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

• SPC 512 of the Medicaid Waivers Manual contains specific information regarding allowable services and requirements that must be met while participating in Intensive In-Home Treatment Services.

• Rights and Responsibilities of Families Participating in Intensive In-Home Treatment Services (Form F-20911) (PDF, 21 KB)

• "Roadmap" to Intensive Services (PDF, 27 KB)

• Autism Diagnosis Confirmation (PDF, 17 KB)

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

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

• Redetermination of Eligibility Process for Children Waiting for Waiver Slot for Intensive In-Home Treatment Services (PDF, 20 KB)

• Transition to Ongoing Services Policy (PDF, 15 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)

• CLTS Local Match Eligibility Chart (PDF, 16 KB)

• Parental Payment Limits "What Does it Cost?"

• CLTS School Policy (PDF, 19 KB)

• CLTS State Match Eligibility Chart (PDF, 18 KB)

• CLTS Waiver Termination Policy (PDF, 93 KB)

• CLTS Waiver Translation Policy (PDF, 13 KB)

• Policy for Transferring a Child from the CIP Waiver to the CLTS Waiver (PDF, 12 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)

• Intensive In-Home Treatment Services Criteria Checklist (Form F-21077) (Word, 75 KB)

• CLTS Waivers Application Checklist (Form F-21080) (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 Initial Denial Letter (Word, 37 KB)

• Sample Level of Care Termination Letter (Word, 37 KB)

• Sample Policy-Related Termination Letter (Word, 31 KB)

• CLTS HSRS Slot Change Request (Form F-00102) (Word-Fillable)

• CLTS HSRS Slot Change Request (Form F-00102) (PDF)

PDF: The free Acrobat Reader® software is needed to view and print portable document format (PDF) files. Learn more.

Last Revised: October 13, 2011