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 during any phase of the enrollment process.

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.

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. Go to 500.4 for more details on Medicaid eligibility.

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 once all steps of the enrollment process have been completed and the effective date of enrollment has been determined. Note: Billing can not begin until OSU confirms that the case is coded correctly in the WMS/eMedNY system and advises the ICC agency to begin billing.

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 - issued by OSU.
• Notification to start billing - made by OSU.

In order to determine the effective date of enrollment and issue the Notice of Acceptance, OSU must receive copies of all of the following completed/signed/approved/dated documents: (Note: the Financial Information Form replaces the referral forms which were formerly required):

• Waiver Application/Freedom of Choice;
• Financial Information Form;
• Transmittal Form - New Enrollments;
• Level of Care Form (907 MED);
• Medicaid Application (if one is necessary);
• Initial Service Plan (reviewed and signed by LGU); and
• Service Plan Budget (reviewed and signed by LGU).

These forms are sent to OSU using the “Transmittal Form - New Enrollments” The Transmittal Form Instructions provides additional guidance on how to proceed. The required completed forms and the Transmittals must be sent to OSU as soon as possible after completion.

It is anticipated that for most cases the forms will be sent to OSU in two groups, at different times:

Transmittal 1 – copies of: Application/Freedom of Choice; Financial Information Form; Level of Care (907 MED); and the Medicaid application/documentation, if applicable to case (see Note below). Do not postpone sending the application/referral/LOC forms while you are waiting for approval of the service plan and budget.

Transmittal 2 – copies of: approved Initial Service Plan; and approved Initial Budget. Transmittal 2 should be sent to OSU as soon as the signed 901 MED Service Plan and 906 MED Budget are received from the LGU. Failure to send these forms promptly to OSU will result in delays in issuing the Notice of Acceptance and in making the coding changes that are necessary in order for providers to start billing Medicaid.
For Transmittal 2, the ICC Supervisor uses the photocopy of Transmittal 1 as the original and completes the Transmittal 2 portion on the bottom of that form. The original is then sent to OSU and a photocopy is retained in the ICC file.

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, send the copy of the Medicaid application (LDSS 2921) to OSU in Transmittal 2.

Completed by:
The ICC Supervisoris responsible for completing, signing and dating the Transmittal forms and sending all required forms to OSU. OSU checks the signatures on the form to the list of authorized ICC supervisors.

Important Note : The entire packet will be returned to the ICC Supervisor unprocessed if the transmittals are not fully and legibly completed, and all required documents are not enclosed and/or are not properly dated and signed. See the beginning of the form for additional instructions for completion.

Distribution:
Originals are sent to OSU; copies are kept by the ICC agency. Send all originals to:

NYS Office of Mental Health
Finance Group, Operation Support Unit
44 Holland Avenue, First Floor
Albany, NY 12229
Attention: Stephanie Wollman (HCBS Waiver)

Supply of Forms:
Word process or photocopy forms.
Note: Do not modify content of the form.