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Ann Marie T. Sullivan, M.D., Commissioner
Governor Andrew M. Cuomo

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

500.2

Overview of the Enrollment Process, Withdrawal from Waiver and Transmittals to OSU

The enrollment process for the OMH Home and Community Based Services (HCBS) Waiver involves three distinct phases. Encompassed in these phases are ten separate steps, all of which must occur before a child can be officially enrolled in the Waiver.

All of the steps in the process are necessary to ensure that the HCBS Waiver is serving only those children who meet the clinical, Medicaid and financial eligibility criteria for the Waiver; that freedom of choice and admission processing requirements are met; and that enrollment in the Waiver does not exceed the number of authorized slots.

While the enrollment process may seem complex and multi-faceted, many of the steps occur simultaneously. In addition, some steps may not be necessary in specific cases, e.g. filing a Medicaid application is not necessary for child who is in receipt of Medicaid prior to Waiver application. However, all necessary steps should be carried out in the order and time frames outlined in the sections that follow.

The entities that play significant roles in the enrollment process for the OMH HCBS Waiver are: the referral source; child/family; single point of access (SPOA); local governmental unit (LGU); Waiver Individualized Care Coordination (ICC) provider/agency and the individual care coordinator (ICC); OMH Operations Support Unit (OSU); and the Medicaid Unit in the local department of social services (LDSS). It is important that all parties be knowledgeable about their responsibilities in the enrollment process and that they are aware of the time frames that must be met in order to ensure the earliest possible enrollment date and maximum reimbursement.

Participation in the OMH HCBS Waiver is voluntary. Therefore, a parent may decide to withdraw his or her child from consideration for admission to the HCBS Waiver. The process for the voluntary withdrawal is the Administrative Withdrawal (AW) and can occur only when the Transmittal I has been submitted to OSU and prior to submission of Transmittal II . The AW is processed and sent to OSU through the Demographics screen in CAIRS.

The Phases of Enrollment

Each enrollment phase is carried out with different time frames and by different parties. The phases, with their related steps, are listed below and are explained in subsequent sections.

Phase I
Steps: 1 - Referral; 2 - Screening; and 3 - Level of Care Determination

These three steps should be done in an efficient and timely manner to ensure that families know as quickly as possible and what services/level of care the SPOA/LGU feels are appropriate/available to the child , e.g. within 30 days of the date a complete referral package is received by the SPOA.

Referrals are usually completed by other providers directly to the SPOA; however families can "self-refer".

Screenings are performed by the SPOA/LGU with input from the ICC Program Director or other ICC agency designee.

Level of Care Determinations are performed by two LGU representatives.

Phase II
Steps: 4 - Waiver Application; 5 - Medicaid Application; 6 - Health Insurance Options

Timeframe forPhase II:In order to ensure maximum Medicaid reimbursement, all steps in this phase should be completed within 30 days of the date that the Waiver application is signed.

Waiver Application - completed by child/family.

Medicaid Application - usually completed and filed by the ICC Agency, however, the family may file the application themselves. In either case, the family must furnish the necessary information/documentation needed to complete application. Eligibility determined by LDSS. The LDSS has 45 days (90 if disability determination is involved) to issue the Notice of Decision regarding Medicaid eligibility; however when issued, it should be retroactive to the date the application was filed. Go to 500.4 for more details on Medicaid eligibility.

Health Insurance Options - always involves ICC and child/family. May involve LDSS if family wishes to enroll in MA managed care plan.

If a child is enrolled in Child Health Plus (CHP) prior to Waiver the family should be advised that they have to apply for Medicaid to receive Waiver services, and dis-enroll from Child Health Plus; and upon discharge there may be a gap in coverage between when the Medicaid closes and the CHP starts. There usually is a one month gap in coverage. Also, the family needs to re-apply for CHP and may need to follow-up to ensure that the CHP becomes effective. Each family should be given The Child Health Plus Re-Enrollment Information Letter within 30 days of enrollment into the Waiver. The ICC is expected to review the letter with the family and respond to their questions.  A copy of letter should be kept in Child record, see Client Chart Index Section 3. 

Phase III
Steps: 7 – Service Plans; 8 – Service Plan Budgets; 9 - Approval of Service Plan/Budget; and10 - Notifications (i.e. Medicaid eligibility, Waiver enrollment and start billing)

The initial Service Plan and Budget must be approved and signed by the Local Government Unit (LGU) within 30 days of the date the Waiver Application is signed to ensure maximum Medicaid reimbursement.

OSU will issue the Notice of Decision regarding Waiver Enrollment with the effective date of enrollment once all steps of the enrollment process have been completed and the data has been sent to OSU. Note: Billing cannot begin until OSU advises the ICC agency to begin billing. This billing information is provided through the HCBS Waiver Effective Billing Date Report accessed through CAIRS Client Reports.

Responsible parties:

  • Service Plan and Budget – developed by ICC with child, family and other providers and approved by LGU.
  • Medicaid Notice - issued by LDSS
  • Notice of Enrollment in Waiver - OSU completes the Notice of Decision and the Waiver agency accesses it through CAIRS.
  • Notification to start billing - OSU advises the Waiver Agency through the Effective Billing Date Report in CAIRS and the Waiver agency accesses it thorugh CAIRS.

Instructions for Transmittals #1 and #2

In order to determine the effective date of enrollment and issue the Notice of Acceptance, OSU must receive the dates that the provider agency entered into CAIRS from the following completed/signed/approved/dated documents:

The dates and information from the above are to be entered into CAIRS. It is anticipated that for most cases the data will be entered in CAIRS and will be sent to OSU in two groups, at different times: See HCBS Waiver Enrollment Process For the New CAIRS Demographics Screen.

Transmittal 1 – Enter required data elements into CAIRS including the date of the Application/Freedom of Choice form and date of the level of care form.

Transmittal 2 – Enter required data elements into CAIRS including the initial Service Plan. The date of the initial Service Plan is the date of the last signature, generally the date signed by the LGU.

Note: If a Medicaid application is necessary for the case and it has not been filed with the LDSS by the time Transmittal 1 is ready to send to OSU, then if the Medicaid application has been filed when Transmittal 2 is sent change the Medicaid status to Application Pending on the CAIRS Demographic Screen.

Completed by:
The ICC agency designates who will input the required data into CAIRS with supervisory review and approval.

Withdrawal from the Enrollment Process

Participation in the OMH HCBS Waiver is voluntary. Therefore, a parent may decide to withdraw his or her child from consideration for admission to the HCBS Waiver during the period of time when Transmittal I has been sent to OSU in CAIRS but prior to submittal of Transmittal II of the enrollment process. If a parent indicates a desire to withdraw his/her Waiver referral/application, the ICC Agency should draft a letter with the following statement:

"I, the parent/guardian of (child’s name), wish to voluntarily withdraw my child from consideration for enrollment in the HCBS Waiver."

The parent must sign and date the letter. The original of the letter is retained in the ICC file. If the withdrawal occurs after the Level of Care (LOC) determination has taken place, a copy must be sent to the LGU; and if it occurs after the LOC and Application to Participate (Transmittal 1) have been sent to OSU, then process the case as an Administrative Withdrawal through CAIRS.

When Billing Can Begin

ICC Agencies must not begin billing for Waiver services until specifically advised to do so by OSU. The notification of the Effective Billing Date is done electronically in a report through CAIRS via the Program Notes screen. The report is the HCBS-Waiver Date Advised to Bill Notices. ICC billing staff must wait for notification via this report advising of the enrollment date before initiating billing. Important Note: Receipt of the Notice of Decision - Acceptance form is not to be interpreted as an instruction to begin billing. Notification via the Effective Billing Date Report is required before billing may begin. See Notification Screen and Reports PDF Document (12kb) detailed instructions.

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.