Children's Medicaid System Transformation

Draft HCBS Workflow for Stakeholder Comment

May 23, 2018

Today´s Agenda


Purpose of Today´s Webinar

To provide an overview of the DRAFT HCBS Workflow for stakeholder review and feedback

The Draft workflow reflects the following considerations:

  • Current 1915(c) Waiver processes
  • Lessons learned from adult HCBS implementation
  • Streamlining processes

Stakeholder comments on this webinar are due by Wednesday, May 30, 2018. Please submit your comments to the DOH BH Transition Mailbox BH.Transition@health.ny.gov. In the subject line please indicate HCBS Workflow Comments

NOTE: Today´s webinar focuses on HCBS Workflow. Separate webinars will be scheduled on the HCBS Eligibility Determination Process and the Role of the Independent Entity

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Overview of the DRAFT HCBS Workflow

Through the HCBS workflow, the Health Home Care Manager (HHCM), the Independent Entity, the Medicaid Managed Care Plan (MMCP), and HCBS provider(s) will work together to ensure timely access to HCBS for individuals who are eligible for, and can benefit from such services

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Phasing in the Expansion of HCBS Capacity

January 1, 2019 to June 30, 2019

  • Capacity is the combined volume of all 1915(c) wavier slots – HCBS eligibility is limited to new openings (backfilling) under that total capacity for newly identified HCBS Level of Care (LOC) eligible children
    • OMH SED 1915(c) waiver (NY.0296)
    • DOH Care at Home (CAH) I/II 1915(c) waiver (NY.4125)
    • OPWDD Care at Home 1915(c) waiver (NY.40176)
    • OCFS Bridges to Health (B2H) SED 1915(c) waiver (NY.0469)
    • OCFS B2H Medically Fragile 1915(c) waiver (NY.0471)
    • OCFS B2H DD 1915(c) waiver (NY.0470)

Beginning July 1, 2019

  • Capacity limits will be expanded over a three–year phase in period
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Capacity Management

DOH, working in conjunction with State partners, will individually monitor all transitioning 1915(c) waiver children to Health Home care management or the IE (should an individual choose to opt out of comprehensive Health Home care management) prior to January 1, 2019. No transitioning child will lose services

The State Partners are working on developing Capacity Management protocols. The Department will utilize information within the UAS, the system used to record and track HCBS Eligibility Determination, to help manage capacity

The State will have communication protocols in place to communicate with HH CM, the IE and children and families about available capacity for children determined to be HCBS eligible


Transition
October 1, 2018 – December 31, 2018


1915(c) Waiver Care Managers Transitioning to Health Home

  • To preserve the expertise of existing waiver providers in the Children´s Transformation, all existing waiver care managers/agencies providing care management under the six 1915(c) will transition to Health Homes
  • 1915(c) Transitioning Children are children that are currently enrolled and receiving HCBS services as of December 31, 2018 that will transition to Health Home care management and the 1115 waiver
  • 1915(c) Transitioning Children who elect Health Home care management will continue to receive it from their current care manager/agency
  • This linkage between care managers, children and families help preserve care manager/agency relationships with the child and their family, continuity of care and ensure a seamless transition

Continuity of Care

1915(c) Transitioning Children:

  • Will remain eligible for HCBS until at least one–year after their initial Health Home CANS–NY (first possible date is October 1, 2018) without the need for the new HCBS LOC Eligibility Determination
  • Are not required to change Care Manager/ Care Management Agency
  • Will have a plan of care that crosswalks 1915(c) services to 1115 or State Plan for continued authorization

HCBS – Transitioning Children

Children/Adolescents who are enrolled in HCBS under the 1915(c) waivers MUST transition to Health Home care management services or to the Independent Entity (should an individual choose to opt out of comprehensive Health Home care management) by December 31, 2018

  • Children/adolescents transitioning between October and December 31, 2018, will receive one–year of continued HCBS from the date of the signed and completed Health Home CANS–NY without the new LOC criteria being initiated
  • Until December 31, 2018, the current 1915(c) HCBS eligibility processes for each of the 6 previous listed waivers, will remain intact until the transition to the 1115 occurs on January 1, 2019
  • Effective January 1, 2019, Children/adolescents who are not enrolled in 1915(c) HCBS, including children on the current 1915(c) waiver waitlists, will need to have their HCBS LOC eligibility determined under the new HCBS Eligibility Determination

When transitioning to Health Home care management and preparing for the newly aligned HCBS and SPA services beginning in January 2019, the Health Home care manager will update and complete a comprehensive POC inclusive of:

  • Current 1915(c) Waiver HCBS identified under the newly aligned service language, title, and information
  • Updated frequency, scope and duration for each service
  • Any newly identify needs
  • Assurance that the POC meets the Health Home comprehensive POC requirements

Subsequently, prepared to present the newly aligned comprehensive POC inclusive of HCBS to Medicaid Managed Care Plan (if appropriate) in January 2019

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Role of Independent Entity – During Transition Process

  • The State will contract with an Independent Entity (IE) – an organization that will be required to have across the State administration of processes and quality oversight related to children´s HCBS processes
  • Beginning in November 2018 and through the end of the transition period (December 31, 2018) the role of the Independent Entity will be limited to accepting referrals of 1915(c) Transitioning Children who are eligible for or in receipt of HCBS and who opt out of Health Home
    • For Fee–for–Service children that opt out of Health Home – The IE will work with the State to monitor access to care and maintain the HCBS plan of care
    • For children enrolled in MMCP, the MMCP will monitor access to care and coordinate with the IE to maintain the HCBS plan of care
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1115 Transition
Beginning January 1, 2019

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HCBS eligibility through Level of Care (LOC)

Beginning January 1, 2019
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 the Independent Entity

Health Home care managers or the Independent Entity will work with the child, family, and providers to determine HCBS eligibility

The Uniform Assessment System (UAS) which houses the CANS–NY, will also house the HCBS Eligibility Determination for LOC and LON

HCBS Level of Care (LOC) Determination is comprised of meeting three factors: Target Population, Risk Factors, and Functional criteria as outlined within the Children´s 1115 Demonstration

*See the appendix for the outline of the LOC Factors


HCBS eligibility – Target Population

Children may be eligible for LOC HCBS under one or more of the following Target Populations, however only one Target Population is necessary to pursue to reach HCBS services

Effective January 1, 2019 – LOC HCBS Eligibility Criteria Under Age 21 – Target Population Criteria
Serious Emotional Disturbance (SED)
Medically Fragile Children (MFC)
Developmental Disability (DD) and Medically Fragile
Developmental Disability (DD) and 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

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

*There will be a separate Webinar regarding HCBS Eligibility Determination


HCBS eligibility – Risk Factors

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

Level of Care (LOC) Risk Factors include:

  • A list of risk factors specific to each Target population Criteria (as outlined in Appendix and within the Children´s 1115 Demonstration) AND;
  • 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.
    • A NYS developed form will be utilized as the documentation from the LPHA, to be placed in the case record

HCBS eligibility – 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 Eligibility Determination

Level of Care (LOC) Functional Criteria:

Functional criteria is a subset of questions from the CANS–NY tool except for the following LOC Target Populations

  • Developmental Disability (DD) and Medically Fragile (MFC)
  • Developmental Disability (DD) and in Foster Care
  • The two above Target Populations will be determined by the OPWDD DDRO
  • The DDRO will work in conjunction with the HH care manager and the Independent Entity to determine HCBS eligibility

*More information on DD MCF and DD Foster Care in appendix


HCBS Processes

The Target Population and the Risk Factors can be obtained and worked on simultaneously

Children already connected to service providers, can utilize their existing providers (if they meet LPHA requirements) to meet the risk factor condition

If the child is already enrolled in HH with a completed CANS–NY, that CANS–NY may be utilized by the HH CM to complete the HCBS Eligibility Determination. Additionally, HH CM can determine HH and HCBS eligibility separately or simultaneously due to similar needed documentation

HCBS Eligibility Determination is good for one year regardless of service utilization. Separate timelines for CANS–NY and HCBS Eligibility will be maintained, since the CANS–NY is required every six months or can be done earlier if a significant life event occurs

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Health Home Plan of Care and HCBS

  • Children who are eligible for HCBS are required to have care management and a care plan for their HCBS services
  • Children who are eligible for HCBS are eligible for Health Home
  • Children who are Health Home eligible are NOT automatically eligible for HCBS
  • Health Home care managers develop a single Health Home comprehensive plan of care that includes all services a child needs (health, behavioral health, community and social supports, specialty services etc.)
  • The Health Home comprehensive plan of care will be updated or developed to include HCBS for children that are eligible for HCBS and enrolled in Health Home – Health Homes will ensure the Health Home care plans meets care plan requirements for HCBS
  • There is not a separate HCBS care plan for members enrolled in Health Home
  • Enrolling children who are eligible for HCBS in Health Home ensures children receive a comprehensive plan of care that includes ALL the services a child needs

General Requirements

The HCBS Eligibility Determination must be completed face–to–face by the Independent Entity or the Health Home Care Manager with the child. For more information regarding HCBS requirements for independent assessment, see Section 1915(i)(1)(F) of the Social Security Act.

Eligibility for Children´s Aligned HCBS equals Health Home eligibility. All children who meet HCBS eligibility criteria are eligible for Health Home care management services, regardless of whether the child meets Health Home eligibility criteria. If a child becomes eligible for Health Home through HCBS determination process and, at some point is deemed no longer HCBS eligible, the child will also lose their Health Home eligibility unless the child meets Health Home chronic conditions eligibility and appropriateness.

HCBS Eligibility Determination is an annual determination. 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.

Should the member, who was previously determined HCBS eligible, refuse HCBS and/or leave HCBS and later request service, a HCBS Eligibility re– determination is not needed if their request is within the one–year eligibility determination window from the last HCBS Eligibility Determination.

Information on signature requirements for ALL POC

  • POC must be signed by the responsible parent, guardian or legally authorized representative and the child/adolescent, if age appropriate. All involved providers, inclusive of the HCBS providers will be involved in the development of the POC and be given the opportunity to sign the POC whenever it is revised for any reason.
  • However, at a minimum, the parent, guardian, legally authorized representative and/or child must sign the POC at least once prior to submitting the completed POC to the MMCP.
    • Updated and revised POC should also have the family and/or child/adolescent signatures, otherwise proper documentation would be needed in the care record how their input was part of the updated/revised POC and why a signature could not be obtained.
  • Inability to obtain HCBS providers signatures will not impact the MMCP´s authorization, or provision of HCBS. If providers are refusing to sign the POC, or if the parent, guardian, legally authorized representative and/or child/adolescent chooses not to share their POC with certain providers, the HH care manager should document this.
    • The MMCP and/or Lead Health Home may be able to assist the HH care manager in engaging providers that are not actively participating in the child´s integrated POC.
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Home and Community Based Services Workflow

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Overview of HCBS Workflow

Five Step Process

  1. Individual is determined eligible or re–assessed for HCBS eligibility annually
  2. Development of Plan of Care with the child and family
  3. Referrals to HCBS providers are made
  4. Children access services
  5. Ongoing monitoring of the Plan of Care

Step 1: Individual is determined HCBS eligible or re–assessed for HCBS eligibility annually
  • HHCM or IE will complete the HCBS Eligibility Determination within the UAS as outlined previously.
Step 2: Development of Plan of Care with the child, family and involved providers
  • Child in HH: A Comprehensive Plan of Care (POC) is developed through the coordination of information from the CANS–NY assessment, the HCBS Eligibility Determination, the Health Home comprehensive assessment, and the inter– disciplinary team meeting which is a discussion with the child, their family, supports, and involved providers.
  • Child with IE: For individuals who opt out of HH, the IE will develop a HCBS plan of care utilizing the HCBS Eligibility Determination and a discussion with the child, their family, supports, and involved providers.
  • The POC is a person–centered discussion with the child and family, surrounding the strengths and needs of the child and their development of comprehensive Plan of Care inclusive of HCBS.
  • The development of the Plan of Care should specifically outline the types of services to be provided to the child and family by their chosen providers.
Step 3: Referrals to HCBS providers are made
  • Upon completion of the Plan of Care, the Health Home Care Manager or IE will work with the family (and MMCP as appropriate) to identify available HCBS providers and obtain child/family consent for referrals.
  • The Health Home Care Manager or IE will document the HCBS provider(s) in the child´s POC and submit the child´s POC to the MMCP, if applicable.
  • The HHCM or IE will follow up on referrals made and will work to keep the child and family engaged, ensuring linkage to service. Contacting the child, parent, guardian, and legally authorized representative throughout the referral/intake process.
Step 4: Children access services
  • HCBS Provider(s) conduct an intake/assessment regarding their particular service area to determine Frequency, Scope, and Duration in conjunction with the family/child.
  • HCBS Provider(s) coordinate with HH Care Manager or Independent Entity to provide them with these details to inform and update the plan of care.
Step 5: Ongoing monitoring of the Plan of Care
  • All POC will reviewed and monitored to ensure that it is comprehensive, integrated, person–centered, and that the HCBS listed in the POC are appropriate for helping the child attain their recovery goals.
  • If the POC is updated to reflect changes in HCBS, the revised POC should be shared with the MMCP.

HCBS Workflow in an MMCP Environment

  • The MMCP will be prompted to automatically authorize HCBS upon notification by the HCBS provider that the child has engaged in care.
  • It is required that the HHCM submits a POC listing the specific HCBS prior to the date of the first HCBS appointment – this serves as notice to the plan and will permit initial authorization of the service.
  • This initial authorization begins a 60–day clock from the time that the MMCP receives notification from the HCBS provider. The automatic authorization permits by service and includes 96 units or a total of 24 hours of service, not to exceed 60 calendar days duration.
  • The MMCP will notify the child, parent, guardian, and legally authorized representative, HCBS provider, and HHCM of the service authorized and timeframe of authorization.
  • Review by the MMCP is required when HCBS exceeds 60 days/96 units/24 hours of service (whichever is first).
  • The HCBS provider must use the Authorization form to submit a request for additional days/units/hours. The request must recommend scope, frequency, and duration.
  • To avoid disruption in service, the HCBS provider is encouraged to submit this request as soon as it is apparent that the service will exceed the limit. Requests submitted less than 14 days before expiration of service may not be authorized before runout.
  • The MMCP will review the request and issue a determination within authorization request timeframes described in the Medicaid Managed Care Model Contract. The MMCP may request additional information related to the service authorization request from the HCBS provider to ensure that the service is appropriate and meets the needs of the child.

HCBS Workflow in a FFS Environment

  • The HCBS POC serves as service authorization and the HHCM or IE are required to monitor the POC services
  • Upon completing referrals, the HHCM or IE will coordinate with the child, parent, guardian, and legally authorized representative and referred providers to ensure the POC includes appropriate Frequency, Scope and Duration
  • The expectation is the HHCM or IE will coordinate with the child, parent, guardian, and legally authorized representative to ensure appropriate services as related to goals within the HCBS POC are maintained or discontinued based on person– centered planning discussions
  • FFS Service authorizations will be reviewed by the State as part of required ongoing monitoring
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Specialized Authorization and Utilization Management Protocols

  • Children who meet HCBS Eligibility are at risk of hospitalization or removal from their homes and community. As such, they are a high needs population requiring immediate access to services and supports that can avert re–hospitalization and admission to higher levels of care. Therefore, in order to support eligible children, access to certain services are critical in order to maintain them in their homes and communities. These services include:
    • Respite (Crisis & Planned)
  • These services provide the necessary supports to children and their families during the time of initial identification of need and determination of eligibility to help divert ER visits, inpatient admissions and out–of–home placements.
  • Individual service authorization can occur for this purpose, enabling immediate access prior to submission of a comprehensive plan of care (POC) helps to bridge HCBS Eligible children to receiving the full array of needed services while staying in the comfort and safety of their homes and/or the community.

Future guidance will be available which outlines additional processes and authorization requirements for the following HCBS:

  • Accessibility Modifications,
  • Adaptive and Assistive Equipment,
  • Respite and
  • Non–Medical Transportation
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Summary

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HCBS and Care Management/Coordination Process

Child in MMC – Table 1.0
  HCBS Eligibility Determination Eligible for HCBS Plan of Care Care Management Monitor Access to Services
In Health Home Health Home Yes HH Comprehensive POC with HCBS Health Home MMCP
Not yet Health Home HH/IE Yes, elects HH HH – Comp POC with HCBS Health Home MMCP
HH/IE Yes, Opts out of HH IE – HCBS POC MMCP MMCP
HH/IE No, but eligible for and elects HH HH – Comp POC w/o HCBS Health Home MMCP
Child in FFS – Table 2.0
  HCBS Eligibility Determination Eligible for HCBS Plan of Care Care Management Monitor Access to Services
In Health Home Health Home Yes HH Comprehensive POC with HCBS Health Home Health Home
Not yet Health Home HH/IE Yes, elects HH HH Comp POC with HCBS Health Home Health Home
HH/IE Yes, Opts out of HH IE – HCBS POC   IE
HH/IE No, but eligible for and elects HH HH – Comp POC w/o HCBS Health Home Health Home
Child not Medicaid
  HCBS Eligibility Determination Eligible for HCBS Plan of Care Care Management Monitor Access to Services
Not yet Health Home IE Yes IE – initial HCBS POC See Table 1.0 OR Table 2.0 See Table 1.0 OR Table 2.0
IE No, but eligible for and elects HH– Comp POC w/o HCBS Health Home See Table 1.0 OR Table 2.0
Child DD in Foster Care
  HCBS Eligibility Determination Eligible for HCBS Plan of Care Care Management Monitor Access to Services
In Health Home DDRO Yes Health Home Comprehensive POC with HCBS Health Home Health Home or if enrolled, MMCP
Not yet in Health Home DDRO Yes See Table 1.0 OR Table 2.0 See Table 1.0 OR Table 2.0 See Table 1.0 OR Table 2.0
Child MF/DD
  HCBS Eligibility Determination Eligible for HCBS Plan of Care Care Management Monitor Access to Services
In Health Home Health Home, OR DDRO Yes Health Home Comprehensive POC with HCBS Health Home Health Home or if enrolled, MMCP
Not yet in Health Home HH/IE OR DDRO Yes See Table 1.0 OR Table 2.0 See Table 1.0 OR Table 2.0 See Table 1.0 OR Table 2.0

Direct referrals to Health Homes by community providers and plans should be made for children likely eligible for Health Home or HCBS (Children eligible for HCBS are eligible for Health Home)

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Next Steps

This DRAFT HCBS Plan of Care Workflow PowerPoint will be posted after this webinar for stakeholder comments. Comments are due by Wednesday May 30, 2018 and need to be submitted to the DOH BH Transition Mailbox BH.Transition@health.ny.gov

NOTE: Separate upcoming webinars will be held regarding the HCBS Eligibility Determination Process and the Role of the Independent Entity

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Questions

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Resources to Keep Informed

DOH Transition Mail Log
BH.Transition@health.ny.gov

Health Home Bureau Mail Log
https://apps.health.ny.gov/pubdoh/health_care/medicaid/program/medicaid_health_homes/emailHealthHome.action

OMH Managed Care Mail Log
BHO@omh.ny.gov

Children´s Designation Mail Log
OMH–Childrens–Designation@omh.ny.gov

Subscribe to DOH Health Home listserv
http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/listserv.htm

Subscribe to children´s managed care listserv
http://www.omh.ny.gov/omhweb/childservice/

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APPENDIX

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Level of Care (LOC) HCBS Eligibility Determination Criteria: Serious Emotional Disturbance (SED) January 1, 2019
Target Criteria
SED
  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) and 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
  3. SED is defined to include any one of the following Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses:
    • Schizophrenia Spectrum and Other Psychotic
    • Personality Disorders
    • Disorders
    • Paraphilic Disorders
    • Bipolar and Related Disorders
    • Gender Dysphoria
    • Depressive Disorders
    • Elimination Disorders
    • Anxiety Disorders
    • Sleep–Wake Disorders
    • Obsessive–Compulsive and Related Disorders
    • Sexual Dysfunctions
    • Trauma – and Stressor – Related Disorders
    • Medication– Induced Movement Disorders
    • Feed and Eating Disorders
    • Attention Deficit/Hyperactivity Disorder
    • Disruptive, Impulse–Control and Conduct Disorders
    • Tic Disorder
Risk Factors
SED
The child meets one of the factors 1–4 as well as factor 5.
  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 (6) 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 AND
  5. A licensed practitioner of the healing arts (LPHA), who has the ability to diagnose within his/her scope of practice under State law, has determined in writing, that the child, in the absence of HCBS, is at risk of institutionalization (i.e., hospitalization). The LPHA has submitted written clinical documentation to support the determination.
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
Functional Criteria SED Algorithm applied to a subset of questions from the Child and Adolescent Needs and Strengths New York (CANS–NY)
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Level of Care (LOC) HCBS Eligibility Determination Criteria: Medically Fragile Child (MFC) Population January 1, 2019
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
Risk Factors MFC A licensed practitioner of the healing arts (LPHA), who has the ability to diagnose within his/her scope of practice under State law, has determined in writing, that the child, in the absence of HCBS, is at risk of institutionalization (i.e., hospitalization or nursing facility). 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.
Functional Criteria MFC Algorithm applied to a subset of questions from the Child and Adolescent Needs and Strengths New York (CANS–NY)
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Level of Care (LOC) HCBS Eligibility Determination Criteria: Developmental Disability and Medically Fragile Child January 1, 2019
*NOTE: Children who qualify as both DD and MFC may more expeditiously access HBCS services by using the Medically Fragile process and then at a later date pursue DD eligibility;
Target Criteria DD MFC
  1. Age 0 through child´s 21st Birthday, and
  2. Determined Medically Fragile
  3. 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 to that 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.
Risk Factors
DD MFC
The child must be Medically Fragile as demonstrated by a licensed practitioner of the healing arts (LPHA), who has the ability to diagnose within his/her scope of practice under State law, has determined in writing, that the child, in the absence of HCBS, is at risk of institutionalization (*i.e., hospitalization or nursing facility) The LPHA has submitted written clinical documentation to support the determination.
Functional Criteria
DD MFC
Office for People With Developmental Disabilities (OPWDD) ICF–IDD Level of Care and/or Algorithm applied to a subset of questions from the Child and Adolescent Needs and Strengths New York (CANS– NY)
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Level of Care (LOC) HCBS Eligibility Determination Criteria: Developmental Disability and Foster Care – January 1, 2019
Target Criteria
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
Risk Factors
DD Foster Care
The child must meet either criteria 1 or 2
  1. a current Foster Care (FC) child in the care and custody of Local Departments of Social Services (counties and New York City) (LDSS) or a child in the custody of OCFS Division of Juvenile Justice and Opportunities for Youth (DJJOY) or
  2. a FC child who enrolled in HCBS originally while in the care and custody (LDSS) or (DJJOY). Once enrolled, eligibility can continue after the child is discharged from LDSS and OCFS DJJOY custody so long as the child continues to meet targeting, risk and functional criteria (no break in coverage permitted). This risk factor continues Maintenance of Effort for children up through, but not including, their 21st birthday).
Functional Criteria
DD Foster Care
Office for People With Developmental Disabilities (OPWDD) Level of Care using the ICF–IDD LOC eligibility tool
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Level of Need (LON) HCBS Eligibility Determination Criteria: Serious Emotional Disturbance (SED)
Target Criteria
SED
  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) and 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
  3. SED is defined to include any one of the following Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses:
    • Schizophrenia Spectrum and Other Psychotic
    • Personality Disorders
    • Disorders
    • Paraphilic Disorders
    • Bipolar and Related Disorders
    • Gender Dysphoria
    • Depressive Disorders
    • Elimination Disorders
    • Anxiety Disorders
    • Sleep–Wake Disorders
    • Obsessive–Compulsive and Related Disorders
    • Sexual Dysfunctions
    • Trauma – and Stressor – Related Disorders
    • Medication– Induced Movement Disorders
    • Feed and Eating Disorders
    • Attention Deficit/Hyperactivity Disorder
    • Disruptive, Impulse–Control and Conduct Disorders
    • Tic Disorder
Disqualifying diagnoses and enrollment: A child may not solely have a developmental disorder (299.xx.315.xx.319.xx.) or Organic Brain syndrome (290.xx.293.xx.294xx) or Autism spectrum disorder 299.00 (F84.0) (unless if co–occurring with SED ) and may not be enrolled in an OPWDD waiver
Risk Factors
SED
The child must meet all three of the Factors 1, 2 and 3.
  1. The child has a reasonable expectation of benefiting from HCBS and
  2. The child requires HCBS to maintain stability, to improve functioning, to prevent relapse to an acute inpatient level of care and/or to maintain residence in the community , and
  3. A licensed practitioner of the healing arts (LPHA), who has the ability to diagnose within his/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. More restrictive setting is defined as: RRSY, RTF, RTC, or other congregate care setting such as SUD residential treatment facilities, group residences, institutions in the OCFS system or hospitalization.
Functional Criteria
SED
Algorithm applied to a subset of questions from the Child and Adolescent Needs and Strengths New York (CANS–NY)
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Level of Need (LON) HCBS Eligibility Determination Criteria: Abuse, Neglect, Maltreatment or Health Home Complex Trauma (ANMCT)
Target Criteria
ANMCT
  1. Age 0 through child´s 21st Birthday, and
  2. Children who have experienced physical, emotional, or sexual abuse or neglect, or maltreatment and are currently in the custody of LDSS, or
  3. Have Complex Trauma as defined by Health Home and Complex Trauma Assessment and Determination Tools see Department of Health website for definition and tools here.
Risk Factors
ANMCT
The child must meet the following risk factors (a and (b or c) and d and e):
  1. The child has a reasonable expectation of benefiting from HCBS and either b or c.
  2. The child requires HCBS to maintain stability, improve functioning, prevent relapse to an acute inpatient level of care and maintain residence in the community or
  3. The child who, but for the provision of HCBS, would be at risk for a more restrictive setting and
  4. A licensed practitioner of the healing arts (LPHA), who has the ability to diagnose within his/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; and
  5. And one or more of the following risk factors
    1. Medicaid Community Eligible
    2. A former FC child who was enrolled in HCBS originally while in the care and custody of LDSS with no break in eligibility.
    More restrictive setting is defined as: RRSY, RTF, RTC, or other congregate care setting such as SUD residential treatment facilities, group residences, institutions in the OCFS system or hospitalization.
Functional Criteria
ANMCT
If a child is already Medicaid eligible (i.e., either currently in foster care or eligible through community eligibility rules), then a child meeting LON HCBS ANM or Complex Trauma target criteria, risk factors, and functional criteria is eligible to receive HCBS.

If a child is not already eligible for Medicaid and qualifies under no community eligibility rules, then a child meeting such criteria must be a former foster care child who was enrolled in HCBS originally while in the care and custody of LDSS with no break in HCBS eligibility. If the child continues to meet LON HCBS ANM or Complex Trauma target criteria, risk factors, and functional criteria, the child should be considered for Medicaid eligibility under the Family of One financial criteria.

Children meeting Health Home complex trauma criteria and risk factors who are not in foster care or were not formerly in foster care when enrolled in HCBS are not eligible for Medicaid under Family of One financial criteria.
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Children with a confirmed or possible Developmental Disability who are Medically Fragile or in Foster Care

  • When a child meets target criteria for Medically Fragile and a suspected Developmental Disability (DD); the child may be found HCBS eligible using either requirements for Medically Fragile LOC or DD Medically Fragile LOC.
  • When a child is assessed for HCBS eligibility using the DD Medically Fragile LOC criteria the determination of their Developmental Disability will be determined by OPWDD´s Developmental Disabilities Regional Offices (DDROs)
  • Children who are Developmentally Disabled and Medically Fragile may also be found HCBS eligible using the subset of CANS–NY questions to determine Level of Care (LOC) functional criteria under the HCBS LOC Medically Fragile Eligibility Determination Criteria completed by the HHCM or DDRO
  • However, to ensure the child has access to adult HCBS provided under the OPWDD HCBS Waiver and other State Plan clinic services, the child should subsequently seek a Developmental Disability eligibility determination through the DDRO. This should occur well before the child´s 21st birthday.
  • As part of providing comprehensive care, Health Home care managers should ensure this referral and determination is made for its Medically Fragile DD children.
  • For the target criteria of Children in Foster Care with a Developmental Disability, only the OPWDD DDRO can determine the functional criteria using the ICF–IDD Level of Care determination. The DDRO will complete the HCBS Eligibility Determination in coordination with HHCM.
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Individuals not eligible for or decline Children´s Aligned HCBS

  1. Child is found not eligible for HCBS based on the HCBS Eligibility Determination.
  2. Child is found eligible for HCBS but child and family do not feel HCBS will help them reach their identified goals and therefore decline HCBS.
  3. Child is found eligible for HCBS but child and family choose to remain in a State Plan service already meeting their need(s).
  4. Child is found eligible for HCBS and resides in a setting that is not considered home and community based (see NYS´ "HCBS Final Rule Statewide Transition Plan" for more information).

If the child is not pursuing HCBS for any reason including those described above and is enrolled in Health Home, HHCMs will document this in the child´s POC. The HHCM would not move forward with the remaining workflow described in this document but will instead continue to work with the child and family in their role as a HHCM on the completion of required Health Home assessments, plans of care and referrals to other service providers.