Children's Aligned HCBS LOC Eligibility Determination

  • Webinar is also available in Portable Document Format (PDF)

REVIEWING

Home and Community Based Services (HCBS) Level of Care (LOC) Eligibility Determination

April 23, 2019

Agenda

  • Purpose of Webinar
  • New 1915c Children´s Waiver
  • HCBS/LOC Eligibility Purpose
  • Pathways to HCBS
  • HCBS/LOC Eligibility Determination
    • SED
    • Medically Fragile
    • Developmentally Disabled and Medically Fragile or in Foster Care
  • Capacity Management
  • Documentation / Forms

Today´s Purpose

The New Children´s Waiver began Monday, April 1, 2019, and the new HCBS/LOC Eligibility Determination available within the Uniform Assessment System (UAS).

The purpose of today´s webinar is a re–training of the new HCBS/LOC Eligibility Determination process to ensure providers are correctly completing the process with the proper documentation so that children/youth receive HCBS accordingly.

Reason for restricting down the HCBS/LOC Eligibility Determination within the UAS in the first week of April:

  • A number of HCBS/LOC Eligibility Determination were completed incorrectly
    • These will be removed from the system
  • Providers requested additional guidance to complete HCBS/LOC Determination
  • The Target Population of Developmental Disability and Medically Fragile has a programmed error
  • The required forms needed to properly determination HCBS, work with the family and notify the family were not completed

HCBS/LOC Determination

To align with the purpose of the New Children´s Waiver, the HCBS/LOC Eligibility Determination allows:

  • ➣ For expanded number of providers to be able to conduct HCBS eligibility
  • ➣ Easier access for children and families to access HCBS eligibility – no wrong door
  • ➣ Children who are found HCBS eligible, have access to the full array of HCBS

The HCBS Children´s Waiver is for children and youth with Medicaid who have highest needs, therefore it is incumbent upon the HHCM/C–YES to ensure that the HCBS/LOC Determination process is completed as outlined with proper supporting documentation.


New Children´s Waiver


1915c Children´s Waiver Began April 1, 2019

The following six 1915c Home and Community Based Services (HCBS) Waivers´ are consolidate into the new consolidated 1915c Children´s Waiver

  • OMH SED HCBS 1915(c) waiver
  • DOH Care at Home (CAH) I/II 1915(c) waiver
  • OPWDD Care at Home (CAH) 1915(c) waiver
  • OCFS Bridges to Health (B2H) SED 1915(c) waiver
  • OCFS B2H Medically Fragile (Med Frag) 1915(c) waiver
  • OCFS B2H DD 1915(c) waiver

New 1915c Children´s Waiver Design

On April 1, 2019, the new consolidated 1915c Children´s Waiver gave authority to provide Home and Community Based Services (HCBS) to all children who meet HCBS Level of Care determination under one wavier

  • One set of service descriptions and rates for all eligible children
  • Consistent Health Home Care Management services
  • One State Medicaid agency with partner agency team to support delivery, monitoring and oversight
  • Expanded array of services for all HCBS children
  • One process for services to families and children

Connecting Children and Families to Services

The new 1915c Children´s Waiver design outlines that the care management/coordination for HCBS will be Health Home comprehensive care management unless the child/family opts–out to C–YES´ for HCBS only case management.

  • Children who are eligible for HCBS are eligible for Health Home without Health Home eligibility and appropriateness needing to be determined.
  • Children who are Health Home eligible are NOT automatically eligible for HCBS
  • Children who are no longer eligible for HCBS will also lose HH care management unless they are found Health Home eligible and appropriate.

When a child is HCBS eligible, they are eligible for the ENTIRE HCBS array beginning April 1, 2019; however, the child should only utilize services needed to remain in the community or achieve their personal goals.


HCBS Eligibility Determination Criteria

Effective April 1, 2019, the State has implemented new HCBS Level of Care (LOC) Eligibility Determination criteria

  • The LOC HCBS Eligibility Determination criteria replaces criteria and tools used under the six 1915(c) waivers
  • HCBS purpose:
    1. Enable children to remain at home, and/or in the community, thus decreasing institutional placement
    2. To safely return a child from a higher level of care, back to the community with services to maintain them at home and/or in the community
    3. Expand service options currently available to children and adolescents for better outcomes

Please note: Not all children on Medicaid nor in Health Home will need HCBS


Transitioning Waiver Children and the New HCBS/LOC Determination Process

For any transitioning 1915c HCBS Waiver child, where the annual LOC recertification is due on or after April 1, 2019, the new HCBS/LOC Eligibility Determination will need to be completed.

  • If an annual LOC recertification is due for a transitioning child between April 1, 2019 – March 31, 2020, and the child does not meet the new HCBS/LOC criteria but is at risk for institutionalization (hospital/nursing home) in absence of the waiver, the Health Home care manager or C–YES will contact the waiver capacity manager team at capacitymanagement@health.ny.gov for a review of eligibility to determine if the child can stay on the waiver.
  • Additional documentation may be needed by the State from the HHCM/C–YES to determine if the child will remain eligible for the new Children´s waiver under old eligibility criteria for the first year. The HHCM/C–YES will only be contacted, and documentation will only be needed if the State notifies the HHCM/C–YES.

If the child is eligible under the eligibility criteria of the former Waiver, a Level of Care exception will be issued for one year.

The exception process will no longer exist after April 1, 2020.


Pathways to HCBS


HCBS eligibility through Level of Care (LOC)

Children/adolescents who are already enrolled in Medicaid who are believed to be HCBS eligible and or in need of HCBS will be referred to Health Homes. Those not enrolled in Medicaid will be referred to C–YES.

Health Home care managers or the C–YES will work with the child, family, and providers to determine HCBS eligibility.

HCBS is available to ALL children under the age of 21 that meet eligibility, there is no exclusion group.

The Uniform Assessment System (UAS) which houses the CANS–NY, will also house the HCBS.

Eligibility Determination for LOC

ONLY HHCM, C–YES assessors and DDROs can complete HCBS/LOC eligibility Determination.


Already Health Home Enrolled

For children who are already enrolled in Health Home care management with Medicaid, the HHCM should determine if the new HCBS array of available services would be beneficial for the child/youth.

  1. The HH CM should review the enrolled child/youth´s CANS–NY and comprehensive assessment compared to the services already being delivered.
  2. The HH CM should discuss with involved providers whether of services being delivered are meeting the child/youth´s needs.
  3. The HH CM should review the ´Children´s HCBS Planning and Plan of Care Development´ webinar to review suggested guidance regarding children who should be considered for HCBS eligibility.
  4. The HH CM should discuss the option with the family, if it is believed that HCBS would benefit the child/youth who is at risk of placement or for a child in placement to be able to return to their home/community from placement.
    • ➣ At any time the HH CM and multi–disciplinary team can determine that due to an increase in need for additional services and supports, HCBS Eligibility should be pursued.

Child/Youth with High Needs

HCBS Eligibility Determination should be pursued if a child/youth is considered to have high needs (e.g. recent increase in need or discharge from a higher level of care) in which HCBS intervention would assist:

  • Child/youth in a nursing home, hospital or residential placement with the potential to safely return home and to their community.
  • Child/youth who has difficulty remaining safely home and in their community – a number of hospital/inpatient occurrences.
  • Child/youth at risk of hospitalization, nursing home or residential placement due to complex medical or behavioral health needs and/or multi–system involved.

Please note these considerations when referring the child/youth to HH CM/C–YES. If the child/youth currently does not have Medicaid, then C–YES will assist with determining HCBS/LOC eligibility and gathering the necessary information to submit a Medicaid application packet.


New Health Home Referral

There may be times when a newly referred child/youth is identified to have significant needs during the HH enrollment and assessment (CANS–NY/Comprehensive Assessment) process that would indicate the need for HCBS.

  • Determine that the child/youth meet eligibility for HCBS and that other available services i.e. Children and Family Treatment and Support Services alone won´t address the needs.
    • Enable children to remain at home, and/or in the community, thus decreasing institutional placement.
    • To safely return a child from a higher level of care, back to the community with services to maintain them at home and/or in the community.
  • Discuss with the child/family the information obtained during the enrollment/assessment process regarding the need for HCBS, how HCBS would address the needs of the child/youth and the potential benefits.
  • The involved providers at a multi–disciplinary team meeting can review/discuss the need for HCBS due to an increase in need for additional services and supports.

Child/Family Choice for HCBS

As the HHCM/C–YES work with the family and involved providers to gather the information and documentation to conduct the HCBS/LOC Eligibility Determination – the HHCM/C–YES will discuss with the family (as outlined in previous slides) the identified strengths/needs and the potential services that may assist the family.

The HHCM/C–YES must discuss with the child/family their interest in pursuing HCBS/LOC Eligibility and Services – documentation of such interest must be noted in the case file.

The referral alone for HCBS does not preclude the HHCM from identifying other State Plan Services such as Children and Family Treatment and Support Services (CFTSS) or other Medicaid services prior to conducting the HCBS/LOC Determination.


Level of Care HCBS Eligibility
April 1, 2019


Foundation of the HCBS/LOC Determination

The HCBS/LOC Eligibility Determination (HCBS/LOC) is used as part of a collaborative process with the child and family to obtain the necessary information and documentation to determine HCBS eligibility.

The HCBS/LOC is a decision tree type instrument. One section must be completed with specific conditions met, before the assessor can move on to the next section of the tool.

Once assessors learn the HCBS/LOC tool and process, gathering all necessary information and documents upfront and going into the UAS at specific times will be more efficient instead of how it is outlined in this webinar.

    The HCBS/LOC Eligibility Determination criteria for LOC HCBS includes three (3) components applied in the following order:

  1. Target Population,
  2. Risk Factors, and,
  3. Functional Criteria

HCBS Eligibility – Target Population

Each Target Population has specific outlined diagnoses, conditions and or requirements that must be obtained and documented within the individual´s case record prior to being able to move forward with the HCBS Eligibility Determination.

LOC HCBS Eligibility Criteria Under Age 21 – Target Population Criteria
Serious Emotional Disturbance (SED)
Medically Fragile Children (MFC)
Developmental Disability (DD) and Medically Fragile (DDRO Only)
Developmental Disability (DD) and in Foster Care (DDRO Only)

HCBS/LOC Eligibility – Process

Children may be eligible for HCBS/LOC under one or more Target Populations.

The HHCM/C–YES must decide what Target Population to pursue based upon diagnosis and other information provided regarding the referred child.

Once the HHCM/C–Yes staff learn the different requirements for each Target Population, working with the family and other providers to gather all the necessary information for Target, Risk and Functional will assist with maneuvering within the UAS for the completion of HCBS/LOC Eligibility Determination.

Should the HHCM/C–YES believe that the child may be eligible through a different Target Population due to multiple conditions/diagnoses/complex needs of the child than another HCBS/LOC Eligibility Determination can be completed once the information and proper documentation is gathered for the specific Target Population.

If the child is found not to be HCBS/LOC eligible, then the child/family will need to receive only one Notice of Decision for the HCBS/LOC Eligibility Determination completed.


General Requirements

The HCBS Eligibility Determination must be completed face–to–face by the HHCM/C–YES with the child/family. For more information regarding HCBS requirements for independent assessment, see Section 1915(i)(1)(F) of the Social Security Act.

HCBS Eligibility Determination is an annual determination unless there is a significant life event. Regardless of the timeline of the CANS–NY completion for Health Home, the HCBS Eligibility Determination timeline will remain one year from the signing of the HCBS Eligibility Determination Outcomes within the UAS, unless a significant life event required another HCBS/LOC to be completed which resets the one–year eligibility clock.

Should the member, who was previously determined HCBS eligible, refuse HCBS and/or leave HCBS and later request service, a HCBS/LOC Eligibility re–determination will be needed if the last HCBS/LOC Eligibility Determination conducted was six (6) months ago or longer.

Should a child be determined not HCBS/LOC eligible, if there is a change in the child´s circumstances and/or condition, the child/family and/or providers can request another HCBS/LOC assessment to be conducted – there is no required waiting period.


HCBS/LOC Reassessment Reasons: Change of Circumstances

Through person–centered care planning and collaboration with providers, child, and family, if knowledge of the child´s change in circumstances as outlined below, a new HCBS/LOC Eligibility Determination is needed:

  • Significant change in child´s functioning (including increase or decrease of symptoms or new diagnosis)
  • Service plan or treatment goals were achieved
  • Child admitted, discharged or transferred from hospital/detox, residential setting/placement, or foster care
  • Child has been seriously injured in a serious accident or has a major medical event
  • Child´s (primary or identified) caregiver is different than on the previous HCBS/LOC
  • Significant change in caregiver´s capacity/situation

HCBS/LOC Documentation Requirements

The Health Home care manager and C–YES are responsible for obtaining documentation that verifies individuals meet the eligibility criteria, e.g., work with health care professionals to obtain documentation identifying eligible conditions.

HHCM/C–YES need to document in the members case file how the target population criteria, risk factors and functional criteria were verified.

A diagnosis alone is not sufficient as target population must be determined and documented by a licensed professional.

Provider and professionals may need assistance from HH CM/C–YES to outline what is needed for HCBS/LOC eligibility so they can be helpful to produce the appropriate documentation required.

There will be several forms needing to be completed and gathered by the HHCM/C–YES to support the HCBS/LOC eligibility process and document Target, Risk and Functional criteria.

For the annual HCBS/LOC Eligibility Determination, current/updated documentation is needed for the eligibility each time the HCBS/LOC is conducted – refer to the target populations for the specific information needed.

The HHCM/C–YES will ensure that the child´s case file is up to date with all documentation gathered and provided by professionals.

  • The role and function of the HHCM/C–YES is not to make determinations throughout the process but rather to collect information to verify Target Population, Risk and Functional criteria of the HCBS/LOC eligibility.

HCBS/LOC Determination
Serious Emotional Disturbance (SED)
Target Population


Target Population Selection within the UAS

Target Population Selection within the UAS

Level of Care HCBS SED Eligibility

To determine SED to meet the Target Population, then all three criteria below must be met:

  1. Age 0 through child´s 21st Birthday, and,
  2. Child has Serious Emotional Disturbance: Serious emotional disturbance (SED) means a child or adolescent has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM)
    • Schizophrenia Spectrum and Other Psychotic Disorders
    • Bipolar and Related Disorders
    • Depressive Disorders
    • Anxiety Disorders
    • Obsessive–Compulsive and Related Disorders
    • Trauma – and Stressor – Related Disorders
    • Feed and Eating Disorders
    • Disruptive, Impulse–Control and Conduct Disorders
    • Personality Disorders
    • Paraphilic Disorders
    • Gender Dysphoria
    • Elimination Disorders
    • Sleep–Wake Disorders
    • Sexual Dysfunctions
    • Medication–Induced Movement Disorders
    • Attention Deficit/Hyperactivity Disorder
    • Tic Disorder
AND
  1. Has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis, as determined by a licensed mental health professional.

The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas.

Ability to care for self (e.g., personal hygiene; obtaining and eating food; dressing; avoiding injuries); or

  • Family life (e.g., capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or
  • Social relationships (e.g. establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or
  • Self–direction/self–control (e.g., ability to sustain focused attention for a long enough period of time to permit completion of age–appropriate tasks; behavioral self–control; appropriate judgment and value systems; decision–making ability); or
  • Ability to learn (e.g., school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

SED Documentation

  • The HHCM/C–YES are responsible for requesting and acquiring documentation from a Licensed Mental Health Practitioner in which the practitioner attests to diagnosis and functional impairment. This may be indicated through assessments such as: Psychiatric Evaluation, Psychological Assessment or Psychosocial Assessment.
  • If the documentation does not explicitly articulate the SED criteria, then HHCM/C–YES are responsible to inform the Licensed Practitioner of the eligibility criteria and request documentation of the needed information.
  • The role and function of the HHCM/C–YES is not to determine if a child is SED but rather to collect information to verify HCBS/LOC eligibility.
    • ➣ To conduct the annual HCBS/LOC reassessment, it has to be determined that the child/youth continues to have functional deficits to meet SED.
    • ➣ The SED criteria is the same for Health Home only eligibility.

HCBS/LOC Determination
Serious Emotional Disturbance (SED)
Risk Factors


HCBS/LOC Eligibility – SED Risk Factors

Once the Target Population information has been obtained and documented, the Risk Factors must be noted with supporting documentation obtained.

SED Risk Factors have two factors to establish

  1. For the SED Target Population, there is a list of risk factor questions/criteria specific to this Target Population – outlined on the next slide
AND
  1. A Licensed Practitioner of Healing Arts (LPHA) who has the ability to diagnose within his or her scope of practice under state law has determined in writing that the child, in the absence of HCBS, is at risk of treatment in a more restrictive setting. The LPHA has submitted written clinical documentation to support the determination.

Risk Criteria – SED Risk Factor Requirement

It is the responsibility of the HHCM/C–YES to obtain the documentation that supports the chosen risk factor below, through placement/hospital records and/or provider information.

The child meets one of the factors 1–4
  1. The child is currently in an out–of–home placement, including psychiatric hospital, or
  2. The child has been in an out–of–home placement, including psychiatric hospital within the past six months, or
  3. The child has applied for an out–of–home placement, including placement in psychiatric hospital within the past six months, or
  4. The child currently is multi–system involved (i.e., two or more systems) and needs complex services/supports to remain successful in the community.

Out–of–home placement in LOC Risk Factor #1–4 includes: RRSY, RTF, RTC, or other congregate care setting such as SUD residential treatment facilities, group residences, institutions in the OCFS system or hospitalization. Multi–system involved means two or more child systems including: child welfare, juvenile justice, OASAS clinics or residential treatment facilities or institutions, OMH clinics or residential facilities or institutions, OPWDD services or residential facilities or institutions, or having an established IEP through the school district.


LPHA Attestation – SED Risk Factor Required

To capture the Licensed Practitioner of Healing Arts (LPHA) determination and LPHA Attestation form (DOH 5275) must be completed:

  • A NYS developed form will be utilized as the documentation from the LPHA, to be placed in the case record.
  • Within the UAS the LPHA Attestation signature date is required to ensure it was obtained within the proper annual redetermination timeframe.

It is the responsibility of the HHCM/C–YES to provide the LPHA with the attestation form and the required documentation for review by the LPHA to determine the completion of the LPHA Attestation form for the selected SED Target Population.


HCBS/LOC Determination
Serious Emotional Disturbance (SED)
Functional Criteria.


HCBS/LOC Eligibility – SED Functional Criteria

Once the Target Population and Risk Factors information has been obtained and documented, then the Functional Criteria must be established to finalize the HCBS/LOC Eligibility Determination.

SED Level of Care (LOC) Functional Criteria:
  • Functional criteria is a subset of questions from the CANS–NY tool completed by the HHCM/C–YES.

It is the responsibility of the HHCM/C–YES to obtain the documentation that supports the answers to the subset of the CANS–NY to meet the HCBS/LOC Functional Criteria.

  • If a full valid CANS–NY has already been competed for the child, then the HHCM can save time by linking to an existing CANS–NY (as outlined in the appendix) or just complete the subset of the questions within the HCBS/LOC tool.

SED Functional Criteria 0–5

SED Functional Criteria 0–5
Relationship to child
14. Decision–Making, 15. Parenting Stress, 24. Care/Treatment Involvement
Child Strengths
30. Social Relationships, 31. Relationship Stability
Child Needs and Functioning
36. Attachment, 37. Living Situation, 43. Social Functioning
Child Development
45. Agitation, 58. Sensory Reactivity, 59. Emotional Control, 60. Frustration, 61. Temperament
Risk Behaviors
69. Self–Harm, 70. Aggressive Behavior, 71. Fire Setting, 72. Problematic Social Behavior,
Trauma Symptoms Module
A. Traumatic Grief, B. Re–experiencing, C. Hyperarousal, D. Avoidance, E. Numbing, F. Dissociation, G. Affective or Physiological Dysregulation
Behavior Health Module
A. Attention/Concentration, B. Impulsivity, C. Depression, D. Anxiety, E. Oppositional, F. PICA, G. Anger Control,
Preschool/Child Care Functioning Module
B. Preschool/Child Care Behavior, D. Preschool/Child Care Attendance

SED Functional Criteria 6–21

SED Functional Criteria 6–21
Relationship to child
14. Decision–Making, 15. Parenting Stress, 24. Care/Treatment Involvement
Child Strengths
30. Social Relationships, 31. Relationship Stability,
Child Needs and Functioning
40. Living Situation, 43. Decision–Making–Judgement
School/Academic Functioning
50. School Behavior, 52. School Attendance
Risk Behavior
54. Suicide Risk, 55. Self–Injurious Behavior, 56. Other Self–Harm, 57. Danger to Others, 58. Fire Setting, 59. Sexually Reactive Behavior, 60. Sexual Aggression, 61. Delinquent Behavior, 62. Bullying, 63. Runaway, 64. Problematic Social Behavior, 65. Eating Disturbance
Trauma Symptoms Module
A. Traumatic Grief, B. Re–experiencing, C. Hyperarousal, D. Avoidance, E. Numbing, F. Dissociation, G. Affective or Physiological Dysregulation
Behavior Health Module
A. Psychosis, B. Attention/Concentration, C. Impulsivity, D. Depression, E. Anxiety, F. Oppositional, G. Conduct, H. Emotional Control, I. Anger Control, J. Attachment

HCBS/LOC Determination
Medically Fragile Child (MFC)
Target Population


Level of Care (LOC) HCBS Eligibility Determination Criteria: Medically Fragile Child (MFC) Population
Target Criteria MFC Age 0 through child´s 21st Birthday, and the child must have documented physical disability using the following protocols:
  1. Current SSI Certification, or
  2. LDSS–639 disability certificate, or
  3. Forms: OHIP 0005, OHIP 0006 and OHIP 0007 completed by appropriate professionals and caregivers to be reviewed and approved by an LPHA (Licensed Practitioner of the Healing Arts)

The listed forms have been updated with new form numbers, however the HCBS/LOC Eligibility Determination within the UAS still will have the old forms listed:

  • LDSS–639 is now DOH–5144 form
  • OHIP 0005, OHIP 0006 and OHIP 0007 are now DOH 5151, DOH 5152 and DOH 5153

Target Population – Medically Fragile

When beginning the HCBS/LOC Eligibility Determination for the Medically Fragile Target Population Criteria, you will indicate the child Medically Fragile as defined:

Medically Fragile children are children who have a chronic debilitating condition or conditions, who may or may not be hospitalized or institutionalized, and meet one or more of the following criteria: is technologically dependent for life or health sustaining functions; requires complex medication regimen or medical interventions to maintain or to improve their health status; or is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health or development at–risk..

For medical fragility the child must have a documented physical disability using one of the following protocols:

  • Current SSI Certification, or
  • DOH–5144 disability certificate, or
  • Forms: DOH 5151, DOH 5152 and DOH 5153 completed by appropriate professionals and caregivers to be reviewed and approved by an LPHA.

For the Medically Fragile Target Population only one of the three options needs to be identified and documented to meet the Target Population. For the annual HCBS/LOC Eligibility Determination, current/updated documentation is needed for the eligibility each time the HCBS/LOC is conducted..

  1. Current SSI Certification – as determined by New York State Office of Temporary and Disability Assistance (OTDA), NYS Supplemental Program (SSP) for either Supplemental Security Income (SSI) or Social Security Disability (SSD)
    • For a child before the age of 18 it is every three years if the diagnosis may improve
    • For adults it is every three years for diagnosis that may improve and every seven years for long term diagnosis

OR.

  1. DOH–5144 disability certificate
    • The length of disability coverage varies from case to case. For example, the minimum is usually 12 months and the maximum can be as long as ten years.

OR.

  1. Forms DOH 5151, 5152 and 5153
    DOH–5151 – "Childhood Medical Report" completed by physician
    DOH–5152 – "Questionnaire of School Performance" completed by teacher (if applicable)
    DOH–5153 – ´Description of Child´s Activities Report" completed by parent/guardian
    • These forms would need to be completed yearly for the annual redetermination of HCBS/LOC Eligibility.
  • All forms must be completed by appropriate professionals and caregivers to be reviewed and approved by an Licensed Professional of the Healing Arts (LPHA).
  • These forms would accompany the LPHA Attestation that needs to be completed for the Medically Fragile Risk Factors to be reviewed by the LPHA.

HCBS/LOC Determination
Medically Fragile Child (MFC)
Risk Factors


HCBS/LOC Eligibility – MFC Risk Factors

Once the Target Population information has been obtained and documented, the Risk Factors must be noted with supporting documentation obtained.

Medically Fragile Risk Factors have one factor to establish

A Licensed Practitioner of Healing Arts (LPHA) who has the ability to diagnose within his or her scope of practice under state law has determined in writing that the child, in the absence of HCBS, is at risk of treatment in a more restrictive setting. The LPHA has submitted written clinical documentation to support the determination.

For the Risk Factor for Medically Fragile, institutionalization is defined as hospitalization or nursing facility.


LPHA Attestation – MFC Risk Factor Required

To capture the Licensed Practitioner of Healing Arts (LPHA) determination and LPHA Attestation form (DOH 5275) must be completed.

  • A NYS developed form will be utilized as the documentation from the LPHA, to be placed in the case record.
  • Within the UAS the LPHA Attestation signature date is required to ensure it was obtained within the proper annual redetermination timeframe.

It is the responsibility of the HHCM/C–YES to provide the LPHA with the attestation form and the required documentation for review by the LPHA to determine the completion of the LPHA Attestation form for the selected MFC Target Population.

  • For the MFC Target Population if the DOH 5151, 5152 and 5153 forms where utilized to determine the Target Population, then the LPHA must review them along with the rest of the documentation to complete the LPHA Attestation.

HCBS/LOC Determination
Medically Fragile Child (MFC)
Functional Criteria


HCBS/LOC Eligibility – MFC Functional Criteria

Once the Target Population and Risk Factors information has been obtained and documented, then the Functional Criteria must be established to finalize the HCBS/LOC Eligibility Determination.

MFC Level of Care (LOC) Functional Criteria:
  • Functional criteria is a subset of questions from the CANS–NY tool completed by the HHCM/C–YES.

It is the responsibility of the HHCM/C–YES to obtain the documentation that supports the answers to the subset of the CANS–NY to meet the HCBS/LOC Functional Criteria.

  • If a full valid CANS–NY has already been competed for the child, then the HHCM can save time by linking to an existing CANS–NY (as outlined in the appendix) or just complete the subset of the questions within the HCBS/LOC tool.

HCBS/LOC Eligibility – MFC

For the MFC Target Population to meet functional criteria of the HCBS/LOC Eligibility Determination, the subset of the CANS–NY assessment is utilized:

CANS–NY Subset for ages 0–5
D. CHILD DEVELOPMENT
53. Eating
54. Mobility
55. Positioning
56. Transferring
57. Elimination
93. Medical Health Module
A. Life Threatening
B. Chronicity
E. Impairment in Functioning
F. Intensity of Treatment
CANS–NY Subset for ages 6–21
88. Medical Health Module
A. Life Threatening
B. Chronicity
E. Impairment
F. Intensity of Treatment
89. Self–Care Activities of Daily Living Module
A. Eating
B. Toileting
F. Mobility
G. Positioning
H. Transferring

The HHCM/C–YES will work with the family to understand their strengths and needs surrounding these assessment items.


Developmental Disability (DD) and Medically Fragile Child (MFC)
AND
Developmental Disability (DD) and Foster Care
Target Populations


Alternative for DD and MFC Target Population

For Children who are Medically Fragile with a DD which has not yet been determined by the Office for People with Developmental Disabilities (OPWDD), the HHCM/C–YES are encouraged to access the Medically Fragile Target Population for HCBS/LOC eligibility determination.

  • This will ensure a more timely HCBS/LOC determination and access to services
MFC HCBS/LOC Determination Outcomes:
  • If the child is not found eligible for the Children´s Waiver MFC HCBS/LOC but is also believed or is diagnosed with a DD condition, then the child should be referred to OPWDD for the potential determination of DD eligibility and ICF–IDD LOC for the OPWDD Comprehensive Waiver.
  • If the child is found eligible for the Children´s Waiver MFC HCBS/LOC, then to ensure the child has access to adult HCBS services provided under the OPWDD Comprehensive HCBS Waiver and other State plan clinic services, the child should also subsequently seek OPWDD determination of DD eligibility and ICF–DD LOC.
    • As part of providing care management and planning transition care, Health Home care managers/C–YES must ensure this referral and determination is made for its MFC DD children well before the child´s 21st birthday.

Development Disability and MFC or Foster Care

These HCBS/LOC Determination tracks can ONLY be completed by OPWDD – DDROs

To be eligible for HCBS/LOC through these target populations:

  • The individual child needs to be found Developmentally Disabled and Medically Fragile
OR
  • The individual child needs to be found Developmentally Disabled and Foster Care
    • The child is currently in Foster Care or was previously in Foster Care
    • Eligibility for child that received HCBS while in Foster Care continues upon discharge if there is no break in coverage or eligibility
  • OPWDD – DDROs will complete the HCBS/LOC Eligibility Determination for all children that would meet DD MFC and DD Foster Care – new children and annual re–determinations
    • This is a change for the foster care system and from the B2H program

Level of Care (LOC) HCBS Eligibility Determination Criteria for:
  • Developmental Disability and Medically Fragile Child
  • Developmental Disability and Foster Care
Target Criteria DD MFC and DD Foster Care
  1. Age 0 through child´s 21st Birthday, and
  2. Child has developmental disability as defined by OPWDD which meets one of the criteria a–c as well as criteria d, e and f.
    1. is attributable to intellectual disability, cerebral palsy, epilepsy, neurological impairment, familial dysautonomia, Prader–Willi syndrome or autism; or
    2. is attributable to any other condition of a child found to be closely related to intellectual disability because such condition results in similar impairment of general intellectual functioning or adaptive behavior of a child with intellectual disability or requires treatment and services similar to those required for such children; or
    3. is attributable to dyslexia resulting from a disability described above; and
    4. originates before such child attains age 22; and
    5. has continued or can be expected to continue indefinitely; and
    6. constitutes a substantial handicap to such child´s ability to function normally in society

Target Population – DD MFC AND DD Foster Care

HCBS/LOC determined by OPWDD DDROs – following the OPWDD eligibility process, which includes the ICF–IID Level of Care Eligibility Determination (LCED) completion.

  • The HHCM/C–YES will work with the family and other involved providers to gather the necessary documentation needed to refer the child to the DDRO
  • The HHCM/C–YES will make a referral and provide the required information for either of the Target Populations of DD MFC or DD Foster Care and work with the DDRO to determine that the child meets the DD ICD–IID LCO

Developmental Disability Checklist

The DDRO will need this information to determine if a person is HCBS/LOC eligible:

  • The Transmittal for Determination of Developmental Disability Form must accompany all requests sent to the DDRO for eligibility determinations.
  • A psychological report which includes an assessment of intellectual functioning (´IQ test´). This report should include all summary scores from the assessment (Full Scale, Index, Part and Subtest scores). For people with IQ scores above 60, an interpretive report of a standardized assessment of adaptive behavior, including summary, composite, scale, and domain scores, is required. For people with IQ scores below 60, an adaptive assessment may be based on an interpretive report using information gathered from interviews with caregivers, records review, and direct observations.
  • For conditions other than Intellectual Disability, a medical or specialty report that includes health status and diagnostic findings to support the diagnosis. If available, a recent general medical report should be included in all eligibility requests.
  • A social/developmental history, psychosocial report or other report that shows that the person became disabled before age 22. This is required for all eligibility requests. In some cases, the DDRO may require additional information to determine eligibility. The DDRO may request additional information or further evaluation, and may either recommend where additional assessments may be done or arrange for them to be done.

Referral Process to the DDROs for Children with DD MCF and DD Foster Care

The HHCM/C–YES will refer and communicate with the Regional DDROs through the HCS secure file transfer Secure File Transfer 2.0 Quick Reference Guide(PDF).

The HHCM/C–YES will collect the necessary information and complete the referral.

information and transfer all documentation to the DDROs.

The DDROs have access to the UAS HCBS/LOC assessment tool and will be able to complete the tool for the HHCM/C–YES.

The DDROs will review the information provided and complete the Target, Risk and Functional HCBS/LOC Eligibility within the UAS.

NOTE: Additional for Guidance regarding the DDRO process is forthcoming

Office for People with Developmental Disabilities – DDRO Children´s Liaison´s Contact List through Secure File Transfer

Region 1: Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Wyoming, Yates, Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans Mailbox Email Address
Childrensliaisonregion1@opwdd.ny.gov
Region 2: Broome, Chenango, Delaware, Otsego, Tioga, Tompkins, Cayuga, Cortland, Onondaga, Oswego, Herkimer, Lewis, Madison, Oneida, Clinton, Essex, Franklin, Hamilton, Jefferson, St. Lawrence Mailbox Email Address
Childrensliaisonregion2@opwdd.ny.gov
Region 3: Fulton, Montgomery, Saratoga, Schenectady, Schoharie, Warren, Washington, Albany, Rensselaer, Orange, Sullivan, Rockland, Westchester, Columbia, Dutchess, Greene, Putnam, Ulster Mailbox Email Address
Childrensliaisonregion3@opwdd.ny.gov
Region 4: Queens, Kings, New York, Bronx, Richmond Mailbox Email Address
Childrensliaisonregion4@opwdd.ny.gov
Region 5: Nassau, Suffolk Mailbox Email Address
Childrensliaisonregion5@opwdd.ny.gov

Outcomes for DD MFC Population


DD MFC Services Options

The DDROs will need to communicate with the HHCM/C–YES the potential options for each assessed child/youth.

DD and MF eligible (DD ICF–IDD eligible and MF):
  • Eligible for both the Children´s Waiver and the OPWDD Comprehensive Waiver
  • Child/family should review the comparison of each waiver and determine where they want to be served
DD and MF in–eligible (DD ICF–IDD eligible but not MF):
  • Not eligible for the Children´s Waiver for HCBS but eligible for the OPWDD Comprehensive Waiver
  • If already enrolled in Medicaid, the child may be eligible for Health Home Serving Children (HHSC) if meeting Chronic Conditions and Appropriateness requirements
  • Child/family should review the services under the Comprehensive Waiver vs. HHSC care management only and determine where they want to be served
DD and MF in–eligible (DD ICF–IDD in–eligible and not MF):
  • Not eligible for the Children´s Waiver or OPWDD Comprehensive Waiver
  • If already enrolled in Medicaid, the child may be eligible for Health Home Serving Children (HHSC) if meeting Chronic Conditions and Appropriateness requirements

Capacity Management


Obtaining HCBS

Once a child/youth is determined HCBS eligible, communication with the DOH Capacity Management team will need to occur to determine if there is an available slot for HCBS.

Regardless of Target Population, no child will be able to begin receiving HCBS without DOH Capacity Management team approval as ALL HCBS eligible children are being tracked for:

  • Overall slot management
  • Tracking of Family of One processing
  • Ensuring proper RE Codes are placed on the member´s file
  • Billing and Services auditing purposes

Capacity Management Verification

Regardless of Target Population, no child will be able to begin receiving HCBS without DOH Capacity Management team approval.

All identified transitioning children from a former waiver will have a slot if verified.

DOH Liaison and Capacity Management will verify all transitioning children with previous waiver providers by April 30th to ensure an accurate account of all transitioning children.

Please note: Transitioning children will only be counted in a slot if agreed upon by the DOH liaison. If you are not sure that a transitioning child is counted please contact your liaison or capacitymanagement@health.ny.gov(with non–child specific information) and someone will contact you to discuss your concerns.


Communication and Collaboration with Child/Family


Collaboration with the Child/Family

As previously noted, prior to HCBS eligibility being pursued by the HH CM/C–YES, the child/family must identify that they are interested in pursuing HCBS eligibility and this must be documented within the case record. The HHCM/C–YES cannot determine on their own to pursue HCBS eligibility..

Each time, the HCBS Eligibility Determination process is completed a Notice of Decision must be sent.

  • Unless the child was a transitioning child from a former waiver and as outlined in slide 10, then a Level of Care exception could occur
  • Formal Notice of Decision letter will need to be sent to the child/family with fair hearing rights

Each time, the HCBS Eligibility Determination process is completed and the child/youth is found eligible, the HHCM/C–YES obtains consent that child/family accepts HCBS:

  • Freedom of Choice form must be signed by the child/family – Freedom of Choice – DOH–5276
    • Choice of HCBS instead of Institutional / Residential care
    • Choice of Services and Providers
    • Choice of Health Home or C–YES

HHCM/C–YES educates child/family on next steps including HCBS service array.

  • Consent from the child/family must be obtained for HCBS referral and to share the Level of Care and other pertinent information

• HHCM/C–YES engages family in identification of goals.

The State has developed Forms and Letters mentioned to provide to providers.


Q&A


Children and Youth Evaluation Service
Your Connection to Home and Community–Based Service

Referral Form Instructions

The Children and Youth Evaluation Service (C–YES) accepts referrals from individuals and providers including a parent, wider family member, doctor, therapist, school guidance counselor, CBOs and others:

  • Individuals and families should call C–YES so that we can send you a Referral Form and a pre–paid return envelope in the mail right away! You can mail back the form in the envelope at no cost to you. Call C–YES at 1–833–333–CYES (1–833–333–2937). TTY: 1–888–329–1541
  • Providers and Organizations with secure email protocols can download the Referral Form below. Return the form to: CYESREFERRAL@MAXIMUS.COM. Be sure to include the child/youth´s name and contact information!
    C–YES Referral Form

Questions? Call 1–833–333–CYES (1–833–333–2937). TTY: 1–888–329–1541..


Updates, Resources, Training Schedule and Questions

  • Please send any questions, comments or feedback on Health Homes Serving Children to: hhsc@health.ny.gov or contact the Health Home Program at the Department of Health at 518.473.5569
  • Specific Questions/Comments regarding Transition services
    BH.Transition@health.ny.gov
  • Subscribe to the HH Listserv

Additional Information and Support

UAS–NY Support Desk
uasny@health.ny.gov
or
518–408–1021, option 1
Monday – Friday
8:30 AM – 12:00 PM
1:00 PM – 4:00 Pm
.

MAPP Customer Care Center
MAPP–customercarecenter@cma.com
Phone: 518–649–4335

CANS–NY Training
support@CANSTraining.com
Or
www.canstraining.com and click on contact us.

Commerce Accounts Management Unit (CAMU)
866–529–1890
.


APPENDIX


Health Homes Serving Children List of Acronyms

  • ACS: NYC Administration of Children Services
  • AI: AIDS Institute
  • ALP: Assisted Living Program
  • ASA: Administrative Service Agreement
  • BAA: Business Associate Agreement
  • BHO: Behavioral Health Organization
  • CAH: Care at Home
  • CBO: Community Based Organizations
  • CMA: Care Management Agency
  • CFTSS: Children and Family Treatment and Support Services
  • CPST: Community Psychiatric Support and Treatment
  • CYES: Children´s Waiver is Children and Youth Evaluation Services
  • DEAA: Data Exchange Agreement Application
  • EI: Early Intervention
  • Emedny: Electronic Medicaid system of New York
  • FFS: Fee For Service
  • HCBS: Home and Community Based Services
  • HCS: Health Commerce System
  • HH: Health Home
  • HHSC: Health Home Serving Children
  • HHTS: Health Home Tracking System
  • HIT: Health Information Technology
  • IE: Independent Entity
  • LDSS: Local Department of Social Services
  • LGU: Local Government Unit
  • MAPP: Medicaid Analytics Performance Portal (Health Home Tracking System HHTS)
  • MCO/MCP: Managed Care Organization / Managed Care Plan
  • MRT: Medicaid Redesign Team
  • MMIS #: Medicaid Management Information Systems
  • NPI #: National Provider Identifier
  • OASAS: Office of Alcoholism and Substance Abuse Services
  • OCFS: Office of Children and Family Services
  • OLP: Other Licensed Practitioner
  • OMH: Office of Mental Health
  • OPWDD: Office of People with Developmental Disabilities
  • PMPM: Per Member Per Month
  • PSR: Psychosocial Rehabilitation
  • SED: Serious Emotional Disturbance
  • SMI: Serious Mental Illness
  • SPA: State Plan Amendment
  • SPOA: Single Point of Access
  • SPOC: Single Point of Contact
  • TCM: Targeted Case Management
  • UAS–NY: Uniformed Assessment System
  • VFCA: Voluntary Foster Care Agency

Change to SED Health Home Definition

In order to ensure that all children eligible for HCBS are eligible for Health Home, New York is updating its definition of Serious Emotional Disturbance (SED) as a single qualifying condition, to align with the HCBS definition of SED utilized by the historic Office of Mental Health 1915(c) Children´s SED waiver.

  • If a child has one of these conditions or attributes, they are eligible for HCBS and Health Home.
  • A new change is that if they are no longer eligible for HCBS, they will retain their Health Home eligibility so long as they retain the condition under the new SED diagnosis, retain active Medicaid, and Health Home appropriateness
  • Please refer to the table in the next slide for guidance on HCBS and Health Home eligibility criteria.
  • Additional guidance has been issued to Health Homes Serving Children

Serious Emotional Disturbance HH Definition

Health Home Eligibility Criteria Compared to HCBS Eligibility Criteria
Examples Include:
Note: if the child is eligible for HCBS, the child is eligible for Health Home. If a child is eligible for Health Home, the child may or may not be eligible for HCBS HCBS Eligible? (if Meet Target Risk and Functional Criteria) Health Home Eligible Without HCBS Eligibility
SED: Elimination Disorders* Yes Yes (New)
SED: Sleep Wake Disorders* Yes Yes (New)
SED: Sexual Dysfunctions* Yes Yes (New)
SED: Medication Induced Movement Disorders* Yes Yes (New)
SED: Tic Disorder* Yes Yes (New)
SED: ADHD* Yes Yes (New
All other SED Health Home Conditions (see appendix for SED HH Definition)* Yes Yes
Medically Fragile Yes Yes, if have two or more HH chronic conditions or single qualifying HH condition
Complex Trauma (Health Home Definition) Yes Yes

*Serious emotional disturbance means a child or adolescent has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) AND has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis. (See the appendix for HH eligibility).


Linking to Existing CANS–NY


Link to CANS–NY

Certain target populations collect Functional Criteria data using the same items that are used in the CANS–NY. The assessor can save time and effort by linking to a recently completed CANS– NY assessment within the UAS.

  • This process utilizes items and related responses from the most recently signed/finalized CANS–NY assessment.

To determine if a CANS–NY assessment is eligible to be linked to a HCBS/LOC Eligibility Determination. The CANS–NY assessment must:

  • be the most recently signed and finalized assessment for the child,
  • have a finalization date less than 6 months old,
  • be for the same age range as the HCBS/LOC Eligibility Determination, and
  • have the Target Population Selection in HCBS/LOC Eligibility Determination answered

Additional information found in the om–line UAS CANS–NY Training site.


Link to CANS–NY.