Guidance for Use of the Continued Eligibility for Services (CES) Tool

Revised: September 2024

  • Document is also available in Portable Document Format (PDF)

Background:

Health Home Care Management is a voluntary program that should be provided to members only for as long as they continue to want the service and continue to need the service.

There are several obvious ways that a Care Management Agency (CMA) will know someone is appropriate for disenrollment. For example:

  1. Member asks to close their case
  2. Member disengages from care and cannot be found despite Diligent Search
  3. Member is in or is expected to be in an excluded setting for more than six months
  4. Member dies
  5. Member is no longer eligible for Medicaid
  6. Member moves out of state and/or service area
  7. Etc.

This guidance is meant to address situations where the member may be appropriate for disenrollment, but it is not obvious and may appear (at a surface level) that the member is participating in and benefiting from the program.

These cases can be identified with periodic screening for Continued Eligibility.

Definitions:

Case Conference - Multidisciplinary Team (MDT)/Interdisciplinary Team (IDT)/Child & Family Team Meeting (CFTM)/Case Review Meeting/Case Conference/Care Conference/Care Team Meeting - consists of the member, member supports (including parent, guardian, legally authorized representative), Medicaid Managed Care Plan, healthcare and service providers, collaterals and others approved by the member to ensure member needs are addressed in a comprehensive manner. The composition of a Multidisciplinary Team may vary at any point in time during the member's enrollment and from member to member. These terms can be used interchangeably.

Continued Eligibility for Services Tool - The New York State Department of Health (DOH) - approved Health Homes screening tool. It prompts the user to answer the minimum number of questions required to determine whether the member should continue in the Health Home program or be disenrolled. Completion of the tool generates a recommendation of "Recommend Continued Services", "Recommend Disenrollment" or "More Information Needed".

Voluntary Disenrollment - Member knowingly and voluntarily leaves the program.

Involuntarily Disenrollment - Member either does not know about or does not agree with the Care Management Agency's (CMA's) decision to disenroll the member. The Notice of Determination for Disenrollment in the New York State Health Home Program form (DOH-5235) is used to provide fair hearing rights.

Graduation - Member no longer needs any care management support. They may still use other supports like family, friends, home attendants, etc.

Step-Down - Member needs a lower-level intensity of care management support (Managed Care Agency (MCO)/Managed Long Term Care (MLTC) Telephonic Case Manager, Housing Case Manager, Patient Centered Medical Home Case Manager, etc.)

Step-Up - Member needs a higher-level intensity of care management support (Assisted Outpatient Treatment

(AOT) Case Management, Health Home Plus (HH+) Case Management, Assertive Community Treatment (ACT) Case Management, Institutional Setting)

Guidance:

The Continued Eligibility for Services (CES) Tool is completed for members enrolled in Health Homes Serving Adults (HHSA) ONLY. Care Management Agencies (CMAs) must use the Continued Eligibility for Services (CES) Tool at least annually and every six 6 months thereafter (Month twelve (12), then Month eighteen (18), then Month twenty-four (24)…) on all enrolled (non-pended) Health Home Serving Adults (HHSA) members to identify members who no longer want or need the Health Home level of service and take appropriate steps to disenroll such members.

For members who are Health Home Plus (HH+) (Serious Mental Illness (SMI and HIV), Health Home Plus (HH+) Eligible, or Adult Home Plus (AH+) at the time a Continued Eligibility for Services (CES) Tool is due, the Continued Eligibility for Services (CES) Tool should NOT be completed. When a member is stepped down from Health Home Plus, the Continued Eligibility for Services (CES) Tool is first be due for completion twelve (12) months following the date of step down from the Health Home Plus level of service. When a member is stepped down from Adults Home Plus (AH+) and continues to want HHCM services, they are automatically placed into Health Home Plus (HH+) for up to twelve (12) months. Continued Eligibility for Services (CES) Tool requirements will then resume [refer to section above].

The Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) provides warning validation codes for expiring and expired Continued Eligibility for Services (CES) Tool submissions for all populations except Health Home Plus (HH+). Health Homes utilize a mechanism for monitoring when members with a history of Health Home Plus (HH+) eligibility and enrollment require Continued Eligibility for Services (CES) Tool completion.

The Care Management Agency (CMA) will endeavor for disenrollments prompted by a Continued Eligibility for Services (CES) Review to be Voluntary, but there are certain circumstances where they may be Involuntary.

The use of a Continued Eligibility for Services (CES) Tool does not replace the requirement to disenroll members organically as reasons to disenroll present themselves. The Continued Eligibility for Services (CES) Tool is not required to be completed prior to all disenrollments, nor should it be. Members do not need to meet the criteria of the Continued Eligibility for Services (CES) Tool before graduating. Rather, the tool is to be used at defined timeframes to help identify additional members who are appropriate to graduate, step down, or step up from HHCM management services.

The Continued Eligibility for Services (CES) Tool process does not change any requirements in the Disenrollment Policy. It is an additional check point.

Although the tool may recommend "disenrollment", there are many types of disenrollment. The Care Management Agency (CMA) indicates whether the case was ultimately disenrolled as a graduation, step down, step up, etc. within the chart and in the segment end reason code.

Continued Eligibility for Services (CES) Tool Billing Block

When submission of the recommended outcome from the Continued Eligibility for Services (CES) Tool into Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) does not occur timely, a billing block occurs in the system preventing subsequent billing instances from occurring until such time when the required Continued Eligibility for Services (CES) Tool information is submitted.

NOTE: The Continued Eligibility for Services (CES) Tool billing block was implemented in Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) effective 6/1/24. For specific information related to implementation of the Continued Eligibility for Services (CES) Tool billing block, refer Connection Between Continued Eligibility for Services (CES) Tool and Billing Instances in Medicaid Analytics Performance Portal (MAPP) Health Home Tracking System (HHTS) v.4 (XLSX) (this document is found on the Medicaid Analytics Performance Portal (MAPP) webpage under Health Home Tracking System where additional information for the Continued Eligibility for Services (CES) Tool

Procedure:

  1. The Care Management Agency (CMA) will complete a Continued Eligibility for Services (CES) Tool for enrolled (not pended) adult members that are neither eligible nor enrolled in Health Home Plus (HH+) or Adult Home Plus (AH+) on the following schedule:
    • New Members enrolled on/after 11/1/23:
      • Complete Continued Eligibility for Services (CES) Tool twelve (12) months post-enrollment and every six (6) months thereafter
    • Existing Members
      • Complete Continued Eligibility for Services (CES) Tool at twelve (12) months based on the consent date, or the segment start date (whichever is later), and every six (6) months thereafter.
    2. NOTE: For members who are Health Home Plus (HH+), HH+ Eligible, or Adult Home Plus (AH+) the Continued Eligibility for Services (CES)Tool should NOT be completed. When a member is stepped down from Health Home Plus (HH+), the Continued Eligibility for Services (CES)Tool would first be due for completion twelve (12) months following the date of step down from the Health Home Plus (HH+) level of service. When a member is stepped down from Adult Home Plus (AH+) and continues to want Health Home Care Manager (HHCM) services, they are automatically placed into HH+ for up to twelve (12) months. Continued Eligibility for Services (CES)Tool requirements will then resume. The Continued Eligibility for Services (CES)Tool would be due twelve (12) months following the date of step down from Health Home Plus (HH+).
  2. The Care Management Agency (CMA) may choose to complete a Continued Eligibility for Services (CES) Tool for a member off-cycle at any time. This could be prompted by a request from the New York State Department of Health (DOH), the member's Managed Care Agency (MCO), or other reasons. The Health Home cannot require a more frequent time frame.
  3. The Continued Eligibility for Services (CES) Tool can be completed by the Case Manager, Supervisor, or a Quality Assurance staff (QA). It is recommended that it is done by Quality Assurance staff (QA). staff or supervisors so that it is based solely on the documentation in the chart, and there is no conflict of interest or bias.
    • 3.1 If completed by a Care Manager/Care Coordinator, supervisory review is required. The Care Management Agency (CMA) Supervisor must document the outcome of this review in the member's record.
  4. Member and Care Team involvement is intentionally not required to complete the Continued Eligibility for Services (CES) Tool. The Continued Eligibility for Services (CES) Tool should be completed based upon a chart review, provided that all documentation is present in the member's record. If answers are unclear, yielding a result of "More Information Needed", the tool must be completed a second (2nd) time within the following sixty (60) calendar days, during which time the member and/or care team member(s), a supervisor and the Health Home should be consulted about those specific questions. If the tool recommends Disenrollment, the member and Care Team would become involved to discuss and plan for an appropriate disenrollment.
  5. The Continued Eligibility for Services (CES) Tool examines whether the member has Risk Factors (Needs HHCM) and is fully Engaged in the Health Home level of service (Wants and is receiving desired Health Home Care Management (HHCM).
  6. The Continued Eligibility for Services (CES) Tool outcome identifies a member as being in one of three possible categories, as follows:
    • Recommend Continued Health Home Services
    • Recommend Disenrollment (with appropriate Transition Planning)
    • More Information Needed
      • Used if there is not enough information in the record to answer a question.
  7. If the recommendation is to Continue Health Home Services, services should continue for the member. All usual processes for assessment, care planning, and ongoing service should be followed.
    • 7.1The risk factor(s) that contributed to the recommendation on the Continued Eligibility for Services (CES) Tool should be incorporated into the Health Home Plan of Care if they are not there already. The tool's determination may be shared with the member in the course of ongoing Plan of Care development.
  8. If the recommendation is to Disenroll, the Care Manager follows the following steps:
    • 8.1 Review the outcome of the Continued Eligibility for Services (CES) Tool and the reason disenrollment is recommended with the member and Care Team members as appropriate.
    • 8.2 Determine what type of disenrollment makes sense for the member. The most common disenrollment following a Continued Eligibility for Services (CES) Review would be graduation, step down, or withdrawal of consent.
    • 8.3 Identify the most appropriate program for the member.
    • 8.4 Identify whether the member agrees with the disenrollment recommendation (Voluntary) or does not agree (Involuntary).
      • It is recommended that a Transition Goal be added to the Health Home Plan of Care to be worked on over time. This may be appropriate in cases where complex referrals are needed, or where it would be appropriate to use Motivational Interviewing to help the member feel confident and ready for disenrollment.
      • It is also possible that in cases where the disenrollment recommendation was prompted by a lack of engagement, and the member does not agree with the recommendation, the possibility of disenrollment motivates them to begin fully engaging with the Health Home Care Manager (HHCM) and their Plan of Care.
    • 8.5 Proceed to disenrollment, following all normal disenrollment processes, including appropriate letters, forms, referrals, and notification to Care Team members.
      • If the member is not in agreement, they may dispute the disenrollment through the Fair Hearing Process. The Notice of Determination for Disenrollment in the New York State Health Home Program (DOH 5235) form is issued to the member with other required steps, as per the Health Home Notices of Determination and Fair Hearing Policy - HH0004
    • 8.6 The case should be closed within sixty (60) calendar days from the recommendation to disenroll.
    • 8.7 In some cases, while working on a disenrollment plan, a new risk factor could present itself that would support a member remaining in Health Home. For example: the member informs the Health Home Care Manager (HHCM) that they are experiencing homelessness, which was not previously disclosed.
      • The Health Home Care Manager (HHCM) must alert the Care Management Agency (CMA) Supervisor and discuss next steps. If the Supervisor agrees that this new information could alter the result of the Continued Eligibility for Services (CES) Tool, the Supervisor may initiate the completion of a new tool.
        • The Care Management Agency (CMA) supervisor must document in the member's record to include the new information identified, the reason for not following the Continued Eligibility for Services (CES) Tool recommendation for disenrollment, and the directive given to complete a new Continued Eligibility for Services (CES) Tool.
        • Identification of the new risk factor(s), documentation of the new information, and completion of a new Continued Eligibility for Services (CES) Tool must occur within sixty (60) calendar days from completion of the initial Continued Eligibility for Services (CES) Tool and the outcome of the new Continued Eligibility for Services (CES) Tool must be implemented.
      • Failure to complete a follow-up Continued Eligibility for Services (CES) Tool within sixty (60) calendar days of the initial Continued Eligibility for Services (CES) Tool leads to suspension of billing for services to the member (refer to the Continued Eligibility for Services (CES) Tool Billing Block section above)
        • If the new Continued Eligibility for Services (CES) Tool's outcome is "Recommend Continued Services", then the HHCM continues work with the member, per policy.
        • If the new Continued Eligibility for Services (CES) Tool's outcome is "Recommend Disenrollment" then the member must be disenrolled by within sixty (60) calendar days after the initial Continued Eligibility for Services (CES) Tool's completion date.
  9. If the recommendation is "More Information Needed", the Care Manager will:
    • 9.1 Review the recommendation with the member.
    • 9.2 Engage in a prompt and concerted effort to collect information to determine more definitively whether a member is still appropriate for Health Home Enrollment or whether the member should be Disenrolled.
    • 9.3 Case Conferences and consultation with other providers is recommended when any of the questions are answered as "Unclear". Therefore, the purpose of the Case Conference is to determine the answers to those questions. Sources such as PSYCKES may also be used to obtain information.
    • 9.4 Following the Case Conference the Care Management Agency (CMA) should complete another Continued Eligibility for Services (CES) Tool to generate a recommendation within sixty (60) calendar days from the initial Continued Eligibility for Services (CES) Tool outcome.
    • 9.5 Failure to complete a follow-up Continued Eligibility for Services (CES) Tool within calendar sixty (60) days resulting in a determination of either Recommend Continued Enrollment or Recommend Disenrollment may lead to suspension of billing for services to the member (refer to the Continued Eligibility for Services (CES) Tool Billing Block section above)

  10. Copies of any Continued Eligibility for Services (CES) Tools completed for the member must be available in the case record, either built into the Electronic Health Record (EHR), or uploaded as separate documents.
  11. Health Homes are required to provide quality oversight, training, and guidance to their Care Management Agency's (CMA's) related to the Continued Eligibility for Services (CES) Tool. This could include data analysis as to any outliers within their networks, percentage of cases where a Continued Eligibility for Services (CES) Tool Recommendation was not followed, etc.

    12. Resources:

    Additional information related to the Continued Eligibility for Services (CES) Tool can be found on the Health Home Policy and Updates webpage: