Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

Policy

Medicaid Expenditure Reports by Catogory

• Medicaid Expenditure Profile by Child: gives expenditures by category by month as well as year-to-date totals for the last 24 months for those children enrolled during these years who have not been discharged in the last 6 months.  Children with multiple known Medicaid ID numbers will have expenditures reported under their separate ID’s. The individual child tables are arranged by recipient Medicaid ID number. Counties will receive reports only for children in their county.
• Medicaid Expenditure Profile by HCBS Waiver Provider:  gives total expenditures for all enrolled children by category by month for each calendar year of ICC Agency participation in the HCBS Waiver. Also gives number of enrolled children per month, average expenditure per child by month, and year-to-date (YTD) totals with YTD average expenditures based only on months with reported data.
• Medicaid Expenditure Profile by HCBS Waiver Provider -Average Child Usage: gives average expenditures over all enrolled children by category by month for each calendar year of ICC Agency participation in the HCBS Waiver.
• Medicaid Expenditure Profile - Entire State of New York:   gives expenditures by category by month and year-to-date total for each calendar year of HCBS Waiver.
• Medicaid Expenditure Profile -New York City/Rest of State: gives expenditures by category by month and year-to-date total for each calendar year of HCBS Waiver.
• Budgeted vs. Expended Report -annualizes expenditures and compares them to the budgeted amounts and is given by ICC Agency, region, and NYC/Rest of State.  It should be a useful tool in evaluating utilization and expenditures for your enrolled children and families.
  • The report gives total program estimated expenditures and average amount per slot as budgeted for current calendar year in rate setting worksheets prepared by ICC Agencies.
  • Actual year-to-date (YTD) expenditures for a specified period are provided.  Medicaid billing for this period should be fairly complete.
  • YTD expenditures are annualized for the year.
  • Total annualized YTD program expenditures are compared to total budgeted for all allocated slots.  Thus the percentage includes underspending due to unfilled slots as well as differences due to service utilization.
  • The annualization on a per-slot basis only looks at children who have Medicaid billings and therefore is a better representation of what is being spent on the "average" child in the program.
  • The percentages of expended dollars to budgeted dollars depend on how close an ICC Agency has estimated expenditure by category. These percentages do not, by themselves, tell us whether the levels of service are appropriate or inappropriate.

Roster Reports

• New/Previous Enrollments, Start-up Children, and Current Disenrollments. This ICC Agency-level report gives roster activity by child for the previous month and includes child’s county, Medicaid data consent status, and insurance information as well as  a reminder on evaluation forms due.
• Roster Update. These reports summarize roster activity for the previous month (previously enrolled children, new enrollments, disenrollments, children in start-up, total including children in start-up, and approved slots) by county for each ICC Agency and by ICC Agency for each region.

Medicaid Exception Report

• Waiver Services Billing Exception Report . Enrollees with waiver services billed outside of their enrollment period (before the enrollment date and on or after the disenrollment date) are identified on this report, and all paid claims falling outside the enrollment period are reported.  For purposes of programming, the service dates shown on these reports is one month earlier than what your agency actually used when billing.

• Generally, no claim should show a service date prior to the enrollment date. Claims are allowed on the first of the month after a discharge if the child has not lost Medicaid eligibility in the intervening period. Daily respite may be billed for the actual days of service in the subsequent month.  This will be allowed until such time as the daily respite billing instructions are changed. Otherwise, there should be no claims on or after the disenrollment date.  If billings were previously corrected by adjustments 12 months after the service date, they may not be reflected in these reports.

Expenditure Categories

• Medical/Other - All other services besides HCBS Waiver services, licensed mental health services, and private mental health practitioner-delivered services:
• IP M/S: Inpatient Medical/Surgical services;
• Long Term Care: Typically nursing home or long term home health care; could include some nursing services;
• Emergency: Emergency room services delivered outside Comprehensive Psychiatric Emergency Program (CPEP); could include psychiatric emergency care;
• Physician: Services billed by physicians, including specialists, but not psychiatrists;
• OP Medical: Outpatient medical or surgical services; could include mental health services delivered in outpatient setting not licensed by the Office of Mental Health;
• OP Substance Abuse: Outpatient alcohol or substance abuse services delivered in settings licensed by the Office of Alcoholism and Substance Abuse;
• SSHSP-MH: Services defined as mental-health related which are delivered through the School Supported Health Services Program for children in special education and billed by local school districts;
• SSHSP-Other:  Services not defined as mental-health related which are delivered through the School Supported Health Services Program for children in special education and billed by local school districts;
• Pharmacy: Drugs prescribed and paid for through Medicaid,may be related to mental health diagnoses or not ;
• Transportation: Transportation services, e.g., ambulance, cab to treatment appointments, paid by Medicaid;
• Dental: Dental services;
• HMO/Managed Care: Medicaid managed care premiums;
• FC Medical Per Diem: Medical per diem paid to voluntary agencies for certain contracted medical expenses for children in foster care and
• Eye, Ear, DME, Other: Eye, ear, durable medical equipment, or any other medical/surgical service provided through Medicaid.
• Outpatient Mental Health - Services provided by licensed mental health programs, e.g., clinic, day treatment, partial hospitalization, or intensive psychiatric rehabilitation treatment (IPRT) programs or by private mental health practitioners, e.g., psychiatrists, psychologists, social workers:
• Clinic - Regular: Clinic treatment services, including individual, group or crisis services;
• Clinic - Collateral: Clinic treatment services provided to client collateral(s) individually or in groups;
• Day Treatment -Regular: Day treatment, partial hospitalization or IPRT services provided to client;
• Day Treatment -Collateral: Day treatment, partial hospitalization or IPRT services provided to client collateral(s);
• Private Practitioner: Services provided by private mental health practitioners, e.g., psychiatrists, psychologists, social workers;
• CPEP: Services provided in specialized Comprehensive Psychiatric Emergency Program for mental health emergencies and
• ICM/SCM: Intensive or Supportive Case Management services; HCBS Waiver enrollees cannot receive these services during their enrollment periods but may either before or after HCBS Waiver participation.
• Psychiatric Inpatient/Residential -Psychiatric services received in an acute general hospitals, private psychiatric hospitals, state-operated psychiatric centers or residential services delivered by programs licensed by the Office of Mental Health:
• Acute General Hospital: Hospitals licensed by the Department of Health; ranges from small rural community hospitals to large metropolitan teaching hospitals. Some hospitals have specialized inpatient psychiatric departments which are licensed by the Office of Mental Health;
• Private Psychiatric Hospital: Hospitals, licensed by the Office of Mental Health, specializing in psychiatric services;
• State Psychiatric Center: Hospitals operated by the Office of Mental Health. Children’s Psychiatric Centers only serve children.  Psychiatric Centers may have specialized children’s units and
• CR/FBT/TFH: Community Residences, Family-Based Treatment, and Teaching Family Homes, and all residential programs licensed by the Office of Mental Health. HCBS Waiver enrollees cannot receive these services during their enrollment periods but may either before or after HCBS Waiver participation.
• HCBS Waiver Services - the six HCBS Waiver services:
• ICC - Regular: Individualized Care Coordination - Regular;
• ICC - Start-up: Start-Up ICC Case Management available for up to one month between application signing and official enrollment dates;
• ICC - Inpatient: Inpatient ICC Case Management available for periods of inpatient hospitalization as long as the child returns to the HCBS Waiver after discharge from an acute general, private psychiatric or state-operated psychiatric hospital;
• Respite: either hourly or daily respite services; Family Support Skill Building Intensive In-Home: Intensive In-Home services delivered by
• subcontracting agencies;
• ICC - Intensive In-Home: Intensive In-Home services delivered by ICC’s who have been approved to deliver "bundled" services;
• Crisis Response
• ICC - Crisis: Crisis Response services delivered by ICC’s who have been approved to deliver "bundled" services.

Items for ICC Agencies to Review

As ICC’s and the ICC Agency Program Director review the financial management reports, the following items should be addressed, both on a specific child level and systematically over the whole program.

• CAIRS - Is the roster on CAIRS current?
• Missing Data -Is any known expenditure or expenditure category missing (with no explanation), e.g., transportation?  For New York City, are hospitalizations in state-operated psychiatric centers not being captured? If so, perhaps we are missing a second Medicaid ID number for the child.
• Enrollment/Census Data -Since many calculations depend on an accurate count of active cases, correct information is critical. Please check to see whether start-up, enrolled or disenrolled children are properly listed on the roster report.  Are there enrolled children whose expenditures are not appearing, given a 3-month claim lag? Are disenrolled children’s expenditures appearing past the disenrollment date?
• Higher Expenditures -Does any category seem larger than expected (compared to the service plan or program rate worksheet budget) with no identifiable reasons?
• Frequency and Intensity of Other Outpatient Mental Health Services -Is the frequency or intensity of other outpatient mental health services consistent with care plans and  rate worksheet estimate?
• Service Utilization Patterns -  Are the overall service utilization patterns consistent with expected current levels, e.g., are inpatient psychiatric costs too high, CPEP/ER too high, medical care too low, no needed substance abuse treatment? Are the patterns consistent with levels desired for planned disenrollment?
• Relative Amounts and Types of Expenditures -Examine the relative amounts and types of expenditures for each child and the program as a whole. For example, if day treatment is high and alternative packages of HCBS Waiver services or additional work with the schools could allow the child to return to more normalized educational settings, should care plan work toward this, should more outreach efforts be made to teachers and schools so they can understand what the HCBS Waiver can do to help? Or if several CPEP visits have taken place over a short period of time, could more intensive in-home services be put in place to divert/defuse potential crises?
• Medical Care -Is the child receiving preventive medical care and attention to chronic physical problems, e.g., physical exams at the appropriate intervals, management of asthma or diabetes?  Has the child had an opportunity to be evaluated for possible organic causes of symptoms associated with the mental health diagnosis?
• Dental, Vision, Hearing -Has the child’s dental, vision, and hearing needs been addressed?
• School Supported Health Program Services (SSHPS) -Is the child receiving SSHPS through his or her school district? How do these services relate to the HCBS Waiver Individualized Care plan? This is an area where we are still trying to gather information to resolve issues of possible coordination/overlap, as well as fiscal responsibility.
• Unpaid Claims -Are there billings which do not appear because they have been denied – single occurrences or systematically?  Call your Computer Sciences Corp. (CSC) contact or Diana Marek.
• Inappropriate Claims -Generally, no claim should show a service date prior to the enrollment date. Claims are allowed on the first of the month after a discharge if the child has not lost Medicaid eligibility in the intervening period. Correct billing of daily respite is complicated by denial of multiple days on a single claim line and some agencies have billed the actual days of service in the subsequent month. This will be allowed until such time as the daily respite billing instructions are changed. Otherwise, there should be no claims on or after the disenrollment date.
• Overall Comparison - How does the reported utilization generally compare to the individual child’s service plan budget and the program rate worksheet?  Look at both Waiver and non-Waiver services. If there are differences, do they indicate reported levels below budgeted amounts because of unmet need, e.g., unavailable respite services? If need is greater than anticipated, e.g., day treatment, frequent hospitalizations, why?  Is this something your program can address for an individual child (substitution of another service) or for the program as a whole (look for new avenues to supply subcontract workers)? Is this an issue that your LGU, OMH Field Coordinator, or Parent Advisor might help with (local resources, brainstorming solutions)? Is this an issue that should be brought to OMH Central Office’s attention (e.g., services for siblings) or Computer Sciences Corporation (denied claims)?  Or, is this an indication that the ICC and child/family should revisit the care plan because the needs originally expressed have changed (either the situation has changed or those involved in the process are better able to articulate those needs)?

Issues Regarding the Data

• Data Reliability. Since there is a lag in the Medicaid adjudicated claims data, we cannot guarantee that all current Medicaid expenditures will be reported, paid, and appear on the reports. There is at least a three-month lag for most mental health outpatient and inpatient billings to be paid. Additionally, we cannot capture data for children until their applications for the HCBS Waiver have been forwarded to the OSU. It is especially important that ICC Agencies submit claims and resolve denials promptly. Claims paid 12 months after the service date will not be supplied by DOH to OMH or included in the fiscal reports.
• COPs. (Comprehensive Outpatient Program) Outpatient amounts include COPs payments, which are not subject to the budget cap. COPs allows enhanced reimbursement under Medicaid to designated providers who have agreed to certain additional requirements in the provision of outpatient mental health services.
• Enrolled Children. The enrollee count by month on the agency-specific profiles is based on calendar days rather than months and half-months, so it may understate ICC Agency capacity. The average expenditure per child per month calculation may be affected by this circumstance.
• Confidentiality. Medicaid data released to HCBS Waiver providers, LGU’s, and OMH staff are to be maintained under strict rules regarding confidentiality as per HIPAA regulations.
  • These data shall only be used for Medicaid program administration purposes.
  • Only staff performing duties specified under the HCBS Waiver Program shall be permitted access to this information.
  • All staff having access to recipient-identifiable information shall be instructed in the confidential nature of such data and the limitations relating to its use and handling.
  • Medicaid recipient-identifiable data shall be kept in locked areas or secured data base files when not under the direct control of authorized staff members.
  • Any Medicaid recipient-identifiable data, including copies and merged databases, shall be returned to the NYS Department of Health (DOH) upon completion of the HCBS Waiver or, with DOH approval, destroyed and written certification of destruction furnished to DOH.
  • Information regarding alcoholism or drug abuse services or HIV services are subject to other specific Federal and State laws and regulations.
  • DOH reserves the right to monitor and audit usage of these data on-site.

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.