Exploring Medicaid Waivers

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Exploring Medicaid Waivers

• Debra Holloway
• The Arc of Virginia
• Family Involvement Project

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Different Institution - Different Waiver

• Waivers provide funding for a wide variety of
  services for people of all ages who have
  disabilities or are elderly so that they may
  remain in their homes and communities rather than
  an institutional placement such as a hospital,
  nursing home
• or ICFs/MR (intermediate care facility)

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Medicaid

• Means Low income Wrong!
• Waiver eligibility is not dependent on
• income.

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Waiver Must be Cost Effective

• Virginias waiver programs for the elderly and
  disabled are expensive but still less costly than
  compatible institution care.
• The elderly and disabled represent
• 30 of Medicaid program recipients.

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What are the services?Different Waivers have
different services.

• Adult Day Health Care
• Assistive Technology
• Case Management
• Companion Services
• Crisis Intervention/Stabilization
• Day Support
• Environmental Modifications
• Family Caregiver Training
• Nursing Services
• Nutritional Supplements
• Personal Care Services
• Personal Emergency Response System
• Prevocational Services
• Residential Support
• Respite
• Skilled Nursing
• Supported Employment
• Therapeutic Consultation
• Transition Coordination

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There are seven waivers administered by the
Commonwealth of Virginia

• Elderly or Disabled with Consumer Direction
  (EDCD)
• Individual and Family Developmental Disabilities
  Supports (IFDDS)
• HIV/AIDS
• Technology Assisted (Tech)
• Mental Retardation (MR)
• Day Support
• Alzheimers Assisted Living (AAL) Waiver managed
  by the Facility and Home-Based Care Unit
• Mental Health Waiver (Demonstration Waiver)

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• Elderly or Disabled with Consumer Direction
  Waiver (EDCD)
• Technology Waiver (Tech)
• Individual and families with Developmental
  Disabilities Waiver (DD)
• Mental Retardation Waiver
• (MR Waiver, ID or intellectually disabled)

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Consumer-Directed Services

• Individual or family caregiver directs and
  controls who, how, and when services are provided
• Virginia offers consumer-directed services in 4
  Waivers
• Elderly or Disabled with Consumer-Direction
  Waiver (since 2005) - Personal Care, Respite
• Developmental Disabilities Waiver (since 2000) -
  Personal Care, Respite, Companion
• Mental Retardation Waiver (since 2001) - Personal
  Assistance, Respite, Companion
• AIDS Waiver (since 2003) Personal Assistance,
  Respite

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Consumer-Directed Services

• Individual is the employer of record with the IRS
• Service Facilitator (SF) writes documentation of
  need based on information from the individual,
  monitors the service and provides support as
  needed to the individual so that the individual
  can be an employer of their staff
• SF provides training on recruiting, interviewing
  staff, how to handle difficult situations, how to
  complete employment paperwork, etc.
• SF provides list of people who have said they
  want to work as consumer-directed staff and shows
  how to place an advertisement for attendants,
  companion aides and respite workers (the list and
  ads do not have to be used)
• DMAS (using a contractor, PPL) pays the
  attendants, companion aides and respite workers
  on behalf of the individual

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Consumer-Directed EmployeesAttendants,
Companions, Respite Workers

• Consumer-Directed employees may not be -
• Parents of minor children or spouses of the
  individual receiving consumer-directed services
• If the Consumer-Directed employee lives with the
  person receiving services -
• Service Facilitator must have objective written
  documentation as to why there are no other
  providers available to provide care

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Elderly or Disabled with Consumer Direction
Waiver

• This waiver is constructed to allow persons to
  remain in the community that meet nursing
  facility level of care.
• Current enrollment 14,034
• No waiting list
• Screening is conducted by the Preadmission
  Screening team made up of a representative from
  The Department of Health and the Department of
  Social Services using the Uniform Assessment
  Instrument (UAI)

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Eligibility

• This waiver serves the elderly and persons of all
  ages with disabilities. The individual may
  receive this service through a service provider
  or though consumer direction.
• An individual can remain on the waiting list for
  another waiver while being served by the EDCD
  Waiver.

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Criteria

• Qualify for Medicaid (individual)
• Meet long term care criteria according to Uniform
  Assessment Instrument (UAI)
• Pre-Admission Screening Criteria
• Functional capacity (the degree of assistance an
  individual requires to complete activities of
  daily living) and
• Medical or nursing needs
• Risk of nursing facility placement

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Examples

• Functional Dependencies
• bathing, dressing, toileting, transferring,
  eating/feeding
• Medical and nursing needs
• catheter care, supervision for adequate
  nutrition and hydration, therapeutic exercise and
  positioning, management of those with sensory,
  metabolic, or circulatory impairment.

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Getting Started

• Request for screening, contact your local Health
  Department
• Schedule visit with pre-admission screening teams
  of the Department of Health Department of
  Social Services.
• Completed Medicaid application (childs
  information only!)

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Services

• Adult Day Health Care
• Personal Care (agency or consumer directed)
• Respite 720 hrs. (agency or consumer directed)
• Personal Emergency Response System (PERS)
• Transition Services (5000 max)
• Transition Coordination

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Technology Assisted Waiver (Tech)

• No age limit to eligibility
• No waiting list
• Currently serving 319 individuals.

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Eligibility

• Serves individuals who need a medical devise to
  compensate for the loss of a vital body function
  and requires substantial and ongoing skilled
  nursing care to remain safely in their homes.
• Screening UAI is used for adults and Tech Waiver
  scoring tool is used for children
• The Department of Medical Assistance Services
  (DMAS) reviews individuals private insurance
  policy for private duty nursing benefits
• Case management provided by DMAS nurses
• Different rules for children and adults

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Criteria

• Doctor must certify need for care and need
  substantial and ongoing skilled nursing care and
• Care must be cost effective and
• Primary caregiver must be trained and accept
  responsibility for 8 hours or more per day

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Screening Process

• DMAS receives a referral from community
  resources, family, other parties
• DMAS completes a Scoring Tool to determine if the
  individual meets the specialized care criteria
  for the waiver
• If the criteria is met DMAS conducts a home
  assessment.
• DMAS works with the primary caregiver, referral
  source to secure appropriate nursing care for the
  individual in the home
• DMAS authorizes needed services for the provider
  agency upon the start of care

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Services

• Private Duty Nursing (16 hours maximum a day,
  except children may have 24 hours a day for the
  first 30 days after hospital discharge)
• Personal Care (adults only)
• Respite Care (360)
• Environmental Modifications (5000)
• Assistive Technology (5000)
• Durable Medical Equipment
• Transition Services (5000)

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Individual and Family Developmental Disabilities
Support Waiver (DD)

• Wait list is maintained by the Department of
  Medical Assistance Services (DMAS)
• Recipients served FY07 594, and 640 are waiting.
• Can be placed on the waiting list at age 5 years
  8 months

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Eligibility Criteria

• Related Conditions Waiver
• Must be 6 years of age and over and meet the
  related conditions criteria, including autism
  and
• Individual must not have a diagnosis of Mental
  Retardation.
• Meet the level of care for admission to an
  ICF/MR. The individual must meet 2 out of 7
  levels of functioning.

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Screening

• The Virginia Department of Health Child
  Development Clinics will screen individuals with
  the Level of Functioning (LOF) Survey which is
  the assessment instrument used to determine
  eligibility to for an ICF/MR
• You can download a copy of the Request for
  Screening from www.dmas.virginia.gov. Compete
  the form and fax or mail it to the CDC. The
  psychological assessment is a requirement of the
  screening determination.

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RELATED CONDITIONSalso referred to as
developmental disability

• Severe chronic disability
• Attributable to a condition, other than mental
  illness
• Manifested before the age of 22
• Likely to continue indefinitely
• Results in substantial limitations in 3 or more
  areas of major life activity
• Self-care
• Understanding and use of language
• Learning
• Mobility
• Self-direction
• Capacity for independent living

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Transitioning from MR to DD Waiver

• Annually each child receiving MR Waiver services
  who will be 6 years of age the following year can
  be up for consideration for transfer to the DD
  Waiver.
• If the child meets DD Waiver eligibility the
  child can transition to the DD Waiver.

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Services

• Adult Companion (CD Agency/up to 8 hours a
  day)
• Assistive Technology (5000)
• Crisis stabilization
• Crisis supervision
• Environmental Modifications (5000)
• In-home residential
• Prevocational
• Companion Care
• Day support
• Skilled nursing
• Supported employment
• Therapeutic consultation
• PERS
• Family/caregiver training (80 hours a year)
• Respite care (720)
• Personal attendant services
• Transition Services (5000)

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Mental Retardation Waiver (MR)

• Day-to-day MR waiver operations are managed by
  the Department of Mental Health, Mental
  Retardation and Substance Abuse Services
  (DMHMRSAS)
• Locally, MR Waiver services for individuals are
  coordinated by case managers employed by
  Community Services Boards
• Wait list - Waiting list as of 12/08 4,375
• 7,942 waivers approved
• 400 new MR Waiver slots funded, 200 available
• July 1, 2009, 200 available January 1, 2010

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Eligibility

• Individuals must have an evaluation that reflects
  their current level of intellectual and adaptive
  functioning.
• Six and over a psychological evaluation with a
  diagnosis of mental retardation.
• Six and under either a psychological or
  standardized developmental evaluation that states
  the child has a diagnosis of mental retardation
  or is at developmental risk.

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Criteria

• All individuals receiving MR Waiver services must
  meet the ICF-MR level of care.
• Case Manager completes a Level of Functioning
  Survey. The individual needs to have
  significant needs in two or more of the surveys
  seven categories.

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Waiting List

• Urgent
• Non-Urgent

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Urgent Criteria for the MR Waiver

• Primary caregivers are both 55 yrs or older (or
  if 1, is 55 or older)
• Living with a primary caregiver who is providing
  the service voluntarily and without pay and they
  cant continue care
• There is a clear risk of abuse, neglect, or
  exploitation
• Primary caregiver has chronic or long term
  physical or psychiatric condition significantly
  limiting ability to provide care

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• Individual is aging out of a publicly funded
  residential placement or otherwise becoming
  homeless
• Individual lives with the primary caregiver and
  there is a risk to the health or safety of the
  individual, primary caregiver, or other
  individual living in the home because
• Individuals behavior presents a risk to himself
  or others OR physical care or medical needs
  cannot be managed by the primary caregiver even
  with generic or specialized support arranged or
  provided by the CSB

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MR WAIVER WAITING LISTSUrgent and Non-urgent

• CSBs and DMHMRSAS maintain Urgent and Non-Urgent
  lists
• CSB maintains Planning list
• CSB provides individual with written notice if
  placed on a waiting list and if there is a change
  in status to another list
• CSB determines who is the most urgent
• Only after all Urgent needs are met statewide
  will Non-urgent needs be served

• Slot moves with you to a different town in VA
• Vacant or new slots are allocated by the CSB
  unless there is no need in the CSBs area
• Non-urgent meet criteria for the MR Waiver,
  including needing services within 30 days, but
  dont meet Urgent criteria
• Planning list need services in the future

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Services

• Adult Companion Care
• Assistive Technology (5000)
• Congregate Residential
• Crisis Stabilization/Supervision
• Day Support
• Environmental Modifications (5000)
• Family/caregiver Training
• In-home Residential
• Medication Monitoring
• PERS
• Personal Care (Agency or Consumer Directed)
• Prevocational Services
• Private Duty Nursing/Skilled Nursing
• Respite Care (720) (Agency or Consumer Directed)
• Therapeutic Consultation
• Supported Employment
• Transition Services (5000)

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Early Periodic Screening, Diagnosis, and
Treatment (EPSDT)

• Medicaid benefits available to children under the
  age of 21
• ? Must be eligible for Medicaid
• ? Monitor to prevent health and disability
  conditions from occurring or worsening, including
  services to address such conditions
• ? Treatment to correct or ameliorate
  conditions, including maintenance services

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EPSDT

• Immunizations
• Check ups and lab tests
• Mental health assessment and treatment
• Health education
• Eye exams and glasses
• Hearing exams and hearing aids implants
• Dental services
• Personal care, nursing services
• Other needed services, treatment and measures for
  physical and mental illnesses conditions

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Medical Necessity

• The medical justification for a service must
  accompany the request for EPSDT treatment
  services
• -Services not covered
• Respite
• Environmental Modifications
• Vocational
• Educational

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Health Insurance Premium Payment Program (HIPP)

• If an individual receiving waiver services has
  private health insurance, Medicaid will be the
  individuals secondary insurance
• DMAS may reimburse the individual for all or a
  portion of their monthly private health insurance
  premium

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HIPP

• Application must be completed separately from the
  Medicaid application.
• 1-800-432-5924
• Visit www.dmas.virginia.gov scroll to Client
  Services click on More Services then click on
  HIPP Information

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Recipient Appeal

• A person may appeal if their benefits are
• -Terminated
• -Denied
• -Suspended
• -Reduced

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Medicaid Appeals

• Fair Hearing
• Right to challenge decisions and actions
  regarding Medicaid
• Appeal must be requested within 30 days of the
  decision or action that you disagree with
• Decision should be issued by the Hearing Officer
  within 90 days

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Steps

• Request an appeal or review
• (804)-371-8488
• Notify appeals division in writing
• Be specific about what you want
• -Results in a hearing
• -Decision made

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MYTH or FACT

• All persons with a disability of MR/ID will
  qualify for MR Waiver. MYTH
• I can be on a wait list for the DD Waiver or the
  MR Waiver while I am receiving services from
  another Waiver. FACT

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Waiting Lists

• MR Waiver has 2 waiting lists
• Urgent and Non-urgent
• CSB determines who is the most urgent to receive
  available MR Waiver funding
• DD Waiver waiting list
• First come, first served with wait list numbers
  assigned
• 10 of available money allocated for emergency
  situations
• DMAS staff determine who receives available
  emergency slots
• No waiting list for AIDS, Alzheimers, EDCD and
  Tech
• Waiting lists are permissible, but waiting lists
  must move at a reasonable pace. What is a
  reasonable pace?

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The Arc of VirginiaFamily Involvement Project

• Debra Holloway
• Family Involvement Project Manager
• 888-604-2677
• ext. 103
• dholloway_at_arcfip.org

• The Arc of Virginia
• 888-604-2677
• www.arcofva.org