1. Youth Empowerment Services (YES) A Medicaid Waiver Program for Children with Severe Emotional Disturbances Clinical Eligibility Determination Texas Department of State Health Services May 21, 2015

2.  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

3.  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

4.  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

5.  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

6.  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

7. 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.)

8. 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.)

9.  The child/youth must meet CANS 6-17 Assessment Criteria A Clinical Eligibility Life Domain Functioning Developmental 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

10.  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 ANDScore 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 AND Score of 1, 2 or 3 on Psychiatric Hospitalization Module: Time Since Most Recent Discharge

11.  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