Yes Waiver Clinical Eligibility Overview

The Youth Empowerment Services (YES) Waiver Clinical Eligibility (Clinical Eligibility or CE) is the sole mechanism to determine whether a child or youth meets the criteria to qualify for YES Waiver Services. The Clinical Eligibility is completed by the Local Mental Health Authority/Local Behavioral Health Authority (LMHA/LBHA) in the Clinical Management for Behavioral Health Services (CMBHS) data system and submitted to Health and Human Services Commission (HHSC) using CMBHS.

HHSC reviews the information submitted by the LMHA/LBHA and issues a formal eligibility determination — an approval or a denial — based on requirements outlined in the YES Waiver Policy manual within five business days.

The Clinical Eligibility document is a multi-purpose document which contains information related to an individual’s clinical eligibility for and enrollment in YES Waiver. It summarizes the individual’s clinical history and is used to:

• Determine clinical eligibility for YES Waiver;
• Transfer an enrolled participant’s YES Waiver services; or,
• End a participant’s enrollment in the YES Waiver program.

Before You Start a Clinical Eligibility Document

You must have the role of YES Waiver LPHA to create a YES Waiver Clinical Eligibility. For a list of CMBHS Roles and what Page Rights (Read-Only or Read-Write) they have, click here.

A user must be logged into a YES Waiver LMHA/WPO location to document a YES Waiver Clinical Eligibility in CMBHS.

Review the participant’s Client Workspace. Make sure that:

• there is a mental health diagnosis at the LMHA location.
• there is a YES Assessment (CANS) created within the last 90 days.

How a YES Waiver Clinical Eligibility is Determined

The LMHA/LBHA can complete the YES Waiver Clinical Eligibility only after completing the YES Assessment (CANS) in CMBHS.

To qualify for YES Waiver services five clinical eligibility criteria must be met. Criteria A and B are based on the results from the CANS. If a potential participant does not meet Criterion A but the clinician recommends enrollment in YES Waiver, supporting documentation may be provided to YES Waiver staff for consideration during the determination.

The criteria — met and not met — display in the YES Waiver Clinical Eligibility Section.

• Criteria A is based on the results from the CANS.
• Criteria B is based on the results from the CANS.
• Criterion C requires a yes or no answer to whether a potential participant has tried and failed outpatient therapy or partial hospitalization. If a psychiatrist has documented why an inpatient level of care is required, then this criterion is met.
• Criterion D assesses whether a potential participant meets — or is likely to meet — inpatient hospitalization guidelines without YES Waiver services. If the potential participant does not meet criteria, a physician’s signature must be obtained to verify that the criterion is not met.
• Criterion E identifies whether the potential participant has a mental health primary diagnosis.

How to document a Pending, Initial, or Annual Renewal YES Waiver Clinical Eligibility in CMBHS

To document and submit a Pending, Initial, or Annual Renewal Clinical Eligibility document:

 

1. Navigate to the YES Waiver Clinical Eligibility page by using the Client Services Toolbar.
   1. Select Special Services Documentation
   2. Select YES Waiver Services
   3. Select YES Waiver Clinical Eligibility
2. Once the Clinical Eligibility document is open, select the appropriate Clinical Eligibility Type from the options provided in the dropdown list.
3. Enter the Performed-on date. This date is the date of the in-person clinical assessment and should be the same date as the CANS Assessment Date.
4. Enter comments in Notes on Eligibility Type as needed.
5. The Start Date and End Date will automatically populate based on the selected Clinical Eligibility Type. HHSC may update this information as needed.
6. Complete the Facility Question by selecting Yes or No. If the response is Yes, include the facility name, date(s) of residence, and length of stay.
7. Review the participant’s diagnosis codes in the Diagnosis Information section. This information will auto-populate from the participant’s most recent diagnosis. (NOTE: You may select View Complete Diagnosis Record at any time to view the participant’s diagnosis record.)
8. Review the CANS Assessment Criteria section. This information will auto-populate from the participant’s most recent YES Assessment (CANS). The Assessment Date should be the same date as the Performed on Date. (NOTE: Select View CANS Assessment at any time to view the participant’s most recent YES Assessment ‒ CANS. The LPHA is responsible for ensuring that the YES Assessment (CANS) is accurate before submitting.)
9. Complete the Additional Eligibility Criteria.
   1. Criteria C: Outpatient therapy or partial hospitalization has been attempted and failed OR a psychiatrist has documented reasons why an inpatient level of care is required. Select Yes or No.
   2. Criterion D: Check the Medicaid psychiatric inpatient hospitalization criteria below which the client meets.
      1. Select View Criteria Details to review inpatient hospitalization criteria. The specific criterion will appear in a pop-up window. Select the criterion that the client meets. If no criterion is met, select None. (NOTE: If a client DOES NOT meet Criteria D and all other criterion are met, a physician’s signature is required.)
   3. Criterion E: The Medicaid eligible youth must have a valid Axis I diagnosis as the principle admitting diagnosis. Select Yes or No. This answer should align with information from the Diagnosis Information section.
10. Enter comments in Notes on Clinical Eligibility as needed. (NOTE : If a client DOES NOT meet Criterion A and the clinician is requesting a waiver, supporting comments must be included in this section.)
11. Complete the Signatures section. Signatures should match the Performed on Date. Refer to the Clinical Eligibility section for guidance on required signatures based on Clinical Eligibility type.
12. Select Ready for Review from the options provided in the dropdown list and select Save.
13. After the document’s status is in Ready for Review, the document will be available to HHSC in CMBHS for review and to issue an eligibility determination.
14. The eligibility determination will appear at the bottom of the document as Approved, Approved on Appeal, or Denied. If additional information is required to determine eligibility, HHSC may place the document back in Draft status.

NOTE: If the Clinical Eligibility document is denied, complete a new Child and Adolescent Uniform Assessment (UA) to request LOC-4 or LOC-A from the Managed Care Organization (for Medicaid clients) and the Utilization Management department (for indigent clients). The participant’s UA will reflect LOC-YES until it is changed.

 

 

---

YES Waiver Clinical Eligibility Data Field Detail

Clinical Eligibility Type (Required)

Select the Clinical Eligibility Type that matches the client’s situation. The following eligibility types are described below.

 

1. Pending
2. Initial
3. Annual Renewal
4. Termination
5. LMHA Transfer Out
6. LMHA Transfer In

Clinical Eligibility Type Detail

Pending Clinical Eligibility

1. Submit a Pending Clinical Eligibility for individuals who are not actively enrolled in an approved Medicaid type at the time of the clinical assessment.
2. The approved Pending CE document helps support medical necessity requirements for Medicaid.
3. An approved Pending Clinical Eligibility conditionally authorizes enrollment in the YES Waiver, pending Medicaid eligibility.

Initial Clinical Eligibility

Submit an Initial Clinical Eligibility for individuals who are actively enrolled in an approved Medicaid type at the time of the assessment.

1. An approved Initial Clinical Eligibility authorizes enrollment in the YES Waiver for a period of 365 days.
2. Providers cannot bill YES Waiver services for individuals who are not actively enrolled in Medicaid. (For further guidance on Medicaid, including approved Medicaid types, refer to the Medicaid Overview section of the YES Waiver Manual.)

Annual Renewal Clinical Eligibility

Submit an Annual Renewal Clinical Eligibility for enrolled YES Waiver participants who are within 45 days of the expiration of their current eligibility end date. This date can be found on a participant’s current Clinical Eligibility.

Annual renewals follow the same process as the Initial Clinical Eligibility to assess the clinical criteria, completing a YES Assessment CANS, and updating the Diagnosis. A Qualified Mental Health Professional (QMHP) may conduct the renewal Clinical Eligibility and give a recommendation to renew for another year. A Licensed Practitioner of the Healing Arts (LPHA) clinician must approve the renewal recommendation.

1. The document may be submitted up to 45 days before the current Clinical Eligibility End Date.
2. The Annual Renewal Clinical Eligibility must be submitted at least 10 days before the current Clinical Eligibility End Date. This will ensure that there are no gaps in services.
3. An approved Annual Renewal Clinical Eligibility authorizes enrollment in the YES Waiver for an additional year or 365 days.
4. When an Annual Renewal is not completed before the current eligibility End Date, services should not be provided until a new Initial Clinical Eligibility is approved.

NOTE: If an Annual Renewal Clinical Eligibility is not received in a timely fashion, the LMHA/LBHA may be required to resubmit an Initial Clinical Eligibility.

---

Termination Clinical Eligibility

Submit a Termination Clinical Eligibility when an enrolled YES Waiver participant leaves the program. An approved Termination Clinical Eligibility authorizes the participant’s termination from YES Waiver.

1. A Termination Clinical Eligibility must include an acceptable reason for the participant’s termination.
2. Select a termination reason, as supported by YES Waiver policy, in the Notes on Eligibility Type dropdown section. Based on the selected termination reason, you may need to select a required option.
3. Attach the participant’s transition plan to the Clinical Eligibility before submitting the Termination Clinical Eligibility to HHSC.

When the selected Notes on Eligibility Type is "Participant no longer meets Waiver eligibility," the user is able to select from four choices, displayed as radio buttons:

• Not eligible for Medicaid services

• No longer eligible at annual reassessment

• No longer resides within the service region

• No longer resides with LAR

Anytime a participant decides to end YES Waiver services, termination documentation must be submitted to HHSC. This documentation includes a Clinical Eligibility termination and a transition plan.

Transition plans are required when a client moves to a different level of care or ages out of YES Waiver to transition to adult services. Refer to the YES Waiver Policy Manual regarding acceptable reasons for a participant to terminate from services.

For more information, click on Eligibility Termination Type.

LMHA Transfer Out Clinical Eligibility

Submit an LMHA Transfer Out Clinical Eligibility for enrolled YES Waiver participants who will be moving outside of the current LMHA catchment area AND the participant is requesting continued enrollment in YES Waiver. An LMHA Transfer Out Clinical Eligibility document should not be submitted when the participant’s relocation is:

1. within the current LMHA catchment area and
2. expected to be temporary (less than 90 days), such as when the participant is visiting a family member.
3. All LMHA Transfer Out Clinical Eligibility should be coordinated with the receiving, or new, LMHA.

LMHA Transfer In Clinical Eligibility

Submit a LMHA Transfer In Clinical Eligibility for enrolled participants who have moved into the LMHA catchment area from a different LMHA catchment area.

1. All LMHA Transfer In Clinical Eligibility should be coordinated with the sending, or old, LMHA.
2. For more information on the Transfer CE process, refer to Transfer Processes.

Performed on Date (Required)

For an Initial Clinical Eligibility, the Performed on Date is the date the in-person Clinical Eligibility Team met with the participant and family.

For an Annual Renewal Clinical Eligibility, the Performed on Date will default to the first day of the new eligibility year.

CANS Assessment Criteria (Auto-populated from the YES Assessment CANS)

The CANS Assessment Criteria is not required for a Termination Clinical Eligibility. This field will automatically populate with information from the participant’s most recent YES Assessment (CANS).

The LMHA/LBHA should review the Assessment Date and confirm the date corresponds with the most recent YES Assessment (CANS).

Do not submit a Clinical Eligibility document until the most recent YES Assessment (CANS) is in CMBHS.

Notes on Eligibility Type (Conditionally Required)

The Notes on Eligibility Type field is required only when the Clinical Eligibility type is Termination .

For all other Clinical Eligibility types, use this section to include additional information about the submitted Clinical Eligibility. The LMHA/LBHA can document information such as barriers to timely submission.

NOTE: Do not use this section to provide information about the client’s eligibility. List information related to eligibility in the Notes on Clinical Eligibility Type section.

Start Date (Required)

This field will automatically populate to the date the Clinical Eligibility document is created. If an individual meets eligibility criteria, HHSC will update this section to reflect the date of formal enrollment in YES Waiver.

NOTE: HHSC authorizes the participant’s enrollment in the YES Waiver for an eligibility period of 365 days.

End Date (Required)

For Initial and Annual Renewal Clinical Eligibility types, this field will automatically populate to 364 days after the start date and cannot be edited.

For Termination Clinical Eligibility types, this field will automatically populate to the current date. No YES Waiver services can be delivered after a participant’s Clinical Eligibility End Date.

NOTE: For participants who will be 19 years of age, the Clinical Eligibility end date will populate to one day before the client’s 19 ^th birthday.

Facility Question (Required)

• This is a question about the participant’s living situation.
• Select Yes if the individual has lived in a facility during the last 12 months. Otherwise, select No.
• If the response is Yes, include the facility name, date(s) of residence, and length of stay.

 

---

Diagnosis Information (Required)

This field will automatically populate to include the participant’s most recent mental health diagnosis, unless it is unavailable.

A clinical eligibility document cannot be created for a participant who does not have a mental health diagnosis completed within the last year in their Client Workspace.

Diagnosis information can be reviewed at any time by clicking on View Diagnosis or navigating to the Client’s Workspace.

NOTE: A clinical eligibility document cannot be created for participants who do not have a mental health diagnosis dated within the last year.

CANS Assessment Criteria (Required)

The CANS Assessment Criteria is a required field for all Clinical Eligibility types except Termination Clinical Eligibility. This field will automatically populate with information from the participant’s most recent YES Assessment (CANS). The LMHA/LBHA should review the Assessment Date and confirm the date corresponds with the most recent YES Assessment (CANS). Do not submit a Clinical Eligibility document until the most recent YES Assessment (CANS) is in CMBHS.

NOTE: It is the responsibility of the LPHA to ensure that the YES Assessment CANS Assessment Criteria is accurate and reflects the needs of the individual.

Additional Eligibility Criteria (Required)

The Additional Eligibility Criteria section is a required field when the Clinical Eligibility type is Pending, Initial, or Annual Renewal. These questions are required to determine clinical eligibility.

Notes on Clinical Eligibility (Required)

The Notes on Clinical Eligibility section is an optional field. The LMHA/LBHA should enter any information relevant to the eligibility determination process.

System Clinical Eligibility Determination (Required)

The System Clinical Eligibility Determination field will automatically populate to summarize information in the Clinical Eligibility document. This area will reflect the outcome of the assessment, including criterion met and not met. Even though this area may say Eligible or Not Eligible, eligibility can only be determined by HHSC.

Treatment Team Signatures (Required)

The Signatures section is a required field based on the type of assessment.

Signatures from the Client (YES Participant) and the Legally Authorized Representative are always required unless there are extenuating circumstances. Anytime the Client and/or LAR are Unable to Sign, the reason must be listed in the comments section. Wet signatures should be obtained for client records.

*A Qualified Mental Health Professional signature is required only when the QMHP has conducted the Clinical Eligibility.

**A Physician signature is required anytime the Client meets all eligibility criteria EXCEPT for Criterion D. By signing the Clinical Eligibility document, the physician confirms that the participant does not require an inpatient level of care AND recommends that HHSC deny enrollment in YES Waiver.

HHSC Review and Approval (Required)

The HHSC Review and Approval section is read-only. The LMHA/LBHA cannot change this. After a Clinical Eligibility document has been submitted to HHSC for review, HHSC will update this section to reflect the participant’s eligibility status as follows:

• Approved: HHSC has approved the LMHA/LBHA’s request to enroll, transfer, or terminate a participant’s clinical eligibility in YES Waiver.
• Approved on Appeal: HHSC has authorized an eligible participant’s continued services until a fair hearing decision is made.
• Denied: HHSC has not approved the LMHA/LBHA’s request to enroll, transfer, or terminate a participant’s clinical eligibility in YES Waiver.

For further guidance on Clinical Eligibility document types, refer to the Clinical Eligibility section.

 

‎

---

YES Waiver Clinical Eligibility Termination Type

Before You Start

• Before creating a Termination YES Waiver Clinical Eligibility document, check the participant’s Client Workspace to ensure that one has not already been started.
• A Termination Clinical Eligibility can’t be entered if there is an Individual Plan of Care without a TMHP authorization number.
• A Termination Clinical Eligibility can be created even if an Individual Plan of Care has not been created.

To enter and submit a Termination Clinical Eligibility document:

1. Navigate to the YES Waiver Clinical Eligibility page by using the Client Services Toolbar.
   • Select Special Services Documentation
   • Select YES Waiver Services
   • Select YES Waiver Clinical Eligibility
2. Once the Clinical Eligibility document is open, select Termination from the options provided in the dropdown list. The Clinical Eligibility will automatically populate to include information from the Initial Clinical Eligibility. The following fields are not required:
   • Facility Question
   • CANS Assessment Criteria. The CANS section will update to NA.
   • Additional Eligibility Criteria (Criteria C, D, E)
   • Notes on Clinical Eligibility
3. Enter the Performed on Date. For unplanned terminations, this date should be the date the LMHA was notified that the family plans to leave the waiver. For planned terminations, this date should be the date of the last Child and Family Team meeting.
   • Enter comments in Notes on Eligibility Type. This section is required and must include the participant’s reason for termination. Refer to the Clinical Eligibility section for further guidance.
   • The Start Date will automatically populate.
   • Select the Clinical Eligibility End Date. This date should be the last date of YES Waiver enrollment.
4. Review the participant’s diagnosis codes in the Diagnosis Information section. This information will auto-populate from the participant’s most recent diagnosis. A Termination Clinical Eligibility cannot be submitted if there is no diagnosis.
5. Enter comments in Notes on Clinical Eligibility as needed.
6. Complete the Signatures section and save document in Ready for Review. Signatures should match the Performed on Date. Refer to the Clinical Eligibility section for further guidance on required signatures.
7. Attach the participant’s transition plan to the Termination Clinical Eligibility.
   • Select Draft from the options provided in the drop-down menu.
   • Select Save.
   • Select Attachments. Attach the transition plan.
   • Select Edit to return to the Clinical Eligibility document.
8. Select Ready for Review from the options provided in the dropdown list.
9. Select Save.

NOTE: YES Services cannot be provided or documented after the Clinical Eligibility End Date.

NOTE: Select View Complete Diagnosis Record at any time to view the participant’s diagnosis record.

Remember, when the selected Notes on Eligibility Type is "Participant no longer meets Waiver eligibility," the user is able to select from four choices, displayed as radio buttons:

• Not eligible for Medicaid services

• No longer eligible at annual reassessment

• No longer resides within the service region

• No longer resides with LAR

After the Clinical Eligibility document has been placed in Ready for Review status, HHSC will review the document and approve or deny the request.

HHSC approval of a Termination Clinical Eligibility will cause CMBHS to automatically create an Individual Plan of Care Termination document. This will end services for the participant.

CAUTION: Even if CMBHS allows you to create a Termination IPC, do not give in to the temptation. CMBHS will automatically create the Termination IPC. If CMBHS does not automatically create the Termination IPC within 24 hour of completion of the Clinical Eligibility Termination, contact the CMBHS Helpline at 1-866-806-7806.

---

Service Delivery Pending Appeal

During an appeal process, the individual may have the right to receive continued benefits. If the individual is eligible to receive continued benefits pending the appeal, HHSC will contact the LMHA/LBHA (BMO) directly with instructions.

NOTE: For further guidance on the Medicaid Fair Hearing process, contact your YES Waiver liaison or HHSC YES Waiver programs at yeswaiver@hhsc.state.tx.us.

‎

---