GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

hospitals for inpatient services.

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

These are codes to restrict recipient to specific

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 GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES

Enrollee in Special Needs MC Plan (HIV SNP)

This code is used to identify enrollees in Special

Needs Plans.
Like mainstream plans, recipients can be members of HIV SNP and enrolled in a Health Home program.

Enrollee in Special Needs MC Plan (HIV SNP)

This code is used to identify enrollees in Special

Needs Plans.

OMH Children's Waiver

Children that received services through this previous waiver have been transitioned to the new Children's
This code is used to identify recipients in the
OMH Home & Community Based Services
(HCBS) waiver for seriously emotionally

This code is for individuals receiving OPWDD for

a limited period of time with no local shares.

Code used for individuals authorized for long

term care services who are eligible for nursing
home level of care and are residing in the
community. Services provided through a

Children receiving OMH TCM services are being transitioned and adults receiving HIV COBRA, OMH TCM
Case Management Program; Medicaid Service

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 GUIDE TO RESTRICTION EXCEPTION (RE) CODES AND HEALTH HOME SERVICES

Recipient is a resident of an ICF-DD Facility.

The care managers must work within the individuals established UT. Limitations on services may apply.
Recipient is subject to Utilization Threshold (UT)

At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish
Recipient is in a HCBS Non-Intensive AHRH to to receive care management through a Health Home they must dis-enroll from the waiver. Health
better serve consumers in their own homes and individuals to
reduce demand for more costly residential determine whether the waiver or Health Homes can best meet their needs.

Recipient is in a HCBS IBS to better serve

consumers in their own homes and reduce
At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish
demand for more costly residential placement.
to receive care management through a Health Home they must dis-enroll from the waiver. Health
individuals to
determine whether the waiver or Health Homes can best meet their needs.

Identifies a recipient in home & community

based services waiver program (HCBS).

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OPWDD HCBS Community Habilitation Phase 2

Identifies a recipient in home & community

based services waiver supervised CR or

At this time OPWDD waiver participants cannot be in a Health Home and the waiver. If waiver participants wish
to receive care management through a Health Home they must dis-enroll from the waiver. Health
individuals to
Identifies a recipient in home & community determine whether the waiver or Health Homes can best meet their needs.
based services waiver supportive IRA & CR.

Identifies a recipient in home & community

based services waiver supervised IRA & CR.

Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care
manager should work with the recipient and contact their Managed Care Plan to ensure compliance
receiving pharmacy services from the primary

Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care
manager should work with the recipient and contact their Managed Care Plan to ensure compliance
provider. Non-emergent transportation must be
ordered by a primary provider only. Ancillary
services (pharmacy, DME & lab) must be
ordered by primary or referred provider.

Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care
manager should work with the recipient and contact their Managed Care Plan to ensure compliance

receive care or be referred for care. Ancillary

services (pharmacy, DME & lab) must be

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Individuals can be in a Managed Care Coordinator Program (MCCP) and enrolled in Health Home, but the care
manager should work with the recipient and contact their Managed Care Plan to ensure compliance
to a primary inpatient provider where s/he must

Recipient enrolled in Nursing Home Transition &

Care at Home (CAH) I (Administered by DOH)

community-based services to physically disabled

home level of care, and allows the child to be at

Children that received services through this previous waiver have been transitioned to the new Children's
Care at Home (CAH) II (Administered by DOH)

community-based services to physically disabled

home level of care, and allows the child to be at

Care at Home (CAH) III (OPWDD)

Children that received services through this previous waiver have been transitioned to the new Children's
community-based services to physically disabled

home level of care, and allows the child to be at

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The Medicaid-waiver CAH IV program provides Children that received services through this previous waiver have been transitioned to the new Children's
community-based services to physically disabled

home level of care, and allows the child to be at

Care at Home (CAH) VI (OPWDD)

The Medicaid-waiver CAH IV program provides Children that received services through this previous waiver have been transitioned to the new Children's
community-based services to physically disabled

home level of care, and allows the child to be at

Bridges to Health (B2H) Seriously Emotionally

Bridges to Health (B2H) Waiver services are

tailored to meet the child's specific, presenting

Bridges to Health (B2H) Developmentally

Children that received services through this previous waiver have been transitioned to the new Children's
Bridges to Health (B2H) Waiver services are
tailored to meet the child's specific, presenting

Bridges to Health (B2H) Medically Fragile

Bridges to Health (B2H) Waiver services are

tailored to meet the child's specific, presenting

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Recipients are those who receive resource

exemptions in the amount of LTC insurance
benefit dollars paid to date. The amount
determines the amount of resources

Recipients are those who have complete

disregard of resources in Medicaid Budget Logic

Recipients have LTC insurance but not through

HCBS/TBI waiver services include: service

coordination, independent living skills training
and development (ILST), structured day program

positive behavioral interventions and support

services (PBIS), community integration
counseling (CIC), home and community support
services (HCSS), environmental modifications

transitional services (CTS).

This code returns an eligible message

"Restricted recipient contact MC plan for

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Recipient has been mandated to receive ASA The care manager should coordinate services within existing Fee-For-Services and Managed Care Plan
services FFS in some instances. The recipient
may also be in PCP where the plan is responsible

Recipient is enrolled in an outpatient rehab

program for mentally ill adults (OMH).
Recipients are exempt from UT.

Recipient is enrolled in an outpatient rehab

program for mentally ill adults (OMH).
Recipients are exempt from UT.

Services (IR/OR)

Recipient is enrolled in an outpatient rehab

program for mentally ill adults (OMH).
Recipients are exempt from UT.
Money Follows the Person

Recipient is excluded from mandated managed

care auto assignment of a plan

Recipient is exempt from managed care

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Recipient is exempt from managed care

Individuals can be in both a Health Home and a MLTC plan. The Health Home and MLTC plan must have
Recipients are marked who are required to an administrative services agreement outlining their respective responsibilities.
enroll in a managed LTC program

Recipient exempt from managed care

OPWDD Waivered Services Look-Alikes

Recipient exempt from managed care

Seriously & Persistently Mentally Ill Adults

Children receiving services through this waiver can either be enrolled in a Health Home or in the waiver,

Recipient exempt from managed care

Member is in outreach or enrolled with a Care

Health Home Program - Health Home

Member is in outreach or enrolled with a Health

System generated based on claims for assisted

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Medicare or Medicaid Hospice Elected HH/CMAs must work with Hospice provider/program to ensure delineation of care management services is
not duplicative.

Community First Choice Option OPWDD

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State-Identified for HARP Assessment

HARP Eligible- Pending Enrollment

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HCBS At Level of Care Acuity

HCBS at Level of Need Acuity

HCBS Serious Emotional Disturbance

HCBS Developmental Disability & in Foster Care

HCBS Developmentally Disabled & Medically

Child in Care of a Voluntary Foster Care Agency

Child is in or Associated with Foster Care

Child is Eligible for Medicaid as Family of One

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF
members out when notified of referral.
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These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

SNF Ventilator Dependent - MC Enrollee These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

NH Resident Pending NH Eligibility

These members are not eligible for enrollment or continued enrollment in the Health Home Program
while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition
Permanently placed in SNF

Care Managers must work with the Nursing Home to identify if the member is permanently placed. If
the member becomes permanently place the member should be disenrolled from the Health Home
System generated based on claims for nursing Program. If a member is transitioning from the NH to the community the Care Manager should work

Care manager can only work with member in the month this code is ended.

Care manage can only work with member in the month this code is ended.

Surplus Client Not Eligible for Medicaid MC or

Care manager should work with the individual to maintain their Medicaid eligibility.

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NYC Enhanced Shelter Allowance

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OPWDD Waivered Services Look-Alikes
Recipient exempt from managed care The Health Home Compatibility Changed from No to Yes with stipulations. Please see above.

Health Home Program - Health Home

System generated based on claims for assisted

System generated based on claims for nursing

Deleted as more specific codes were added. Please see G1 and G2.

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OMH Children's Waiver
This code is used to identify recipients in the
OMH Home & Community Based Services Changed policy notes to delete " (once Health Homes have been designated to serve children)"
(HCBS) waiver for seriously emotionally

Case Management Program; Medicaid Service

Changed policy notes to account for adults completion of transition and children transitioning into Health Homes.

Care at Home (CAH) I (Administered by DOH)

community-based services to physically disabled Changed policy notes to delete " (once Health Homes have been designated to serve children)"

home level of care, and allows the child to be at

Care at Home (CAH) II (Administered by DOH)

community-based services to physically disabled Changed policy notes to delete " (once Health Homes have been designated to serve children)"

home level of care, and allows the child to be at

Care at Home (CAH) III (OPWDD)

community-based services to physically disabled Changed policy notes to delete " (once Health Homes have been designated to serve children)"

home level of care, and allows the child to be at

The Medicaid-waiver CAH IV program provides

community-based services to physically disabled Changed policy notes to delete " (once Health Homes have been designated to serve children)"

home level of care, and allows the child to be at

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Care at Home (CAH) VI (OPWDD)

The Medicaid-waiver CAH IV program provides

community-based services to physically disabled
Changed policy notes to delete " (once Health Homes have been designated to serve children)"

home level of care, and allows the child to be at

Bridges to Health (B2H) Seriously Emotionally

Bridges to Health (B2H) Waiver services are

Changed policy notes to delete " (once Health Homes have been designated to serve children)"
tailored to meet the child's specific, presenting

Bridges to Health (B2H) Waiver services are

Changed policy notes to delete " (once Health Homes have been designated to serve children)"
tailored to meet the child's specific, presenting

Bridges to Health (B2H) Medically Fragile

Bridges to Health (B2H) Waiver services are

Changed policy notes to delete " (once Health Homes have been designated to serve children)"
tailored to meet the child's specific, presenting

Recipient is exempt from managed care

Community First Choice Option OPWDD

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NH Resident Pending NH Eligibility

2/21/2017

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OPWDD Waivered Services Look-Alikes DELETED: To find a Developmental Disability Regional Office copy and paste the following link in your web browser:

ADDED: new instructions for inquiries.

Updated

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Incorrectly labeled with OPWDD

Community First Choice Option OPWDD

Incorrectly labeled without OPWDD

NYC Enhanced Shelter Allowance

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Compatibility Changed from No to Yes

Community First Choice Option OPWDD

Compatibility Changed from No to Yes

4/23/2018

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Case Management Program; Medicaid Service

Changed description to add "OPWDD care management have transitioned into Health Homes." and "First Time Mothers/Newborns (NFP

Health Home Program - Health Home

7/11/18

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 CHANGE LOG

Changed Description from "Tentative date of release is July 2018" to "Released 7/16/18".

Health Home Program - Health Home

Changed Description from "Tentative date of release is July 2018" to "Released 7/16/18".

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OMH Children's Waiver
This code is used to identify recipients in the
OMH Home & Community Based Services Changed Compatibility with the Health Home Program and Description

Care at Home (CAH) I (Administered by DOH)

community-based services to physically disabled Changed Compatibility with the Health Home Program and Description

home level of care, and allows the child to be at

Care at Home (CAH) II (Administered by DOH)

community-based services to physically disabled

Changed Compatibility with the Health Home Program and Description

home level of care, and allows the child to be at

Care at Home (CAH) III (OPWDD)

community-based services to physically disabled Changed Compatibility with the Health Home Program and Description

home level of care, and allows the child to be at

The Medicaid-waiver CAH IV program provides

community-based services to physically disabled Changed Compatibility with the Health Home Program and Description

home level of care, and allows the child to be at

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The Medicaid-waiver CAH IV program provides

community-based services to physically disabled Changed Compatibility with the Health Home Program and Description

home level of care, and allows the child to be at

Bridges to Health (B2H) Seriously Emotionally

Bridges to Health (B2H) Waiver services are

Changed Compatibility with the Health Home Program and Description
tailored to meet the child's specific, presenting

Bridges to Health (B2H) Developmentally

Bridges to Health (B2H) Waiver services are

Changed Compatibility with the Health Home Program and Description
tailored to meet the child's specific, presenting

Bridges to Health (B2H) Medically Fragile

Bridges to Health (B2H) Waiver services are

Changed Compatibility with the Health Home Program and Description
tailored to meet the child's specific, presenting

HCBS At Level of Care Acuity

HCBS at Level of Need Acuity

HCBS Serious Emotional Disturbance

HCBS Developmentally Disabled

HCBS Developmentally Disabled & Medically

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Child in Care of a Voluntary Foster Care Agency

Child is in or Associated with Foster Care

Child is Eligible for Medicaid as Family of One

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OMH Children's Waiver
This code is used to identify recipients in the
OMH Home & Community Based Services
(HCBS) waiver for seriously emotionally
Changed "March 30, 2019" to "at a later date"

Care at Home (CAH) I (Administered by DOH)

community-based services to physically disabled

home level of care, and allows the child to be at

Changed "March 30, 2019" to "at a later date"

Care at Home (CAH) II (Administered by DOH)

community-based services to physically disabled

home level of care, and allows the child to be at

Changed "March 30, 2019" to "at a later date"

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Care at Home (CAH) III (OPWDD)

community-based services to physically disabled

home level of care, and allows the child to be at

Changed "March 30, 2019" to "at a later date"

The Medicaid-waiver CAH IV program provides

community-based services to physically disabled

home level of care, and allows the child to be at

Changed "March 30, 2019" to "at a later date"

Care at Home (CAH) VI (OPWDD)

The Medicaid-waiver CAH IV program provides

community-based services to physically disabled

home level of care, and allows the child to be at

Changed "March 30, 2019" to "at a later date"
Bridges to Health (B2H) Seriously Emotionally

Bridges to Health (B2H) Waiver services are

tailored to meet the child's specific, presenting

Changed "March 30, 2019" to "at a later date"

Bridges to Health (B2H) Waiver services are

tailored to meet the child's specific, presenting

Changed "March 30, 2019" to "at a later date"

Bridges to Health (B2H) Medically Fragile

Bridges to Health (B2H) Waiver services are

tailored to meet the child's specific, presenting

Changed "March 30, 2019" to "at a later date"

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OMH Children's Waiver Changed compatibility from "Yes" to "No" and description from "Children receiving services through this waiver will be transitioning to
This code is used to identify recipients in the Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is
OMH Home & Community Based Services expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
(HCBS) waiver for seriously emotionally Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Care at Home (CAH) I (Administered by DOH)

Changed compatibility from "Yes" to "No" and description from "Children receiving services through this waiver will be transitioning to
community-based services to physically disabled Health Home Care Management or Care Management through an Independent Entity January 2019 -March 2019. This RRE Code is
expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
home level of care, and allows the child to be at Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Care at Home (CAH) II (Administered by DOH)

Changed compatibility from "Yes" to "No" and description from "Children receiving services through this waiver will be transitioning to
community-based services to physically disabled Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is
expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
home level of care, and allows the child to be at Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Care at Home (CAH) III (OPWDD)

Changed compatibility from "Yes" to "No" and description from "Children receiving services through this waiver will be transitioning to
community-based services to physically disabled Health Home Care Management or Care Management through an Independent Entity January 2019 -March 2019. This RRE Code is
expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
home level of care, and allows the child to be at Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

The Medicaid-waiver CAH IV program provides Changed compatibility from "Yes" to "No" and description from "Children receiving services through this waiver will be transitioning to
community-based services to physically disabled Health Home Care Management or Care Management through an Independent Entity January 2019 -March 2019. This RRE Code is
expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
home level of care, and allows the child to be at Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

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Care at Home (CAH) VI (OPWDD)

The Medicaid-waiver CAH IV program provides Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to
community-based services to physically disabled Health Home Care Management or Care Management through an Independent Entity January 2019 -March 2019. This RRE Code is
expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
home level of care, and allows the child to be at Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Bridges to Health (B2H) Seriously Emotionally

Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to
Bridges to Health (B2H) Waiver services are
Health Home Care Management or Care Management through an Independent Entity January 2019 -March 2019. This RRE Code is
tailored to meet the child's specific, presenting
expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to
Bridges to Health (B2H) Waiver services are
Health Home Care Management or Care Management through an Independent Entity January 2019-March 2019. This RRE Code is
tailored to meet the child's specific, presenting expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Bridges to Health (B2H) Medically Fragile

Changed compatibility from "Yes" to "No" and description from"Children receiving services through this waiver will be transitioning to
Bridges to Health (B2H) Waiver services are Health Home Care Management or Care Management through an Independent Entity January 2019 -March 2019. This RRE Code is
tailored to meet the child's specific, presenting expected to end at a future date." To: "Children that received services through this previous waiver have been transitioned to the new
Children's Waiver with Health Home Care Management or Care Management through an Independent Entity. The use of this RRE Code

Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF
Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF
Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Ho me
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF
Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF

SNF Ventilator Dependent - MC Enrollee Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF notified of referral."

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Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF
Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF notified of referral."
Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF notified of referral."
NH Resident Pending NH Eligibility Added "Permanently placed in SNF" and "These members are not eligible for enrollment or continued enrollment in the Health Home
Program while in the Skilled Nursing Facility. Care Managers should work with the Nursing Facility to transition members out when
Permanently placed in SNF notified of referral."
Added "These members are not eligible for enrollment or continued enrollment in the Health Home Program while in the Skilled Nursing
System generated based on claims for nursing Facility. Care Managers should work with the Nursing Facility to transition members out when notified of referral."

Changed DD, HCBS Developmentally to DDFC, HCBS Developmentally Disability & in Foster on February 17.
HCBS Developmentally Disabled

2/17/2021

CHANGE LOG
Code 95 remains compatible with Health Home services. However, the Policy Notes regarding the steps Health Home Care Managers must take
OPWDD Waivered Services Look-Alikes
are outdated and no longer apply, and have been removed:

Recipient exempt from managed care Care Managers must check with OPWDD to ensure an individual is not receiving Care Management from OPWDD before they can be
outreached or enrolled in the Health Home Program. The following
Step 1 - Enter Member's Name, Date of Birth, and CIN number in an excel file.

Step 3 - Send excel file with subject line "RRE Code 95 Check" to OPWDD's BML at:

Updated
4/1/2022

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Medicare or Medicaid Hospice Elected

Added

Updated
4/29/2022

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