Health Homes Serving Children Providers
UPDATE: Updated Children's Waiver Assessment Fee Guidance
IMPACTED PLANS: Medicaid and HIV SNP
Effective October 1, 2024, the New York State Department of Health (NYSDOH) has received State Plan approval from the Centers for Medicare and Medicaid Services (CMS) to pay an Assessment Fee for the initial and annual Children’s Waiver Home and Community-Based Services (HCBS) eligibility determinations conducted by Health Homes Serving Children (HHCS) care managers.
State Billing and Reimbursement Guidelines
Per NYSDOH-issued guidelines, MetroPlusHealth will allow billing and payment of the HCBS Assessment Fee for conducting an initial or annual reassessment:
- The HCBS Eligibility Determination must be conducted annually within 365 days of completion of the previous assessment.
- The Assessment Fee can only be paid one time per year per member, regardless of how many HCBS Eligibility Determinations are conducted for the member within the year.
- The HCBS Assessment Fee is not payable for a “Significant Life Event” assessment.
- Reassessments for continued enrollment completed on or after January 1, 2024, that are not completed timely within the 365 days of the previous assessment, are not billable.
Billing Codes
Rate Code | Rate Code Description | Procedure Code | Modifier |
---|---|---|---|
1875 | Home and Community-Based Services Assessment Fee | G0506 | U1 |
1868 | Health Home-CANS Assessment (Children) | G0506 |
- A new HCBS Eligibility Determination is not needed when a member transfers from one care management agency to another, or to or from Children and Youth Evaluation Services (C-YES) within the eligibility period.
- The HCBS Assessment Fee is not payable for past due assessments completed for HCBS re-enrollment within 60 days after the end of a previous eligibility period.
- However, in extenuating circumstances, the assessment fee may be reimbursable as an initial HCBS Eligibility Determination even if it occurs within 60 days of the end of the previous eligibility period, if the member is disenrolled from the Children’s Waiver because they no longer meet eligibility criteria and the child’s condition worsens after disenrollment, necessitating re-enrollment at any time.
Please refer to the Eligibility and Enrollment Policy for additional guidance on timely completion of HCBS Assessments.
If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].