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

Eligibility for the OMH HCBS Waiver is "3-pronged". A child who applies for the Waiver must meet three sets of eligibility criteria, i.e. clinical, Medicaid, and fiscal. The applicant must be found eligible in all three areas. Ineligibility in one area makes the applicant ineligible for the Waiver.

1. Clinical Requirements

To meet the clinical eligibility requirements, a child or adolescent applying for the OMH HCBS Waiver must:

• have a serious emotional disturbance (SED) ;
• be between the ages of 5 and 18 on the effective date of enrollment; the child can be served in Waiver until s/he turns 21, however, s/he must be enrolled prior to his/her 18th birthday;
• demonstrate complex health and mental health needs;
• require institutional level of care;
• be at imminent risk of admission to an institutional level of care
• or must have a need for continued psychiatric hospitalization;
• have service and support needs that can not be met by just one agency/system;
• be capable of being cared for in the home and/or community if Waiver services are provided; and
• have a viable and consistent living environment with parents/guardians who are able and willing to participate in the HCBS Waiver and support the child in the home and community.

Who Determines: Clinical eligibility is determined by the Local Governmental Unit (LGU) representative.

2. Medicaid Requirements

   The requirements for Medicaid eligibility that must be met under the OMH HCBS Waiver are:

   • The child/adolescent must meet all federal categorical criteria for eligibility, e.g. the child/adolescent must be a citizen of the US or meet the definition of "qualified alien" in order to be eligible for Medicaid.
   • The child/adolescent's own income and resources, after deducting applicable disregards and exemptions, should be less than the current Medicaid Income Exemption Standard for a family of one. If it is not, effective January 1, 2009, a spend-down process may be initiated.
   • Only the child/adolescent's own income and resources are taken into consideration. The parents' income and resources are not counted due to the waiver of parental deeming.
   • The child's Medicaid coverage must be in a county which is participating in the OMH HCBS Waiver.
3. Fiscal Requirements

   To be fiscally eligible for the OMH HCBS Waiver, a child/adolescent must be capable of being served in the community within the federally-approved cost of institutional care and within NYS OMH and Division of the Budget approved caps. A projected annualized budget is included in every service plan for each child.

   Who Determines: Fiscal eligibility is determined by the Local Governmental Unit (LGU) representative.

Enrollment Considerations

• Children in Other Programs: If a child is currently in a Residential Treatment Facility (RTF) and the family wants to have him or her discharged earlier than expected, the child will not be enrolled formally into the HCBS Waiver until the discharge has occurred. Simultaneous enrollment in these two service models is not allowed.

  Likewise, children receiving Intensive Case Management, Supportive Case Management, Community Residence, Family Based Treatment, other Waiver programs and comparable programs in other service systems (e.g., DSS Therapeutic Foster Care) cannot be enrolled in the OMH HCBS Waiver until they have been terminated from such programs.

  Please note, however, that the enrollment activities, e.g. Level of Care determination, Medicaid application and eligibility determination, Service Plan/Budget development and approval, may begin prior to discharge from the RTF or other program.

  Children in Foster Care: At the start of the program, when slots were very limited and the program was not available statewide, children in foster care were not enrolled in the OMH HCBS Waiver. However, since 2000, children who reside in certified or approved foster family boarding homes have been allowed to apply for Waiver enrollment in counties with executed contracts signed by the ICC Agency, LGU, and LDSS regarding this population. It should be noted, however, that children in therapeutic foster care boarding homes are not eligible for the OMH Waiver.

  Like all other applicants for the OMH HCBS Waiver foster care children must meet all of the Waiver eligibility criteria and follow all steps in the enrollment process.

  Two Children From One Family: If there are two children in a family that meet the HCBS Waiver eligibility criteria, they can both be enrolled. However, counties should consider the limited slot capacity of the HCBS Waiver.

  Children with Mental Retardation or Developmental Disabilities: Consistent with OMH policy, the HCBS Waiver may serve children whose IQ is 70 and above. OMRDD serves children whose IQ is 50 and below. A local decision is made to determine the best match of services for children whose IQ is 51-69.

  Children Who Are Not United States Citizens: To be eligible for the Medicaid program, an individual must either be a citizen of the United States, or be a lawfully admitted alien who meets the definition of a "qualified alien" established under the welfare reform legislation in OBRA 96. Since the OMH HCBS Waiver is a Medicaid program, the same rules regarding citizenship/"qualified alien" status apply to the Waiver. If there is any question about a child's citizenship and/or status as a qualified alien, please consult with the Operations Support Unit to discuss what is needed in order to ensure Medicaid eligibility for such a child. Note: Individuals who are in the US illegally can never be eligible for Medicaid and therefore can not be eligible for the Waiver.

Operations Support Unit (OSU)

• The OMH Operations Support Unit (OSU) plays a major role in monitoring the completion of all enrollment steps and in establishing the effective date of enrollment. They do this using information obtained from various Waiver forms, copies of which are faxed or mailed to them at every juncture of the process. It is critical that the Individualized Care Coordination (ICC) Agencies and Local Government Units (LGU’s) are familiar with the OSU's role and adhere to steps that require documentation to be sent to the OSU.

  It is important that all staff involved with record keeping and forms completion become familiar with the required forms. Please note that all originals of forms should be maintained by the ICC agency.

  The OSU is knowledgeable about Medicaid policy and procedures. The Unit also serves as liaison with the local social services districts (LDSS), particularly when there are problems in approving, changing or terminating a child's regular Medicaid or Waiver Medicaid coverage. ICC’s should contact OSU when problems arise with county Medicaid Units. OSU should also be the first line of referral for any case specific Waiver Medicaid eligibility/enrollment issues. Questions regarding the eligibility/enrollment policies contained in this chapter of the Waiver Guidance Document can also be referred OSU who can, if need be, forward them to Central Office Finance Management. The OSU contact is:

  Stephanie Wollman
  Phone: (518) 473-8234
  Fax: (518) 473-2448

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