GIS 15 MA/02: Care at Home III, IV and VI Waivers: Policy Updates Regarding Waiver Eligibility

The purpose of this GIS is to clarify and reinforce current policy requirements regarding Medicaid eligibility for parents or legal guardians of children participating in the Office for People with Developmental Disabilities (OPWDD) CAH III, IV and VI Waiver Programs.

The CAH III, IV and VI Waiver Programs are available to provide medical assistance to families with children living at home who have severe disabilities or medical conditions.

To be eligible for the CAH III, IV and VI waiver programs, the following are required eligibility criteria:

• Must be under 18 years of age
• Have a developmental disability as defined by Mental Hygiene Law
• Demonstrate complex health care needs that are expected to last at least 12 months
• Must be eligible for the level of care provided in an intermediate care facility (ICF) for persons with developmental disabilities
• Not be in a hospital, skilled nursing facility, ICF or other institution
• The child's parents or legal guardian must apply and be denied for Medicaid due to excess income or resources
• The child must be eligible for Medicaid using only the child's income or resources

Parents or Legal Guardian Continued Ineligibility for Medicaid

Once enrolled into either the CAH III, IV or VI Waiver Programs, the child is required to re-certify for Medicaid annually.

The case manager needs to assess and document in the child's case record that the child has recertified for Medicaid coverage annually. The case manager also needs to verify that the child's parents or legal guardian have remained ineligible for Medicaid coverage. The case manager needs to contact the LDSS in upstate counties and Human Resources Administration (HRA) for counties within New York City, on an annual basis to verify the Medicaid status of the parents or legal guardians.

If the parents have been found eligible for Medicaid within the prior year, then the child is no longer eligible for the waiver. The child and their family should be referred to the OPWDD's Front Door to determine if alternative services or programs may be available for the child.

If the parents have not applied for or been found eligible for Medicaid within the prior year, the case manager must then document these findings in the child's record every year while the child is participating in one of the CAH III,IV and VI Waiver Programs.

Questions regarding this GIS can be sent to Lynda Baum-Jakubiak, Statewide CAH Coordinator at 518-486-6466.