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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
New York Regional Office
26 Federal Plaza, Room 37-100
New York, NY 10278
DIVISION OF MEDICAID AND CHILDREN’S HEALTH OPERATION
DMCHO: MV NY SPA 16-0034 Approval
December 22, 2016
Jason A. Helgerson
State Medicaid Director
Deputy Commissioner
Office of Health Insurance Programs
NYS Department of Health
Corning Tower (OCP-1211)
Albany, New York 12237
RE: NY SPA #16-0034
Dear Mr. Helgerson:
The Centers for Medicare & Medicaid Services (CMS) has completed its review of New York
State Plan Amendment (SPA) Transmittal Number 16-0034 which supersedes NY SPA 15-0020.
Effective September 1, 2016, this amendment proposes to continue to reimburse converted
Targeted Case Management (TCM) providers at the existing Health Home Legacy rate from
September 1, 2016 to November 30, 2016.
Enclosed are copies of the approved pages for incorporation into the New York State plan.
Please share with your staff my appreciation for their time and effort throughout this process. If
you have any questions regarding this State Plan Amendment, please contact Maria Varon of this
office. Ms. Varon may be reached at (212) 616-2503.
Sincerely,
Michael Melendez, LMSW
Associate Regional Administrator
Division of Medicaid and Children’s Health Operations
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16
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Attachment 3.1-H
TN# 16-0034 Supersedes TN # 15-0020
Approval Date: 12/22/16 Effective Date: 09/01/16