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Office of Mental Health

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


Enrollment Phase I – Steps 1, 2 and 3

Step 1: Referrals

Decision to Participate in the Waiver

The decision to participate in the HCBS Waiver is the individual child and family's choice. Participation in the HCBS Waiver is voluntary and a family may withdraw at any point in time.

To be screened for eligibility to apply for HCBS Waiver services, the family must go through the Single Point of Access (SPOA) for their county/NYC borough. The SPOA manages the high need community based services in each county/borough. Referrals made to SPOA must include all elements in the OMH Universal Referral FormThe ICC agency to which the child is referred incorporates select information from the Referral Form into the Financial Information Form, which is ultimately entered into CAIRS and sent to OMH’s Operations Support Unit as the “Transmittal 1”.

It is important that the referring source be as knowledgeable as possible about the eligibility requirements of the Waiver in order to ensure: 1) that the referral is appropriate; and 2) that the packet is complete and well-documented.

The county SPOA reviews the referral, completes an assessment and matches the child with the most appropriate services in the county’s continuum of care service delivery system.

If the family and/or referral source has supporting documentation relating to any item in the Referral Information/Universal Referral packet, it may be referenced and attached in lieu of completing the questions. The more complete an application, the easier it will be for the persons making the Level of Care Determination to determine need for this level of service.

The package should contain documentation to show that the child meets all of the clinical eligibility requirements outlined in 500/1. It should also contain as much information as is available at this point to show that the child is also anticipated to meet the Medicaid and Fiscal eligibility requirements of the Waiver (also in 500/1).

Procedures for Forms Completion

Universal Referral Form (URF)
Purpose: The purpose of the Universal Referral Form is to:

  • identify why the referring staff/persons feel the child would benefit from this proposed level of care;
  • provide information related to the child's and family's ability to meet the HCBS Waiver's eligibility criteria;
  • identify the child's and family strengths and informal support structure related to identified needs;
  • describe any functional impairments; and
  • provide an adequate summarization of historical and current events, treatment, and/or information related to treatment needs.

Completed by: The referral information on the Universal Referral Form is completed by the treating staff, agency, private clinician, and/or the person, as appropriate, making the referral.

When Completed: The Referral Information/Universal Referral Form is completed at the time of referral.

Distribution: Original - ICC Agency.

Step 2: Screening

Referrals are made to SPOA. The SPOA reviews the referral packet for completeness and screens the child for potential eligibility for the Waiver.

In the course of the screening, it may become apparent that the child will not meet the eligibility requirements for the Waiver. While the SPOA/LGU/ICC can not refuse an individual's request for screening and Level of Care determination, they can indicate to the individual that it appears unlikely that the SPOA/LGU will be able to make a positive Level of Care (LOC) determination based on the information provided and that pursuit of the application without additional documentation will probably result in denial.

At times, discussions such as these lead to the gathering of additional information that substantiates the need for the level of service. Other times, it may lead to discussions with SPOA regarding accessing more appropriate services and withdrawal of the referral by the family. In some situations, Waiver providers may be asked by the SPOA or LGU to complete the Screening Form for ICC Agency (900 Med) to further assist the SPOA or LGU in determining whether the waiver applicant meets the criteria for Waiver level of care.

Procedures for Screening Forms Completion

Screening Form (900 Med)
Purpose: The purpose of the 900 Med is to:

  • identify, after review of referral and other subsequent information, that all the waiver screening criteria appear to be met for this individual child;
  • indicate the Individual Care Coordinator's recommendation regarding potential eligibility to apply for waiver services.

Completed by: The Screening Form is completed by the Individual Care Coordinator if requested by the SPOA or LGU.

When Completed: When requested by the SPOA or LGU.

Distribution: Copy of Screening Form to SPOA or LGU; original retained in ICC file.

Step 3: Level of Care Determination

Who Conducts Level of Care Determination

One of the Level of Care signatories must be the LGU or his/her designee. Both Level of Care signatories must meet the following qualifications: The signatory must be a psychiatrist, psychologist, registered nurse or nurse practitioner licensed in NYS, Licensed Master Social Worker, Clinical Social Worker or Certified Social Worker with a minimum of three years experience serving children or adolescents with serious emotional disturbances. Both signatories must meet the above criteria; however, if there are extenuating circumstances whereby one member does not meet the above criteria, the LGU must make a request to OMH central office in writing and an exemption may be granted by OMH. Copies of such exemptions are maintained at the OMH Central Office. An example of a situation which could be approved for exemption would be a social worker with a master's in social work who is not licensed but has the prerequisite years of experience. Another example would be an individual who does not meet the above academic criteria but who does have a bachelor's degree in human services and five years serving children or adolescents with serious emotional disturbances.

Making the Level of Care Determination

The SPOA team reviews all information in the referral packet and determines whether the child meets the level of care for Waiver. If it is determined that Waiver is the appropriate level of care, the LGU or his/her designee then completes the Level of Care (LOC) form Level of Care. The recertification date for the level of care is one year from the date on the initial Level of Care. The LOC Recertification is signed by two qualified reviewers including the LGU or his/her designee. Note that each signatory's title/discipline must be clearly indicated.

Notifying the Child and Family Regarding the Screening Results

As soon as the Level of Care form is completed, the LGU representative immediately completes and issues a Result of Screening letter. This letter documents whether or not the child meets the eligibility criteria to apply for HCBS Waiver services and serves as the official notification to all affected parties of the results of the request for screening. This letter is sent to the child/parent(s) or guardian(s), referral source, and ICC Agency.

The Result of Screening letter must be printed on the LGU's letterhead, or as an attachment to a letter sent on LGU letterhead. The LGU may choose to make minor adjustments to the format of this letter to better suit a specific county's needs, however, the overall content of the form must be retained as is.

In addition to advising of the results of the Level of Care Determination, the letter also outlines next steps:

  • If LOC requirements are met, the letter states that the ICC Agency will contact the family to set up a meeting and begin the formal application/enrollment process
  • If LOC requirements are not met, the letter states the referral for the child will be closed unless the family contacts the ICC agency within 10 days of receiving the Results of Screening letter and advise that they wish to:
  • appeal the decision by resubmitting their referral packet with additional documentation and requesting a second LOC determination by the LGU; or
  • choose to continue with the application process without providing any updated/additional documentation.

Waiver Pursuit When Screening Indicates Ineligibility

It is important to note that even though the screening process may indicate that a child does not meet the clinical eligibility criteria for the Waiver, if the family insists on pursuing Waiver enrollment, they must be allowed to do so, even though the end result may be a denial.

It should be clearly communicated to the family that the outcome will not likely change unless someone provides documentation that there has been a substantial change from the original information provided through the referral process.

It is also important to note that there are internal county processes to assist families in accessing appropriate services if they are ineligible for the Waiver or choose not to pursue re-screening or Waiver application. A family must not be left without any options. Each county has a process in place that encourages the referral source to continue working with the child and family to find services/treatment that meets their needs.

Procedures for Forms Completion

Level of Care (907 Med)
Purpose: The purpose of the Level of Care (907 Med) form is to document, after review of referral packet and any other information that may subsequently be provided, whether the Level of Care criteria for the HCBS Waiver are met.

Completed by: Completed by a team of two individuals, one of whom must be a representative of the LGU and both of whom must be members of approved clinical disciplines. The discipline/title of each reviewer must be clearly noted on the form.

When Completed: Complete and send to distributes (see below) within one week of receiving a complete referral packet.
Note: After enrollment in the HCBS Waiver, the Level of Care Determination is reviewed and completed every 12 months.

Distribution: Original – ICC Agency. Copy – LGU file

Result of Screening Letter
Purpose: The purpose of the Result of Screening letter is to:

  • advise the child, his/her parent(s) or guardian(s), and the ICC agency whether or not the child meets the level of care requirements for participation in the HCBS Waiver;
  • apprise the child, his/her parent/guardian what the next steps will be:
  • If LOC criteria are met, ICC will contact family to explain meaning of this decision and begin application process; or
  • If LOC criteria are not met, referral will be closed unless family indicates intent to submit additional documentation and request re-review of LOC. Note: If family requests re-review, must advise intent and submit additional documentation within 10 days of receipt of the Result of Screening form, or referral may be closed.

Completed by: LGU representative.

When Completed/Issued: As soon as Level of Care determination is made, i.e. within one week of the receipt of the referral packet.

Distribution: Original to child/parent(s) or guardian(s); Copies to: referral source, ICC agency, and LGU file.

Supply of form: Word process and/or photocopy. Note: Must be printed on LGU letterhead or facsimile.