ODMRDD Waivers by chenboying

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									    Everything You Need to Know
       Your Medicaid Waiver
    Delaware County Board of Developmental Disabilities
                        November 2009

    What is a Waiver?

     A waiver is another way that Medicaid can pay for
     services to keep people with disabilities in their
     homes so they do not have to move to a long-term
     care facility or nursing home. The local county board
     is required to pay 40% of the cost of waiver services
     and Medicaid pays the remainder (also known as
     HCBS waiver)

     In order for an individual to receive a waiver, they
     must make application to be placed on the waiting

    Waiting List

    The waiting list rule OAC 5123:2-1-08 dictates
      enrollment based on priority categories.

    Refer to the Priority Score Sheet for categories.

    Waiting Lists in Delaware County

       In Delaware County, each priority group has a
       weighted point value which is used to determine
       the individuals priority score
       All waiting lists are ordered first by priority score
       and then date and time of application
       One must have a minimum score of 2 in order to
       meet priority for the Level One Waiver. This
       increases to a minimum score of 11 in order to
       meet priority for the Individual Options Waiver
    Why do I want a waiver?

    Comparison Charts for local funding

    Medicaid Card (therapies, equipment, doctor
     appointments, nursing)

    Can disenroll from the waiver at any time if it is
     not meeting the need

    Applying for a Waiver

      A person must be Medicaid eligible to be eligible for a waiver
      Adults on the waiting lists should apply for Medicaid if his/her
      name is on the waiting list (JFS 7200)
      Medicaid eligibility is determined by the local Job & Family
      Services office and takes into consideration:
      –  Income
      –  Assets
      –  Disability and age
      Children will need to wait until a slot is available and assigned
      before applying for Medicaid due to household income

    Applying for a Waiver continued…

     Delaware County Board of DD will send the
     Medicaid and Waiver applications to the family (7200
     and 2300)
     The family will complete the applications and send
     them to DCJFS. DCJFS will set an appointment and
     send notification to the family
     A person must remain eligible for Medicaid to
     receive waiver services

    Preparing for the Transition to
    Waiver Services

    Begin search for providers
    Providers must be certified by DODD to provide waiver services
    It can take several weeks for a provider to complete the
         certification process
    IO and LV1 providers will not bill DCBDD for waiver services.
        Billing is completed through the MBS on-line application and
        payment is made by DODD
    Medicaid Card Service (State Plan/CORE) providers are listed at

    Waiver Enrollment
    Ages 5 and Under

       Reports from EI Specialists, school staff or therapists that
       document delays in at least three of six areas (reports must
       be less than 6 months old). Delay areas include (OAC
               Adaptive behavior
               Physical development or maturation, fine and gross motor skills, growth
               Cognition
               Communication
               Social or emotional development
               Sensory Development
       Protective Level of Care
       Ohio Developmental Disability Profile*

       *exclusive to the individual options waiver

     Waiver Enrollment
     Ages 6 and Over

        Functional Assessment
                Ages 6-8 Attachment C
                Ages 9-11 Attachment D
                Ages 12-15 Attachment E
                Ages 16+ Attachment F
        Protective Level Of Care
        Medical Evaluation
                Not time sensitive
                Must contain relevant information and confirm diagnosis
        Psychological report
                Not time sensitive
                Must contain relevant information and confirm diagnosis
        Ohio Developmental Disability Profile*
        *exclusive to the individual options waiver
     Individual Options

     Services available with the IOW include:
           Homemaker Personal Care
           Transportation
           Environmental accessibility modifications
           Adaptive & Assistive equipment
           Social work*
           Interpreter*
           Home delivered meals*
           Nutritional services*
           Adult Day Waiver Services

            *exclusive to the individual options waiver

     Level One
     Services available with LV1 waiver include:
           Homemaker/Personal Care
           Informal Respite*
                                                 $5000 annual cap combined
           Institutional Respite
           Transportation
           Personal Emergency Response Systems
                                                                         $6000 cap
           Specialized Medical Equipment and Supplies                   over a 3
           Environmental Accessibility Adaptations                      yr. period

           Emergency Assistance*         $8000 cap over a 3 yr period – must meet
                                          emergency status to access this service.
           Adult Day Waiver Services

        *exclusive to the level one waiver

     Waiver Service Planning

     Complete Individual Support Plan (ISP) with your team
     Complete Payment Authorization for Waiver Services (PAWS)
         –   Read and understand your PAWS (refer to sample PAWS)

     Waiver Utilization
         –   Tracking
         –   Reallocation
         –   Over-utilization

     Your ISP is an ―All Services Plan‖ and is to include all waiver,
     locally funded, and Medicaid card services


      A Medicaid Card is included with the Waiver service
      package and may cover therapies, hospital services,
      nursing services, home health aides, doctor & dental
      appointments and medical equipment

      Many of these services are available through
      Medicaid State Plan Services

     State Plan Services

                  Home Health Services
                       (OAC 5101:3-12-01)

       –   Services anyone with a Medicaid card and a
           Doctor‘s order can access
       –   Available Statewide
       –   No waiting list

     Home Health Services

     Home Health Services include:

           Home Health Nursing
           Home Health Aide
           Skilled therapies (OT,PT,SLP)

        Services must be medically necessary as ordered
           by the treating physician.

     Home Health Services

       Four hours or less per visit
       (intermittent service)

       No more than 8 hours a day combined
       nursing/aide and therapies

       No more than 14 hours per week of

     Home Health Services

       To meet the requirement of ‗intermittent‘, similar
       services cannot be ‗stacked‘

             For example—2 consecutive hours of service
              cannot be authorized as 1 hour of Home
              Health Services aide and 1 hour as Waiver
              HPC provider.

             A 2 hour break is required.

     Home Health Services

     Cannot be billed back to back (stacked) with
                  a similar service type

     For example:

     6am-8am(no break) 8am-12pm(no break)12pm-2pm
      HH Aide        Waiver HPC Provider   HH Aide

                    Not Permitted

     Home Health Services

      MUST have a MINIMUM 2 hour break in services

     For Example:

     6am-10am(break) 1pm-5pm(break) 8pm-10pm
       HH Aide      Waiver HPC Provider   HH Aide


     Home Health Services

     Can be billed back to back with a DIFFERENT
     service type

     For example:

     6am-8am (no break) 8am-12pm (no break) 12pm-2pm
     Home Health Aide   Waiver Nursing   Home Health Aide

     Home Health Services

     Can be billed back to back with a DIFFERENT
     service type

     For example:

         6am-8am (no break) 8am-12pm (no break) 12pm-2pm
         HH Aide          Waiver Informal       HH Aide
                          Respite Provider


     Home Health Services

      Home Health Services
      cannot be provided for
      the purposes of respite
      or habilitative care

     Home Health Services

     Per OAC 5101:3-12-01 (D) (4) (c)

          ―Respite care‖ is the care provided to a
          consumer unable to care for himself or herself
          because of the absence or need for relief of
          those normally providing care.

     Home Health Services

      Must be provided in the
      consumer‘s place of
      residence or in a
      licensed day care, or
      in an Early Intervention
      program .

     Home Health Services

     Home Health Aide Services
     Per OAC 5101-3-12-01(F)(2)(e)

     Services include:
                        Personal Care
                        Routine catheter/colostomy care
                        Assistance with routine maintenance exercises
                         and passive ROM activities in support of skilled
                         therapy goals.
                        Routine care of prosthetic and orthotic devices

     Home Health Services

     Home Health Aide Services
     Per OAC 5101-3-12-01(F)(2)(f)

        Incidental Services can include: light chores, laundry, light
         house cleaning, meal prep and taking out trash
        Main purpose of a Home Health Aide visit cannot be solely to
         provide incidental services
        Incidental services are to be performed only for the consumer
        May NOT provide medication administration

     Home Health Services Worksheet

        The SSA will complete the HHS worksheet for those
         on an MRDD waiver (DCBDD form)
        List all agencies providing home health services
         (aide, therapy and nursing less than 14 hours per
        Attach care plan from home health agency
        Agency must have Dr‘s script, care plan and HHS
         worksheet on file

     Increased Home Health


     Up to age 21

     Must have a comparable institutional level of care (ILOC, ICF
        MR/DD LOC, or SLOC)

     Must need at least 1 skilled service a week (nursing or therapy)

     Have part-time intermittent needs
         (Visits must continue to be 4 hours or less with 2 hour min break in
         between like services)

     Home Health Services

       –   Must be reflected on service plan for children enrolled on a
           DODD-administered waiver. (Use worksheet)

       –   For children on ODJFS-administered waivers, the case
           manager authorizes these services via the service
           planning process.

       –   Provider Type---Medicare Certified Home Health Agency
           providers are listed at http://www.ohiohcp.org/

     Home Health Services Crosswalk

     Services at a Glance       State Plan Therapies
       –   Types of services      –   SLP, OT, PT
       –   Separated into age     –   Fee for Service
           groups                 –   HHA
       –   Eligibility            –   Hospital
       –   Providers              –   Physician
                                  –   IPs (not available for all

     Private Duty Nursing Services

     OAC 5101:3-12-02
     Private Duty Nursing is continuous nursing that is more than 4
         hours per visit.
     PDN is required when more than 14 hours of nursing is needed
        per week.
     Must be provided in the consumer‘s place of residence unless it is
        medically necessary for a nurse to accompany the consumer
        into the community.

     The Private Duty Nursing Service can be provided for the
        purposes of respite care.

     Private Duty Nursing

      ODJFS shall complete a face-to-face assessment to confirm
       that the consumer has a medical condition that requires
       medically necessary PDN services once they receive the
       request form from the CB.

       ODJFS will authorize the amount scope and duration of PDN

       Authorized for no more than 1 year for consumers enrolled on
       an DODD-administered waiver

     Durable Medical Equipment

      5101:3-10-03 "Medicaid Supply List“

                              List of supplies:

     Any Questions?

     Ohio Department of Developmental Disabilities
       –   http://dodd.ohio.gov/
     Delaware County Board of DD
       –   www.dcbdd.org
     Ohio Department of Job & Family Services
       –   http://jfs.ohio.gov/


     Melinda Draper         Roxanne Richardson
     Waiver Coordinator     Support Administrator
     mdraper@dcbdd.org      rrichardson@dcbdd.org
     740-368-5802 ext 506   740-368-5801 ext 308


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