Youth Empowerment ServicesWaiver

Policy & Procedure Manual

December 2017

Table of Contents

YOUTH EMPOWERMENT SERVICES WAIVER PROGRAM

1000 Overview1

1000.1 Notice of Right to Fair Hearing 6

1000.2 Policy Development 7

PARTICIPANT ELIGIBILITY

2000 General Requirements8

2000.1 Demographic Criteria 10

2000.2 Clinical Criteria and Assessment 12

2000.3MedicaidCriteria21

WAIVER PARTICIPATION

2100Medicaid Application Process and Requirements 24

2100.1 Enrollment Process for Individual with Medicaid 27

2100.2 Enrollment Process for Individual without Medicaid29

2100.3 Participant Rights and Responsibilities31

PROVIDER RESPONSIBILITIES

2200 Training Requirements 36

2200.1Community Outreach39

LOCAL MENTAL/BEHAVIORAL HEALTH AUTHORITY RESPONSIBILITIES

2200.2Inquiry List40

LOCAL MENTAL/BEHAVIORAL HEALTH AUTHORITYAND WRAPAROUND PROVIDER ORGANIZATION ROLES AND RESPONSIBILITIES

2200.3Intensive Case Management–Wraparound 46

WRAPAROUND PROVIDER ORGANIZATIONRESPONSIBILITIES

2200.4Individual Plan of Care (IPC)Request 50

2200.5 Co-Occurring Diagnosis 53

2200.6 Critical Incident Reporting54

2200.7 Reporting Abuse, Neglect, or Exploitation57

2200.8 Transition Plan–Level of Care60

2200.9 Transition Plan–Aging Out62

2200.10 Participant Transfer and/or

Change in Comprehensive Waiver Provider64

2200.11 Termination of Waiver Services68

2200.12 Temporary Out-of-Home Living Arrangement71

COMPREHENSIVE WAIVER PROVIDER RESPONSIBILITIES

2300 Credentialing and Enrollment74

2300.1 Criminal History and Background Checks76

2300.2 General Responsibilities78

2300.3 Subcontracted Services81

2300.4 Medication Management83

2300.5Provider Outreach87

2300.6 Provider Network Development88

2300.7 Termination of Provider Agreement89

SERVICES

2400 General Considerations91

2400.1 Adaptive Aids and Supports, 93

2400.2 Adaptive Aids and Supports, Health and Safety Requirements 101

2400.3 Community Living Supports 103

2400.4 Employment Assistance 107

2400.5 Family Supports110

2400.6 Minor Home Modifications113

2400.7 Non-Medical Transportation 115

2400.8 Paraprofessional Services 117

2400.9 Pre-Engagement Services 122

Respite Services

2400.10 In-Home 125

2400.11 Out-of-Home: Camp 128

2400.12 Out-of-Home: Licensed Child Care Center 130

2400.13 Out-of-Home: Licensed Child Care Center

Texas Rising Star Provider132

2400.14 Out-of-Home: Licensed Child Care Home 134

2400.15 Out-of-Home: Licensed Child Care Home

Texas Rising Star Provider 136

2400.16 Out-of-Home: Registered Child Care Home138

2400.17 Out-of-Home: Registered Child Care Home

Texas Rising Star Provider140

2400.18 Out-of-Home: Residential Child Care

Department of Family and Protective Services 142

2400.19 Specialized Therapies: Animal-Assisted Therapy 145

2400.20 Specialized Therapies: Art Therapy 148

2400.21 Specialized Therapies: Music Therapy 150

2400.22 Specialized Therapies: Nutritional Counseling 152

2400.23 Specialized Therapies: Recreational Therapy 154

2400.24 Supported Employment 156

2400.25 Supportive Family-Based Alternatives 159

2400.26 Transitional Services 163

QUALITY MANAGEMENT

2500 Overview 166

2500.1 Health and Human Services Responsibilities 167

2500.2 Confidentiality 170

2500.3 Record Keeping174

BILLING

2600 Enrollment in Texas Medicaid Healthcare Partnership179

2600.1 Local Mental Health Authority180

2600.2 Wraparound Provider Organization and Comprehensive Waiver Provider 181

2600.3 Adaptive Aids and Supports 183

2600.4 Community Living Supports 186

2600.5 Employment Assistance 187

2600.6 Family Supports 188

2600.7 Minor Home Modifications189

2600.8 Non-Medical Transportation 191

2600.9 Paraprofessional Services 193

2600.10 Pre-Engagement Services194

2600.11 Respite In-Home 195

2600.12 Out-of-Home: Camp 196

2600.13 Out-of-Home: Licensed Child Care Center 198

2600.14 Out-of-Home: Licensed Child Care Center

Texas Rising Star Provider200

2600.15 Out-of-Home: Licensed Child Care Home202

2600.16 Out-of-Home: Licensed Child Care Home

Texas Rising Star Provider204

2600.17 Out-of-Home: Registered Child Care Home206

2600.18 Out-of-Home: Registered Child Care Home

Texas Rising Star Provider 208

2600.19 Out-of-Home: Residential Child Care

Department of Family and Protective Services 210

2600.20 Specialized Therapies 211

2600.21 Supported Employment 214

2600.22 Supportive Family-Based Alternatives 215

2600.23 Transitional Services 216

2600.24 18-Year-Old Participants 217

2600.25 Service Notes218

2600.26 Pending Claims 220

2600.27 Payment of Claims 221

APPENDICES

Appendix A Definitions

Appendix B Adaptive Aids and Supports Not Billable List

Appendix C Adaptive Aids and Supports Heightened Scrutiny List

Texas Health and Human Services Commission
Youth Empowerment Services Waiver
YOUTH EMPOWERMENT SERVICES WAIVER PROGRAM
OVERVIEW / 1000

background and history

Texas strives to provide a continuum of services and supports for families with youth who have serious emotional disturbance (SED). The Youth Empowerment Services (YES) Waiver provides comprehensive home and community-based mental health services to children and youth at risk of institutionalization or out-of-home placement due to their SED.

Children and youth may be enrolled in YES Waiver services from ages 3 to 18. The program provides flexibility in the funding of intensive community-based services and supports for youth and their families.

Under direction of the 78th and 79th Texas Legislatures, the Health and Human Services Commission (HHSC) and the Department of State Health Services (DSHS) developed the YES 1915(c) Waiver. The Centers for Medicare and Medicaid Services (CMS) approved the YES Waiver in February 2009. In 2013, the 83rd Legislature directed the YES Waiver to expand statewide which was approved by CMS, effective September 2015.

Waiver enrollment vacancies are allocated by service area (per county) to local mental health authorities or local behavioral health authorities (LMHA/LMBHAs). Allocation of YES Waiver vacancies is determined by HHSC using information on population size, community need, and local infrastructure. HHSC re-evaluates allocations at least annually, or more often as needed. Unused vacancies will be reallocated to areas with greater demand for services.

OBJECTIVES & goals of the yes waiver

The objective of the Waiver is to provide community-based services, in lieu of institutionalization, to eligible youth in accordance with the approved Waiver and program capacity.

The goals of the Waiver are to:

  1. Reduce out-of-home placements by all youth-serving agencies;
  2. Reduce inpatient psychiatric treatment;
  3. Provide a more complete continuum of community-based services and supports;
  4. Ensure families have access to parent partners and other non-traditional support services identified in a family-centered planning process;
  5. Prevent relinquishment of parental custody; and
  6. Improve the clinical and functional outcomes of youth with SED.

The services available through the Waiver are:

  1. Adaptive Aids and Supports;
  2. Community Living Supports (CLS);
  3. Employment Assistance;
  4. Family Supports;
  5. Minor Home Modifications;
  6. Non-Medical Transportation;
  7. Paraprofessional Services;
  8. Pre-Engagement Service;
  9. Respite (In-Home and Out-of-Home);
  10. Specialized Therapies:
  11. Animal-Assisted Therapy;
  12. Art Therapy;
  13. Music Therapy;
  14. Nutritional Counseling; and
  15. Recreational Therapy;
  16. Supported Employment;
  17. Supportive Family-Based Alternatives; and
  18. Transitional Services.

Families enter the program through the LMHA/LBHA. Each family will be assigned a Wraparound facilitator at a Wraparound Provider Organization (WPO) that is responsible for coordinating service planning activities and connecting the family with a chosen Comprehensive Waiver Provider (CWP). CWPs are obligated to develop a sufficient network of direct service providers to serve families in accordance with the Wraparound Plan. The types, locations, and/or availability of servicesmay vary for each CWP.

medicaid services

Youth enrolled in the Waiver are entitled to all Medicaid State Plan behavioral health services, in addition to services specific to the Waiver. Youth participating in the Waiver are authorized into Level of Care–YES (LOC–YES) in accordance with the Texas Resilience and Recovery (TRR) mentalhealth system.For more information about LOC-YES, see the Level of Care Section in the Texas Resilience and Recovery Utilization Management Guidelines for Children’s Mental Health available at:

Medicaid State Plan behavioral health services include, but are not limited to:

  1. Intensive/Targeted Case Management(ICM/TCM)
    (utilized for the coordination of Waiver services);
  2. Psychiatric Evaluation;
  3. Psychological Services;
  4. Counseling;
  5. Crisis Services; and
  6. Mental Health Rehabilitation Services.

contact information

Further information regarding the Waiver is available throughthe Health and Human Services Commission:

  1. Email address:
  2. Website:
  3. Office: 512-838-4334
  4. Fax: 512-838-4372; or
  5. Mailing address:

Health and Human Services Commission

Medical and Social Services Division

Attn: YES Waiver

P.O. Box 149347, Mail Code 2102

Austin, Texas 78714-9347

complaints

To file a complaint contact:

The Health and Human Services Commission

Medical and Social Services Division

Behavioral Health Section

Crisis Services & Client Rights Unit

Monday through Friday, from 8:00 a.m. to 5:00 p.m. at:

Toll Free: 1-800-252-8154

Complaints can also be submitted in writing to:

Texas Health and Human Services Commission

Crisis Services & Client Rights Unit

Mail Code 2018

8317 Cross Park Drive

Austin, TX 78754

OR

Texas Health and Human Services Commission

Crisis Services & Client Rights Unit

P.O. Box 149347

Bldg. Code 1410

Austin, Texas 78714-9347

1

Texas Health and Human Services Commission
Youth Empowerment Services Waiver
YOUTH EMPOWERMENT SERVICES WAIVER PROGRAM
NOTICE OF RIGHT TO FAIR HEARING / 1000.1

notice of right to fair hearing

Per Texas Administrative Code, the written notice to an individual of the individuals’ right to a hearing must be mailed at least 10 days before the date the individual’s eligibility or service is scheduled to be terminated, suspended, or reduced, except as provided by federal rules.

Per TAC,if a hearing is requested before the date a Medicaid recipient’s service, including a service that requires prior authorization, is scheduled to be terminated, suspended, or reduced, the agency may not take that proposed action before a decision is rendered after the hearing.

Within seven business days of an individual being denied initial eligibility,the LMHA/LBHAmust send the Denial of Eligibility letter and Fair Hearing Request form to the individual and legally authorized representative (LAR).

Within seven business days of an individual being denied continued eligibility or terminated from the YES Waiver, the WPO must send the Denial of Eligibility letter and Fair Hearing Request form to the individual andLAR.

Further information regarding the right to a fair hearing is available at: 25 TAC §419.8

Further information regarding the uniform fair hearing rules is available at: 15 TAC RULE §357.11

1

Texas Health and Human Services Commission
Youth Empowerment Services Waiver
YOUTH EMPOWERMENT SERVICES WAIVER PROGRAM
POLICY DEVELOPMENT / 1000.2

consistency with law

No policy or portion of any policy in this manual is operative if it is determined to be inconsistent with applicable law or rule.

1

Texas Health and Human Services Commission
Youth Empowerment Services Waiver
PARTICIPANT ELIGIBILITY
GENERAL REQUIREMENTS / 2000

General requirements for an individual to participate in the YES Waiver include:

  1. Meet demographic criteria;
  2. Meet clinical eligibility criteria;
  3. A reasonable expectation must exist that, without Waiver services, the individual would qualify for inpatient care under the Texas Medicaid Inpatient Psychiatric Admission Guidelines;
  4. Choose, or have the LAR choose, the Waiver as analternative to care in an inpatient psychiatric facility; and
  5. If enrolled, active participation of the individual and LAR regarding:
  1. specified clinical assessments,
  2. person-centered planning forcommunity-based services and supports; and
  3. therapeutic activities for improved clinical outcomes.

An LMHA/LBHA first assesses eligibility, in conjunction with maintenance of an Inquiry List. Once determined eligible, the LMHA/LBHA completes client enrollment and connects the client with services.

In order to participate in the Waiver, an individual cannot be dually enrolled in, nor receive services from, another 1915(c) or 1915(i) program, including, but not limited to the:

  1. Texas Health and Human Services (HHSC) Waiver programs:
  2. Community Living Assistance and Support Services (CLASS);
  3. Home and Community-Based Services (HCS/HCBS);
  4. Medically Dependent Children Program (MDCP);
  5. Consolidated Waiver Program (CWP);
  6. Deaf Blind with Multiple Disabilities (DBMD);
  7. Community-Based Alternatives (CBA); or
  8. Texas Home Living (TxHML).
  9. HHSC 1915(i) programs, including Home and Community-Based Services—Adult Mental Health (HCBS-AMH).
  10. STAR PLUS Community-Based Waiver.

1

Texas Health and Human Services Commission
Youth Empowerment Services Waiver
PARTICIPANT ELIGIBILITY
DEMOGRAPHIC CRITERIA / 2000.1

In accordance with 25 TAC §419.3, to participate in the YES Waiver, an individual must meet the following demographic criteria:

  1. Be 3 through18 years old.
  1. Be eligible to receive Medicaid under an authorized Medicaid Eligibility Group included in the Waiver;
  1. Reside in:
  2. A non-institutional setting with the individual’s LAR; or
  3. The individual’s own home or apartment, if legally emancipated; or
  4. A private residential treatment center (RTC) (excludes the state operated facility, Waco Center for Youth), with a planned discharge date of 30 days or less.

For individuals in substitute care, any phone calls and correspondence shall be copied to the DFPS Caseworker. If the DFPS Caseworker is not engaging in the process, the LMHA/LBHA may contact the DFPS Regional Program Directors for support. If the Regional Program Director is not responsive, the LMHA/LBHA shall contact the HHSC YES Waiver staff.

If an individual meets demographic eligibility criteria, the LMHA/LBHA shall be responsible for completing an assessment for clinical eligibility.

If the LMHA/LBHA has not met maximum enrollment capacity, the LMHA/LBHA shall be responsible for completing an assessment forclinical eligibility within 7 days.

If the LMHA/LBHA has met maximum enrollment capacity, the LMHA/LBHA will be responsible for maintaining the Inquiry List and initiating clinical eligibility determination in accordance with YES policy. [See POLICY 2000.2 and 2200.2 of this manual].

demographic eligibility NOT met

Within seven business days of determining that an individual does not meet the demographic criteria, the LMHA/LBHA shall:

  1. Send the Denial of Eligibility letter and Fair Hearing Request form to the individual and LAR, and DFPS Caseworker-if the individual is in substitute care; Medical Consenter, or Managing Conservator; and
  1. Provide referrals to other services and referrals to the LMHA/LBHA in the individual’s county of residence, as applicable

1

Texas Health and Human Services Commission
Youth Empowerment Services Waiver
PARTICIPANT ELIGIBILITY
CLINICAL CRITERIA AND ASSESSMENT / 2000.2

Once demographic eligibility is determined by an LMHA/LBHA, the LMHA/LBHA completes the assessment for an individual’s clinical eligibility through a two-part assessment process using the YES Assessment and Clinical Eligibility (CE) document in Clinical Management for Behavioral Health Services (CMBHS). The YES Assessment includes the Child and Adolescent Needs (CANS) assessment and community data questionnaire. Some of the information required to complete the YES Assessment may be auto-populatedfrom the Mental Health Uniform Assessment (UA), if an available UA have been completed in the past 90 days. (see User Guide for further information).

Clinical eligibility for the YES Waiverrequires an individual to have serious functional impairment or acute psychiatric symptomatology, as determined by the specific domain scores from the CANS assessmentas part of the clinical eligibility determination.

In addition, a reasonable expectation must exist that, without Waiver services, the individual would qualify for inpatient care under the Texas Medicaid Inpatient Psychiatric Admission Guidelines.

qualifications to perform clinical assessment AND Clinical Eligibility (CE) Document

The qualifications to perform clinical assessments are in accordance with the following:

The initial assessment for clinical eligibility,the YES Assessment,may be performed by a Qualified Mental Health Professional (QMHP) or Licensed Professional of the Healing Arts(LPHA), must be performed at the LMHA/LBHA, and must be signedby an LPHA.

An annual renewalreassessmentcan be performedby a QMHP-CS at a WPO or an LMHA/LBHA; however, an LPHA must review and confirm theindividual would qualify for inpatient care under the Texas Medicaid Inpatient Psychiatric Admission Guidelines. An approval signature from the LPHA is required on the annual renewal reassessment.

CLINICAL ELIGIBILITY DETERMINATION PROCESS

Clinical eligibility must be assessed in accordance with the following process.

  1. Within seven business days of determining demographic eligibility ORup to 30 days in advance but not exceeding 7 days following a vacancy becoming available when enrollments at an LMHA/LBHA are at maximum capacity:
  2. Arrange for a LPHAor QMHPto meet with the individual and LAR to complete the initial Uniform Assessment and Yes Assessment.
  3. An LOC-YES authorization is necessary to access TRR including ICM and other Medicaid State Plan services.
  4. Within five business days of completing the clinical eligibility assessment:
  5. An initial CE document shall be entered into CMBHS.
  6. For an individual without Medicaid, a pending CE document is entered into CMBHS.
  7. The LMHA/LBHA assists the individual in applying for Medicaid.
  8. The LMHA/LBHA is permitted to bill for Pre-Engagement services, inaccordance with BILLING, PRE-ENGAGEMENT SERVICES, policy 2600.10 of this manual.

An individual must meet the clinical level of care criteria in accordance with Criteria A through E.

The individual must score at the identified levels on the following domains on theCANS Assessment:

criteriON a

  1. Score a 0 or 1 on Life Domain Functioning – Developmental; or
  1. Score a 2 or 3 on Life Domain Functioning – Developmental;and
  2. Score a 0, 1, or 2 on Developmental Needs: Cognitive; and
  3. Score a 0 or 1 on Developmental Needs: Developmental.

The individual must score at the identified levels on one or more of the following domains on the CANS Assessment:

  1. Score a 3 on Child Risk Behaviors: Suicide Risk;
  2. Score a 3 on Child Risk Behaviors: Self-Mutilation;
  3. Score a 3 on Child Risk Behaviors: Self Harm;
  4. Score a 2 or 3 on Child Risk Behaviors: Danger to Others;
  5. Score a 2 or 3 on Child Risk Behaviors: Sexual Aggression;
  6. Score a 2 or 3 on Child Risk Behaviors: Fire Setting;
  7. Score a 2 or 3 on Child Risk Behaviors: Delinquency;
  8. Score a 2 or 3 on Caregiver Strengths and Needs: Involvement with Care;
  9. Score a 2 or 3 on Caregiver Strengths and Needs: Family Stress;
  10. Score a 2 or 3 on Caregiver Strengths and Needs: Safety;
  11. Score a 2 or 3 on Life Domain Functioning: School Module; and

a) Score a 2 or 3 on Life Domain Functioning: School Module – School Behavior; or

b) Score a 2 or 3 on Life Domain Functioning: School Module – School Attendance;

  1. Psychiatric Hospitalization Module:

a)Score a 1 on Psychiatric Hospitalization; and

criteriON c

b)Score a 1, 2, or 3 on PsychiatricHospitalization Module – Time Since Most Recent Discharge.

Outpatient therapy or partial hospitalization has been attempted and failed or a psychiatrist has documented reasons why an inpatient Level of Care is required.

criteriON d

A Medicaid-eligible youth must meet at least one of the following Texas Medicaid Inpatient Psychiatric Admission criteria:

  1. The youth is presently a danger to self, demonstrated by at least one of the following:
  1. Recent suicide attempt or active suicidal threats with a deadly plan and an absence of appropriate supervision or structure to prevent suicide;
  1. Recent self-injurious behavior or active threats of same with likelihood of acting on the threat and an absence of appropriate supervision or structure to prevent self-injury; i.e., intentionally cutting, burning, or the like;
  1. Active hallucinations or delusions directing or likely to lead to serious self-harm or debilitating psychomotor agitation or impairment resulting in a significant inability to care of self; or
  1. Significant inability to comply with prescribed medical health regimens due to concurrent primary psychiatric illness and such failure to comply is potentially hazardous to the life of the individual.
  1. The youth is a danger to others. This behavior should be attributable to the individual’s specific SED/mental health diagnosis in accordance with the current Diagnostic and Statistical Manual (DSM)and can be adequately treatedonly in a hospital setting. Danger is presented by:
  1. Recent life-threatening action or active homicidal threats of same with a deadly plan and availabilityof means to accomplish the plan with the likelihood of acting on the threat;
  1. Recent serious assaultive or sadistic behavior or active threats of same with the likelihood of acting on the threat and an absence of appropriate supervision or structure to prevent assaultive behavior; or
  1. Active hallucinations or delusions directly or likely to lead to serious harm of others.
  1. The youth exhibits acute onset of psychosis or severe thought disorientation, or there is significant clinical deterioration in the condition of the youth with chronic psychosis, rendering him or her unmanageable and unable to cooperate in treatment. This youth is in need of assessment and treatment in a safe and therapeutic setting.
  1. The youth has a severe eating or substance abuse disorder, which requires 24-hour a day medical observation, supervision, and intervention.
  1. The proposed treatment or therapy requires 24-hour a day medical observation, supervision, and intervention.
  1. The youth exhibits severe disorientation to person, place, or time.
  1. The youth’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors, including, but not limited to, physical, psychological, or sexual abuse.

criteriONe