribute to discussion and development of the Life Plan as facilitated by the Care Manager and be available to help problem solve and support implementation of the Life Plan and staff action plans.
Comprehensive Assessment Process: the use of one or more tools, to identify the developmental disability, medical, mental health, behavioral health, chemical dependency, social and emotional needs of a person. The Life Plan must include all services identified by the assessments used. State approved functional needs assessments used by OPWDD include the Developmental Disability Profile 2 (DDP2), Coordinated Assessment System (CAS) and/or Child and Adolescent Needs and Strengths (CANS) Assessment. CCO/HH must also have comprehensive assessment tools that are completed within 60 days of enrollment into the CCO/HH and reviewed annually to support Life Plan.
Computer Systems Research and Applications Corporation (CSRA): The fiscal agent for eMedNY.
Conflict-Free Care Management (CFCM): Federal Home and Community-Based Settings rule, 42 CFR 441.301(c)(1)(vi), effective March 2014 requires that “Providers of HCBS for the enrollee, or those who have an interest in or are employed by a provider of HCBS for the enrollee must not provide case management or develop the person-centered service plan (Life Plan).” The intention of this federal rule is to ensure that Case Management services are person-centered and promote the enrollee’s interests, not those of the provider agencies.
Coordinated Assessment System (CAS): OPWDD’s approved and required, functional needs assessment tool specifically tailored to capture the unique health and support needs of people with I/DD in New York State. The CAS is used to help inform the development of the Life Plan for enrollees in a CCO/HH in a way that will ensure equity in service allocation, quality of services provided, and sustainability of OPWDD resources. The CAS is being administered statewide for all people age 18 or older with OPWDD eligibility. At this time the DDP2 will be the assessment tool used to determine CCO/HH PMPM rates. The DDP2 will only be used for the development of the Life Plan until a CAS assessment can be completed.
Data Use Agreement (DUA): A legally binding agreement between the Requestor and NYSDOH by defining the terms and conditions of the Medicaid Confidential Data (MCD)release, should DOH accept the Requestor’s Agreement. An additional purpose of the DUA is to assure DOH that a Requestor will maintain the security of MCD that NYSDOH releases to the Requestor.
Designated CCO/HH Provider: A provider approved and designated by NYSDOH and OPWDD as a provider of CCO/HH services.
Developmental Disability: A severe, chronic disability which originated at birth or during childhood, is expected to continue indefinitely, and substantially restricts the person's functioning in several major life activities.
Dually Eligible Individual: An individual that qualifies and receives both Medicare and Medicaid.
Electronic Health Record (EHR): is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports
eMedNY: Electronic Medicaid system of NYS. Allows NY Medicaid providers to submit claims and receive payments for Medicaid-covered services provided to eligible people.
Equity: OPWDD views equity as providing opportunities for people with developmental disabilities to access supports, services, and resources in a fair and just way that best meets a person’s specific needs. Equity reduces barriers to access often experienced by under-served and under-represented groups.
Fair Hearing: a proceeding before an Administrative Law Judge (ALJ) that provides the opportunity for a person receiving services and the agency to present evidence in support of a determination that the person does not agree with.
Fee-for-Service (FFS) Member: Members who do not belong to a Medicaid managed Care Plan (MMCP) and receive services from providers who are contracted with the State based on an agreed upon rate for services.
Front Door: The Front Door refers to the process by which OPWDD connects people to the services they need and want, by providing assistance in navigating the steps involved in determining OPWDD eligibility, identifying needs, goals and preferences and developing a plan for obtaining those services.
Health Commerce System (HCS): An electronic resource designed to protect the confidentiality of data by requiring that organizations adhere to NYSDOH health data security standards. This secure website can be used to send/request data and reports. The HCS is maintained by the NYSDOH Bureau of HEALTHCOM Network Systems Management.
Health Home Service Provider: A provider of CCO/HH services that has a contractual relationship with a CCO/HH.
Health Home Services: Services as defined in Section 1945(h)(4) of the Social Security Act including: comprehensive Care Management; care coordination and health promotion; comprehensive transitional care from inpatient to other settings; individual and family support; referral to community and social support services; and the use of health information technology to link services as feasible.
Health Information Exchange (HIE): The process of reliable and interoperable electronic health information sharing managed such that confidentiality, privacy and security of the information is maintained. A health information exchange is the platform that is used to manage this process and that has a number of functionalities to allow this secure management and exchange of data.
Home and Community-Based Services (HCBS) Waiver: HCBS services wavier is the Medicaid program that provides services for adults and children with developmental disabilities and provides opportunities for people to receive services in their own home or community rather than institutions or other isolated settings. The waiver undergoes a renewal every five years by the Centers for Medicare and Medicaid Services (CMS). The current HCBS waiver is due for renewal on October 1, 2024, for a period that is slated to be effective through September 2029.
Interdisciplinary Team (IDT): Also known as the Care Planning Team or Circle of Support. The team of people who participate in the person-centered planning process and the development of an enrollee’s Life Plan. The team must be comprised of the enrollee and/or their family/representative, Care Manager, primary providers of developmental disability services and other providers or individuals either as requested by the enrollee or their family member/representative if the enrollee is unable to make their wishes known.
Intellectual Disability: A disability characterized by significant limitations in both intellectual functioning and in adaptive behavior, which covers a range of everyday social and practical skills.
Life Plan: The Life Plan is a document that outlines a person’s goals, desires, outcomes, strengths, and preferences. It helps people define their short-term and long-term goals, established action plans, and tracks progress toward achieving their aspirations. A Life Plan is developed using a person-centered planning process with a person and their care-planning team. The Life Plan is also where supports that define the safeguards needed to assist the person in a manner that addresses physical or other support needs to minimize health and safety risks.
Local Government Unit (LGU): Means a County, except a County within the City of New York. The unit of local government is given authority by the government to provide local services.
Long Term Supports and Services (LTSS): Services and supports used by people of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals and administering medications.
Managed Care Organization/Plan (MCO or MCP): A health maintenance organization/plan or prepaid health service plan, certified under the Public Health Law, that contracts with health care providers and medical facilities to provide care for people at reduced cost(s).
Medicaid: A joint federal and state program that helps with medical costs for some people with low incomes and limited resources and/or high-cost medical conditions.
Medicaid Managed Care (MMC): A health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid health benefits and often additional services through contracted arrangements between state Medicaid agencies and Managed Care Organization/Plan that accept a set per member per month capitated payment for these services.
Medicare: The federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD).
National Provider Identifier (NPI): An identification number assigned by the National Plan and Provider Enumeration System (NPPES).
Office for People With Developmental Disabilities (OPWDD): New York State agency responsible for coordinating services for more than 128,000 New Yorkers with developmental disabilities, including intellectual disabilities, cerebral palsy, Down Syndrome, autism spectrum disorders, and other neurological impairments. It provides services directly and through a network of hundreds of nonprofit service agencies. Supports and services, including Medicaid funded long-term care services, such as habilitation and clinical services, as well as residential supports and services, are primarily provided in community settings across the state. In addition to these Medicaid services, OPWDD also provides New York State-funded family support services.
Person-Centered Planning: is a process directed by the enrollee that helps us learn how they want to live and describes what supports are needed to help them move toward a life they consider meaningful and productive. The planning process empowers the enrollee by building on their abilities and skills, promoting a quality lifestyle that supports them in finding ways to contribute to their community.
Performance Improvement (PI, also known as Quality Improvement): Continuous study and improvement of processes with the intent to improve services or outcomes and prevent or decrease the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement. PI in the Health Home Program aims to improve processes involved in care management service delivery and enrollee quality of life.
Performance Improvement Plan (PIP) also known as Quality Improvement Plan (QIP): A written document that clearly and objectively identifies:
- areas where performance expectations and standards have not been met, including examples to clarify the patterns or severity of performance issues, and the impact of the unmet performance;
- root cause analysis;
- expectations for improvement using measurable goals;
- timeline for improvement to be reached
- assignment of tasks to appropriate staff;
- the need for staff training or support;
- expectations for reviewing progress including any barriers; and,
- sanctions that may be imposed if improvements are not made.
Per Member Per Month (PMPM): The reimbursement arrangement in which a fixed rate of payment per participant per month is made, regardless of whether the participant receives covered items and services in that month, to the FIDA-IDD plan for the performance of all of the FIDA-IDD plan’s duties and responsibilities pursuant to the contract.
Personal Outcome Measures (POMS): Developed by the Council on Quality and Leadership, POMS is a list of twenty-one (21) personal outcomes designed to measure if the person is supported in a way that achieves the outcomes that are most important to them.
Qualified Entities (QE): There are six Qualified Entities (QE) in New York: Bronx RHIO, HealtheConnections, HealtheLink, Healthix, Hixny and Rochester RHIO. Each QE has their own participants who contribute data to the QE’s network. This data is then fed into the larger SHIN-NY network. While each QE is part of the statewide network, participants generally connect to the QE which is geographically closest to them.
Quality Improvement (QI): Systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.
Quality Management Program (QMP): A complete and thorough system that documents processes, procedures, and responsibilities for achieving quality practices and objectives. It is a proactive approach rather than a reactive one, identifying and resolving issues before they occur. The QMP is an ongoing and evolving evaluation of the CCO's ability to continuously improve on overall quality.
Regional Health Information Organization (RHIO): Organizations of regional partners that may include hospitals, physicians, and MCOs and others that oversee the infrastructure for the secure electronic exchange of clinical information.
Significant Change in Condition (SCIC): An SCIC CAS or CANS reassessment is conducted when a significant improvement or decline in a person’s behavior, medical condition or functioning has occurred since the last assessment and before the scheduled reassessment. Some SCIC reassessment qualifying events include:
- Accidents or changes resulting in serious personal injury;
- Major medical changes or prolonged illness;
- Major psychiatric changes resulting in extended inpatient psychiatric hospitalization;
- Significant improvement in behavior or physical functioning that may be related to an improvement in an acute medical condition, recovery from prolonged illness or stabilization resulting from psychiatric and/or medical intervention.
SCIC reassessment qualifying changes will not typically be resolved without intervention by staff. These changes are considered prolonged and enduring and usually impact more than one area of the person’s health or behavioral status. This will require a professional review or revision of the person’s care plan. They often result in a newly identified need for reduced or enhanced support to maintain health and safety. If a person believes that they have had a Significant Change in Condition, they should contact their Care Manager or Qualified Intellectual Disabilities Professional to review any additional needs, including the need for a CAS/CANS reassessment.
Statewide Health Information Network for New York (SHIN-NY): Established in 2016 via regulation in the New York Codes, Rules and Regulations, SHIN-NY is a secured network for sharing electronic clinical records. Sometimes referred to as a network of networks. The SHIN-NY consists of six Qualified Entities (QEs) also sometimes referred to as Regional Health Information Organizations (RHIOs) or Health Information Exchanges (HIEs). Records are accessed and exchanged securely between health care participants with appropriate consent.
State Approved Functional Needs Assessment: OPWDD requires that people who are determined eligible for OPWDD services have a completed state approved functional needs assessment that is used to inform the comprehensive assessment process. The Coordinated Assessment System (CAS) and/or Child and Adolescent Needs and Strengths (CANS) Assessment are used by OPWDD. When the CAS/CANS has been completed for a person, that CAS/CANS functions as OPWDD’s State approved comprehensive functional needs assessment to inform the comprehensive assessment process. If a CAS/CANS has not yet been completed for the person, then the DDP2 may serve as the functional needs assessment to inform the comprehensive assessment process. Regardless of whether the person has a CAS/CANS completed, the CCO/HH must continue to complete the DDP2 every two years for everyone until the CAS/CANS is fully implemented and can inform acuity and tier level.
Timely Notice: per 18 NYCRR § 358-2.23, a timely notice is one that is mailed at least ten (10) days before the date upon which the proposed action is to become effective.
Waiver of Appearance: Per 18 NYCRR § 358-4.3 (c) (1), no later than 5 (five) calendar days before a hearing date, the agency may request a waiver from appearing and elect to present evidence in the form of written documentation in lieu of appearing at the hearing.
Warm Handoff: the transfer of care from one entity to another that occurs with the two entities and CCO/HH enrolled and/or their representative present either in-person or remotely. This handoff of care allows the person and/or representative to ask questions they may have or clarify/correct any information.