Eligibility Questionnaire

Enrollment in a Health Home requires that the patient meet certain eligibility criteria, such as being Medicaid-eligible and experiencing a qualifying diagnosis.

Please fill out the below questionnaire to the best of your ability for the patient in your care. If the individual is eligible for CCF assistance, you will be prompted to fill out and submit a referral application form.

Basic Eligibility:

Does the child/youth currently have active Medicaid coverage?

Yes

Eligibility Type: (If ICD10 code available, please provide)

Two or More Chronic Conditions. (click here to see approved conditions)
List Conditions:

+ Add condition

ONE of the following single qualifying conditions:

Serious Emotional Disturbance (SED) (click here to read Health Home Definition of SED)

List condition:

Complex trauma (click here to Definition and Forms)

HIV / AIDS

Does the patient reside in New York City, on Long Island or in Westchester County?

Yes

Apropriateness Criteria (Check all that apply for patient)

At risk for adverse event (death, disability, inpatient or nursing home admission, mandated preventive services, or out of home placement)

Has inadequate social/family/housing support or serious disruptions in family relationships

Has inadequate connectivity with healthcare system

Does not adhere to treatments or has difficulty managing medications

Has recently been released from incarceration, placement, detention, or psychiatric hospitalization

Has deficits in activities of daily living, learning or cognition issues

Is concurrently eligible or enrolled, along with either their child or caregiver, in a Health Home

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