General

Memorandum

To: Care Coordination Organizations

CEOs of Voluntary Provider Agencies

Developmental Disabilities State Operations Offices (DDSOO) Directors

Developmental Disabilities Regional Offices (DDRO) Directors

Provider Associations

Willowbrook Consumer Advisory Board

From: Allison McCarthy, Director of Office of Strategic Initiatives

Date: February 6, 2023

Subject: Care Coordination Organization/Health Home (CCO/HH) Consent Form Changes

The purpose of this Memorandum is to streamline and clarify the use of CCO/HH consent

forms developed by New York State Department of Health (NYSDOH) and to outline

associated policy revisions, effective the date of this memorandum. The CCO/HH Provider

Policy Guidance and Manual (Version 2018-1) will be updated to reflect these changes. Until

such time please refer to Appendix A to see detailed information on CCO Policy Manual

updates.

It is the responsibility of CCOs to update their Internal Policies and Procedures to align with the

following updates by 8/6/2023.

CCO/Care Manager Responsibilities

Prior to enrollment into a CCO/HH, a person and/or their family member/representative are

required to review and sign consent forms developed by NYSDOH. The CCO/HHs are

responsible for securing completed consent forms for all CCO/HH enrollees including assisting

all parties with understanding and completing the required forms. Care Managers are also

responsible for facilitating any revisions to the required consent forms as needed to ensure

that all providers or supports for which information is shared are included and up to date.

The purpose of the consent forms is to improve the coordination of supports and services by

allowing information sharing among service providers identified by the person and/or their

parent, guardian, or legally authorized representative. At a minimum, the person’s Care

Management Agency, Medicaid Managed Care Plans (MMCP) (when applicable), Home and

Community Based Services (HCBS) providers, as well as the primary care physician and/or

health care provider the person utilizes the most (i.e., mental health provider) must be listed on

the consents.

Consent Form Changes

The most up to date forms are summarized in the chart below and can be found on the Health

Home Serving Children (HHSC) (ny.gov) website. Further information on how these changes

impact current OPWDD policy and additional requirements will be listed in the sections

following this summary chart.

Please note, the chart below captures only those DOH HH forms used by the CCOs that have

been changed or eliminated.

Update

Form

Number

Form Title

Used For:

Eliminated

(combined into

the 5201)

DOH-5200

Health Home Consent

Enrollment for Use with

Children and Adolescents

Under 18 Years of Age

Children/Adolescents under age 18 who

are

not

a parent, pregnant and/or married

and cannot self

-consent and need a

parent, guardian

, or legally authorized

representative to consent.

Revised

DOH-5201

Health Home Consent

Enrollment and Information

Sharing

or Use with Children

and Adolescents Under 18

Years of Age

Eliminated

DOH-5202

Health Home Withdrawal of

Health Home Consent Form

or Use with Children and

Adolescents Under 18 years

of Age

Added

N/A

Health Home Care

Management Tracking Form

for Section 2 of 5201

For internal use by Health Home Care

anagement Agency/Care Manager

only

when section 2 of the 5201

cannot be

completed due to the reason listed on the

5201-consent form.

Eliminated

DOH-5059

Health Home Opt-Out

Adults and Children/Adolescents

Eliminated

DOH-5058

Health Home Patient

Information Sharing

Withdrawal of Consent

• Adults

•

Children/Adolescents 18 years of age

or older

•

Children/Adolescents under age 18

who are a parent, pregnant or

married and able to self-consent.

Revised

FAQ

Health Home Consent

Frequently Asked Questions

for Use with Children and

Adolescents Under 18 Years

of Age

Care Manager conversation with enrollee

prior to completion of the 5201

APPENDIX A

Policy Manual Updates

For clarity, outlined below are the specific sections of the 2018 CCO/HH Provider Policy

Guidance and Manual that are amended as a result of the above consent form changes.

Revisions and additions are denoted by underline.

1. Section 6.4: Enrollment and Information Sharing for Use with Children Under 18

Years of Age: 5200, 5200 FAQ, and Care Manager Tracker form for Section 2

Policy updates:

There are two (2) consent forms that Care Managers must review with enrollees under

18 years of age:

• Frequently Asked Questions (FAQ) For Use with Children Under 18 Years

of Age

o Care Managers must review with enrollee prior to completion of the 5201.

• DOH 5201 - Enrollment and Information Sharing for Use with Children

Under 18 Years of Age

o Section two (2) of the DOH 5201 form should be left blank if the child is

unable to complete or is otherwise not capable of understanding the

information presented in this section; the child does not identify any

protected services; the child does not identify any mental health or

developmental disabilities services; OR, permission is denied by the

child’s Parent/Guardian/Legally Authorized Representative to have the CM

meet alone with the child for review of Section 2. If any of these reasons

apply, the Care Manager must clearly document the reason(s) in the

child’s record and complete the Health Home Care Management Tracker

for Section 2 and continue with attempts to obtain this information at a

later date to assist the child with coordinating these services. This tracking

form was developed as an internal tool for Care Managers to use to

document ongoing attempts when Section 2 Parts A and B cannot be

completed due to the reason(s) identified in the policy above and on the

consent form.

Note: The use of the DOH-5200 titled Enrollment for Use with Children under 18 Years

of Age has been eliminated effective 2/6/2023.

For current enrollees, the revised consent form and tracker must be used at a

minimum:

• By the next annual Life Plan review or within 12 months of implementation:

2/6/2024; or,

• When any changes to consent information occurs (e.g., child moves from DOH

5201 to DOH 5055; to add/remove provider or other entities; a change in

signatories, etc.)

Additional information and guidance on completing these Health Home Consent Forms

can be found on the Health Home Serving Children (HHSC) (ny.gov) website. At this

location, information can be found under Health Home Serving Children Consent

Guidance Documents and Supportive Information including a document titled, Health

Homes Serving Children Consent Document Guidance .

Acceptable Practices for Obtaining Consent Form Signatures

The CCO should follow the consent enrollment process as outlined in the 14 NYCRR

635-11.8 entitled CCO enrollment and review for persons residing in a residential facility

operated or certified by OPWDD or a family care home or 635-11.9 entitled CCO

enrollment and review for persons not residing in a residential facility or a family care

home.

In addition to signing consent via wet signature (ink on paper) the practice of obtaining a

person and/or their family/representative’s signature via electronic means is acceptable

as long as Health Homes and Care Management Agencies are in compliance with all

applicable New York State and Federal laws.

Consent forms may be provided to and received back from the person and/or their

family member/representative, completed and signed either in person, via regular mail,

through email/scan or fax, or through other secured electronic means.

Refer to the following links:

• Electronic Signatures and Records Act (ESRA) | New York State Office of

Information Technology Services (ny.gov)

• 15 U.S. Code Subchapter I - ELECTRONIC RECORDS AND SIGNATURES IN

COMMERCE | U.S. Code | US Law | LII / Legal Information Institute (cornell.edu)

2. Section 6.8 CCO/HH Enrollee Disenrollment/Opt-out Withdrawal of Consent for

Adults and Children under 18 Years of Age

Consent to be enrolled in a CCO/HH and to allow the CCO access to a person’s

personal health information (PHI) as indicated on the DOH-5055/DOH-5201, may be

revoked at the person and/or their family member/representative’s request. It is

important that Adults and Children under 18 who want to disenroll from the CCO/HH

program be fully informed of the consent process.

It is the CCO/HH Care Manager’s responsibility to ensure that the person and/or their

family/representative understand the information, can ask questions, and are issued a

written notification on agency letterhead that includes:

• a clear description of the reason for disenrollment;

• the agreed upon date of disenrollment and end of PHI and other information

sharing;

• how to obtain copies of disenrollment documentation; and,

• how to re-enroll in a CCO at a later time, if desired.

The notification letter may be provided to the person directly, via mail, or through

another method specifically requested by the person. A copy of this notice should be

kept in the person’s Care Management Record and uploaded to CHOICES.

If the DOH-5203 was completed and signed providing consent for release of

educational records for children and adolescents, the DOH-5204 must be signed to

withdraw this consent. It is the CCO/HHs responsibility to notify the person’s care

planning team and the State of a person’s choice to withdraw and, if applicable, when a

person’s participation in OPWDD’s HCBS waiver program should be reviewed for

termination.

Note: The use of the DOH-5202 titled Health Home Withdrawal of Health Home

Consent Form For Use with Children and Adolescents Under 18 years of Age and the

DOH-5058 titled Health Home Patient Information Sharing Withdrawal of Consent has

been eliminated effective: 2/6/2023.

Opt-Out

Also, effective 2/6/2023, the DOH-5059-Opt out form is no longer required. When a

person wants to receive HCBS services and declines CCO/HH enrollment, the CCO/HH

must educate them on the Basic HCBS Plan Support services. A person must be

enrolled in a Care Management service in order to receive OPWDD HCBS services.

Section 6.9: Changing CCO/HHs

The current CCO/HH must issue the person and/or their family member/representative

written notification on agency letterhead that includes:

• a clear description of the reason for disenrollment and the date of disenrollment

(last day of the month that transfer occurs);

• the date all sharing of PHI and other information will cease;

o Information sharing should end the last day of the month prior to

enrollment in the new CCO.

• how to obtain copies of disenrollment documentation; and,

• how to re-enroll in a CCO at a later time, if desired.

The notification letter may be provided to the person directly, via mail, or through

another method specifically requested by the person. A copy of this notice should be

kept in the person’s Care Management Record and uploaded to CHOICES.

If the DOH-5203 was completed and signed providing consent for release of

educational records for children and adolescents, the DOH-5204 must be signed to

withdraw this consent.

The new CCO/HH must obtain a Consent to Enroll Form (DOH-5055 or DOH-5201).