Youth Empowerment Services (YES)

A Medicaid Waiver Program for Children with Severe Emotional Disturbances

Clinical Eligibility Determination

Texas Department of State Health ServicesMay 21, 2015

Youth Empowerment Services (YES) provides comprehensive home and community based mental health services to children/youth at risk of institutionalization and/or out of home placement due to their severe emotional disturbances (SED).

YES Waiver

To participate in YES Waiver, an child/youth must meet the following demographic criteria:

□ Be ages 3-18 years of age (up to one month before 19th birthday).

□ Reside in a county included in the service area. □ Reside in a non-institutional setting with the

child/youth’s LAR; or in the child/youth’s own home or apartment, if legally emancipated.

Demographic Eligibility

To participate in YES Waiver, a child/youth must be eligible for Medicaid. Parental Income and resources shall not be included in determining a child or youth’s special income limit.

The child/youth must meet SSI disability requirements to be eligible for the YES Waiver under the special income limit group.

The LMHA assists with the completion of Disability Determination documentation for children/youth who need to apply for Medicaid.

Upon submission of the Medicaid application to Heath and Human Services Commission (HHSC), the LMHA notifies DSHS.

Financial Criteria

The child/youth must have a valid Axis I diagnosis, DSM-IV-TR diagnosis as the principle admitting diagnosis.

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

There is reasonable expectation that, without waiver services the child/youth would qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines.

Clinical Eligibility

The child/youth must meet at least one of the following Texas Medicaid inpatient psychiatric admission criteria: 1. The child/youth is presently a danger to self;2. The child/youth is a danger to others attributed to the

child/youth’s specific Axis I, DSM-IV-TR diagnosis and can be adequately treated only in a hospital setting;

3. The child/youth exhibits acute onset of psychosis or severe thought disorientation or significant clinical deterioration rending the child/youth unable to cooperate in treatment;

Clinical Eligibility: Texas Medicaid Inpatient Psychiatric Admission Criteria

4. The child/youth has a severe eating or substance abuse disorder, which requires 24-hour a day medical observation, supervision, and intervention;

5. The proposed treatment or therapy requires 24-hour a day medical observation, supervision, and intervention;

6. The child/youth exhibits severe disorientation to person, place, or time;

Clinical Eligibility: Texas Medicaid Inpatient Psychiatric Admission Criteria (cont.)

7. The child/youth’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors, which may include physical, psychological or sexual abuse; or

8. The child/youth requires medication therapy or complex diagnostic evaluation where the child/youth’s level of functioning prohibits cooperation with the treatment regimen.

Clinical Eligibility: Texas Medicaid Inpatient Psychiatric Admission Criteria (cont.)

The child/youth must meet CANS 6-17 Assessment Criteria A

Clinical Eligibility

  Life Domain FunctioningDevelopmental

Score of 0 or 1 OR

Developmental

  Score of 2 or 3 AND Score of 2 or 3 on Developmental Needs Module: Cognitive AND

  Score of 0 or 1 on Developmental Needs Module: Developmental

The child/youth must meet one of the following CANS 6-17 Criteria B

Clinical Eligibility

  Child Risk Behaviors (either of these risk behaviors)  Score of 3 for Suicide Risk OR Self-Mutilation OR Other Self Harm

  Score of 2 or 3 for Danger to Others OR Sexual Aggression OR Fire Setting OR Delinquency

  Caregiver Strengths and Needs  Score of 2 or 3 for Involvement with Care OR Family Stress OR Safety

  Life Domain Functioning  Score of 2 or 3 for School AND Score of 2 or 3 on School Module: School Behavior OR

  Score of 2 or 3 on School Module: Attendance

  Psychiatric Hospitalization  Score of 1 for Psychiatric

Hospitalization ANDScore of 1, 2 or 3 on Psychiatric Hospitalization Module: Time Since Most Recent Discharge

The child/youth must be present during the screening process and the child/youth, LAR and LPHA sign the clinical eligibility determination form that is submitted to DSHS for authorization.

Clinical Eligibility