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Application for Utah's Medically Complex Children's Waiver

Introduction

Medically Complex Children's Waiver Application Instructions

The Utah State Legislature authorized the Medically Complex Children's Waiver (the program) as an ongoing program (HB100, 2018 General Session). Children enrolled in this program will have access to traditional Medicaid benefits as well as respite services. Applications will be accepted on an on-going basis. Once open spots are filled, applicants will be moved to a waitlist.

In order to qualify a child must meet ALL the following criteria:

  • Be 18 years old or younger
  • Have 3 or more separate specialty physicians in addition to their primary care provider; Seen within the last 24 months. Example: Neurologist, Cardiologist, Pulmonologist, etc. *Multiple providers within the same specialty will count as one specialty
  • Have medical complexity that involves 3 or more organ systems
  • Children who are not meeting age appropriate milestones for their activities of daily living; this includes eating, toileting, dressing, bathing and mobility
  • Meet minimum medical score by demonstrating a level of medical complexity based on a combination of need for device-based supports, high utilization of medical therapies, and treatments and frequent need for medical intervention
  • Children who have a SSI Disability Designation through the SSA or a disability determination by the State Medical Review Board, this will be coordinated as part of the MCCW application process

To be considered for participation, this application must be complete and include required attachments. We will be requesting a copy of the most recent history and physical or Well Child Check from the child's physicians. This documentation must include past medical and surgical history, problem or diagnosis list, active medication list, allergies, vital signs, physical exam and a plan of care. We will also be having the Primary Care Provider fill out a certification form.

The information submitted must be no later than the 24-month period immediately preceding the month of program application (or less if the applicant is less than 24 months old). All healthcare information will be verified through medical documentation by Medicaid's clinical staff.

If you have multiple children in your family for whom you are applying, you will need to complete a separate application for each child.

In addition to this application you will be required to provide additional supporting documentation. This documentation must be sufficient to validate the information in this application. Without the supporting documentation your application will NOT be considered complete. Be prepared to complete the online application in one session. The application will take approximately 45 minutes to complete. Once you begin working on the online application, you will not be allowed to save it if it is not complete. To familiarize yourself with the requirements, please review the PDF version (Español) of the application before you begin. There will be a section in the application to upload the following documents:

  • Authorization to Disclose Health Information (Español)
  • You must also provide a copy of the child's most recent clinic notes from an MD or DO licensed provider dated within the last 24 months; the clinic notes should be electronically signed and dated within the last 24 months.
  • If the applicant has an Individualized Education Program (IEP) please include with the submitted application

To be considered for participation, applications must be complete. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. Applications will also be accepted by mail or fax. (Submission address and fax number are included in the PDF version of the application).

Please be aware that the application for this program is a two-step process. The purpose of this application is to determine if your child meets specific program requirements. To determine if your child meets financial eligibility you will be required to complete a Medicaid application with the Department of Workforce Services (DWS). Only the child's income and assets will be used to make the financial eligibility determination.

If your child is selected for participation in the program, you will be contacted by the Department about completing the financial eligibility portion of the application. Additional information on financial eligibility can also be found at: https://medicaid.utah.gov/apply-medicaid

For more information, please contact the Utah Department of Health and Human Services.
Toll-free Phone: 1-800-662-9651, option 5
Email: mccw@utah.gov
Website: https://medicaid.utah.gov/ltc-2/mccw/

Applications WILL NOT be accepted via email. Please do not submit any private health information to this email address.
File Upload
As part of your application, you will be required to provide additional documentation. Please use the inputs below to provide the required documentation. Files must be one of the following types: .pdf, .tif, or .jpeg. Files larger than 2mb will fail to upload. You are required to provide a file for upload in each input box.
If you are experiencing issues with your file upload it may be best to fill out our paper application (Español). This application can be sent via mail or fax by following the instructions on the application.
Please provide a copy of your child's Authorization to Disclose Health Information (Español):
Select fileChange Remove

History and Physical or Well Child Check summary (must be within the last 24 months), please include with the submitted application.

Select fileChange Remove
If the applicant has an Individualized Education Program (IEP) please include with the submitted application.
Select fileChange Remove
Personal Information
Please fill out as much of this section as possible so that we can identify and contact you regarding the status of your application.



Primary Medical Provider Information
Medical Intervention, Consultation and Conditions
Please provide a list of your child's care team that your child has seen in the last 24 months. (These are in addition to your primary care provider):
Please list any additional diagnosis below:
Please Indicate if your child has prolonged dependence for Medical Devices, Treatments, Therapies or Sub-specialty Services
Please Check ALL that Apply
*(Devices not considered implantable technology: Tympanostomy tubes (ear tubes) or balloon dilation of the ear tubes to treat Eustachian Tube Dysfunction. IUD or other types of implantable birth control, regardless of what the IUD is treating.)
(Daily laxative, Miralax, Exlax or enema use does not qualify as a complex bowel program.)
*diagnosis of incontinence, neurogenic bladder, bowel incontinence, or other medical diagnosis that requires use of diaper/incontinence brief daily.
or daily urge incontinence, stress incontinence, overflow incontinence, or functional incontinence.
If you select the checkbox below indicating that your child is administered 5 or more routine medications, please list the medications and frequency:
Daily administration of medication does not include any medications that are PRN or medications prescribed to be taken "as needed" and should include all administration routes.
Please indicate if your child has any of the following functional or developmental limitations and/or prolonged dependence on supportive or mobility-related devices (e.g., braces, AFOs, wheelchairs, shower chairs, gait belts, etc.). Adaptive bicycles, tricycles, etc. do not count if used for recreation and not required for daily ADLs. Child must be dependent on device for daily mobility. If you select the checkbox below indicating that your child relies on additional devices for functional supports, please list the devices:
(e.g. braces, AFOs, wheelchairs, shower chairs, gait belts, serial casting for club and hip dysplasia)
Please list daily mobility devices below:
Daily prolonged oral feeding includes not able to self-feed, arching or stiffening during feeding, refusal of feeding, texture aversion, difficulty chewing, coughing or gagging, frequent spitting or vomiting, excessive food drooling, etc.
Please select the item below that best describes your child's mobility:

Non-ambulatory and is not able to make changes in positioning without assistance. Maintains lying position when not secured into chair.

Able to make slight changes in body or extremity position. Cannot bear weight and needs assistance into chair or wheelchair. Requires a wheelchair for daily mobility.

Makes frequent though slight changes in body or extremity position independently. Is able to walk with assistance or crawl independently.

Walks independently without assistance.

Self Care Skills:
Please answer the questions below to provide information regarding your child's ability to perform age-appropriate self-care tasks.
Please select the most applicable answers from the items below:
Care Giver Impact
Please answer the questions below to provide information regarding how your child's complex medical conditions have impacted family caregivers and finances in the past 24 months.
Please select the most applicable answers from the items below:
If you are applying for multiple children in your family please indicate below:






The next question relates to the out-of-pocket medical expenses incurred by the applicant during the last 24 months

Out-of-pocket medical expenses are defined as expenses for medical care incurred by the applicant.

Expenses include: insurance premiums, deductibles, coinsurance and copayments for covered services, plus costs for services that aren't covered by a primary insurance or all medical costs if the applicant does not have medical insurance. This may include the costs for medical equipment and supplies that aren't covered by insurance.

Examples include but are not limited to: cost of nutritional formula for applicants more than 2 years old, cost of incontinence supplies for applicants more than 3 years old and cost of other medically necessary medical equipment and supplies. Out-of-pocket expenses should not include the cost of home or vehicle modifications or items such as child car seats that would otherwise be required for the general safety of any child.

Self-attestation of out-of-pocket expenses may be subject to post-payment review and audit. In the event of an audit, applicants must be prepared to provide evidence to support the amount of out of pocket expenses claimed.

The next questions are related to how your child's complex medical conditions have impacted your family's employment experience.
Please Check ALL that Apply
The next question is used to identify the medical service coverage resources available to your child.
Please check the box below if your child has medical insurance coverage. If your child has medical insurance coverage please list the insurance providers below:

This can include coverage by publicly funded programs such as Medicaid, CHIP, Medicare etc.

Application Submission

By submitting this application I certify that the information provided is accurate to the best of my knowledge. I understand that intentional mis-statements may be grounds for rejection of my application, or termination of my enrollment in the program. I also understand that my application must be complete in order to be considered, and that if my application is not complete it will be rejected.