Reminder: Children's Home and Community Based Services Medically Fragile and Serious Emotional Disturbance Target Population
- Reminder is available in Portable Document Format (PDF)
December 6, 2024
TO:Health Homes Serving Children, Children's Care Management Agencies, and Children and Youth Evaluation Services (C-YES)
To qualify for Children's Home and Community Based Services (HCBS), a child/youth must meet criteria for one of the following Target Populations:
- Developmentally Disabled/Foster Care
- Developmentally Disabled/Medically Fragile
- Medically Fragile
- Serious Emotional Disturbance (SED)
Criteria for each of these Target Populations can be found in the Children's Home and Community Based Services (HCBS) Waiver Enrollment Policy.
Medically Fragile Requirements
To qualify for the Medically Fragile or Developmentally Disabled/Medically Fragile Target Populations, a child/youth must have a medical condition that is physically disabling, causing several functional limitations for at least a year, or is likely to be fatal, as defined by Social Security Income/Social Security Disability or NYS Disability Review.
In addition to meeting Target Population criteria, the child youth must also be at imminent risk of institutionalization and have a need for complex supports related to their condition and have a medical/physical condition that is negatively affecting and disrupting their ability to complete daily living tasks, which may lead to a high level of care, such as institutionalization and/or nursing home admission (Functional Criteria).
When using an SSI certification to qualify for the Medically Fragile or Developmentally Disabled/Medically Fragile Target Population, the SSI certification MUSTbe linked to the child's/youth's physical medical condition. In addition to the SSI certification, the child/youth must have a medical condition that is physically disabling, causing several functional limitations for at least a year, or is likely to be fatal, as defined by Social Security Income/Social Security Disability or NYS Disability Review.
Children/youth without a physical disability who receive SSI for other reasons (i.e. psychiatric conditions, parental/caregiver concerns, etc.) do not meet and are not appropriate for the Medically Fragile or Developmentally Disabled/Medically Fragile Target Population.
Serious Emotional Disturbance (SED) Requirements
Children/youth enrolled in the Serious Emotional Disturbance (SED) Target Population must meet specific Risk Factors. When utilizing “Multi-system Involvement” risk criteria, the services received from other child-serving systems, must demonstrate that the child needs complex services/supports to remain successful in the community due to their mental health related need. When utilizing an Individualized Education Plan (IEP) or 504 Plan, these must be linked to a mental health related need. Additionally, the care manager's record must display evidence of collaboration/discussion between the care manager, school, and/or family throughout the year related to the IEP/504 Plan implementation and need for complex supports.
Having an IEP or 504 Plan in the record is not enough to substantiate Multi-System Involvement. Children with an IEP or 504 Plan with needs unrelated to mental health supports or who lack a need for complex coordination to support the plan should not be enrolled in the SED Target Population using the 504 Plan/IEP as documentation of Multi-System Involvement.
Required Action
Health Homes/C-YES and care managers should review participant cases accordingly to ensure all children/youth enrolled in the Medically Fragile, Developmentally Disabled/Medically Fragile, or SED Target Population are appropriately enrolled. Health Homes/C-YES must ensure appropriate enrollment in the Children's Waiver and if any participants are found to be missing necessary eligibility criteria (i.e. inappropriate SSI certification, IEP or 504 plan for needs unrelated to Mental Health, etc.), an updated HCBS eligibility assessment must be completed within 30 days of this letter or if the HCBS eligibility assessment cannot be completed due to the lack of supporting documentation, then the updated Notice of Decision with fair hearing rights to disenroll the member must occur.
Questions on this directive should be sent to BH.Transition@health.ny.gov
