Updates and Clarification Regarding Serious Emotional Disturbance (SED) Target Population HCBS Level of Care Eligibility Determination

  • Document also available in Portable Document Format (PDF)

April 4, 2023

Meet Today's Speakers

Colette Poulin, MSSA
Health Program Director
Children's Health Home, Division of Program Development and Management
NY Department of Health

Meredith Ray-LaBatt, MA, MSW
Deputy Director
Division of Integrated Community Services for Children and Families
NYS Office of Mental Health

Agenda

  1. SED Target Population
  2. LPHA Attestation Form Purpose
  3. LPHA Attestation Form Requirements
  4. LPHA Attestation Form Process
  5. Q&A

The goal of today's session is to explain the process and requirements for determining whether children/youth meet the SED Target Population criteria for HCBS

HCBS Children's Waiver

Children/Youth must first meet HCBS Eligibility Determination to be enrolled within the Waiver. The Children's Waiver Purpose:

  • To allow access to an expanded array of services within the Medicaid benefit to address the needs of children/youth
  • To help to maintain children/youth within their home and community and avoid long term residential and institutional stays.
  • To provide ample services and supports to children/youth and their families in order to avoid hospitalizations or out-of-home care for high-risk children/youth.
  • To assist children/youth within an institution access to supportive services to be able to return back to their home and community.

Children's Waiver – HCBS Level of Care

To become eligible and enrolled within the Children's Waiver, an HCBS Level of Care Eligibility Determination must be conducted by either the Health Home care manager or Children and Youth Evaluation Services (C-YES)

This annual assessment has several components that MUST be met for eligibility:

  1. Target Population criteria
  2. Risk Factors, supporting documentation, (if applicable for Target Population)
  3. Functional Impact to Daily Living

HCBS Children's Waiver –Target Populations

There are four Target Populations to access the Children's Waiver

  1. Serious Emotional Disturbance (SED) – which is the focus of this webinar
  2. Medically Fragile (MF)
  3. Developmental Disability/Medically Fragile (DD/MF)
  4. Developmental Disability (DD) and in Foster Care

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SED Target Population

SED Target Population

Target Population: SED

SED is not a Diagnosis, it is a Clinical Determination

This Determination can only be made by a Licensed Mental Health Practitioner/Licensed Practitioner of the Healing Arts (LPHA)		 Health Home / C-YES care managers cannot make an SED determination nor review paperwork i.e., psychological, to infer the SED determination For Health Home enrollment of the single qualifying of SED, the same determination factors must be obtained and documentation needed in the case record.

The SED Determination form for HHSC should be utilized that requires a LPHA signature

SED Requirements

Must meet all mandatory requirements:

1. AGE REQUIREMENT
The child/youth must currently be between the ages of 0 and their 21st birthday.

2. QUALIFYING MENTAL HEALTH DIAGNOSIS REQUIREMENT
The child/youth has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) in one of the diagnostic categories detailed in the LPHA form.

3. FUNCTIONALLIMITATION CRITERIA FOR SED REQUIREMENT
The Medicaid member has experienced functional limitations due to SED over the past 12 months on a continuous or intermittent basis.

Serious Emotional Disturbance (SED)

Serious Emotional Disturbance (SED) means a child or adolescent has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) AND has experienced functional limitations due to emotional disturbance over the past 12 months on a continuous or intermittent basis.

Therefore, the child must meet all three (3) of the following:

  1. The child/youth is currently between the ages of 0 to their 21st birthday

AND

  1. Child/youth has a designated mental illness diagnosis according to the most current Diagnostic and Statistical Manual of Mental Disorders (DSM) in one of the following diagnostic categories:
  • Schizophrenia Spectrum and Other Psychotic Disorders
  • Bipolar and Related Disorders
  • Depressive Disorders
  • Anxiety Disorders
  • Obsessive-Compulsive and Related Disorders
  • Trauma-and Stressor-Related Disorders
  • Dissociative Disorders
  • Somatic Symptom and Related Disorders
  • Feeding and Eating Disorders
  • Disruptive, Impulse-Control, and Conduct Disorders
  • Personality Disorders
  • Paraphilic Disorders
  • Gender Dysphoria
  • Elimination Disorders
  • Sleep-Wake Disorders
  • Sexual Dysfunctions
  • Medication-Induced Movement Disorders
  • Attention Deficit/Hyperactivity Disorders
  • Tic Disorders

AND

  1. The Medicaid member has experienced functional limitations due to serious emotional disturbance over the past 12 months on a continuous or intermittent basis. The functional limitations must be moderate in at least two of the following areas or severe in at least one of the following areas:
    • ability to care for self (e.g., personal hygiene; obtaining and eating food; dressing; avoiding injuries); or
    • family life (e.g., capacity to live in a family or family like environment; relationships with parents or substitute parents, siblings and other relatives; behavior in family setting); or
    • social relationships (e.g., establishing and maintaining friendships; interpersonal interactions with peers, neighbors and other adults; social skills; compliance with social norms; play and appropriate use of leisure time); or
    • self-direction/self-control (e.g., ability to sustain focused attention for a long enough period of time to permit completion of age-appropriate tasks; behavioral self-control; appropriate judgment and value systems; decision-making ability); or ability to learn (e.g., school achievement and attendance; receptive and expressive language; relationships with teachers; behavior in school).

SED for HCBS Eligibility Determination

Once the SED Determination has been made by a LPHA and proper documentation has been gathered, then the HHCM/C-YES can move towards the next part of the assessment process

  • Risk Factors
  • LPHA Attestation Form
  • For Health Home: the SED Determination documentation consist of the LPHA signature on the SED Determination form or LPHA written documentation of SED as part of an assessment completed.
    • The SED Determination form alone is not enough – the assessment documentation from the LPHA must accompany the form, such as a psychological, psycho/social, etc.
  • The Health Home SED Determination form cannot be substituted for the HCBS LOC LPHA Attestation Form, but should be shared with the LPHA completing the Attestation, if a different practitioner

SED Risk Factors

The child/youth must meet oneof the following factors 1–4 ANDmust also meet factor 5.

1.
Currently in an out-of- home placement, including psychiatric hospital

Supporting documentation is needed to support this choice, i.e., admission paperwork, letter form the institution signed and with credentials, discharge paperwork within the last 3 months		 2.
Has been in an out-of- home placement, including psychiatric hospital within the past six months

Supporting documentation is needed to support this choice, i.e., discharge paperwork, letter form the institution signed and with credentials, letter from the SPOA of confirmation of out-of-home placement		 3.
Has applied for an out- of-home placement, including placement in psychiatric hospital, within the past six months

Supporting documentation is needed to support this choice, i.e., Letter from the SPOA that an application/discussion/r eview occurred for an out-of-home placement		 4.
Currently is multi- systems involved* (i.e., two or more systems) and needs complex services/supports to remain successful in the community

Supporting documentation is needed to support this choice, i.e., paperwork from each multi-systems that identify the specific needs of the member for their involvement and meeting the definitions		 5.
Must be SED as determined by a Licensed Practitioner of the Healing Arts (LPHA) who has the ability to diagnose within their scope of practice under NY state law OR to be filled-out by a Licensed Practitioner who is under the supervision of a LPHA who has the ability to diagnose within their scope of practice under NY State law.

Multi-systems Involvement

Defined as two or more child-serving systems, one of which must be involvement in the children's mental health system and at least one other system, as outlined below.

  • If the member is receiving more than one mental health service, this would only count as one system involvement, inclusive of school-based behavioral health services.
    • Other systems can include:
      • Child welfare (e.g., CPS, Foster care),
      • juvenile justice (e.g., Probation),
      • Department of Homeless Services,
      • OASAS clinics or residential treatment facilities or institutions*,
      • OPWDD services or residential facilities or institutions*, or
      • having an established school IEP and in receipt of services through the school district.
    • However, multi-systems involvement does not include systems/services that all children should receive such as school or primary care services.
    • Enrollment in a Medicaid managed care plan, Health Homes/C-YES, HCBS, or other care coordination services also does not count toward multi-systems involvement.

    *Please note that children/youth with an I/DD or SUD diagnosis must have a co-occurring qualifying mental health diagnosis, meet the SED criteria, and be at risk of hospitalization/out of home placement due to their mental health needs, in order to be enrolled in HCBS under the SED Target Population.

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    LPHA Attestation Form Purpose

    • Part of the Children's Home and Community Based Services (HCBS) enrollment application for children/youth who meet criteria for the Serious Emotional Disturbance (SED) Target Population and Risk Factors.
    • The LPHA documentation must demonstrate that, if not for the HCBS available through the Children's Waiver, the child/youth would be at risk of hospitalization or out-of-home treatment as a result of SED.
    • The LPHA Attestation Form is needed for the initial and annual reassessment of LOC to demonstrate the child/youth continues to meet the required clinical and risk factors to receive HCBS.
      • Must be completed by the LPHA.

        Please note that the content and requirements outlined in this webinar are effective immediately, as the changes made to the LPHA Attestation Form and process are to provide additional clarity and do not represent new requirements that were not previously in effect.

        Mental Health Involvement

        For children/youth who need and meet HCBS requirements due to the fact that either:

        1. They are at risk of institutionalization due to mental health high risk/high needs OR
        2. They are currently in an institution for their mental health and need supported services to return to their home and community

        These children/youth MUST be connected to the mental health system prior to HCBS LOC assessment. HCBS are supportive service and not clinical services. If children/youth have significant mental health concerns to meet the HCBS Risk Factors, then they should be connect to clinical mental health providers

        THEREFORE:
        Connection to the mental health system must be documented and only those treating or working with the child/youth surrounding their mental health can complete and sign the LPHA Attestation Form

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        LPHA Attestation Form Requirements

        Only the following practitioners can complete the HCBS LPHA Attestation Form and MUST provide supporting documentation regarding their role with the member:

        • A clinician who is actively serving the child/youth, and who will have to indicate for how long they have been serving the member, or
        • A clinician who has previously worked with the member in a clinical capacity within the last 12 months, or
        • A clinician, that was referred for the purpose of completing the comprehensive evaluation in order
          • *For this response, please attached the relevant supporting document
          • Date of evaluation is required

        OR

        • If the child is identified as having significant needs by the HHCM/C-YES, and they have been unsuccessful in getting a treating clinician to complete the form, HHCM/C-YES may contact the county Children's Single Point of Access (C-SPOA) for assistance. The C-SPOA can work with the HHCM/C-YES to collect required information to complete/sign the form. (Documentation will be required to demonstrate efforts the member/family and care manager has attempted to obtain treatment)

        LPHA Attestation – Requirement

        To meet conflict-free care management requirements:

        The attesting LPHA may not:

        • be a supervisor / director or leadership position associated with oversight of the HHCM or C-YES or
        • a contractor/third party hired by the HHCM/C-YES/HCBS provider for the sole purpose of signing the LPHA Attestation Form or
        • a designated HCBS provider agency/staff who is also affiliated with the HHCM agency who is completing the HCBS Eligibility Determination

        For additional guidance, please refer to the Health Home Conflict Free Care Management Policy

        Functional Criteria

        Once the Health Home/C-YES care manager has gathered the documentation and verified Target Population and Risk Factors (with the LPHA Attestation), then they can proceed to completing the Functional criteria portion of the HCBS LOC assessment, which is a subset of the CANS-NY within the UAS.

        All ratings within the UAS must be supported with documentation. Documentation that will be useful to assist with the support for ratings:

        • The gathered documentation for the SED Determination and the LPHA Attestation
        • Documentation from the multi-system involvement, if applicable
        • School documentation
        • Other involved professionals
        • Family shared information

        To meet the Functional Criteria, the child's/youth's mental health condition is impacting their daily functioning in a number of areas. Having a diagnosis or SED alone is not enough.

        Clarification and Updates Occurring

        The goal of this webinar and updated policy, is to ensure that children/youth who are at high risk and have high needs due to their mental health, are properly connected to mental health services and have access to HCBS

        Documentation of the child's/youth's mental health and supporting documentation of SED and HCBS Risk Factors are key to ensuring compliance with HCBS Eligibility Requirements

        There may be many children/youth who could benefit from HCB Services, however, the Children's Waiver is required to meet the high risk needs of certain populations

        • HH/C-YES care managers should not refer or complete the HCBS LOC for children/youth who will not meet these requirements. Instead, focus should be spent connecting the child/youth to other available services, Medicaid or other, within their community

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        Q&A

        Thank you!

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