Annual HCBS LOC Requirement and Reconcile Process

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Required Annual Home and Community Based Services (HCBS) Level of Care (LOC) Eligibility Determination

This guidance clarifies the requirements and timing for Health Home Care Managers and the Children and Youth Evaluation Service (C-YES) to complete the HCBS/LOC Eligibility Determination and Re-Determination. The new consolidated 1915(c) Children's Waiver for HCBS requires an annual (365 days) HCBS/LOC Eligibility Re-determination to be completed for the child/youth to remain in the Waiver and continue receiving Waiver services.

Children/Youth who previously transitioned from one of the six (6) Waivers between January 1, and March 31, 2019, maintained their annual re-determination (re-certification) date from their previous waiver. If the child/youth from one of the previous waivers did not have an annual HCBS LOC within 2018, then the initial CANS-NY conducted for Health Home or referral acceptance date from C-YES to transition the child/youth to the new consolidated Children's Waiver must be used as the annual HCBS LOC eligibility date and documented why in the case record.

During the transition period, the State allowed an extension for the annual HCBS eligibility re- determination to be completed by June 30, 2019 for expiring HCBS LOCs, due to the significant challenges' providers experienced in the transition from the previous six (6) waivers to the Children's Waiver. It is imperative that children/youth enrolled in the Children's Waiver have an annual active HCBS eligibility in their case record. As a result of the increase notification of expired HCBS LOCs, any child/youth eligible, enrolled, and receiving Waiver services whose has an annual HCBS re-determination that has lapsed or in danger of lapsing, the new HCBS/LOC Eligibility Determination must be completed by November 30, 2019.

All Health Homes, Health Home care management agencies, and C-YES, should audit their records of Waiver enrolled children/youth to ensure all HCBS LOCs are up-to-date. HHCM or C-Yes staff should begin gathering annual re-determination supporting documentation two (2) months prior to the re-determination due date to ensure enough time to complete the annual HCBS LOC.

Note: For children requiring an ICF-IDD LOC from OPWDD Developmental Disabilities Regional Office (DDRO), it is important to remember this process can take up to a month to complete. Timely and on-going communication with the DDRO is encouraged.

Significant Life Event:
As a reminder, if there is a significant life event for a child/youth while receiving HCBS, a new HCBS/LOC Eligibility Determination maybe need. A significant life event is something that occurs in child's/youth's life that impacts their functioning, daily living situation or those that care for the child/youth. Reasons for HCBS/LOC Reassessment Change of Circumstances:

  • Significant change in child's functioning (including increase or decrease of symptoms or new diagnosis)
  • Service plan or treatment goals were achieved
  • Child admitted, discharged or transferred from hospital/detox, residential setting/placement, or foster care
  • Child has been seriously injured in a serious accident or has a major medical event
  • Child's (primary or identified) caregiver is different than on the previous HCBS/LOC
  • Significant change in caregiver's capacity/situation

If the child/youth is also enrolled in the Health Home program, a significant life event may also require a full CANS-NY to be completed.

Placed in an HCBS Restricted Setting:
If a child/youth enrolled in the Children's Waiver is hospitalized or placed in an HCBS restricted setting, then the child/youth can remain in such setting for ninety (90) days prior to having to be discharged from the Children's Waiver program. If the waiver child/youth is also enrolled in the Health Home program while entering an HCBS restricted setting, the Health Home care manager would "pend" the enrollment segment and follow the Health Home "Continuity of Careand Re-engagement for Enrolled Health Home Members # HH0006" policy.

September 2019