CurrentIndependent HealthPolicy N/A

Children's Home and Community Based Services (HCBS) Coverage Criteria

Defines coverage and care management for Children's Home and Community Based Services (HCBS) for Independent Health members participating in the New York State children's waiver; describes who is eligible and which services are delivered by the health plan versus designated health homes. Affects members under age 21 on the children's waiver and their care managers/providers.

Policy Summary

PayerIndependent Health

PolicyChildren's Home and Community Based Services (HCBS) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnsure members are eligible for the New York State children's waiver and receive mandatory care management to access covered HCBS services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

under 21age limit for services covered by the health plan

multipleservices listed as covered

mandatorycare management required

Coverage Criteria

General Coverage Criteria

Covered when ALL of the following are met

Eligibility and Age: Member is eligible for HCBS and participates in the New York State children's waiver; member is under age 21

Services listed are available to members under 21 on the children's waiver

Care Management: Member must receive care management; Independent Health will coordinate with the member's existing Health Home Care Management Agency (CMA) or the State-operated C-YES to provide care management

Care management is mandatory for children/youth participating in the Children's Waiver

Coverage for Children's Home and Community Based Services (Children's HCBS) applies to members who are eligible for HCBS and participate in the New York State children's waiver. The policy therefore implicitly excludes individuals who are not eligible for the waiver or who are not participating in the waiver, since the listed services are described as available to waiver participants. Relevant services available through the health plan for members under age 21 include community habilitation, caregiver/family advocacy and support services, prevocational and supported employment (age 14+ where noted), respite (planned and crisis), palliative therapies (expressive therapy, massage therapy, bereavement, pain and symptom management), and non-medical transportation; other supports (environmental and vehicle modifications, adaptive/assistive technology, transitional care coordination and transitional services) are accessed through designated health homes using the Medicaid card.

Policy Summary

PayerIndependent Health

PolicyChildren's Home and Community Based Services (HCBS) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnsure members are eligible for the New York State children's waiver and receive mandatory care management to access covered HCBS services.

SourceLink

On This Page

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Provider Actions & Requirements

Prior Authorization

Prior Authorization / Eligibility — confirm care management and waiver participation

Prior authorization is not specifically required by Independent Health for Children's HCBS in this policy; however, services are available only to members who are eligible for HCBS and participating in the children's waiver and require care management. Providers must confirm member eligibility and participation in the children's waiver and coordinate with the member's care manager before initiating services.

Applies to members <21 enrolled in the Children's Waiver
Confirm HCBS eligibility and waiver participation before providing services
Coordinate with care manager (Health Home CMA or State C-YES) prior to service delivery

Note

Provider action — coordinate with member's care manager

Providers should ensure care management is in place for all Children's Waiver participants and work with the designated care manager to arrange services. If the member's care management is through a Health Home Care Management Agency (CMA), continue coordination with that CMA. If care management is provided by the State-operated Children and Youth Evaluation Service (C-YES), Independent Health will coordinate with C-YES to provide care management.

Verify whether care management is through Health Home CMA or State C-YES
Coordinate service planning and referrals with the member's care manager

Documentation Required

Care Management Documentation Required

Care management documentation is required for waiver participants. Providers must document that the member is eligible for HCBS, is participating in the children's waiver, and has an active care management plan that supports the requested services.

Document HCBS eligibility and children's waiver participation in the medical record
Include care management plan and evidence of coordination with Health Home CMA or C-YES

Note

Eligibility and Age — members under 21, waiver required

Children's HCBS services covered through the member's health plan apply only to members under age 21 who are eligible for HCBS and participating in the children's waiver. Certain services (Environmental/Vehicle Modifications, Adaptive and Assistive Technology, Transitional Care Coordination/Services) are accessed through designated health homes using the member's Medicaid card — providers should direct members to their designated health home for these services.

Covered for members under 21 who are HCBS-eligible and enrolled in the children's waiver
Services via designated health homes (use Medicaid card): Environmental Modifications, Vehicle Modifications, Adaptive and Assistive Technology, Transitional Care Coordination, Transitional Services

Definitions

Children's HCBS definition — what HCBS are and where they are provided

DefinitionChildren's Home and Community Based Services (HCBS) are personal, flexible services provided where children/youth and families are most comfortable to support goals and help maintain children in home or community settings.

PurposeSupport children/youth with complex health, developmental, or behavioral needs to remain at home or in the community and avoid hospital or long-term care placement.

Eligibility / Where providedCovered for members participating in the New York State children's waiver; services are provided in home and community settings (where children/youth and families are most comfortable).

Service examples provided by the health plan for members under 21Community habilitation; caregiver/family advocacy and support; prevocational services (age 14+); supported employment (age 14+); planned and crisis respite; palliative therapies (expressive, massage, bereavement, pain/symptom management); non‑medical transportation.

Services accessed through designated health homesEnvironmental and vehicle modifications; adaptive and assistive technology; transitional care coordination and transitional services are accessed via designated health homes using the Medicaid card.

Care management definition — role and who provides it

DefinitionCare management is the service that provides a person who helps find and obtain the services that are right for the child/youth.

RequirementCare management is mandatory for children/youth participating in the Children's Waiver.

Providers who may deliver care managementExisting Health Home Care Management Agencies (CMAs) or the State-operated Children and Youth Evaluation Service (C‑YES); Independent Health will work with the member's CMA or C‑YES to provide/coordinate care management.

RoleCoordinates services and assists families in accessing appropriate supports across home and community settings.

OpenPayer

Children's Home and Community Based Services (HCBS) Coverage Criteria

Coverage Criteria

Coding

Provider Actions & Requirements

Background

Definitions