Eligibility Criteria for CCAC Services

Transcription

1 3.1 Overview of Eligibility Criteria The Community Care Access Centre (CCAC) must determine eligibility for: professional, personal support and homemaking services, supplies, equipment or other goods within their legislative authority, school services (professional and personal support services), and equipment for children/youths in schools and receiving home schooling within their legislative authority, and long-term care (LTC) homes. Chapter #7 in this manual describes eligibility criteria for CCAC home care services and chapter #9 in this manual describes eligibility criteria for CCAC school services. Subsection #3.9 in this manual describes eligibility for adult day services (ADS) while subsection #3.10 in this manual describes eligibility for Enhanced Respite funding services. This section outlines the legislation, regulations and policies relating to Ontario Health Insurance Plan (OHIP) coverage as the primary eligibility requirement for CCAC services. Subsection 2(1) of Regulation 33/02 of the Community Care Access Corporations Act, 2001 (CCACA) provides that the CCAC is deemed to be an approved agency under the Long-Term Care Act, 1994 (LTCA). The LTCA states: Plan of service s. 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges, the agency shall, (a) assess the person s requirements; (b) determine the person s eligibility for the services that the person requires; and (c) for each person who is determined to be eligible, develop a plan of service that sets out the amount of each service to be provided to the person Legislated Criteria Subsections 13(3) and (4) of Regulation 552 of the Health Insurance Act (HIA) provide the conditions under which home care services are prescribed as insured services. The HIA states: s. 13(3) Home care services provided by a home care facility to an insured person in his or her home are prescribed as insured services. September

2 Clarification: To be eligible for service from a CCAC, a person must be insured under the OHIP. Generally, this means that the person is a resident of Ontario, and is eligible and entitled to receive Ontario s health care services. s. 13(4) It is a condition of payment for insured services under subsection (3) that, (a) Revoked: O. Reg. 173/95, s. 1 (1). (b) the services are necessary to enable the insured person to remain in his or her home or to make possible the insured person's return to his or her home from a hospital or other institution; (c) the needs of the insured person cannot be met on an out-patient basis; (d) the insured person is in need of at least one professional service, if the service for which payment is sought is described in clause (c), (d), (e) or (f) of the definition of "home care services" in subsection (1). (See definition of home care services in subsection #2.3 in this manual.) Clarification: The person must need at least one professional service in the home (i.e., nursing, physiotherapy, occupational therapy or speech language pathology. Note that social workers and dietitians are excluded from the definition of professional services for this purpose) in order to be eligible for dressings and medical supplies, diagnostic and laboratory services, hospital and sickroom equipment, and transportation services to and from home to a hospital, health facility or attending physician s office. s. 13(4)(e) the services are provided in the insured person's home where such has been approved by the Minister as being suitable to enable the required care to be given; Clarification: The setting where the service is delivered must be appropriate in terms of safety, space and privacy and adequate to support the necessary equipment and supplies that may be required. Where the setting is not appropriate, every effort must be made to adapt the program or equipment to fit the space, or to assist the person to modify his or her environment in order to allow the service to be provided there safely and adequately. When such arrangements cannot be made, alternative courses of action should be discussed with the individual or the individual s substitute decision-maker (SDM). Every effort should be made before declaring the person ineligible on the grounds that the setting is unsuitable. This section also restricts service provision to a person s home to the exclusion of other sites. s. 13(4)(f) the services are available in the area where the insured person resides; and Clarification: The person can only access the services that are available within the person s CCAC catchment area (e.g., in some cases, not all services may be available within the area). s. 13(4)(g) the services are reasonably expected to result in progress towards rehabilitation. Clarification: It must be shown that the provision of service is goal-oriented. September

3 3.2 Validation of Ontario Health Cards To be eligible for Community Care Access Centre (CCAC) services under the Long-Term Care Act, 1994 (LTCA), a person must be an insured person under the Health Insurance Act (HIA) pursuant to Regulation 386/99 under the HIA. Individuals who have not applied for a health card number may apply to become insured persons and receive a health card in accordance with section 11 of the HIA and sections 2, 3 and 3.1 of Regulation 552 of the HIA. All Ontario health card numbers must be verified by the CCAC for all services and admissions to long-term care (LTC) homes Validation Process The CCAC must verify an applicant s Ontario health card number by using one of the following three health card validation systems: 1. The Ministry of Health and Long-Term Care (MOHLTC) Interactive Voice Response (IVR) system, The IVR system enables the CCAC to determine the status of a health card number and version code at the time of service. IVR is accessed using a MOHLTC approved PIN number and a touch tone phone. 2. The MOHLTC Health Number Look-Up (HNLU) service, The HNLU service is appropriate to use in situations where a client does not have his or her health number/version code available at the time of service or, if after validating the health number/version code using the IVR system, the IVR system indicates the client has an incorrect version code. Client consent is required before releasing any information. Health Number Release form (# ) can be printed from website: [ =WWE&NO= ]. (For clients not having a health card or number in their possession, see subsection #3.2.2 in this manual.) 3. For additional information, the CCAC can contact a MOHLTC staff person as follows: call the local OHIP office (The number is in blue pages of the telephone book under Health.); check the website at: [ and go to OHIP; from anywhere in Ontario, call the general information line at ; or from area code 416, call (416) Hours of operation for these services are 8:30 a.m. to 5:00 p.m., Monday through Friday. September

4 3.2.2 Client Does Not Have a Health Card or Number in His or Her Possession A CCAC that is registered with the HNLU system, will ask the person who does not have his or her health card or number in his or her possession to complete and sign the Health Number Release form (# ) which can be printed from website: [ WE&NO= ]. Client Has OHIP Coverage With the release form completed, the CCAC calls a HNLU telephone number at anytime (24 hours, seven days a week). The HNLU agent provides the number to the CCAC at time of registration. The CCAC identifies itself with its designated HNLU PIN number. An HNLU agent releases the required information if available. The CCAC follows up by faxing the person s completed Health Number Release form to the HNLU. Client Does Not Have OHIP Coverage (See subsection #3.4 in this manual.) September

5 3.3 Residency Requirements for OHIP Coverage To qualify for Ontario Health Insurance Plan (OHIP) coverage, a person must be a resident of Ontario as defined in Regulation 552 of the Health Insurance Act (HIA). Except for those residents identified in section 1.1(1)(a) below, a resident must ordinarily be present in Ontario which means the resident must make his or her permanent and principal home in Ontario and, with some exceptions, be present in Ontario for 153 days in any given 12-month period. Regulation 552 of the HIA states: s. 1.1(1) a resident is an individual, (a) who is present in Ontario by virtue of an employment authorization issued under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration, or (b) who is ordinarily resident in Ontario and who is one of the following: 1. A Canadian citizen or a landed immigrant under the Immigration Act (Canada). 2. A person who is registered as an Indian under the Indian Act (Canada). 3. A Convention refugee as defined in the Immigration Act (Canada). 4. A person who has submitted an application for landing under the Immigration Act (Canada), who has not yet been granted landing and who has been confirmed by the federal Department of Citizenship and Immigration as having satisfied the medical requirements for landing. 5. Revoked: O.Reg. 87/95, s A person who has finalized a contract of employment or an agreement of employment with a Canadian employer situated in Ontario and who, at the time the person makes his or her application to become an insured person, holds an employment authorization under the Immigration Act (Canada) which, i. names the Canadian employer, ii. states the person's prospective occupation, and iii. has been issued for a period of at least six months. 7. The spouse, same-sex partner or dependent child under the age of 19 years of a person referred to in paragraph 6 if the Canadian employer provides the General Manager with written confirmation of the employer's intention to employ the person referred to in paragraph 6 for a period of three continuous years. Note: The General Manager is the person responsible for administering OHIP. s. 1.1(1) 8. A member of the clergy of any religious denomination who has finalized an agreement of employment to minister on a full-time basis to a religious congregation in Ontario for a period of not less than six consecutive months and whose duties will consist mainly of preaching doctrine, presiding at liturgical functions and spiritual counselling. 9. The spouse or same-sex partner and the dependent children under the age of 19 years of a member of the clergy referred to in paragraph 8 if the religious congregation provides the General Manager with written confirmation that it intends to employ the member for a period of at least three consecutive years. September

6 10. A person granted a minister's permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86, 87, 88 or 89 or, if the permit is issued for the purpose of an adoption by an insured person, as case type A person granted an employment authorization under the Live-in Care Givers in Canada Programme or the Foreign Domestic Movement administered by the federal Department of Citizenship and Immigration. Regulation 552 of the HIA states: s. 1.1(1) For the purposes of subsection (1), a person is ordinarily resident in Ontario only if, (a) in the case of an insured person or of a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority, the person, (i) makes his or her permanent and principal home in Ontario, and (ii) subject to subsections (3), (4), (5) and (6), is present in Ontario for at least 153 days in any 12-month period; and (b) in the case of a person who is applying to be an insured person for the first time or who is re-establishing his or her entitlement after having been uninsured for a period of time, other than a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority, the person, (i) intends to make his or her permanent and principal home in Ontario, and (ii) is present in Ontario for at least 153 days immediately following the application. Subsections 1.1(3) and (4) of Regulation 552 of the HIA provide that some persons may be exempted from the requirement to remain in Ontario for 153 days in 12-month period if: the person is required to travel frequently outside Ontario for his or her employment; the General Manager has approved payment for a treatment to be provided to the person outside Canada; or the person leaves Canada to work, to attend a full-time educational program, or to engage in missionary work if he or she intends to return to make a permanent and principle home in Ontario and met the 153 day requirement for the two years immediately prior to leaving Ontario Three-Month Waiting Period for OHIP Coverage Applications The HIA states: s. 3(1) A resident who is not otherwise an insured person may become an insured person by submitting an application to the General Manager. (1.1)1. An application under subsection (1) shall be in the form approved by the Minister. September

7 (2) A resident making an application under subsection (1), shall be present in Ontario at the time of submitting the application. (3) A resident who makes an application under subsection (1) shall only be enrolled as an insured person three months after the day the person becomes a resident Exceptions to the Three-Month Waiting Period for OHIP Coverage The HIA states: s. 3(4) The three-month waiting period referred to in subsection (3) does not apply to the following persons who are residents and who apply to become insured persons: 1. A child under the age of 16 who is adopted by an insured person. 2. A newborn born in Ontario to an insured person. 3. A person who satisfies the General Manager that he or she has been resident in Ontario for at least three months at the time of his or her application to become an insured person. 4. A member of the Canadian Forces who was an insured person immediately before becoming a member and is discharged from the Canadian Forces. 5. A member of the Royal Canadian Mounted Police who had been appointed to a rank therein and who was an insured person immediately before becoming a member and is discharged. 6. A Canadian diplomat who returns to Ontario after a posting to a place outside Canada and who was an insured person immediately before the posting. 7. The spouse, same-sex partner or dependent child under 19 years of age, of a Canadian diplomat referred to in paragraph 6 who was an insured person immediately before the posting of the Canadian diplomat. 8. An inmate at a penitentiary as defined in the Corrections and Conditional Release Act (Canada) who is released. 9. An inmate at a correctional institution established or designated under Part II of the Ministry of Correctional Services Act who is released. 10. A person who, i. takes up residence in Ontario directly from elsewhere in Canada where the person was insured under a government health plan or a hospital insurance plan, and ii. upon taking up residence in Ontario, becomes a resident of an approved charitable home for the aged under the Charitable Institutions Act, a home under the Homes for the Aged and Rest Homes Act or a nursing home under the Nursing Homes Act. 11. A Convention refugee as defined in the Immigration Act (Canada). 12. A person who has made a claim to be a Convention refugee under the Immigration Act (Canada) and in respect of whom, i. a senior immigration officer has determined that the person is eligible to have his or her claim determined by the Refugee Division, and ii. a removal order, as defined in the Immigration Act (Canada), has not been executed. 13. A person granted a Minister's permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86, 87, 88 or 89 or, if the permit is issued for the purpose of an adoption by an insured person, as case type 80. September

8 14. A person who is present in Ontario by virtue of an employment authorization issued under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration. 15. A pregnant woman who became pregnant before April 1, 1994 and who applied to become an insured person during the course of that pregnancy. 16. A pregnant woman who, i. has submitted an application for landing under the Immigration Act (Canada) and has not yet been granted landing, ii. became pregnant before April 1, 1994, and applied to become an insured person during the course of that pregnancy, and iii. has been confirmed by the federal Department of Citizenship and Immigration as having satisfied, A. all the medical requirements for landing, or B. all the medical requirements for landing except for the requirement to submit to an x- ray. September

9 3.4 Persons without OHIP Coverage are Ineligible for CCAC Services Ontario Health Insurance Plan (OHIP) coverage is one eligibility criterion for Community Care Access Centre (CCAC) services. This subsection identifies the circumstances under which a person may or may not be covered by OHIP and where CCAC services can be provided Persons Who May be Eligible for OHIP Coverage Newcomers to Ontario from another country may be eligible for CCAC services if they have applied for and are entitled to OHIP coverage and have served their three-month waiting period. Newcomers from another Canadian province or territory who have moved to Ontario may be eligible for CCAC services if they have applied and qualify for OHIP coverage and have served their three-month waiting period. (See other eligibility criteria in section #3.1 in this manual.) Persons Without OHIP Coverage Not Eligible for CCAC Services Visitors to Ontario from another province or country, including foreign students, are not eligible to receive CCAC services. Royal Canadian Mounted Police (RCMP) are not eligible to receive CCAC services if these services are covered by their Public Service Health Care Plan. Note: RCMP personnel are not entitled to receive a drug card from the CCAC, as drug coverage is available through their Public Service Health Care Pan. Canadian Armed Forces personnel are not eligible to receive CCAC services if these services are covered by the National Defense Medical Centre. Inmates of federal penitentiaries are not eligible for OHIP as their health insurance coverage is through the Canadian government (although inmates of the Province of Ontario corrections institutions are covered by OHIP for their period of incarceration, CCACs must assess whether these inmates require CCAC services if similar services are provided by correctional institutions) Visitors from Other Provinces/Territories Not Eligible for CCAC Services May be Eligible for Hospital and Primary Care Services Visitors to Ontario from another province or territory who require emergency or in-patient services in a hospital are covered for these services by their home province s or territory s health insurance plan through a reciprocal agreement between provinces or territories. Visitors who require the services of a physician/nurse practitioner in an office, clinic or community September

10 health centre may receive those services and the physician/clinic may directly bill the visitor s health insurance program of their home province or territory. Alternatively, the physician/clinic may bill the visitor for the service and the visitor should submit the bill for reimbursement to the health insurance plan in the visitor s home province Role of the Case Manager When a Person is Deemed Ineligible for Service Because He or She Does Not Have a Valid Ontario Health Card When an individual is deemed ineligible for CCAC services because the individual does not have valid OHIP coverage, the case manager must: explain the reasons for not providing CCAC funded service; assist the person with his or her options (including directing the person to the local OHIP office to confirm whether OHIP coverage is a possibility); and link the person to the appropriate health, social service or community resources that can address the person s needs. The case manager s judgement will determine the duration of the provision of case management service to the individual (e.g., families requiring ongoing assistance with end of life care to a loved one who does not have OHIP coverage, may receive case management services). September

11 3.5 Out-of-Province Applicants to Ontario s Long-Term Care Homes Residents of other provinces or a territory who plan to move to Ontario and need to be placed in a long-term care (LTC) home are first required to have prior approval of Ontario Health Insurance Plan (OHIP) coverage Pre-Registration Process for Obtaining an Ontario Health Card When a Community Care Access Centre (CCAC) receives a request for placement of a person who is planning to move from another province directly into a LTC home, the CCAC must redirect the person, or the person s lawfully authorized substitute decision-maker (SDM), to OHIP head office at the following address: OHIP Pre-Registration for Long-Term Care Eligibility and Portability Services Registration and Claims Branch Ministry of Health and Long-Term Care 49 Place d Armes, 3 rd floor Kingston, ON K7L 5J3 telephone: (613) facsimile: (613) Eligibility Services will provide a Registration for Ontario Health Coverage form and preregistration information to the person or the person s lawfully authorized substitute (e.g., power of attorney). The person or his or her SDM will complete and return the OHIP registration form to Eligibility Services, along with a copy of a suitable citizenship or immigration document such as a Canadian birth certificate, landed immigrant document or Canadian passport. If the applicant is eligible for OHIP coverage, Eligibility Services will give prior approval of the applicant s OHIP coverage and send a letter confirming prior approval to the CCAC. This letter will serve temporarily to fulfill the eligibility requirement that the person is insured under the Health Insurance Act (HIA), and allows the CCAC to proceed with the applicant s eligibility determination and authorization of admission processes. The applicant is not registered for OHIP coverage or issued a health insurance number until after the applicant has arrived in Ontario and has been admitted to a LTC home. On the day of admission to the LTC home, the CCAC must send Eligibility Services a completed Authorization for Admission to a LTC Facility indicating that the applicant has been placed. Eligibility Services will then complete the applicant s OHIP registration, issue the new resident an Ontario health insurance number that is effective on the day of admission to the LTC home and will advise the CCAC. September

12 Note: To be eligible for this pre-registration process, the applicant must be an insured resident of another province or territory in Canada when applying for OHIP coverage/admission to the LTC home, and the applicant must move directly into a provincially-regulated LTC home (e.g., a resident in Winnipeg must move directly into a LTC home in Toronto). Applicants living outside Canada are not eligible for this pre-registration process, even if they are Canadian citizens returning to Ontario. September

13 3.6 OHIP Coverage/CCAC Services for Homeless Persons Homeless persons do not always have Ontario Health Insurance Plan (OHIP) coverage or the supporting documentation required to obtain coverage. With the person s consent, a Community Care Access Centre (CCAC) must contact the local district OHIP office to confirm whether the individual has valid OHIP coverage using the Health Number Release form process (outlined in subsection #3.2 in this manual). A homeless person who does not have OHIP coverage nor the documents required to obtain coverage, can apply for coverage with the support of an agency (as approved under the Long- Term Care Act, 1994 (LTCA)) that works with the homeless. The local OHIP office can advise how to assist the person. The process is as follows: To eliminate barriers to health care access, the Ministry of Health and Long-Term Care (MOHLTC) policy permits an approved agency dedicated to serving the homeless to issue a special agency letter that confirms the person s identity and supports the person s application for OHIP coverage. In the letter, the agency commits to assisting the person in obtaining necessary documents to meet eligibility requirements for health coverage and to provide the agency s residential/mailing address for the person. The homeless person visits a local MOHLTC office or an outreach registration site (usually a community health centre) and provides the agency letter plus whatever documents the person has to register for health coverage. The MOHLTC will usually provide the person with one-year interim health coverage to allow the agency to assist the person in obtaining necessary documentation to meet eligibility requirements for health coverage. Persons who use the agency letter process to obtain health coverage must meet the photo and signature requirements of the photo health card. There are no exemptions. September

14 3.7 OHIP Coverage/CCAC Services for Refugees Interim Federal Health Program Essential medical coverage for refugee claimants in Ontario is usually paid for by the Interim Federal Health (IFH) program administered by Citizenship and Immigration Canada. The purpose of the IFH is to pay for in-canada health care for certain immigrants who are unable to pay for expenses related to urgent and essential services. Coverage is provided pending their qualification for other means of payment. This applies principally to refugee claimants, convention refugees and members of the humanitarian designated classes. The fund is not meant to replace provincial health plans and does not provide the same extent of coverage allowed to permanent residents. The IFH program benefits are limited to: essential health services for the treatment and prevention of serious medical and dental conditions (including immunizations and other vital preventative medical care); essential prescription medications; contraception, prenatal and obstetrical care; and the immigration medical examination for those individuals who are unable to pay for the exam. Note: The IFH program does not cover routine medical or eye or dental exams Eligibility for Interim Federal Health Program Eligibility for the IFH program is determined by Citizenship and Immigration Canada Process to Obtain Approval for CCAC In-home and School Services Before a Community Care Access Centre (CCAC) may provide service to a refugee, prior approval is required from Citizenship and Immigration Canada. The person must be in possession of an Interim Health Certificate of Eligibility, a document issued to the person by an immigration officer. Attached to the certificate is a letter that outlines the benefits to which the person is entitled. The CCAC must fax a copy of the Interim Health Certificate of Eligibility document and background information that outlines the services required, the reason for home care, an estimate of the time frame for the service to be carried out, and the expected date of discharge from service to: September

15 Medical Director, IFH/CIC Interim Federal Health Program Jean Edmonds Building 365 Laurier Avenue West South Tower, 14 th Floor Ottawa, ON K1A 1L1 toll free facsimile: Note: The Interim Federal Health Program Information Handbook for Health Care Providers can be accessed at: [ Once the Medical Director of the IFH program reviews the information, the CCAC is advised if the service has been approved and CCAC services may be initiated. The CCAC must send a copy of the Interim Health Certificate of Eligibility with the first invoice submission and monthly invoices to: FAS Benefit Administrators Ltd Street, 9 th Floor Edmonton, AB T5K 3T4 toll free telephone (English and French): [email protected] website: September

16 3.8 OHIP Coverage/CCAC Services for a Person on Leave of Absence from a LTC Home A person who is a resident of a long-term care (LTC) home and who is on a leave of absence from the LTC home (e.g., on vacation, or as a result of a home outbreak), may be eligible to receive home care services from the Community Care Access Centre (CCAC). The same applies to a person who is in the LTC home Convalescent Care Program or on a leave of absence from a hospital. The person must have valid Ontario Health Insurance Plan (OHIP) coverage and must be assessed as eligible and needing services provided by the CCAC. The CCAC must determine the priority for the person to receive the assessed services. September

17 3.9 Eligibility for Adult Day Services Program Description Adult day services (ADS) are community support services that provide supervised individual programming in a group setting in order to: assist individuals to achieve and maintain their maximum level of functioning; prevent premature and inappropriate institutionalization; and provide respite, information and support to caregivers. ADS are intended to provide services to individuals with high care needs and their caregivers. ADS serve the frail elderly and/or individuals with Alzheimer disease, progressive cognitive disorders or dementias. Components of the service include: planned social, recreational and physical activities; meals; transportation (if required); personal support/attendant care and minor health care services (e.g., monitoring medications). Note: Medical services are not included in the range of services offered in ADS Community Care Access Centre and Adult Day Services In some cases, the Community Care Access Centre (CCAC) and the ADS may agree that the CCAC will be responsible for assessments and determination of eligibility for ADS. In collaboration with staff of the Ministry of Health and Long-Term Care (MOHLTC) regional office, both the CCAC and ADS must establish local eligibility criteria for priority admission to the ADS. The CCAC must develop agreements with other CCACs regarding the acceptance and processing of applications from outside their catchment area Optional Trial Period An optional trial period is available to assess whether ADS can appropriately serve a person who is deemed eligible by the CCAC. For example, ADS may not be suitable for a person in situations where the safety of other clients is compromised or the care needs of the client exceed the ability of the services. September

18 3.10 Eligibility for Enhanced Respite Funding Program Description Enhanced Respite for Children who are Medically Fragile and/or Technology Dependent (Enhanced Respite) is a grant paid to eligible families who are caring for a child at home who is medically fragile and/or technology dependent. The Ministry of Children and Youth Services (MCYS) is responsible for the provision of funding and policies related to Enhanced Respite, including the criteria used by the Community Care Access Centre (CCAC) to determine eligibility for funding. Families caring for medically fragile and/or technology dependent children often need more services and supports than may be available through other programs and service providers. The respite needs of these parents are typically very high. Families may provide 16 or more hours of care daily and routinely provide monitoring and care at night. 1 Under Enhanced Respite, a family may receive up to $3500 per eligible child annually. There are no restrictions on the type of respite a family may purchase. Funds may be used flexibly to purchase in-home or out-of-home services or a combination of in-home and out-of-home services. The grant is provided in addition to care, treatment and/or funding from other sources. The Enhanced Respite funding must not result in any reduction in existing funding from other sources. This includes, but is not limited to, funds provided under the Special Services at Home and/or the Assistance for Children with Severe Disabilities programs and home care services arranged by the CCAC CCAC Responsibilities The CCAC is responsible for determining a child s eligibility in accordance with approved eligibility criteria. Related CCAC responsibilities include the following activities: provide eligible families with written notification of their eligibility for Enhanced Respite; and notify the Ministry of Children and Youth Services-Ministry of Community and Social Services (MCYS-MCSC) regional office of decisions of eligibility made on behalf of children. 1 Enhanced Respite for Families Caring for Medically Fragile and/or Technology Dependent Children at Home: Implementation Plan, September

19 Role of the MCYS-MCSS Regional Office The regional offices, which administer the funding paid on behalf of eligible families, are responsible for the following activities: inform eligible families of the amount approved for the current fiscal year and provide the families with authorization numbers; reimburse families based on submitted invoices for respite services or pay the service provider directly; and monitor the Enhanced Respite resources provided to eligible families Eligibility Criteria for Enhanced Respite Funding Eligibility Criteria 2 Only medically fragile and/or technology dependent children with chronic conditions who meet the following eligibility criteria based on their age and care requirements will qualify for the enhancement: age: children under 18 years of age; and care requirements: child s care requirements resulting from medical or physiological condition(s) that require ongoing, frequent or time-consuming caregiver intervention and monitoring on a 24-hour basis for survival; there must be a demonstrable risk of significant exacerbation of the child s health status associated with not meeting the 24-hour care requirements; children with behavioural disorders alone are not eligible; and only children who meet the above criteria and fall within the following categories of care requirements will qualify: 2 Enhanced Respite for Families Caring for Medically Fragile and/or Technology Dependent Children at Home: Implementation Plan, September

20 Group Group 1 Group II Group III Group IV Group V 3 Medically fragile who meet care requirements, but do not use technological device Care Requirements/Needs Children dependent at least part of each day on mechanical ventilators Children requiring prolonged intravenous administration of: nutritional substances drugs Children with prolonged dependence on other device-based support for: tracheotomy tube care suctioning oxygen support tube feeding Children with prolonged dependence on other devices which compensate for vital body functions who require daily or near daily nursing care, including children requiring: apnea monitors (cardio respiratory) renal dialysis due to kidney failure urinary catheters or colostomy bags plus substantial nursing care Children who are medically fragile according to the care requirements, but do not use a technological device are eligible, even if the child sleeps through the night. Eligibility should not be declined solely because the child sleeps through the night. Enhanced Respite funding for a Group V child may be used to purchase either in-home or out-of-home respite services or a combination of in-home and out-of-home respite. There is no restriction on the type of respite care that may be purchased by a family. Note: It is recognized that aspects of the eligibility criteria for Enhanced Respite funding would benefit from additional clarification. Such requests most often are related to the Group V category, children who are medically fragile according to the care requirements but who do not use a technological device. 3 The addition of a fifth category of care was made in a February 15, 1999 memorandum sent to CCACs from the Office of the ADM, Office of Integrated Services for Children (OISC). September

21 3.11 Services to First Nations Persons Services to Persons Residing in First Nations Communities Health and social services in First Nations communities are funded by both federal and provincial levels of government through the Federal Department of Indian and Inuit Affairs, Health Canada s Medical Services Branch and the Ontario Ministry of Health and Long-Term Care (MOHLTC). The First Nations manage and deliver various health and social services such as healing centres, clinics offering medical services and some long-term care services for their members. The numbers and types of such services have been negotiated over time, under various initiatives and funding sources, and vary from community to community. Individuals residing in First Nations communities are eligible for Community Care Access Centre (CCAC) services. CCACs must first assess whether these individuals require CCAC services if similar services are provided through the First Nations community. CCAC services should coordinate with and complement services available in the First Nations community rather than duplicate those services. To achieve this goal, CCAC staff need to be aware of the services available in First Nations communities within their service area. The CCAC may enter into formal agreements with First Nations or organizations representing First Nations (e.g., Union of Ontario Indians) in order to formalize a process that will facilitate and ensure that ongoing, effective linkages are maintained Long-Term Care Services to Aboriginal Persons Not Residing in First Nations Communities Aboriginal people not living in First Nations communities may also receive services from the CCAC. CCACs must assess requirements and determine eligibility for services on the same basis as any other Ontario resident. The MOHLTC provides funding to some aboriginal organizations to provide home and community care services to aboriginal people both on and off reserve. The types and availability of services vary across the province. September