Home and Community Based Services Staffing
To receive HCBS under Medicaid, a child/youth must be determined eligible based on
meeting Target Population, risk factors, if applicable, and functional criteria measured
by the HCBS/LOC Eligibility Determination. Only HHCMs or C-YES can determine
HCBS/LOC Eligibility Determination; for some Target Populations, the assistance from
the OPWDD DDRO is necessary for the HCBS/LOC eligibility determination.
Children/youth receiving HCBS through enrollment in a 1915(c) Medicaid Children’s
Waiver will have continued access to HCBS for as long as the child/youth continues to
meet the eligibility criteria for the 1915(c) Medicaid Children’s Waiver as listed below.
Children/youth who are eligible and appropriate for HCBS must have a physical health,
developmental disability, and/or mental health diagnosis with related significant needs
that place them at risk of hospitalization or institutionalization, or that HCBS is needed
for the child/youth to return safely home and to their community from a higher level of
care. (Institutionalization refers to children/youth at risk of being admitted to a higher
level of care such as out-of-home residential settings, hospitalization, ICF-I/ID, or
nursing facility).
This information is required to be
reported to NYS DOH as part of
the waiver annual case review and
audit to meet performance
measures within the Children’s
Waiver and reported to CMS.
Children and youth must be under 21 years old and eligible for Medicaid to receive
Children’s HCBS. Children’s HCBS eligibility is comprised of three components: 1)
target criteria, 2) risk factors, if applicable, and 3) functional criteria.
The HCBS eligibility groups are as follows:
Level of Care (LOC): children/youth that meet institutional placement criteria.
There are four subgroups for children/youth within the LOC group:
The services described in this document are accessible to eligible children/youth once a
Plan of Care (POC) is in place. Further information regarding the POC can be found in
the Children’s HCBS POC Workflow Policy.
To access Children’s HCBS, a child/youth must meet LOC criteria (target criteria, risk
factors, if applicable, and functional limits) using the HCBS/LOC Eligibility Determination
which is housed within the Uniform Assessment System (UAS) along with the Child and
Adolescent Needs and Strengths – NY (CANS-NY) assessment. Only a HHCM, C-YES,
or the OPWDD Developmental Disabilities Regional Office (DDRO; refer to the DDRO
Manual for Children’s Waiver for additional information) are given access in the UAS to
complete the HCBS/LOC Eligibility Determination. During this evaluation and
assessment, the care manager must maintain regular contact with the child/family.
Upon signing and finalizing the HCBS/LOC Eligibility Determination within the UAS, the
HHCM/C-YES assessor will be presented with an outcome of either HCBS/LOC eligible
or not HCBS/LOC eligible, for the identified Target Population. The assessor MUST sign
the UAS Outcome report to lock the HCBS eligibility determination and if found eligible,
trigger the 12 months (365 days) of eligibility. Additionally, this trigger will send a report
to DOH Capacity Management system to add the Recipient Restriction Exception
1. Serious Emotional Disturbance (SED)
2. Medically Fragile Children (MFC)
3. Developmental Disability (DD) and Medically Fragile
4. Developmental Disability (DD) and Foster Care
