GIS 16 MA/001: Care At Home (CAH) I/II Waiver Quarterly Report Form, CAH I/II Waiver Retroactive Eligibility Period and CAH I/II Waiver Application Submission Process

To: All Local District Commissioners, Medicaid Directors, Care At Home Coordinators

From: Mark Kissinger, Director, Division of Long Term Care

Subject:Care At Home (CAH) I/II Waiver Quarterly Report Form, CAH I/II Waiver Retroactive Eligibility Period and CAH I/II Waiver Application Submission Process

Effective Date: Immediately

Contact Person: Division of Long Term Care
Linda Milano, (518) 473-6020

The purpose of this GIS is to advise Local District Social Services (LDSS) staff that the State is implementing a revised Care At Home (CAH) I/II Quarterly Report Form for the fourth quarter (October-December). This revised Quarterly Report Form will replace the previous Quarterly Report Form and will include a new section for home and vehicle modifications. Please read and follow the instructions included with the revised Quarterly Report Form. The fourth quarter reports must be submitted by January 31, 2016.

Also, this GIS is to advise the LDSS that the determination of enrollment to the CAH I & II waiver program is determined by the date the LDSS receives the Medicaid Waiver CAH I & II program application form signed by a parent/guardian. Paid or unpaid medical bills for the three-month period prior to the month of application may be eligible for payment/reimbursement. The three-month retroactive period begins on the first day of the third month that precedes the month the applicant applies for assistance. For example: If the signed application is received on April 30th, the three month retroactive period is the period between January 1st through March 31st. The Medicaid Waiver Care At Home I/II program application cover sheet has been revised to include the date of receipt of the application by the LDSS.

In order to process a CAH I/II waiver application, the application must include the following:

  • CAH I/II Application Cover Sheet-use revised form and include date received by LDSS
  • Proof of Medicaid (MA) eligibility
  • If MA eligible based on parental income/resources, then the child's MA number/client identification number (CIN#) will suffice.
  • If MA ineligible when parental income/resources is counted, the scratchpad budget is required, showing the child is MA eligible when parental income/resources is not counted. Also provide the Notice of Decision.
  • Home Health Assessment Abstract (HHA)- must be current and updated every 6 months
  • Pediatric Patient Review Instrument (PPRI)
  • Child's birth certificate
  • Documentation of Disability (SSI letter or DSS-639)
  • Physician orders - must be complete and must be renewed every 60 days
  • Budget
  • Case Management Plan of Services
  • Choice of Care
  • Application Form signed by parent/guardian (must be signed and dated)

Please be advised if a CAH I & II waiver application is not complete, the application will be returned to the LDSS.

In addition, the CAH I & II waiver program has initiated an electronic process for CAH I & II waiver applications. Please submit requests for CAH I & II applications via email at or via fax at (518) 473-2537. If not capable of submitting via email or fax, applications will be accepted by mail.

If you require any assistance regarding CAH I & II operations, please contact Linda Milano, CAH Coordinator, at 518-473-6020, or via email at