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Office of Mental Health

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

500.4

Phase II – Steps 4, 5, and 6

Step 4: Waiver Application/Freedom of Choice

Face-to-Face Meetings with the Child

The ICC agency contacts the family to schedule a face-to-face meeting as soon as possible after the Results of Screening letter has been issued and they know that a slot will be opening up. The purpose of this meeting is to begin the formal application and enrollment process.

Completing the Application/Freedom of Choice Form

During the initial face-to-face meeting, the ICC and family must complete the:

  • Application to Participate/Freedom of Choice - This is the formal application to the HCBS Waiver. Completion/signature of this form starts the formal eligibility determination process which ends with the issuance of a formal Notice of Decision/Rights of Appeal.

The form and its content are required by the federal government as proof that family members are voluntarily choosing the HCBS Waiver as an alternative to institutional level of care. Although it can be word processed and printed on ICC agency letterhead, the content should not be changed. Note that a witness of the parent/guardian's and child's signatures is required to attest to the voluntary nature of the signatures.

Significance of the Date the Application is Signed

The date the family signs the Application to Participate/Freedom of Choice form is significant for the following reasons:

  • Once the application form is signed, the ICC agency may start to provide start-up ICC services. Note: During the period between the signing of the application and the date the child actually becomes enrolled in the Waiver only start-up ICC services can be billed and reimbursed. The remaining five waiver services can not be billed separately until after the effective date of enrollment has occurred.
  • The application date starts the 30/45* day window, during which time the determination of eligibility for the Waiver should be completed in order to:
  • meet Medicaid statutory requirements; and
  • assure that the ICC agency is able to receive full reimbursement for services provided.

    *30 days for the ICC to complete the required paperwork and 45 days for the LDSS/OSU to issue the applicable Notices of Acceptance. (Note: If Determination of Disability is required, the LDSS statutorily has 90 days rather than 45 days to finalize the determination and issue the notice.)

Continuing the Enrollment Process

During the face-to-face meeting with the family, the ICC should discuss steps 5-8 of the enrollment process with the family and may begin to gather the information and do the work necessary to complete these steps.

Procedure for Form Completion

Application for Participation/Freedom of Choice
Purpose: The purpose of the Application for Participation/ Freedom of Choice is to:

  • provide the family with written confirmation of the clinical eligibility criteria for the Waiver;
  • document family's request to apply for participation in the HCBS Waiver;
  • ensure that family is aware of their freedom of choice between hospital treatment or participation in the Waiver;
  • establish the date that the ICC agency can begin to provide ICC services; and
  • start the 30 day enrollment (start-up) period "clock", i.e. date of enrollment must be effective within 30 days of the date the application is signed if ICC agency is to receive maximum allowable reimbursement.

    Note: regarding billing for the enrollment period: 1. Child must be enrolled a sufficient number of days and receive required contacts to bill half or full month, or two consecutive half months, respectively.  2. The maximum amount of time that can be billed during start-up is 30 days, or one month regardless as to how long the start-up period takes. It is therefore to the providers’ advantage to complete and submit all necessary CAIRS based information to OMH (OSU) in a timely manner.

Completed by: Completed by the child and child's parent(s) or guardian(s) with assistance from the ICC agency.
Note: Witness is required for parent/guardian's signature.

When Completed: Completed at the face-to-face application meeting with the family, which is scheduled when it is known that there will be a vacant slot in the program which can be filled within the next 45 days.

Distribution: Original - ICC file.

Supply of form: Word process or photocopy supply of form
Note: This form may be printed on ICC letterhead, but the content of the form should not be modified.

Step 5: Medicaid Application

Introduction

The following focuses on the Medicaid component of Waiver eligibility. It provides information needed to understand how a child qualifies for Medicaid under the Waiver; to know when a Medicaid application is necessary; and how to complete/file the application package. While this contains much information about the Medicaid application process, specific situations may require additional information. The OMH Operations Support Unit (OSU) is available to respond to questions regarding the Medicaid program/eligibility process.

Important Note : It is expected that a sizable number of children who apply for the Waiver will already be in receipt of Medicaid at the time they apply. The ICC must verify that the conditions of the child’s Medicaid eligibility meet all Waiver requirements. The following deals primarily with those children who, except for the Waiver, would other-wise be ineligible for Medicaid. 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.

Medicaid Eligibility Requirements

Participating County

It is the responsibility of the Medicaid Unit in the local social services district (LDSS) to determine whether a child applying for the OMH HCBS Children's Waiver meets the Medicaid requirements for Waiver enrollment.

In order to participate in the OMH HCBS Waiver, a child must have Medicaid coverage in a county which is participating in the OMH HCBS Waiver.

In the normal situation a child will reside and be eligible for Medicaid in the same county in which his/her Waiver program operates. However, there are situations where the county responsible for a child's Medicaid coverage may not be the county where a child resides. The most common situation where this occurs is adoption subsidy cases, i.e. hard to place children who receive subsidy support payments and automatic Medicaid from the placing LDSS when they are adopted, sometimes by families from other counties.

If both counties are participants in the Waiver, then it is up the family and the ICC programs involved to decide which program can best serve the child/family's needs. If the family lives close enough to be served by the program that operates in the county that is responsible for the child's Medicaid, this is the preferred choice but it is not mandatory. For all incidents involving Oneida County, the only non-participating county, contact OSU.

General Program Categorical Requirements

The child must meet all federal categorical criteria for Medicaid eligibility, including:

Identity - It is the responsibility of any applicant for Medicaid to document his/her identity. The preferred proof of identity is a copy of a photo ID card. However, since children do not usually have these documents, a birth certificate is accepted. For other acceptable sources of proof of identity, contact the OMH Operations Support Unit (OSU).

Residence - Applicants for Medicaid must provide proof of residence in a county. Contact OSU for acceptable sources of proof of residence.

Citizenship - To be eligible for Medicaid, an applicant must be a citizen of the US (i.e. born in the US or someone who has acquired citizenship through the naturalization process) -or- must meet the definition of "qualified alien". The best proofs of citizenship are the birth certificate (for US born) or Certificates of Citizenship/Naturalization (i.e. INS forms N-550, N-560, N-561 and N-570). Qualified Alien (QA) status is more difficult to determine/document. Contact OSU for information on all acceptable proofs of citizenship/QA status.

Note: We strongly recommend that you contact the Operations Support Unit (OSU) as soon as possible if there is any question at all regarding the citizenship status of a child who is applying for the Waiver. OSU staff can assist you in your efforts to determine as quickly as possible whether the child will meet the Medicaid program's citizenship/QA requirements, thereby minimizing the outlay of any expenses for which you may not be able to be reimbursed.

Age -Normally, any one under the age of 21 is considered to be a "child" for purposes of the Medicaid program. However, for enrollment in the OMH HCBS waiver, an applicant must be over age 5 and under age 18 on the effective date of his/her enrollment. Any child who will be under 5 or over 18 as of the expected date of enrollment can not be considered for enrollment. A copy of a birth certificate is the preferred proof of birth.
Note: A child can be served in Waiver until s/he turns 21, however, s/he must be enrolled prior to his/her 18th birthday.

Financial Requirements

Normally when a child who applies for Medicaid resides in his parents' home, both the child's and the parents' income(s) are counted when determining the child's Medicaid eligibility. This is referred to a "parental deeming". However, under the conditions of the OMH Waiver, parental deeming has been waived and only the child's own income and resources are taken into consideration in determining the Waiver applicant's Medicaid eligibility. Consequently, you only have to gather/document the child's income/resource data, not the parent(s)'.

To qualify for the waiver, the child/adolescent's own income and resources, after deducting applicable disregards and exemptions, must be less than the current Medicaid Exemption Standards for a family of one, or a plan for a spend down must be made and accomplished. See the section titled "Assembling the Medicaid Application" for information regarding what kinds of income must be considered as belonging to the child. Contact OSU for the current Medicaid Exemption Standards.

Note: Medicaid Exemption levels, like all federally funded benefits (e.g. SSI, SSA, VA) are usually increased as part of the annual cost of living adjustment (COLA) that takes place January 1st each year. At this time, each Medicaid recipient's eligibility is recalculated using the new standards and any increases in income that may have resulted as a result of the COLA.

Spend Down: Effective January 1, 2009, CMS approved the State's request to allow children to be enrolled in the Waiver whose countable income is in excess of the current MA Income Exemption Standard, IF all other criteria is met and the child's income can be "spent down" to the Medicaid allowable monthly amount. This is accomplished when the child's excess countable income above the allowable monthly Medicaid income is spent on medical expenses that the child incurs or the amount of the monthly excess income is paid directly to the local district of social services. The ICC agency must document how excess income is handled.

Category/Budgeting Requirements

Under OMH HCBS Waiver for Children and Adolescents with Serious Emotional Disturbances (SED), parental deeming of income and resources is waived and the child is budgeted as a household of one. Medicaid eligibility must be determined using the budgeting methodology most beneficial to the child.

A child applying for the OMH Waiver may be eligible for Medicaid in either of the following categories: ADC- related or SSI-related. It is expected that most of the Medicaid applications filed for OMH Waiver children will be filed for the child only using the ADC-related category and will be budgeted using the ADC budgeting methodology. If the child is ADC-Related, there is no resource test and it is not necessary for the LDSS or State Review Team (SRT) to make a disability determination for the child. However, if the circumstances of the case are such that SSI-related budgeting is more advantageous for the child, the case must be referred for a disability determination and there is a resource test.

The reason to request that the local social services district (LDSS) budget as ADC-related rather than SSI-related is because the ADC category/budgeting does not require that the child be certified as disabled, which means less paperwork on your part and a quicker eligibility determination by the LDSS.

The only circumstance in which the LDSS may be asked to determine initial eligibility using the SSI-related category/methodology rather than ADC, is when ADC budgeting necessitates an income spend down, i.e. the child has countable income in excess of the current MA Income Exemption Standard. Because the SSI budgeting methodology allows more income disregards than the ADC methodology (e.g. $20/mo unearned income disregard, 1/3 child support disregard), it is possible that the excess income can be reduced to the allowable countable income and the child could qualify under SSI without a spend down, or less of one.

Example 1: A child applying for the Waiver on 3/1/07 receives a dependent child benefit from SSA in the amount of $709/month. Since the 2007 Medicaid Income Exemption is $700/month, the ADC category/methodology is used this child would have a spend down of $9/month. However, if SSI budgeting were used, the LDSS would be able to disregard the first $20 of the SSA benefit as an unearned income disregard, leaving the child with only $689/month countable income. This compared to the year 2007 $700/month Medicaid Income Standard makes the child eligible for MA without a spend down.

Example 2: A child applying for the Waiver on 3/1/07 receives child support from his father in the amount of $920/month. Using the ADC budgeting methodology, the child would need a $220/month spend down to be eligible for the Waiver. However, under SSI budgeting the first 1/3 of child support payment may be disregarded in addition to the $20 unearned income disregard. Therefore, after disregarding the $20 unearned income disregard and then $300 (1/3 of $900) as the 1/3 child support disregard, the child is left with $600/month in countable income, or an amount less than the 1/1/07 MA Income Exemption Standard of $700/month, making him eligible for the Waiver with no need of a spend down.

There are other income disregards that are allowed for both the ADC and SSI categories. However, except for the two disregards mentioned in the examples above, the occurrence of these disregards will most likely be quite rare. Please consult OSU with any question regarding whether a source of income received by a Waiver applicant qualifies for disregard. It should be noted that if the parents wish to apply for Medicaid as a family (i.e. not just for the Waiver applicant), this is allowable. However, when the final determination is made, the case must be fully eligible in a federally participating category of assistance (i.e. ADC-related, SSI-related) in order for the child to meet the requirements for Waiver Medicaid. In the event that the family is found eligible in a non-federally participating category, then the child should be taken out of his family's case and s/he should be re-budgeted in his/her own case to see if s/he meets the eligibility requirements for Waiver Medicaid.

When is a Medicaid Application Necessary?

Applicant Not Already in Receipt of Medicaid - A Medicaid application must be completed and filed for any child who is not already in receipt of Medicaid at the time s/he applies for the Waiver.

Applicant Already in Receipt of MA in LDSS - If a Waiver applicant is already in receipt of Medicaid in a local social services district (LDSS)1 at the time s/he applies for the Waiver, a Medicaid application for this child will most likely not need to be filed. However, the ICC must verify that the Medicaid case that is open for the child is in a federally participating category (ADC related, SSI related (if case involves other family members).

If both of these requirements are met, then no MA application is necessary for this child. However, if either of these requirements are not met, the ICC (or OSU) may have to request that the Medicaid Unit in the LDSS take the child out of the existing case (if in a case with other family members) and/or re-budget the child by him/herself using ADC-related or SSI-related budgeting.

OMH OSU automatically performs a look-up on the Welfare Management System (WMS) for each new child who applies for the Waiver to determine existing MA status and see if there is any special action that needs to be taken. This is usually done when the CAIRS Transmittal 1 is received. However, for questions regarding the child’s Medicaid status, any time before the application is signed, contact OMH OSU and request their assistance in checking the Medicaid system (WMS).  

Applicant Already in Receipt of MA in District 97 - If the child who is applying for the Waiver resides in any of the following residences/ facilities, s/he will most likely be in receipt of Medicaid in District 97 at the time of application: Psychiatric Center (PC) or Community Residence (CR) operated by the NYS Office of Mental Health; or a Residential Treatment Facility, Family Based Treatment (FBT) home, or Teaching Family Community Residence (TFCR), all which are certified but not operated by the OMH.

District 97 Medicaid cases are administered by different units within the OMH Finance Group (i.e. Special Projects Unit (SPU) for RTF, FBT and TFCR cases; and Patient Resource Offices for PC inpatients and residents of state operated community residences.) District 97 Medicaid is only applicable during the period of time that the child resides in the OMH operated or certified facility. As soon as they are notified that the child has been discharged from the PC, CR, RTF or TFCR, OMH staff close the District 97 case.

Therefore, a Medicaid application must be completed and filed for any child who is in receipt of District 97 Medicaid at the time s/he applies for the Waiver. This application must be filed with the LDSS that is fiscally responsible for the child, i.e. usually the county where the child's parent(s) reside.

Note: If a Medicaid application has already been filed by the child/family (or someone else on the child's behalf) and is still pending at the time the child applies for the Waiver, it is important that you ensure that the family responds to any requests for missing information/documentation so that the application is not denied due to failure to furnish requested information. In addition, both OSU and the LDSS must be advised regarding the pending Waiver application. The LDSS must budget the case correctly (i.e. apply Waiver rules from the effective date of Waiver enrollment onward and regular Medicaid rules for any period prior to Waiver enrollment) and notify OSU so they can ensure that the case is coded correctly in WMS.

Assembling the Medicaid Application

Who Completes / Signs

The Application for Medicaid (LDSS-2921) may be completed and signed either by the parent(s) or by the ICC Agency. If the ICC Agency completes, signs and files the application on behalf of the child/family, the parent(s) must complete the Authorized Representative Consent Form designating the ICC to act as the child's authorized representative.

Required Contents of the Medicaid Package

All Medicaid Application packages must contain the following materials:

  • Medicaid Application Form (LDSS- 2921) Fully completed, dated and signed. Note: Keep a supply on hand and use the above named form when filing applications for Medicaid for Waiver children. However, some County Medicaid Units may ask that a different version of the Medicaid application form be completed for some cases, i.e. Access NY Health Care.
  • Copies of All Required Documentation/verifications. These can include but are not limited to proof of the child's:
    • identity
    • age
    • Social Security Number (SSN)
    • legal residence
    • income (including child support paid for the child, Social Security Dependent's benefits)
    • resources (including bank accounts, savings bonds, trust funds)
    • health insurance coverage (carried by parent/guardian)
    • family's shelter and utility costs

Documentation Requirements

Medicaid will not be approved by the LDSS if they do not receive all required verifications. Every effort should be made to include copies of the required documentation with the initial application package filed with the LDSS. However, in the event that there is a piece(s) of documentation that is taking time to obtain, do not delay filing the application because of the missing documentation. In such a case, simply notate the application to show that you are in process of obtaining the specific piece(s) of documentation and will forward under separate cover. Then be sure that the missing documentation is sent to the LDSS as soon as possible.

Failure to furnish all documentation requested by the LDSS could result in denial of the application. If this happens, the application process may need to be repeated and could result in lost reimbursement. It is important to establish a good system to ensure that all required information/documentation is sent to LDSS and that all requests for additional information are responded to quickly. If the family is the one filing the application and responding to contacts from the LDSS, it is important that the ICC monitor the process closely to ensure that all information is furnished.

  • Cover Letter - Used to introduce/identify child to the LDSS as an OMH HCBS Waiver applicant and to reiterate the special rules in effect when processing/budgeting OMH Waiver cases.

The following materials are optional:

  • Documentation of Disability - This information is required only if requested by the LDSS to process the application using the SSI-related category/budgeting methodology. If ADC related budgeting is being sought, this information is not necessary.(See section above titled "Category/Budgeting Methodology" for more information).
  • Request to Be Considered for Enrollment in a Medicaid HMO/PCP. Note: This is only included in the application package if the family has decided they wish to enroll in a Medicaid managed care plan. It could also be submitted at a later date.

Note: Consult with OSU if you have any questions regarding documentation requirements or if requests for information do not appear to correspond with the procedures outlined in this manual and/or those provided to LDSS’s in the "Dear Commissioner Letter" issued by the State DOH.

Filing the Application Package

Where and When to File

As previously noted, it is the responsibility of the LDSS Medicaid Unit in a specific county to determine whether a child applying for the OMH HCBS Children's Waiver meets the Medicaid requirements for Waiver enrollment. Therefore, for all applicants except those for whom NYC is fiscally responsible for the Medicaid, the application package must be submitted to the Medicaid Unit 2 in the County in which the child resides with his parent(s). For children for whom NYC is fiscally responsible, the application package must be submitted to the HRA's Authorized Representative Unit located at 34th Street, NY, NY for processing.

The date that the LDSS receives a Medicaid application is referred to as the "protective filing date" and it is this date that controls the From Date of the applicant's Medicaid coverage. For Waiver Medicaid cases, because there is no three month retroactive period as with other MA applications, maximum retroactivity is the first of the month in which the LDSS receives the package.

If an ICC agency wishes to be to be able to claim maximum allowable reimbursement for services provided during the Start-up period, the Medicaid application must be filed with the LDSS no later than the last day of the month following the month in which the Application to Participate in the Waiver is signed. For example, if the family signs the Application to Participate on 7/1, then the Medicaid application must be received by the LDSS no later than 8/31.

It is in the applicant's and the ICC Agency's best interests, to document the "protective filing date" of the application. It is strongly recommended that whenever an application is hand delivered to a LDSS, that the deliverer obtain a signed/dated receipt from whoever accepts the package at the LDSS; and when the application package is mailed to the LDSS, that it be mailed via a method that will guarantee documentation of delivery and acceptance by the LDSS as of a specific date.

LDSS Processing

Timeframes

By law, the LDSS has 45 days for an ADC related case and 90 days for an SSI disability-related case to complete the eligibility determination process and issue a Notice of Decision regarding Medicaid eligibility. It may take the Districts longer than this to make a final decision, especially if the application package does not contain all of the information/documentation that is needed. However, no matter how long it takes the LDSS to render a decision, if the case is approved, eligibility should be granted retroactive to the first of the month in which the application was received (i.e. "protective filing date" - see "filing the Application Package"). If it is not, please consult with OSU.
Reminder: All requests for additional documentation/information made by the LDSS should be responded to promptly to ensure the quickest possible decision and to reduce chances that the application will be denied.

Face-to-Face Interviews

Medicaid statute/regulations require that the Medicaid District conduct a face-to-face interview with each applicant. How district(s) wishes to carry out this requirement and who must/can fulfill this requirement is something that each ICC Agency must discuss with their local county Medicaid contacts during an introductory meeting that should be set up at the time the Waiver is first implemented in a county or a new provider.

Notice of Medicaid Decision

Once the LDSS completes the eligibility determination, they will send a Medicaid Notice of Decision - Acceptance or Denial (LDSS 3622) to the child/family to advise the results of the determination. This Notice reflects only the decision regarding the Medicaid component of Waiver eligibility. It is not the notice regarding overall acceptance to the Waiver program; that Notice is issued by OSU once they have confirmed that the applicant is fully eligible in all three areas (clinical, Medicaid and fiscal) and have established the effective date of enrollment.

In the unlikely3 event that the LDSS denies the child's Medicaid application, the notice contains information regarding their Fair Hearing rights. When necessary contact OSU or OMH Central Office Division of Child & Family Services staff to discuss whether appeal should be sought.

LDSS Letter to Commissioner Regarding Start Up

When the Waiver is implemented in a new county, the State Department of Health, Office of Medicaid Management (DOH, OMM) sends the local DSS Commissioner a letter apprising him/her of the start-up of the Waiver in his/her county. Attached to this letter are procedures which provide background regarding the OMH Waiver and provide instructions for LDSS processing. Note that there are two different versions of the letter – one for NYC HRA; and one for the remaining county LDSS’s.

The Commissioner is also requested to name person(s) within his county who will function as the primary contact(s) for the ICC when filing applications and for OSU in dealing with systems related and policy issues. This letter also advises that the contact will be requested to attend an orientation meeting with the ICC Agency and OSU to answer any questions that exist and to work out any local procedures that may be needed.

Procedures for Forms Completion

Application For Medical Assistance Ldss-2921
Purpose: The Application for Medical Assistance (LDSS-2921) must be fully completed, signed and dated in order for the local department of social services (LDSS) to perform a determination of a child's eligibility for Waiver related Medicaid, a key requirement for enrollment in the OMH HCBS Children's waiver. The application package should also contain copies of all required documentation.

Completed by: The Application for Medical Assistance may be completed by the parent(s) or by the ICC Agency as the child's authorized representative. If completed by the ICC agency, the child/family must sign the Financial Consent Form.

When Completed: Completed/filed as soon as possible after the Waiver application is signed. Application should be received by LDSS MA Unit within 30 days of the date Waiver application is signed to ensure maximum claim coverage.

Guidelines for Completion: - See a publication issued by the State Department of Health, titled "How to Complete the Social Services Application" .

Distribution: Original – To LDSS; Copies – ICC file, child/family
Note: The application should be sent to LDSS with copies of all required documentation and the Cover Letter for Medicaid Application.

Supply of Form: Order from DSS Forms Unit.

Authorized Representative Consent Form

Purpose: The purpose of the Authorized Representative Consent Form is to provide documentation that the ICC has been authorized by the child/family to file for Medicaid on the child's behalf and to represent the child/family throughout the Medicaid eligibility determination process.

Completed by: Completed either by the ICC or the parent and signed by the parent.

When Completed: Completed only if the parent wishes the ICC to file the Medicaid application on the child's behalf. If completed, should be done so at the time the Waiver application is signed.

Guidelines for Completion: - Enter name of child, parent and ICC Agency in appropriate blanks. Have parent(s) sign and date.

Distribution: Original – ICC file; Copy – child/family

Supply of Form: Word process or photocopy supply of this form.

Cover Letter for Medicaid Application
Purpose: The purpose of the Cover Letter for the Medicaid Application it to identify the accompanying application as belonging to an OMH Waiver applicant so that the LDSS will apply the special Medicaid eligibility rules that pertain to our Waiver Medicaid applicants.

  • identify the accompanying application as belonging to an OMH Waiver applicant so that the LDSS will apply the special Medicaid eligibility rules that pertain to our Waiver; and

Completed by: Completed by the ICC Agency.

When Completed: Completed as soon as the Medicaid application is ready to send to the LDSS. If parent is filing application with the LDSS, the ICC should give the letter to the parent to cover the application.

Guidelines for Completion: - Self-explanatory.

Distribution: Original – LDSS w/ Medicaid Application package; Copies – ICC file, child/family

Supply of Form: Word process or photocopy supply of this form.PDF Document

Step 6: Health Care Options

Health Care Plans

Introduction
The HCBS Waiver initial service plan budget (see Phase III, Step 8) is responsible for the cost of all health care services (medical and psychiatric) that are paid by fee-for-service Medicaid for an enrolled child. This includes not only the six (6) HCBS Waiver services but also all medical and psychiatric services covered under New York State's Medicaid State Plan.

Therefore, if a child being considered for enrollment has high medical costs in addition to his/her psychiatric needs (HCBS Waiver and other State Plan services), the ICC Agency may have difficulty remaining under the program cap, i.e., per slot cap x's number of slots.

One way of being able to consider a higher cost child for enrollment and still remaining within the budgetary limits of the HCBS Waiver is to find other payors, besides Fee-for-Service Medicaid, who will pay for as much of his/her health costs as possible. At the present time there are two realistic options for this: 1) private health insurance coverage through the family; and 2) enrollment of the child in a Medicaid Managed Care Plan through the LDSS.

Private Health Care Insurance

The child may already have coverage under health insurance plan(s) purchased by his/her parent(s) or by the parent(s)' employers(s). If that is the case, these benefits must be used to the extent possible to meet the child's health expenses. In fact, it is a requirement of the Medicaid program that all Third Party Insurance coverage be documented by the LDSS; reported in the Welfare Management (WMS) and eMedNY systems; and be billed prior to claims being submitted to Medicaid, i.e., Medicaid is the "payor of last resort".

However, sometimes a family may have access to health insurance coverage (e.g., through an employer) but has opted not to take advantage of it (or is considering canceling it) because of cost. In cases like this, the LDSS sometimes will pay the premiums if they can document the cost effectiveness of maintaining the policy. Each county handles these situations differently so that it is necessary to contact the LDSS Medicaid Unit directly to find out their policy should such a case arise.

For a HCBS Waiver child with private health insurance, every dollar of health care cost paid by the insurance carrier is a dollar "saved" by the HCBS Waiver budget.

Medicaid Managed Care Plans

All county LDSS’s and the New York City Department of Health contract with managed care organizations to provide managed health care services to their Medicaid recipients. Some Plans cover more services than others, but all Plans covering non-SSI children cover a core group of medical and psychiatric services.
Note: Plans covering SSI children cover a core group of medical service; psychiatric services are usually “carved out” of the SSI plans and are paid by Medicaid FFS wraparound coverage.

Medicaid pays the Plan a monthly premium for each Medicaid recipient who is enrolled in the Plan. It is the responsibility of the recipient to obtain all needed services from the Plan and/or the Plan's contractors. It is the responsibility of the Plan to provide or pay for all covered services that the recipient needs. Medicaid Fee for-Service coverage is available to Medicaid managed care enrollees only for Medicaid services not covered under the Plan's contract.

Some categories/groups of Medicaid recipients are required to enroll in a Medicaid managed care plan, i.e., mandatory enrollment. The rest of the Medicaid population can choose a managed care plan or choose Medicaid Fee-for-Service, i.e., voluntary enrollment, unless in an excluded category.

Until recently4, only children eligible for Medicaid in the ADC categories were subject to mandatory enrollment in Medicaid managed care plans in the counties. However, any child identified on the Medicaid system (exception code 94) as having serious emotional disturbance (SED), was exempted (excluded) from mandatory managed care enrollment, but could enroll voluntarily if they wished. Therefore, since SED status is a requirement of the HCBS Waiver program, Waiver enrollees have been able to elect to participate in the county Medicaid managed care plans, or not.

If a HCBS Waiver child is enrolled in a Medicaid managed care plan, only the monthly premium paid to the Plan (plus any non-covered services that are billed Fee-for-Service) will charge back against the HCBS Waiver budget.

Assessment of Need

When processing the referral/application of a potential enrollee to the HCBS Waiver, the ICC Agency must:

  • obtain complete information/documentation about the family's private health insurance entitlements;
  • obtain as much information about the child's physical health care needs as possible in order to accurately assess their impact on the HCBS Waiver budget;
  • determine whether the purchase of private health insurance and/or enrollment in a Medicaid Managed Care Plan would allow the HCBS Waiver program to remain under the budget cap; and
  • ensure that the LDSS and OSU are aware of any private health insurance benefits that cover the child (so that proper entries can be made in the WMS Third Party Resource (TPR) subsystem).

Once a child who has private health insurance/Medicaid Managed Care coverage is enrolled in the HCBS Waiver, the ICC Agency must ensure, to the extent possible, that the child utilizes covered providers and that insurance/managed care benefits are billed before claims are passed on to Medicaid Fee-for-Service.

Enrollment in a Medicaid Managed Care Plan

Enrollment Requirements

Since the status of managed care implementation differs quite widely from county to county, Individualized Care Coordinators (ICC’s) are encouraged to contact the Medicaid Managed Care Coordinator (MCC) in the county to obtain county specific enrollment/program information. In addition to advising the status of implementation of managed care in his/her county (voluntary vs. mandatory), the MCC can also provide information regarding:

  • which Medicaid recipients are required to enroll in managed care; which recipients are exempt from mandatory enrollment requirements but eligible to voluntarily enroll; and which recipients are excluded from participation in managed care;
  • processes for enrollment and disenrollment, exemption and guaranteed eligibility;
  • benefit packages offered by the different Plan providers (SSI recipients vs. non-SSI recipients); and
  • mental health, alcohol, and substance abuse treatment services which are available through Medicaid managed care.

Note: An HCBS Waiver child may be subject to different enrollment requirements than other family members. For example, some family members may be subject to mandatory enrollment requirements and lock-in provisions, while the HCBS Waiver child may voluntarily enroll in Medicaid managed care and disenroll at any time because of serious emotional disturbance (SED).

Premiums

Premiums paid to the Managed Care provider are billed directly to Medicaid for months that the child is enrolled in the Medicaid managed care plan. As mentioned previously, for enrollees in the HCBS Waiver, these monthly premiums charge back against the HCBS Waiver budget. They will appear on the fiscal management reports under the Medical/Other category.

Medicaid Managed Care after Waiver Disenrollment

The family may continue enrollment in Medicaid managed care after the child's HCBS Waiver disenrollment if the child remains Medicaid-eligible. In some plans, there is a guaranteed 6-month enrollment and the managed care plan may not unilaterally disenroll a child until 6 months after enrollment date, even if Medicaid eligibility is lost. The county Medicaid managed care contact person should have information on whether a particular plan has this guarantee.


  1. Does not include individuals who have Medicaid in OMH, i.e. "District 97". See separate paragraph dealing with District 97 cases.
  2. The specific person to which the application is delivered/addressed in the county Medicaid Unit will depend on the arrangements that have been worked out locally between the LDSS and the ICC agency.
  3. Unlikely due to the fact that the SPOA/LGU/ICC should have performed preliminary screening of the child's eligibility during the screening/referral phase. Children who are clearly ineligible for MA will most likely have been screened out of the process before a Waiver application is filed.
  4. Effective 1/1/07, State DOH began implementing mandatory enrollment of the SSI/SSI-related populations.

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