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Office of Mental Health

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

100.1

Background, Philosophy, Goals, Target Population, Services, Stakeholders, Funding, Serious Emotional Disturbance (SED) Criteria

Policy

Background

In Chapter 170 of the Laws of 1994, the NYS Legislature provided the authority for the NYS Department of Social Services to apply for a general waiver on behalf of the Office of Mental Health, pursuant to Section 1915(c) of the Federal Social Security Act. This authority was later transferred to the NYS Department of Health. The general waiver provides Medical Assistance to children and adolescents who meet the eligibility criteria and also reimburses several community-based services not previously included in the Medical Assistance program. The children and adolescents whom the Home and Community-Based Services (HCBS) Waiver serves are those who, if not for the HCBS Waiver, would be admitted to institutional levels of care, including long term Residential Treatment Facilities and intermediate psychiatric inpatient care.

The Federal Health Care Financing Administration (now CMS) approved New York's request to waive three statutory requirements per Section 1915(c) of the Social Security Act on January 1, 1996. The first waiver was of the state wideness and comparability requirements to allow the implementation of the HCBS Waiver on a demonstration basis in a limited number of counties and boroughs of New York City. Secondly, the requirements relating to amount, duration and scope of services were waived which made it possible to offer six new Medicaid services (individualized care coordination, respite care, skill building services, intensive in-home services, crisis response services and family support services) in addition to existing State Medicaid Plan services. The third statutory requirement waived was parental deeming. For children who are enrolling in the HCBS Waiver, their parents'/guardians' income and resources are not considered when determining the child's eligibility for Medicaid; a child is considered a family of one.

The HCBS Waiver is reviewed every five years by the Center for Medicare and Medicaid Services and was last approved for a five year period in December, 2008.

Philosophy

Data has shown that children with a serious emotional disturbance are more apt to attain optimal development when supported in their home and community environment. The Office of Mental Health recognizes that these children and adolescents are at unique risk of missing the opportunities necessary to meet the developmental imperatives of their age. The HCBS Waiver ensures that New York’s children and families have access to services that are culturally relevant and that lead to improved resiliency, the achievement of age specific developmental imperatives and a supportive home environment.

The HCBS Waiver utilizes a strength-based, individualized care model to promote wellness, leading to success for the child and family. It ensures effective interventions by implementing a collaborative partnership with the family, treatment provider(s), core waiver services and other natural supports.

The following describes major values emphasized by the HCBS Waiver program.

Child and family participation and freedom of choice are essential to planning and strategizing for effective outcomes.

Success for children requires both effective treatment and the services that Waiver provides. Initial and on-going collaboration between providers and natural supports is fundamental to enhancing resiliency, meeting the imperatives of developmental stages, and promoting wellness for each child and their family.

Psychiatric diagnosis alone does not define the child. The family environment plays a key role in the child's progress and continued success.

All domains of life impact on a child's level of functioning and overall wellness and must be considered in service planning.

Safety is a primary concern throughout enrollment.

The least restrictive environment is the environment of choice for a child and family's success.

Cultural competence is a crucial building block for effective engagement and intervention.

A skilled workforce enables effective care.

Outcome measures provide indicators of program effectiveness.

Goals

The goals of the Home and Community Based Services Waiver are:

Target Population
The target population for the HCBS Waiver is children and adolescents:

Additionally, the youngsters must be eligible for Medicaid under the HCBS Waiver (i.e., are currently enrolled in Medicaid or could be enrolled by meeting federal eligibility standards) in a county with a HCBS Waiver program and be capable of being served in the community at or below the federally approved average yearly cost which is adjusted periodically.

* Children in foster care who reside in foster family homes, including approved relative homes, are also eligible for the HCBS Waiver. The following cannot be enrolled in this HCBS Waiver unless they will be discharged and returned home by the enrollment date: children in Residential Treatment Facilities (RTF), Intensive Case Management, Supportive Case Management, Community Residences, Family Based Treatment, Teaching Family Homes, services in other Waiver programs or services in comparable programs in other systems (e.g., DSS Therapeutic Foster Care).

The Six Waiver Services

There are six specific services that comprise the HCBS Waiver. The services are: Individual Care Coordination, Respite, Intensive In Home, Skill Building, Family Support Services and Crisis Response. Each child must have Individual Care Coordination. The remaining five services are selected as indicated by the child, family and ICC to support goals and objectives in the Service Plan.

The HCBS Waiver services are defined as follows:

Individualized Care Coordination (ICC): This service provides the first and ongoing point of engagement for the child and family. It performs the case management functions for the HCBS Waiver and oversees delivery of the remaining five services. It ensures on-going partnership with the Waiver child and family as well as on-going collaboration with treatment providers. Individualized Care Coordination encompasses development and oversight of service plans that are:

Individualized Care Coordination additionally includes:

The remaining services may be provided by the Waiver program directly or via subcontract with other providers. All services must relate directly to the Waiver child and must be stated as such in the service plans.

Respite Services (RS) provides a needed break for the family and the child to ease the stress at home and promote overall wellness for the child and his/her family. Respite Services' activities include providing supervision and recreational activities that match the child's developmental stage and/or community outings with child e.g school, appointment or a program. Respite care may be provided on a planned or emergency basis, day or night, in the child's home or in the community by trained respite workers with one Waiver child or a group of Waiver children (See Billing Chapter 600).

Family Support Services (FSS) has the following characteristics:

Family Support Services offers activities designed to enhance the health and growth of children and adults in the family unit to ultimately develop safe, stable, and supportive families who are connected to their communities. Family Support Services provide resources, including, but not limited to: education, training, advocacy and supports. Family Support also assists the family by introducing and connecting them to activities in the community (e.g., educational, cultural, recreational) which would foster family cohesion. Such activities must be consistent with the family's budget to assure the possibility of continuing the activities post Waiver enrollment. Family Support group activities for parents (i.e. game nights, annual picnics) are provided as a venue for engaging parents with similar experience as a way of assisting in building natural support systems in their communities. Family Support Services may be provided to Waiver parents/guardians and family members who have frequent and regular caretaking responsibilities for the Waiver child. (See Billing Chapter 600)

Skill Building Services (SBS) focuses on helping the child to be successful in the home, community and school by acquiring both social and environmental skills associated with his/her current developmental stage. Skill Building Services utilizes an individualized, strength based approach in assisting the child in recognizing his/her functional assets/strengths and those that need developing. Support is offered through a variety of activities in areas such as completing homework, problem solving, functional social skills such as receiving a compliment, asking for help, etc., verbal skills, the development of play skills and imagination, organizational skills, cooperation, peer relationships, managing public transportation, empathy, etc. Skill Building may also assist youth in developing skills for independent living and by facilitating access to, monitoring and supporting vocational training. Skill Building Services may be provided to the child's family to support the child's development and maintenance of skills sets. Skill Building may be provided to an individual Waiver child or a group of Waiver children. (See Billing Chapter 600)

Intensive In-Home Services (IIH) provides services that support the child's emotional and social development and learning. IIH provides intensive, on-going interventions that are specified in the child's Waiver Service Plan that may support the child and family in implementing both their Treatment Plan (from the clinical provider) and the Waiver Service Plan (established by the Waiver program). This service reinforces the desired behavioral or cognitive changes by assisting the child and family in everyday application of the clinical treatment plans' strategies and resultant insights. Interventions may include anger management, socialization, psycho-education, crisis de-escalation, support in working through safety plans, parent-child relationship building, parenting skills, feedback on emotional self-regulation in situational contexts, sibling relationship building, developing healthy coping mechanisms, making healthy choices, building self self-esteem, identity issues, etc. These services may be provided in the home or in the community to an individual Waiver child and their family. (See Billing Chapter 600)

Crisis Response Services (CR) reinforces the agreed upon safety plan that the child and family have developed and attempts to stabilize occurrences of child/family crises when they arise. These services may include assessment, consultation, linkage and immediate intervention wherever necessary, for example, in schools, at home and work. This service is available 24 hours a day, seven days a week. (See Billing Chapter 600)

Oversight

The New York State OMH Division of Children and Families and the NYS Department of Health provide oversight, consultation, education, and technical assistance for all aspects of the HCBS Waiver Program. The Division of Children and Families works in close collaboration with various OMH departments including OMH Counsel, Operations Support Unit (OSU), Community Budget, and Finance.

Partnerships / Stakeholders

The HCBS Waiver's success is dependent on the cohesive establishment and maintenance of partnerships with the Local Government Unit (LGU), the Single Point of Access (SPOA), the Individualized Care Coordination (ICC) Agencies (the identified agencies responsible for the Waiver Program in each county), the local Department of Social Services Medicaid Units, the local Department of Social Services Children's Services, the OMH Regional Field Offices and the Office of Children and Families Services (OCFS) Regional Field Offices. Additional stakeholders include the NYS Division of the Budget and the federal Center for Medicare and Medicaid Services.

Waiver Program Funding

The NYS Department of Health provides all Medicaid adjudicated claims for each child enrolled in the HCBS Waiver Program. Based on the Medicaid claims data received from the agencies, the OMH reports to the federal government on service costs and demonstrates that the total statewide Medicaid expenditures are below the Federally defined cost of institutionalization. The NYS Division of the Budget imposes a lower cap per enrolled child which recognizes the actual historical costs for waiver children as well as New York State budgetary constraints. The cap increased in fiscal years 2006 - 07 by 2.8% and will increase in the subsequent two years, 2007 -2008, and 2008 - 09, based on CPI. There is no local share for Medicaid expenditures for children enrolled in the HCBS Waiver slots that are funded by OMH. However, in 2005, the NYS Office of Children and Families Services to further extend services purchased HCBS waiver slots utilizing their preventive services funds. Preventive services slots have a 50% Federal, 30.55% OCFS (State) and 19.45% local (county) share.

Conclusion

Implementation of the Home and Community-Based Services Waiver has been an important step for New York State. Data indicates that as the number of children served by the HCBS Waiver increases, with the support of Waiver many children are capable of remaining in the community with their families, rather than being institutionalized. Families whose children have been enrolled in the Waiver report feeling more confident supporting their children's growth and wellness. Ways to further enhance the HCBS Waiver's ability to serve the children and families of New York State are continually examined. Feedback from participants, providers, counties and other state agencies, as well as outcome data, are used in developing initiatives. The NYS OMH is continually identifying ways to enhance the HCBS Waiver. Initiatives to enhance the HCBS Waiver are developed based on feedback from participants, providers, counties, state agencies and outcome data.

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