Bureau of Long-Term Support
Medicaid Home & Community-Based
Waivers Manual

APPENDIX E: Supplemental Information Specific to the Children's Long-Term Support (CLTS) Waivers

Materials Specific to Autism Related Services Through the Waivers

• Early Intensive Behavioral Intervention (EIBI) Services: SPC 512 (PDF, 36 KB)

• Consultative Behavioral Intervention (CBI) Services: SPC 512.10 (PDF, 36 KB)

• Rights and Responsibilities of Families Participating in EIBI or CBI Services (PDF, 15 KB)

• "Roadmap" to EIBI and CBI Services (PDF, 20 KB)

• Procedure for Accessing Medicaid Eligibility for Children on the State Wait List for Autism Treatment Services (PDF, 17 KB)

• Information Regarding Medicaid Fee-For-Service Card Services (PDF, 26 KB)

• Redetermination of Eligibility Process for Children Waiting for Autism Treatment Services (PDF, 20 KB)

• Transition to Ongoing Services Policy (PDF, 9 KB)

Materials Related to All Services Through the Waivers

• Citizenship Verification Memo (PDF, 16 KB)

• Critical Incident Reporting Overview (PDF, 24 KB)

• Critical Incident Report (Form F-22541)

• Parental Payment Limits "What Does it Cost?"

• CLTS School Policy (PDF, 19 KB)

• CLTS Waiver Termination Policy (PDF, 93 KB)

• CLTS Waiver Translation Policy (PDF, 13 KB)

• Missed Services Policy (PDF, 16 KB)

• Determination of Exceptional Care Needs for Children in Child Care or Foster Care Setting (Form F-21072) (PDF, 22 KB)

• Informed Consent - Children's Long-Term Support Functional Screen (Form F-21076) (Word, 44 KB)

• CLTS Functional Screen: Change in Eligibility (PDF, 17 KB)

Checklists and Letters for Use by County Waiver Agencies

• Child Information Eligibility Worksheet (Form F-21232) (Word, 301 KB)

• Autism Treatment Services Criteria Checklist (Form F-21077) (Word, 75 KB)

• CLTS Waivers Eligibility Verification - Step One (Form F-21080) (Word, 87 KB)

• CLTS Waivers Application Checklist - Step Two (Form F-21080A) (Word, 87 KB)

• CLTS Waivers Recertification Checklist (Form F-21078) (Word, 75 KB)

• Sample Health Savings Account Letter (Word, 26 KB)

• Sample Level of Care Termination Letter (Word, 37 KB) Please use this document and the comments that are included as a guide for writing your own letter.

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Last Revised: April 22, 2013