Staffing for Home and Community-Based Services
To be eligible for HCBS (Home and Community Based Services) under Medicaid, a child or youth must meet specific criteria, which include being part of a designated Target Population, having certain risk factors (if applicable), and meeting functional requirements as determined through the HCBS/Level of Care (LOC) Eligibility Assessment. Only Health Home Care Managers (HHCMs) or C-YES (Children and Youth Evaluation Service) are authorized to make this determination. In some cases, assistance from the OPWDD (Office for People With Developmental Disabilities) Developmental Disabilities Regional Office (DDRO) may be required.
Children and youth enrolled in the 1915(c) Medicaid Children’s Waiver can continue to receive HCBS as long as they remain eligible under the waiver’s criteria. This eligibility is based on having significant physical health, developmental disability, or mental health needs, which place them at risk of hospitalization or institutionalization, or make HCBS necessary for their safe return home from a higher level of care. Higher levels of care refer to settings such as out-of-home residential programs, hospitals, ICF/IID (Intermediate Care Facilities for Individuals with Intellectual Disabilities), or nursing facilities.
This information must be reported to the New York State Department of Health (NYS DOH) as part of the waiver’s annual case review and audit, which is used to track performance measures under the Children’s Waiver and reported to the Centers for Medicare & Medicaid Services (CMS).
Children and youth under the age of 21 who are eligible for Medicaid may qualify for Children’s HCBS based on three components: 1) target population, 2) risk factors (if applicable), and 3) functional criteria.
The HCBS eligibility categories include:
Level of Care (LOC): children and youth who meet criteria for institutional placement. There are four subgroups within this category:
Serious Emotional Disturbance (SED)
Medically Fragile Children (MFC)
Developmental Disability (DD) and Medically Fragile
Developmental Disability (DD) and Foster Care
Children who are eligible can access these services once a Plan of Care (POC) is established. More details about the POC can be found in the Children’s HCBS POC Workflow Policy.
To determine HCBS eligibility, the child/youth must meet the LOC criteria, including target population, risk factors (if applicable), and functional limitations, as part of the HCBS/LOC Eligibility Assessment. This process is conducted through the Uniform Assessment System (UAS), alongside the Child and Adolescent Needs and Strengths (CANS-NY) assessment. Only authorized HHCMs, C-YES, or OPWDD DDRO personnel can complete this assessment within the UAS. Throughout this process, care managers are required to maintain regular communication with the child and their family.
Once the HCBS/LOC Eligibility Determination is finalized in the UAS, the outcome—either eligible or not—will be documented. If the child is deemed eligible, the care manager must sign the UAS Outcome Report, which will lock the eligibility for 12 months (365 days). Additionally, the system will notify the DOH Capacity Management system, which will initiate the Recipient Restriction Exception process.