Children’s Long-Term Support (CLTS) Waivers
December 2007
DATE (This date must be at least 10 calendar days before the end date in Option 1 or 2 below, taking into account mailing time, weekends and/or holidays). FAMILY NAME ADDRESS ADDRESS ADDRESS Dear NAME: This letter is to inform you that your , , no longer meets the Level of Care requirement necessary to be eligible for the Children’s Long-Term Support Medicaid Home and Community-Based Services Waiver (CLTS Waiver). COUNTY: PICK Option 1 or 2, DELETE the other option. Please see “Termination of CLTS Waiver Participation” on how to establish end dates. OPTION 1: Your child’s CLTS Waiver services and your child’s eligibility for Wisconsin Medicaid will end on: OPTION 2: Your child’s CLTS Waiver services will end on : Your Wisconsin Medicaid eligibility will continue through . The determination of Level of Care is based on Federal Medicaid institutional admission criteria for hospitals, nursing facilities, psychiatric or developmental disabilities institutions. These Level of Care requirements are reflected in the Wisconsin Department of Health and Family Services (DHFS) 2003 CLTS Waiver application to the Centers for Medicaid and Medicare Services and the 2005 CLTS Waiver amendments. These criteria state that the child must have substantially compromised functional capacity across multiple major life domains, and require long-term nursing, restorative, or substantial treatment supports or services. These criteria are integrated into the Level of Care determination process. The criteria for each of the Levels of Care are described in part below. Children with Physical Disabilities (Hospital or Nursing Home Level of Care): The Hospital Level of Care is intended only for those children with severe life threatening conditions, requiring daily active interventions to sustain life. These are children with a complex, unstable condition, requiring direct observation, monitoring or performance of specific nursing procedures e.g. intravenous nutrition, ventilator support and/or skilled oxygen care.
SampleLOCTerminationLetter.doc
Children’s Long-Term Support (CLTS) Waivers
December 2007
The Nursing Home Level of Care includes the child with complex and long-term condition(s) with a high risk for sudden changes in medical status. The child must also require complex nursing care or rehabilitative services from others on a daily basis. This Level of Care is intended for the child whose long-term illness or physical disability has reached a relatively stable state but who continues to need basic and direct medical or restorative nursing services from others to maintain stability. These children’s physical or medical needs require frequent and complex interventions throughout the day.
Children with Developmental Disabilities: The Intermediate Care Facilities for the Mentally Retarded (ICF-MR) Levels of Care require that a child have at a minimum a developmental disability that results in both a substantial cognitive impairment that manifests itself in substantial functional limitations when compared to age appropriate activities in at least two additional developmental domains, in addition to the need for active treatment. Active treatment is defined as the child’s need for a combination and sequence of interdisciplinary special or generic supports that are individually planned and coordinated and are of lifelong or extended duration. For treatment to be categorized as active it must be continuous and pervasive throughout the child’s daily routines and carry over from home to school to community. Children with Mental Health Disabilities The Severe Emotional Disturbance Level of Care is based upon admission criteria for Medicaid-funded psychiatric institutions. The child must have a mental health diagnosis in addition to acute psychiatric symptoms (e.g. psychoses, suicidality, violence or lifethreatening eating disorders), or have substantial behavioral issues or functional impairment in multiple domains. The intensity of the child’s mental health needs must be of such severity as to put the child at risk for long-term psychiatric hospitalization. This determination must be supported by allowable documentation from the child’s psychiatrist or psychologist. Your child’s eligibility was reviewed against these criteria using information provided by You have the right to appeal this decision. You may request a county grievance by: You may also request a fair hearing by writing to the Wisconsin Division of Hearings and Appeals. The Division of Hearings and Appeals (DHA) must receive your written request no later than 45 days from the CLTS Waiver services End Date specified above. The hearing would take place as close as possible to your area of residence. If you request a hearing before the CLTS Waiver services end date above, you child’s services may continue if so you choose
SampleLOCTerminationLetter.doc
Children’s Long-Term Support (CLTS) Waivers
December 2007
until a hearing decision is reached; please indicate to the DHA if you want services to continue until the hearing decision is reached. Please Note: Per the Code of Federal Regulations 42 CFR § 431.230, if you choose to request a hearing on this termination and the hearing decision upholds the termination, you may be required to reimburse the cost of the services provided during the period of the hearing process. The address for submitting a written hearing request is: Division of Hearings and Appeals 5005 University Avenue, Ste. 201 Madison, WI 53705-5400 If you have questions, please contact Sincerely, cc: Children’s Services Section, Department of Health and Family Services Division of Hearings and Appeals
SampleLOCTerminationLetter.doc
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