Different Pathways to Enrolling in Care Coordination Organizations and Services
If you are looking to get care coordination services, there are two pathways to care coordination for children under the age of 18.
Path 1 (under 18):
- Child has Medicaid as their health insurance based on parental income
- OPWDD Eligibility is given and LCED completed
- Child enrolls and is assigned a Care Manager/Care Coordinator
- Care Manager/Care Coordinator helps the child apply for Waiver Services (could be approved or denied and are often denied for children under 12)
- Child/family can access Family Support Services and Care Management without Waiver approval
- Can apply for Waiver again when they exhaust FSS/are older and more appropriate for Waiver services.
Path 2 (under 18):
- Child does not have Medicaid because family does not qualify based on parental income. Child has Child Health Plus or third-party insurance.
- OPWDD Eligibility is given and LCED completed
- Child cannot enroll in CCO because they don’t have Medicaid. They can EITHER
- Pursue FSS only with the support of the Member Relations team or on their own
OR
- Apply for Waiver services with a Specialized Admissions Coordinator (SAC) on the Care Connection team
- OPWDD reviews the request for Waiver services (still no Medicaid). OPWDD can either approve or deny the Waiver request.
- If approved, OPWDD provides the SAC and the family with a letter of intent. This says the child is approved for Waiver services and the parents’ income should be waived so that Medicaid can be approved. Once this is received, the family works with Benefits Coordinator to apply for Medicaid with the letter of intent. Once Medicaid is approved, the child enrolls in a CCO and is assigned a Care Manager/Care Coordinator who further coordinates Waiver services.
- If denied, child/family can continue to access FSS services on their own or with Member Relations. They cannot have a Care Manager/Care Coordinator because Waiver services were denied, so no Medicaid is forthcoming. They can appeal the denial and can access IDD Ombudsman program for support with an appeal. Can apply for Waiver services again at a different time when situation is different, or updated information can be provided.
Other Pathways to Coordinated Care Services
There are also other pathways to care coordination services. Here are the other ways:
- A person can enroll in a new CCO as a change from another CCO.
- If a person needing services is over 18, parental income doesn’t apply, and obtaining Medicaid is a more straightforward process.
- People can also transition from one Waiver to another, which is an easier switch because the person already has Medicaid but would need to apply for Waiver services with OPWDD. Care Managers/Care Coordinators can help with this.
- If a person is 18 or over and wants to enroll, an Enrollment Specialist would help the person get eligibility and once given, would send to Benefits Coordinator to help with Medicaid application. Then, the person can enroll, and a Care Manager/Care Coordinator can help access Waiver services.