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Office of Mental Health

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

500.6

Medicaid Recertification and Waiver Level of Care Recertification

Policy

Each child’s clinical eligibility for the HCBS Waiver’s level of care and each child’s eligibility for Medicaid must be recertified annually. The recertification of the clinical eligibility for the HCBS Waiver is to ensure that the child meets the required level of care so that Waiver resources can be used appropriately to serve and benefit eligible children and adolescents in the community. This is done annually by the local mental health governmental unit (LGU) using the Level of Care (LOC) form. When the child no longer meets the Waiver’s level of care, the slot will become available for others to enroll.

The annual recertification of the Medicaid eligibility ensures that the child continues to meet the Medicaid eligibility criteria so that Medicaid will continue to pay for Waiver services.

Time Line

The initial Waiver Notice of Decision (NOD)-Acceptance letter shows the recertification timeframes for both the clinical eligibility for the Waiver level of care and for Medicaid eligibility. The clinical eligibility recertification of level of care is normally one year from the date of the signing of the initial Level of Care form. The level of care recertification date is shown on the Waiver Notice of Decision-Acceptance letter in the 2nd paragraph, 1st box which reads: “Current authorization for Waiver eligibility will expire effective ______.   In order to continue enrollment in the Waiver program, you will be required to recertify Waiver clinical eligibility at least annually with your local mental health governmental unit (LGU).” (I.E., If the original LOC is signed 3/15/10, it will expire and require re-evaluation of level of care and signing by 3/14/11.)

The Medicaid recertification date is shown on the NOD-Acceptance letter in the 2nd paragraph, 2nd or 3rd box depending on whether the child is eligible for SSI or MA only. If MA only, it is recertified annually and it is the 2nd box which reads: “Current Medicaid authorization will expire effective ________. You will be notified by your local Department of Social Services when it is time to recertify.” If SSI, it is the 3rd box and will read: “As long as you remain eligible for a SSI cash payment, separate recertification of Medicaid eligibility is not required.” In this case, the MA continues as long as there is SSI.

For children who had Medicaid prior to enrolling in the HCBS Waiver, the Waiver and Medicaid recertification dates will likely be different. For children who are eligible for Medicaid only because of their enrollment in the Waiver (i.e. children who qualify because of the parental income deeming waiver), the two recertification dates may be the same. To have the Waiver and Medicaid recertification dates the same, a HCBS Waiver LOC recertification must be completed prior to its annual review. (Note: In such a case, the annual recertification of level of care will be one year from the most recent signing of the LOC.)

Required Recertification Actions

Medicaid: The child and family will receive a letter from the local social services district notifying them that their Medicaid is up for recertification. Typically, the letter will state required documentation and what the process is for recertification and instruct the family to call for an appointment. The ICC will not automatically receive a copy of this notice unless arrangements have been made with the local district. Therefore, it is important to remind the family that, when any notice is received from the local social services district, their ICC must be informed and shown the paperwork. In some counties, including NYC, Medicaid recertification processes will begin far in advance of the known recertification date. If the case is not re-certified, the counties may terminate MA prior to the current certification (or authorization) end date. This is happening more frequently and can cause billing problems because the Medicaid may be ended two months prior to the recertification date that is listed on the NOD-Acceptance Letter. Therefore, it is important that the ICC be informed and take proactive measures to get the recertification done in a timely manner.

HCBS Waiver Level of Care: For recertification, the child and family's current service plan and budget, including any needed documentation to support continued need for this level of care, must be submitted to the LGU for review. The Level of Care form must be signed by the two LGU representatives, returned to the ICC agency and filed in the child’s case record. This will serve as continued proof that the child meets HCBS Waiver clinical eligibility requirements. This work must be completed by the child’s Waiver recertification date (i.e., one year from the signature date of the initial or prior Level of Care).

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