Exploring Medicaid Waivers

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Exploring Medicaid Waivers Powered By Docstoc
					Exploring Medicaid

Debra Holloway
The Arc of Virginia
Family Involvement Project
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)

   Means “Low income” – Wrong!

   Waiver eligibility is not dependent on
Waiver Must be Cost
   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.
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
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 (DD)
 Mental Retardation Waiver

 (MR Waiver, ID or intellectually disabled)
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
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
Consumer-Directed Employees
Attendants, Companions, Respite
   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
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)

   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.

 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
   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 your local
    Health Department
   Schedule visit with pre-admission screening
    teams of the Department of Health &
    Department of Social Services.
   Completed Medicaid application (child’s
    information only!)
   Adult Day Health Care
   Personal Care (agency or consumer directed)
   Respite 720 hrs. (agency or consumer directed)
   Personal Emergency Response System (PERS)
   Assistive Technology ($5000 max calendar year)
   Environmental Modifications ($5000 max calendar
   Transition Services ($5000 max)
   Transition Coordination
Technology Assisted
Waiver (Tech)
   No age limit to eligibility
   No waiting list
   Currently serving 319 individuals.
   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
   Screening: UAI is used for adults and Tech Waiver scoring
    tool is used for children
   The Department of Medical Assistance Services (DMAS)
    reviews individual’s private insurance policy for private duty
    nursing benefits
   Case management provided by DMAS nurses
   Different rules for children and adults

   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
             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
   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
   Transition Services ($5000)
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
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.
   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 Compete
    the form and fax or mail it to the CDC. The
    psychological assessment is a requirement of the
    screening determination.
also referred to as developmental
   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
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
   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)
Mental Retardation
Waiver (MR)
   Day-to-day MR waiver operations are managed by
    the Department of Mental Health, Mental
    Retardation and Substance Abuse Services
   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

   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.

   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
Urgent Criteria for the MR
   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 can’t
    continue care
   There is a clear risk of abuse, neglect, or
   Primary caregiver has chronic or long term physical
    or psychiatric condition significantly limiting ability
    to provide care
   Individual is aging out of a publicly funded
    residential placement or otherwise becoming
   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:
      – Individual’s 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
Urgent and Non-urgent
   CSBs and DMHMRSAS                   Slot moves with you to a
    maintain Urgent and Non-             different town in VA
    Urgent lists                        Vacant or new slots are
   CSB maintains Planning list          allocated by the CSB unless
   CSB provides individual with         there is no need in the
    written notice if placed on a        CSB’s area
    waiting list and if there is a      Non-urgent = meet criteria
    change in status to another          for the MR Waiver,
    list                                 including needing services
   CSB determines who is the            within 30 days, but don’t
    most urgent                          meet Urgent criteria
   Only after all Urgent needs         Planning list = need
    are met statewide will Non-          services in the future
    urgent needs be served
   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)
Early Periodic Screening,
Diagnosis, and Treatment
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
   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
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 (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

   Application must be completed
    separately from the Medicaid
   1-800-432-5924
   Visit scroll to
    “Client Services” click on “More
    Services” then click on “HIPP
Recipient Appeal

 A person may appeal if their benefits
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

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

 Be specific about what you want

-Results in a hearing
-Decision made

   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
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, Alzheimer’s, EDCD and Tech

Waiting lists are permissible, but waiting lists must
 move at a reasonable pace. What is a reasonable
The Arc of Virginia
Family Involvement Project
Debra Holloway         The Arc of Virginia
Family Involvement     888-604-2677
  Project Manager
ext. 103