Exploring Medicaid Waivers

Document Sample
Exploring Medicaid Waivers Powered By Docstoc
					Exploring Medicaid

Debra Holloway
The Arc of Virginia
Family Involvement Project
   Medicaid Waivers were developed to
    encourage people with disabilities and
    the elderly to access services in their
    homes and communities.
   Virginia’s 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.
There are seven waivers administered by
the Commonwealth of Virginia

   Elderly or Disabled with Consumer Direction
   Individual and Family Developmental Disabilities
    Supports (IFDDS)
   Technology Assisted (Tech)
   Mental Retardation (MR)
   Day Support
   Alzheimer’s Assisted Living (AAL) Waiver managed
    by the Facility and Home-Based Care Unit
   Mental Health Waiver (Demonstration Waiver)
 Elderly or Disabled with Consumer
  Direction Waiver (EDCD)
 Technology Waiver (tech)
 Individual and families with
  Developmental Disabilities Waiver
 Mental Retardation Waiver
 (MR Waiver)
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 12,187
   No waiting list

   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.

   Adult Day Health Care
   Personal Care (agency or consumer
   Respite 720 hrs. (agency or consumer
   Personal Emergency Response System
   Medication Monitoring

 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
Pre-admission Screening
   A recipient may qualify for nursing facility level of care or
    placement in a waiver by meeting one of the following
    -Dependent in 2 to 4 ADL’s, plus semi-dependent or
    dependent in behavior and orientation, plus semi-dependent
    in joint motion or semi-dependent in medication
    administration; or
    -Dependent in 5 to 7 ADL’s and dependent in mobility; or
    -Dependent in 2 to 7 ADL’s plus dependent in behavior and
    orientation; AND
    -Have medical nursing needs
   Functional Dependencies:
    bathing, dressing, toileting, transferring,
   Medical and nursing needs:
    catheter care, supervision for adequate
    nutrition and hydration, therapeutic exercise
    and positioning, management of those with
    sensory, metabolic, or circulatory
Getting Started

   Request for screening, contact either
    the local Department of Social Services
    or the local Health Department
   Schedule visit with nurse
   Completed Medicaid application
    (child’s information only!)
   Meet with Home Health Care Agency
Technology Assisted
Waiver (Tech)
   No age limit to eligibility
   No waiting list
   Currently serving (2007) 295

   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.
   Recipients with private insurance which
    provides PDN as a benefit must exhaust this
    service prior to waiver service initiation
   Private Duty Nursing (16 hours maximum a
    day, except children may have 24 hours a
    day for the first 30 days after hospital
   Personal Care (adults only)
   Respite Care (360)
   Environmental Modifications ($5000)
   Assistive Technology ($5000)
   Durable Medical Equipment

   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
(younger than 21)

   Children must depend part of the day on a vent; or
    require prolonged intravenous nutrition, drugs or
    peritoneal dialysis; or have a daily dependency on
    other devise-based respiratory or nutritional
    support including tracheotomy tube care, oxygen
    support, or tube feeding; and
   Individuals who have been determined to need
    substantial and ongoing nursing care as indicated
    by a score of a minimum of 50 points on the
    objective scoring criteria
             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
   If the criteria is met DMAS conducts a home
   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
Individual and Family
Developmental Disabilities
Support Waiver (DD)
   DMAS is the administrator of the
   Recipients served FY07 594, and 591
    are waiting.
   Can be placed on the waiting list at
    age 5 years 8 months

   Home and community-based care
    services that enables the individual six
    years of age or over to remain at
    home rather than being placed in an
    Intermediate Care Facility (ICF/MR)
   Adult Companion
   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
   Respite care (720)
   Personal attendant services

   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.
   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.
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
   If the child meets DD Waiver eligibility
    the child can transition to the DD
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 12/07 3,893

   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.
   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

   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 survey’s seven
Waiting List

   Urgent
   Non-Urgent
Waiting List
 Urgent  - Needing waiver
  services immediately
 Non-urgent – needing waiver
  services within 30 days

   The individual consumer or their
    representative employs and monitors
    staff providing services exclusive to
   Public Partnerships, LLC (fiscal agent)
Early Periodic Screening,
Diagnosis, and Treatment

   Medicaid’s program for children up to
    age 21 with a preventative treatment

   Screening/Well Child check-ups, lead
    testing and immunizations
   Treatment services to correct a
    medical condition, make it better, or
    prevent the child’s health status from
Specialized Services:
 The following services are covered only
  under EPSDT
 All require pre authorization at DMAS
-Specialized Medical Treatment
-Hearing Aids
-Specialized and Substance Abuse Residential
-Personal Care (ADL dependency in 3 areas)
-Private Duty Nursing
Medical Necessity

 The medical justification for a service
  must accompany the request for
  EPSDT treatment services
-Services not covered
Environmental Modifications
Health Insurance Premium
Payment Program
   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

   1-800-432-5924
   Visit www.dmas.virginia.gov scroll to
    “Client Services” click on “More
    Services” then click on “HIPP
Recipient Appeal

 A person may appeal if their benefits

   Fails to take application for medical
   Personal Care hours are reduced
   EDCD Waiver is terminated for LOC

 Request an appeal or review
 Notify appeals division in writing

 Be specific about what you want

-Results in a hearing
-Decision made