Transition Process for Participants Aging out of MCCY

The Bureau of Special Health Care Needs (DSDS/SHCN) Medically Complex Children and Youth (MCCY) Program, the additional Home and Community Based Service (HCBS) options within the Division of Senior and Disability Services, Field Operations (DSDS/FOPS), and the Department of Mental Health, Division of Developmental Disabilities (DMH/DD) work in collaboration to provide a smooth transition for MCCY participants who are moving to MO HealthNet adult service coverage at the age of 21 and will no longer qualify for MCCY services. All three agencies offer HCBS service options for individuals 21 years of age and older. Therefore, it is pertinent that the transition process for MCCY participants is coordinated with the respective agencies to ensure there is no lapse in service, lack of participant choice and that all services are explored and authorized appropriately. This document outlines the services available through each agency, transition contacts, and specific transition process, with role clarification of each agency’s staff. 

Overview of Available Services for Individuals Age 21

Department of Health & Senior Services – Division of Senior & Disability Services

Bureau of Special Health Care Needs (SHCN) 

• Medically Complex Adult Waiver (MCAW)

Home and Community Based Services (HCBS), Field Operations (FOPS)

• Agency Model In Home Services (IHS)
• Consumer Directed Services (CDS)
• Adult Day Care Waiver (ADCW)
• Independent Living Waiver (ILW)

Department of Mental Health – Division of Developmental Disabilities

• Comprehensive Waiver
• Community Support Waiver
• Partnership for Hope Waiver

Helpful Links

• SHCN Webpage
• MCAW Webpage
• MCCY-MCAW Regional Map
• HCBS Webpage
• HCBS Services Manual
• DMH Regional Office Map
• DD Waiver Fact Sheet
• DSDS & DCPH and DMH-DD HCBS Quick Guide

This list does not encompass all services available through DSDS and DMH/DD, only those applicable to participants age 21 who have been enrolled in MCCY.

Transition Contacts

• DSDS/SHCN: Heather VanHorn – Heather.VanHorn@health.mo.gov
• DSDS/FOPS: Cassie Lewis – Cassie.Lewis@health.mo.gov  
• DMH/DD: Melissa Myers – Melissa.Myers@health.mo.gov

Transitioning Participants Reporting Process

DSDS/SHCN is responsible for maintaining a list of participants who will turn 21 and age out of MCCY in the upcoming twelve (12) months. Biannually (January and July), the DSDS/SHCN contact will send the list of participants who will age out of MCCY in the next 12 months in the form of a spreadsheet to the DSDS/FOPS and DMH/DD designated contacts to make them aware of upcoming MCCY transitions.

The following information is included on the participant list:

• Participant Name
• DCN
• Date of Birth
• Age
• SHCN Program Enrollment 
• Anticipated MCCY Closure Date
• MCCY Authorized Services
• MCCY Service Coordinator (SC)
• MCCY Region 
• County of Residence
• Indicator of whether the participant has an active DMH waiver 

Additionally, on a monthly basis, the DSDS/SHCN contact will run reports to capture any new MCCY enrollments or closures of MCCY participants who will turn 21 within the next 12 months. The DSDS/SHCN contact will notify the DSDS/FOPS and DMH/DD contact via email monthly if there are any new enrollments or closures to ensure the participants are added or removed from the transition list accordingly. 

Preparing Individuals for Transition to Adult Services

The MCCY SC is responsible for discussing transition options with the MCCY participant/responsible party at least one (1) year prior to the participant’s 21st birthday, if not sooner, in preparation for the transition to adult services. MCCY SCs will outline to the MCCY participant/responsible party that an interagency meeting will be completed with the respective parties, dependent on the services the individual is eligible for, and will then facilitate initiation of scheduling of said meetings with DSDS/FOPS and DMH/DD.

Transition Process

1. Six (6) months prior to the participant’s 21st birthday, the MCCY SC will email the DSDS/FOPS and DMH/DD contacts, copying the DSDS/SHCN East/West Regional Coordinator (RC), to notify them of a MCCY participant who is nearing closure of MCCY services, due to age, to initiate scheduling of an interagency transition meeting. Transition meetings will be scheduled for all participants who would benefit from receiving additional information regarding options offered through available DSDS/FOPS and DMH/DD programs in order to make the most informed decision regarding their future services. The MCCY SCs will use the ‘DSDS/SHCN – MCCY Service Coordinator Email Notification’ template in the ‘MCCY Transition Meeting Email Templates’ document (Attachment 1) to clearly specify what services are authorized through MCCY and which agency is responsible for taking lead in facilitation and coordination of services moving forward. 
2. When the DSDS/FOPS and DMH/DD transition contacts receive the notification email from the MCCY SC, they will forward on to their respective staff to notify them of the need to attend and/or schedule the interagency transition meeting, using the referenced ‘DSDS/FOPS Notification’ and ‘DMH/DD Notification’ email templates included in the ‘MCCY Transition Meeting Email Templates’ 

Please note that the information provided in these notification emails will vary between MCCY participants who are authorized for private duty nursing (PDN) versus personal care aide (PCA)/advanced personal care (APC) services, as DSDS/SHCN cannot offer services past the age of 21 for PCA participants, while DSDS/SHCN oversees the Medically Complex Adult Waiver (MCAW) for PDN-eligible individuals.

• For MCCY PDN participants who are eligible for MCAW through SHCN, the transition meeting will be scheduled and coordinated by the MCCY SC and will be conducted with the participant/responsible party, MCCY SC, DSDS/FOPS and DMH/DD representatives
  • MCCY SC is responsible for scheduling the transition meeting to take place during the participant’s scheduled quarterly home visit 
  • MCCY SC will then invite the identified DSDS/FOPS and DMH/DD representatives (which will be provided by the DSDS/FOPS and DMH/DD transition contacts within one (1) month of the initial scheduling notification email) to the scheduled transition meeting 
• For MCCY PCA/APC participants who are no longer eligible to receive services through SHCN, the transition meeting will be scheduled and coordinated by DMH/DD and conducted with the participant/responsible party, DSDS/FOPS and DMH/DD representatives
  • DMH/DD will respond to the initial email from the MCCY SC to confirm receipt and acknowledge acceptance of the responsibility to schedule the transition meeting and work with the participant/family to plan for supports
  • DMH/DD representative will contact the DSDS/FOPS transition contact to identify the DSDS/FOPS representative who will be attending the transition meeting (Please note that DSDS/FOPS can only complete an assessment within 90 days of the individual’s 21st birthday and a transition meeting cannot take place prior to this date)

• For all transition meetings, the designated DSDS/SHCN, DSDS/FOPS and DMH/DD contacts will NOT be the agency representative attending the transition meeting. Their role is to facilitate coordination of the process and act as that agency’s transition liaison, but not to attend meetings, as this will be the responsibility of the respective field staff team members. 

   

3. Three (3) months prior to the participant’s 21^st birthday, the transition meeting will be conducted with the participant/responsible party and the respective DSDS/SHCN, DSDS/FOPS and DMH/DD representatives.
   • Transition meetings are preferred to be completed in-person, but may also be completed virtually or via phone when needed 
   • Representatives should be prepared to discuss service options available through their agency to assist the participant/responsible party with making an informed decision regarding their future service options
   • Representatives should ensure the following topics are discussed;
     • All available services options the individual is eligible for 
     • Participant choice of services
     • Medicaid eligibility service limitations 
     • Exhaustion of state plan services prior to utilization of waiver services
     • Restriction of dual-waiver enrollment 
     • Differences in comparable services offered through each agency 
     • Variation in providers 
     • Clear outline of steps that must be completed by the family and/or provider agency(ies) to establish adult services prior to the individual’s 21^st birthday (i.e. timeline for decision-making, who to notify, assessments, waiver termination if switching waivers, forms, etc.) 
   • Representatives should provide the participant/responsible party the ‘Transition Information for Individuals Aging Out of the Medically Complex Children & Youth (MCCY) Program’ (Attachment 2) and ensure the contact information section is completed for their respective agency so that the individual may follow up with any questions
4. After completion of the transition meeting, the participant/responsible party is responsible for notifying the agency(ies) of their choice in services. The agency representative who is notified of the participant’s choice in service should send a follow up email to other agency’s transition meeting attendees to ensure they are also aware of the choice. Once notified of participant choice, please reference your specific agency’s policies and procedures for enrollment and/or termination of waivered services when choosing to enroll in a different waiver to avoid dual-waiver enrollment. 
5. One (1) month prior to the participant’s 21^st birthday, the DSDS/SHCN East/West RC will email the DSDS/FOPS and DMH/DD contacts, copying the MCCY/MCAW Program Manager, notifying them of the participant’s pending closure from SHCN services.

• The email will include the following participant information:
  • Name
  • DCN
  • Date of Birth 
  • County of residence
  • MCCY SC name
  • Closure date
  • This notification is required if any of the following apply:
    • The participant/responsible party has selected a DMH waiver
    • The participant/responsible party has selected a different DSDS waiver, other than MCAW
    • The participant is not eligible for MCAW and has not received communication from DSDS/FOPS or DMH/DD