Children's Waiver HCBS Eligibility Determination by C-SPOA Coordinators Policy #HH0020

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Policy Title: Children's Waiver Home and Community Based Services Eligibility Determination by Children's Single Point of Access Coordinators Policy
Policy Number: HH0020
Issued Date: February 2025
Effective Date:
Approved by:

This policy is applicable to Health Homes Serving Children (HHSC), Health Home Care Management Agencies (HH CMAs), Health Home Care Managers (HHCM), Children and Youth Evaluation Services (C-YES), and Children's Single Point of Access Coordinators (C-SPOAs).

Purpose
The purpose of this policy is to outline the circumstances under which a Children's Single Point of Access (C-SPOA) Coordinator would conduct a Home and Community Based Services (HCBS) Eligibility Determination and collaborate with a Health Home Serving Children (HHSC) to enroll HCBS eligible children in the Children's Waiver and Health Home program, specifically High Fidelity Wraparound (HFW), as appropriate.

This policy applies to children/youth being discharged from OMH State-Operated Psychiatric Centers (PC), Residential Treatment Facilities (RTF), Children's Community Residences (CCR), and Youth Assertive Community Treatment (ACT).

Introduction
The role of the C-SPOA is to support children with significant mental health challenges or Serious Emotional Disturbance (SED) and their families/caregivers who are most in need by assisting in the identification of and facilitating the connection to needed mental health services and supports. C- SPOAs are responsible for determining service eligibility for community-based services, helping to manage access to services, and coordinating with providers as children transition to/from out-of-home treatment.

C-SPOAs receive referrals for a variety of programs and services in the community and help identify which services are best suited to meet the child/youth's needs. If needed, C-SPOAs help facilitate access to specialty intensive services or residential settings for a child/youth with SED that is at risk of returning to, or is stepping down from, out-of-home and/or intensive treatment programs, including State PC, RTF, CCR, and Youth ACT.

When children/youth are being discharged from these settings/programs, adequate services and supports are needed for the child/youth, and their family/caregiver, to maintain therapeutic gains, avert risk of re-admission, and maintain the child/youth in the home. Further, the arrangement for such services needs to occur as quickly as possible to ensure timely access to care at the time of, or shortly after, discharge from these restrictive settings and programs. C-SPOAs often collaborate with these settings/programs to facilitate access to community-based services upon discharge.

To help expedite such access to care, an amendment to the Children's Waiver was approved, expanding those authorized to perform the Children's Waiver HCBS Eligibility Determinations to include C-SPOA through the Local Governmental Unit for children/youth meeting the criteria for SED. As a result, for children/youth being discharged from RTF, CCR, Youth ACT, or OMH State-Operated Psychiatric Centers, that are not already enrolled in a Health Home, the C-SPOA can conduct an

HCBS Eligibility Determination for any Medicaid or District 97 Medicaid enrolled child/youth. If found HCBS eligible, the C-SPOA will assist to connect the child/youth to an appropriate Health Home Care Management Agency (HH CMA), with preference given to HH CMAs implementing High Fidelity Wraparound (HFW).

NOTE: The process to assist children/youth being discharged from an RTF or OMH state-operated psychiatric center with District 97 Medicaid is outlined in HCBS Determination for ChildrenDischarging from OMH Residential Treatment Facility or Psychiatric Centerguidance.

Procedure
When a child/youth is being discharged from a RTF, CCR, Youth ACT, or OMH State-Operated Psychiatric Center, the C-SPOA will be notified, and will utilize the MAPP Health Home Tracking System (HHTS), the Uniform Assessment System (UAS), and other resources to identify the services already involved and working with the child/youth, specifically as it relates to the Health Home and Children's Waiver programs. The C-SPOA will work with the discharging agency and other involved providers to coordinate discharge. For all discharges, the discharging program will complete the required Universal Referral Form (URF), Part 1. Depending on the child/youth's Medicaid and Health Home status, the C-SPOA will do the following:

Option 1: The child/youth does not have Medicaid

If the child/youth does not have Medicaid and the C-SPOA determines that HCBS is needed and the child/youth may meet the eligibility criteria, the C-SPOA will ensure a referral is made to the Children and Youth Evaluation Services (C-YES) and assist in collecting the necessary documentation for the HCBS Eligibility Determination. The C-SPOA will remain available for consultation, as needed, and ensure an HCBS and Medicaid eligibility outcome occurs.

If the child/youth is not HCBS eligible, the C-SPOA will continue to work with the child/youth/family to connect them to other services within the community, as appropriate.

If the child/youth is determined HCBS eligible, the C-SPOA will complete the HFW screening. If HFW eligible, the C-SPOA will work with the Health Home to determine an available HFW care manager and then work with the child/youth/family to determine their interest to enroll in HFW. The C-SPOA will continuously collaborate with C-YES to ensure a timely transfer referral to the HH program, CMA, and HFW, if available and the child/youth and family chose to enroll.

Option 2: The child has Medicaid but is not currently enrolled in HHSC

If the child/youth has Medicaid and the C-SPOA determines that HCBS is needed when working with the discharging agency and the child/youth/family, the C-SPOA will conduct the HCBS Eligibility Determination within the UAS.

The C-SPOA will also complete the HFW screening. If the screening indicates HFW is appropriate, the C-SPOA will work with the Health Home to determine an available HFW care manager and then work with the child/youth/family to determine their interest to enroll in HFW.

If found HCBS and/or HFW eligible, the C-SPOA will send the referral packet to the Lead Health Home, using their preferred method of fax, secure e-mail, or the Health Commerce System secure file transfer.

The referral packet will contain the following:

  • C-SPOA Universal Referral Form, Childrens Single Point of Access Application Part 1 - 9/18/2023 (ny.gov) which includes an attestation of SED
  • Discharge Summary / Information from the referral source, containing the most recent diagnoses, medications, evaluations, and upcoming appointments
  • Signed Licensed Practitioner of the Healing Arts Form-DOH 5275 (ny.gov)
  • Health Home Opt-In Form
  • Notice of Decision Form FDOH 5287 (ny.gov)
  • UAS / CANS-NY Printout containing appropriate HCBS indicators
  • The HFW screening tool
  • The HFW Agreement Form DOH-5817 (EN), if appropriate

Upon receipt of the referral packet, the Lead HH will assign the child/youth to an appropriate HH Care Management Agency (CMAs)with capacity to enroll. High Fidelity Wraparound (HFW) designated CMAs within the HH network must be assigned when the child/youth has screened as eligible for HFW, availability is confirmed, and the child/youth and family agree to enroll. The HHSC will contact the referring C-SPOA to provide contact information for the assigned HH CMA.

If an HCBS Eligibility Determination and connection to HH CMA can be completed prior to discharge, the C-SPOA will host a meeting between the CMA and child/youth/family to initiate the warm handoff process. The warm handoff process includes direct communication and involvement of the child/youth and their family/caregiver. The C-SPOA will remain available for consultation, as needed.

Option 2(a): The child has OMH District 97 Medicaid but is not currently enrolled in HHSC

The same process outlined above in Option 2 will occur for children/youth with community Medicaid as those with OMH District 97 Medicaid. Children/youth who are being discharged from an RTF or OMH State-operated Psychiatric Center (PC), may be enrolled under OMH District 97 Medicaid.

When a child/youth enters an RTF or State PC, the New York State Department of Health (DOH), in conjunction with the Office of Mental Health (OMH), is responsible for (re)determining Medicaid eligibility for the child/youth. When Medicaid eligibility is established, the child/youth is enrolled in Medicaid under District 97. The eligibility continues while the child/youth is in the RTF or State PC and continues for the month of discharge and one (1) month after the month of discharge. This extension is to prevent a gap in coverage and allow time for the Local Department of Social Services (LDSS) to determine continued Medicaid eligibility.

For children/youth who have Medicaid coverage under OMH District 97, upon return to their county of residence post-discharge, the LDSS will extend Medicaid coverage beyond the month after discharge, if necessary, to complete a re-determination of Medicaid eligibility. If the child/youth is not otherwise eligible for Medicaid based on household income and/or assets, but is eligible for HCBS, Family of One (Fo1) budgeting will be used to determine Medicaid eligibility. A new Medicaid application is not required upon RTF/PC discharge in these situations. However, the LDSS may require additional information to determine the continued eligibility of the child/youth.

The C-SPOA and assigned HH CMA will provide the LDSS with the HCBS Eligibility Determination outcome for Family of One (Fo1) budgeting to be considered and prevent a gap in coverage, while services and care management are being established.

NOTE: The process to assist children/youth being discharged from an RTF or OMH state-operated psychiatric center with District 97 Medicaid is outlined in HCBS Determination for Children Discharging from OMH Residential Treatment Facility or Psychiatric Center guidance.

Option 3: The child has Medicaid and is already enrolled in HHSC
If the child has Medicaid and is enrolled in HHSC, the C-SPOA will outreach to Lead Health Home and/or HH CMA to notify them of the pending discharge and request the HHCM to conduct an HCBS Eligibility Determination. If the C-SPOA has received information that is pertinent to care management and/or HCBS eligibility, including any of the documents listed above, the C-SPOA will provide them to the HHCM. The C-SPOA will remain available for consultation, as needed, and verify the eligibility determination and HCBS enrollment were completed. Additionally, due to a significant life event the HHCM will conduct a CANS-NY reassessment and the HFW screening for the possibility of connecting the child/youth to HFW care management.

Discharged children not referred from C-SPOA

If for some reason a HH CMA receives a direct referral for a child/youth who is being or has been discharged from an RTF, CCR, Youth ACT program, or OMH state-operated PC, and already enrolled in the HH program, the care manager will contact the C-SPOA to make them aware of the discharge.

If not already enrolled in HH program, the care manager will contact the C-SPOA to make them aware of the discharge and proceed in completing the HHSC enrollment, inclusive of HFW screening when completing the CANS-NY, and HCBS eligibility determination, if appropriate. Such referrals are not required to go through the C-SPOA. However, the C-SPOA is still available to the HH CMA for assistance, as needed. The C-SPOA should be added to the HH Consent to Release Information DOH-5201 for this purpose.

Resources

If you need to find or contact your local C-SPOA Coordinator, you can find contact information by clicking on your county in the map.