Home and Community Based Services Manual
4.35.2 Healthy Children and Youth Service Coordination
Introduction
The Healthy Children and Youth (HCY) Program provides service coordination and authorization for medically necessary services for MO HealthNet recipients with special health care needs from birth to age twenty-one (21).
Purpose
The Bureau of Special Health Care Needs (BSHCN), the Bureau of Home and Community Based Services Field Operations and the Department of Mental Health (DMH) collaborate to provide a smooth transition for HCY participants who are moving to MO HealthNet adult coverage at the age of twenty-one (21) and will no longer qualify for HCY services. All three offer services for participants twenty-one (21) years of age and older.
Process
HCY Service Coordinators (SC) will begin discussing transition options with the participant/responsible party at least one year prior to the participant’s twenty-first (21st) birthday. HCY SCs will also offer to schedule interagency transition meetings for participants aging out of HCY who are eligible for the Medically Fragile Adult Waiver (MFAW). These transition discussions allow participants and families to learn about all agencies and the programs offered. The Transition for Aging Out of HCY resource guide provides information on available programs.
Participants receiving only Advanced Personal Care Assistance/Personal Care Assistance (APCA/PCA) who are not eligible for MFAW will be referred to available DSDS and DMH programs. DSDS and DMH will coordinate a joint transition meeting for those participants without SHCN representation.
SHCN maintains a list of participants who will age out of HCY. This list will be sent to the available DHSS/DSDS and DMH/DD program's designated contacts biannually to make them aware of upcoming HCY transitions. The following information is included on the list:
- Participant
- DCN
- Date of Birth
- Age
- SHCN Program Enrollment
- Anticipated HCY Closure
- HCY Authorized Services
- HCY Service Coordinator (SC)
- HCY Region
- County Residence
- Indicator of whether the participant has an active DMH waiver
New HCY enrollments that will reach the age of twenty-one (21) within twelve (12) months of their initial enrollment and need a multiagency transition meeting will be sent to the designated contacts at time of enrollment. Discussions on transitioning are as follows:
- Twelve (12) months prior to the participant’s twenty-first (21st) birthday
- HCY SC will discuss transition information and multi-agency options with the participant/responsible party.
- Six (6) months prior to the participant’s twenty-first (21st) birthday
- HCY SC will schedule an interagency transition meeting to occur three (3) months prior to the participant’s twenty-first (21st) birthday. This will include participants who would benefit from receiving additional information regarding options offered through available DSDS and DMH programs to make the most informed decision regarding their future services.
Note: SHCN will not schedule or participate in transition meetings for participants who receive only APCA/PCA services and are not eligible for MFAW. The HCY SC will notify the DSDS and DMH program contacts of these referrals. The families will be informed that DSDSS and DMH will contact them to schedule a transition meeting to provide information about options available through each agency.
The transition meeting will be conducted with the participant/responsible party, HCY SC (as applicable), and DSDS and DMH contacts (preferably at a face-to-face home visit). This meeting allows the participant/responsible party to discuss options with all representatives, address their questions, and make an informed decision regarding their future service options.