Children's Waiver Fee-for-Services Authorization Policy
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Policy Title: Children's Waiver Home and Community Based Services (HCBS) Authorization Policy for Fee-for-Service (FFS) Participants
Policy Number: CW0019
Effective Date: January 2, 2025
Referral and Authorization Portal System Effective Date: October 21, 2024
Applicable to : Children's Waiver Home and Community Based Service (HCBS) Providers, Health Homes, and Care Management Agencies providing HCBS under the 1915(c) Children's Waiver.
Purpose
Home and Community Based Services support children and caregivers to avoid imminent out-of-home, institutional placements, such as psychiatric hospitalization, residential treatment, or nursing home admission, or assist the child to return to their home and community after discharge from an institutional level of care. Children who are found eligible and enrolled in the Children's Waiver will be referred to designated HCBS providers to receive Children's Waiver services. All HCBS provided to children, beyond a short-term initial service period, must be authorized prior to service delivery.
This policy outlines the Children's HCBS authorization process for children enrolled in Fee-for-Service (FFS) Medicaid.
For information on the Medicaid Managed Care Plans (MMCP) authorization process for participants enrolled in MMCP Medicaid, refer to the HCBS Plan of Care Workflow Policy available HCBS Plan of Care Workflow.
Contents
- Referral to HCBS Providers
- Initial Service Period
- Requests for Authorization and Reauthorization
- Notification of Authorization Determination
- Service Plan Updates
- Additional Resources
Definitions of Key Terms
Child/Children: Throughout this document, the term “child” or “children” refers to a child/youth under age 21. Child/Children and youth are used interchangeably in this policy.
Duration: The length of time the member is expected to need a service, in days, weeks or months. Requested duration cannot exceed six (6) months.
Family: Within this document the term “family” is used and defined as the primary caregiving unit inclusive of the wide diversity of primary caregiving units in our society. Family is a birth, foster, adoptive or self-created unit of people residing together, with significant attachment to the individual, consisting of adult(s) and/or child(ren), with adult(s) performing duties of parenthood/caregiving for the child(ren), even if the individual is living outside of the home.
Frequency: The length of time of each anticipated encounter and how often the service will be offered to the child/youth/family. For example, services may be delivered for one hour on a weekly, biweekly, or monthly basis, according to the needs of the child/youth and family.
Initial Service Period: The period of time after accepting an HCBS referral, but prior to obtaining HCBS Authorization. Services can be provided for 96 units/24 hours or 60 days (whichever comes first). The initial service period begins on the first date of billable service for the participant and is service specific. The initial service period is used to complete an intake assessment to finalize service goals and objectives and determine Frequency/Scope/Duration for the service. If the service is needed beyond the initial service period, services must be authorized in accordance with this policy for FFS participants or by the participant's managed care plan.
Parent, guardian, or custodian: Individuals who have custody/guardianship of a child/youth and who can consent to the child/youth's services.
Legally authorized representative: A person or agency authorized by state, tribal, military, or other applicable law, court order or consent to act on behalf of a person.
Participant/Member: A child/youth under the age of 21 years old, enrolled in the New York State 1915c Children's Waiver. Participant and member are used interchangeably in this policy.
Scope: The service components and interventions being provided and utilized to address the identified needs of the child. When submitting an authorization to the portal this field can be used to identify the length of time each encounter for each service will be, example: 1 hour, 30 minutes, etc.
Policy and Procedure
I. Referral to HCBS Providers
Once a child is found eligible for the Children's Waiver and enrolled, the Health Home or care manager must develop a Plan of Care with the child/family to identify their needs, goals, and services. The care manager then makes a referral to a designated HCBS provider for the service(s) specified in the Plan of Care, after the child/family has chosen a provider.
II. Initial Service Period
Once the referral has been sent and the HCBS provider is selected to provide the service, the HCBS provider will schedule a first appointment with the child/family. During the initial service period, the HCBS provider must meet with the child/family to confirm the need for the service and determine how the service will be delivered.
Although HCBS providers are not required to submit a request for authorization for services provided during the initial service period, prior to delivering any services, HCBS providers must collect and maintain documentation demonstrating a credible need for those services (i.e., to avoid imminent out-of-home, institutional placements, or to assist the child to return to their home and community after discharge from an institutional level of care) such as detailed referral information documenting the need for HCBS services. This requires that the HCBS provider independently evaluate a credible need for the service, the goals of the child/family, and whether the provider can provide a service that will reach the desired goal; it must also assess and document all other paid and natural support services the child may be receiving to ensure a lack of duplication.
If the member's needs are met during the initial service period and no additional services are required, then an HCBS Authorization Request is not needed and the child can be discharged, and the service closed.
III. Requests for Authorization and Reauthorization
If the care manager and HCBS provider, in coordination with the child/family determine that there is a need for services to continue beyond the initial service period, and services are necessary because the child would be at imminent risk of institutionalization absent those services, then the HCBS provider must complete an HCBS Authorization Request within the Referral and Authorization Portal as soon as the Service Plan is completed, but not later than 14 days before the end of the initial service period.
The HCBS provider must demonstrate how the scope of the service aligns with the service definition and how the activities will assist the child/family in reaching the goals outlined in the Service Plan. The HCBS provider must also provide justification for the number of units requested and the anticipated duration of the service. The scope of the services, the number of units and the anticipated duration must be developmentally appropriate for the child and must not overlap with any other paid or natural supports. The HCBS provider must ensure service delivery in accordance with the service definition, exclusions/limitations of the service, and all other Children's Waiver requirements.
The duration requested should be based upon how the service will be provided and when the goal is projected to be accomplished. Each goal for a particular service may have a different targeted completion date based upon the objectives/activities to be provided (see examples in the Authorization Instructional Guide). Requested duration cannot exceed six months. If there is a need to continue services, the HCBS provider must request reauthorization by submitting a new HCBS Authorization Request.
The HCBS provider will enter the IRAMS Referral and Authorization Portal to complete the HCBS Authorization Request and supply all necessary details and information including, but not limited to, the child's hours in school, extracurricular activities, therapy/medical appointments, and other services the child is receiving. Justification for the number of units being requested, and goals that are clearly defined and match the service definition are required. Additional supportive information to justify the need for the service and requested units may be uploaded to the Portal as an attachment.
Note: The care manager will be able to see the authorization request once it has been finalized and submitted.
Reauthorization is required if the child's need for services will continue after the end of an authorized service period. Reauthorization can be requested by submitting a new HCBS Authorization Request no later than 14 days prior to exhausting the authorized service period. If NYSDOH requires additional information upon receipt of a request, NYSDOH will contact the primary provider contact listed in the Portal to request additional information.
IV. Notification of Authorization Determination
Requests for Authorization may be approved, denied, or partially approved. If the authorization is denied or partially approved, the determination reason will be noted in the Referral and Authorization Portal.
After the NYSDOH determination has been made, the HCBS provider will receive an email alert of the determination. HCBS providers will not receive a determination letter outside of the Referral and Authorization Portal.
The care manager will receive notification of the determination in the Daily Digest. NYSDOH will send a Notice of Decision (NOD) to the child/family.
V. Service Plan Updates
Once an authorization determination has been obtained from NYSDOH, the HCBS provider must update the child's HCBS Service Plan to reflect the authorized frequency, scope, and duration of services.
VI. Additional Resources
For additional information refer to the Children's Home and Community Based Services Manual.
For information on how to submit and complete a request for HCBS services: Children's Home and Community Based Services (HCBS) Referral and Authorization User Guide.
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