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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

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

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Form 907 MED (MH) (7-98)
State of New York
Office of Mental Health

Home and Community Based Services Waiver

Level of Care for
Name:
Date of Birth:
Waiver Program:
Instructions: Based on the following criteria, indicate whether the child, in your clinical opinion, meets the level of care requirements for participation in the Home and Community Based Services Waiver Program.
1.   Criteria:
  • The child’s age is between 5 and 18 years of age.
  • The child meets the definition for Serious Emotional Disturbance.
  • The child demonstrates complex health or mental health care needs (relies on Mental Health care, nursing care, monitoring, or prescribed medical or Mental Health therapy in order to maintain quality of life). Receives (or appears to need to receive) medical or Mental Health therapies, care or treatments: that are designed to replace or compensate for a vital functional limitation or to avert an immediate threat to life; and are expected to extend beyond 12 months.
  • The child appears to be capable of being cared for in the community if provided access to, but not limited to, the following services: Individualized Care Coordination, Intensive In-Home Services, Respite Care, Skill Building Services, Family Support Services, Crisis Response Services.
  • The child appears to have service and support needs that cannot be met by one agency/system. The child appears to have a viable and consistent living environment with parents/guardians who are able and willing to participate in the Home /Community Based Services Waiver and support the child in the home and community.

In addition, the child:

  • Currently resides in an institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, and has resided in such a hospital for at least 180 consecutive days, or
  • Had resided in an institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, within the past 6 months and was hospitalized for at least 30 consecutive days, or
  • Is eligible for institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, which provides intermediate or long-term care and treatment, or
  • Has applied for institutional placement, including a hospital as defined in subdivision 10 of section 1.03 of MHL, which provides intermediate or long-term care and treatment or

* SPOA has determined, in the absence of HCBS waiver services, the child would require hospital level of care.

2.  Determination:
  • Yes This child is determined to meet the need for Hospital Level of Care to be eligible to receive services in this program.
  • No  This child does NOT meet the Level of Care criteria to be eligible for services in this program (Specify).
    • Is not between ages of 5 and 18.
    • Does not meet the definition for Seriously Emotionally Disturbed.
    • Does not require, or is not in imminent risk of needing, psychiatric inpatient services.
    • Has not demonstrated complex health or mental health needs.
    • Is not capable of being cared for in the community, if provided access to waiver services.
    • Has service and support needs that can be met by a single agency/system.
    • Does not appear to have a viable and consistent living environment.
    • Cannot be served at less cost than institutional level of care.
3.  Signature: Include printed name, signature, professional title and date.
     1.
     2.

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