1. Medicaid funded long-term services and supports for people with disabilities
Colleen Horton
Hogg Foundation for Mental Health
The University of Texas at Austin
July, 2010

2. What I was asked to do…
Explain Medicaid funding for long term services and support.
Talk about all the waiver programs offered through DADS and DSHS including:
Eligibility requirements (eligibility)
How to sign up
Services available
Funding amounts
Where to get information
Include information about the consumer directed services options.
Provide information on other long term services and supports
Talk about the waiting lists.
Talk about how folks can impact change during the session.

3. Medicaid (Much of the Information in this presentation taken directly from the DADS website)
History
Entitlement program established in Texas in 1967 to provide health care to certain low income individuals; Title XIX of Social Security Act (1965)
Purpose – to provide health coverage to:
Low-income families, children & related caretakers
Pregnant women
Elderly
People with disabilities
Eligibility
Individuals receiving TANF and SSI
Individuals receiving waiver services
Individuals meeting income and disability criteria
Emergency Medicaid Services

4. People with disabilities
30 % or the Medicaid Population
58% of Medicaid Costs

5. Medicaid State Plan The State’s contract with the feds
Entitlement (no waiting list)
Mandatory Services
Optional Services
Mandatory populations
Optional Populations
Texas Medicaid and CHIP in Perspective

6. Mandatory services EPSDT-Texas Health Steps Family planning services
Inpatient/Outpatient hospital care
Physician services
Nurse midwife services
Nurse practitioner
FQHCs
Lab & xrays
Prenatal care
Family planning services
Skilled nursing
Children’s vaccines
Nursing facility care
Home health care
Rural Health Clinics
Nurse practitioners
Rural health clinics

7. Optional Services Durable medical equip. PT, OT, Speech
Personal care services
Dental services
ICFMR
IMDs (under 21, over 65)
Private duty nursing (under 21)
RX drugs (3 per mo.)
Unlimited RX in nursing facilities, ICFMR, managed care
Birthing center
Renal dialysis
Rehabilitation (chronic mental illness, physical, development)
Targeted case management
Medical transportation
Optometry
Podiatry
Emergency hospital services
Licensed professional counselor (LPC)

8. Populations Covered TANF recipients
Families based on age, income, and assets
Newborns up to 12 months whose mother is Medicaid certified at the time of child’s birth
The majority of children in foster care
Some adopted children
Non-disabled, non-pregnant adults over age 65 w/ income below the TANF limit
Children under 19 and pregnant women over the income limit but have significant medical bills (Medically needy/spend down)
SSI recipients (aged, blind and disabled)

9. Optional populations
Individuals receiving Primary Home Care services (up to 300% of SSI income limit)
Individuals receiving waiver services
Childless adults (not covered in Texas)

10. Children in medicaid Some things are different for kids:
All medically necessary services
Texas Health Steps – Early and Periodic Screening, Diagnosis, and Treatment
Comprehensive Care Program
Personal Care Services
Voluntary participation in managed care (Star+Plus)

11. Nuts and Bolts How do I apply for Medicaid?
By phone – call 211 (connects callers with information on health and human services)
On-line
In person
Texas Medicaid and Healthcare Partnership (TMHP) contracts with state to provide Medicaid administration, reimbursement services, claims, prior authorization
Texas Medicaid and CHIP in Perspective
Frew v. Hawkins (1996) – Texas HealthSteps
Alberto, N. – Private duty nursing and personal care services

12. CHIP Children’s Health Insurance Plan
Eligibility
Under 19 years of age
Children in families with low incomes and assets
Services
12 months of health care coverage
Cost Sharing
Enrollment fees are $50 or less per family
co-pays typically $3 -$5

13. how to enroll in CHIP
If you would like to request an application or check the status
of your application, call
 You may also go online to and print an application.
Fax or mail completed applications to the Texas ACCESS Alliance at: P.O. Box Midland, TX  FAX:

14. MAXIMUM MONTHLY INCOME LIMITS FOR HEALTH CARE COVERAGE PROGRAMS FOR CHILDREN
Source: HHSC Financial Services, 2007 Medicaid Expenditures,
Family Size
Medicaid for Children Under Age 1
Medicaid for Children Ages 1 to 5
Medicaid for Children Ages 6 through 18
CHIP
Medicaid for Youth Transitioning out of Foster Care 1
$1,670
$1,201
$903
$1,805
$3,610 2
$2,247
$1,615
$1,215
$2,429
$4,857 3
$2,823
$2,030
$1,526
$3,052
$6,104 4
$3,400
$2,444
$1,838
$3,675
$7,350 5
$3,976
$2,859
$2,150
$4,299
$8,597 6
$4,553
$3,273
$2,461
$4,922
$9,844 7
$5,130
$3,688
$2,773
$5,545
$11,090 8
$5,706
$4,102
$3,085
$6,169
$12,337
For each additional person, add:
$577
$415
$312
$624
$1,247

15. Managed Care STAR STAR+Plus PCCM (Primary Care Case Mgt.) Northstar
Managed care – acute care
STAR+Plus
Managed care – acute care and long term services and supports
PCCM (Primary Care Case Mgt.)
Primarily in rural areas
Northstar
Behavioral health managed care
Dallas/Ft. Worth
IDD Pilot – current study
Managed Care

16. Community Safety Net Services 39 MHMR Community Centers
MRA
Service coordination
Respite
Employment services
Flexible services
LMHA
Children’s mental health services
Adult mental health services
Crisis services
State hospitals

17. Medicaid Buy-IN for Children
Will allow parents of children with disabilities in families with income up to 300% of federal poverty limit, to buy into the state Medicaid Program
SB Authorizing legislation/SB 1 – appropriation (Senator Deuell and Rep. Lucio)
Development - underway
Implementation ???
A program at risk.
Medicaid Buy-IN for Children

18. Medicaid 1915(c) Waivers State/Federally funded
Community-based long term services and supports
State must submit a waiver application to CMS
Texas has too many waivers! Nine different (1915(c) waivers with different administrative units and rules, service arrays, rates, monitoring requirements, billing guidelines, etc.
Developed to provide alternatives to institutionalization
Waive certain Medicaid rules (e.g. state-wideness)
1915(c) waivers “waive off” of some institutional setting (e.g. nursing facility, state school, ICFMR)

19. Texas 1915(c) Waiver Programs
Community Living Assistance and Support Services (CLASS)
Home and Community-based Services (HCS)
Medically Dependent Children’s Program (MDCP)
Deaf-Blind with Multiple Disabilities (DBMD)
Community Based Alternatives (CBA)
Consolidated waiver (CWP)
Youth Empowerment Services (YES)
Texas Home Living (TxHmL)
STAR+PLUS
Federal requirement – waiver programs must be cost neutral in the aggregate.

20. Waiver interest lists August, 2009 CLASS HCS MDCP DBMD CBA
Managed Care
Total
# on interest list
27,674
42,360
14,347 79
34,050
5,633
124,143
March, 2010
30,363
43,385
17,052
262
35,278
5,743
132,083*
(Unduplicated
102,647)

21. Time on the interest list/March 2010 http://www. dads. state. tx
CBA
ICM
STAR+
CLASS
DBMD**
MDCP
HCS
0-1 years
18,979
1,358
4,274
6,909
222
5,464
9,296
1-2 Years
14,847 12 48
6,268 34
4,662
7,934
2-3 years
1,452 2 30
5,458 6
3,917
6,444
3-4 years
N/A 17
4,241
3,009
5,097
4-5 years
2,607
3,899
5-6 years
2,561
3,268
6-7 years
2,320
3,222
7-8 years
2,935
8-9 years
1,290
9+ years

22. CLASS provides home- and community-based services to people with related conditions as a cost-effective alternative to placement in an intermediate care facility for persons with intellectual disabilities or a related condition (ICF-MR/RC).
Class
Community Living Assistance supports and Services

23. CLASS Eligibility requirements
Disability/functional
Related conditions (not primary diagnosis of intellectual disabilities)
Must meet level of care needed for ICFMR eligibility
Must have a need for habilitation
Assessment conducted by direct service agency nursing staff
Must be diagnosed before the age of 21 years
Financial
300% for the federal poverty level; $2,000 countable assets
Based on child’s income, not family income
Determined by HHSC Medicaid enrollment division, not DADS
Service plan may not exceed 200% of cost of care in ICFMR

24. Services available in CLAss
Adaptive aids
Case management
Habilitation
Minor home modifications
Nursing services
OT, PT, Speech
Psychological Services
Behavioral supports
Respite care
Specialized therapies
Medical supplies
Support family services
What’s missing?
Adaptive aids - Reimbursement: Actual cost of item plus requisition fee. The annual allocation is $10,000 per service plan year.
Habilitation attendant/training services: CLASS
This service helps individuals living in their own or their families' homes learn, retain, or improve their skills related to activities of daily living. Services include teaching:
personal grooming and cleanliness, bed making and household chores, preparing and eating food, and the social and adaptive skills necessary to reside in their own home in the community.
Minor home modifications: CLASS
This service is used to assess the need for, arrange for, and modify or improve individuals' living quarters to allow community living and ensure safety, security, and accessibility.
Reimbursement: Actual cost of modifications. The lifetime maximum amount for modifications is $10,000, with an annual maintenance and repair allotment of $300 per service plan year once the lifetime limit is reached.
Nursing services: CLASS
This service, which is provided by a licensed nurse, include: monitoring health conditions, administering and monitoring medication, providing referrals for medical services, and training individuals, their family members, and support personnel.
Psychology: CLASS
This service provides a licensed psychologist to perform services that are directed toward modifying and improving cognitive and affective skills. Services include: counseling individuals and assessing and training direct service providers or family members with regard to a specific individual treatment plan.
Specialized therapies: CLASS
This service includes therapeutic intervention to decrease inappropriate behaviors, provide opportunities for socialization, and improve physical and medical status. Services include:
musical therapy,
recreational therapy,
massage therapy,
hippotherapy,
hydrotherapy,
therapeutic horseback riding,
auditory integration therapy,
nutritional services; and
aquatic therapy.

25. How to apply for class waiver services
Call toll-free to have a person placed on the interest list.
Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.
Need to confirm annually that you want to remain on the waiting list.
Assessment to determine eligibility is not done until services are offered (slot is available).

26. Utilization review/increased costs
Amount of services/budget based on plan of care.
CLASS waiver costs have increased 25% since 2006.
Cost cap for CLASS is approximately $57,000
DADS utilization review unit looking closely at those plans of care that exceed a certain threshold ;
Children - ($43,000) (3/2010)
Adults - $57,368

27. HCS provides individualized services and supports to persons with intellectual disabilities who are living with their family, in their own home or in other community settings, such as small group homes.
HCS
Home and Community-based Services

28. HCS Eligibility Disability Financial
Must have an intellectual disability with IQ of 70 or below, or
Have a related condition with an IQ of 75 or less
Must meet the level of care criteria for an ICFMR
Assessment and service coordination done by local MHMR Center staff
Financial
300% of the SSI income limits; no more than $2000 in countable assets
Based on child’s income, not family income
Determined by HHSC Medicaid enrollment division, not DADS
Service plan may not exceed 200% of cost of care in an ICFMR

29. Services available in HCS
Service Coordination
Adaptive aids
Minor home modifications
Counseling and therapies
Speech, OT, PT
Audiology
Dietary
psychological
Nursing
Dental treatment
Respite
Supported employment
Day habilitation
Residential Services
Supported home living
Foster/companion care
Supervised home living

30. How to apply for HCS waiver services
Apply for services by
Contacting you local mental retardation authority (MRA)
MRA website: or call 211.
Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.
Need to confirm annually that you want to remain on the waiting list. If your local MRA doesn’t contact you, call them!

31. Utilization review/increased costs/waiting list
Amount of services based on assessed Level of Need (LON)
Number of individuals waiting for HCS services = 43,385 (3/2010)
Current waiting time = about 9 years (3/2010)
Service coordination now conducted by local MRA (MHMR community center)
Cost caps vary by level of need.

32. MDCP
MDCP provides services to support families caring for children and young adults who are medically dependent and to encourage de-institutionalization of children in nursing facilities.
Medically Dependent Children’s Program .

33. MDCP Eligibility Disability Financial Eligibility
Must meet medical criteria for nursing facility admission
Must be under the age of 21 years
Must meet disability criteria for social security or Medicaid benefits
Financial Eligibility
300% SSI income limits; no more than $2,000 in countable assets
Based on child’s income, not family’s

34. Services Available in MDCP
Respite
Adjunct support services
Adaptive aids
Minor home modifications
Transition services

35. How to apply for MDCP services
Call to have the child's or young adult's name placed on the MDCP interest list.
Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.
Need to confirm annually that you want to remain on the waiting list. If your local MRA doesn’t contact you, call them!

36. Utilization review/waiting list
Service coordination/case management is performed by DADS regional MDCP staff (nurse and/or social worker)
Cost cap is 50% of cost of nursing facility care (wrap-around Comprehensive Care Program services)
Number of children waiting = 17,052 (3/2010)
Current waiting time = 3-4 years (3/2010)

37. DB/MD waiver provides home and community-based services to people who are deaf-blind with multiple disabilities as a cost-effective alternative to institutional placement. The program focuses on increasing opportunities for consumers to communicate and interact with their environment.
DBMD
Deaf/Blind Multiple Disabilities
DB-MD provides home and community-based services to people who are deaf-blind with multiple disabilities as a cost-effective alternative to institutional placement. The program focuses on increasing opportunities for consumers to communicate and interact with their environment.

38. Eligibility for DBMD Disability/Functional
Meet ICFMR or related conditions care criteria. Have deaf-blindness with a third disability resulting in a need for one or more services.
Financial
Must meet Medicaid eligibility.
Have an individual plan of care that does not exceed specific limits.
Additionally, the proposed rules implement requirements in Senate Bill (SB) 37 and SB 63, 81st Legislature, Regular Session, 2009, which affect the program and require new rules. SB 63 creates a career ladder for interveners, and SB 37 removes the minimum age requirement from the eligibility criteria. The program, prior to September 1, 2009, served only individuals who were 18 years of age or older.

39. Services available in DBMD
Adaptive aids
Medical supplies
Assisted living *
Behavior support
Case managements
Chore Provider
Employment assistance
Minor home mods
Habilitation
Intervener
Nursing services
OT, PT, Speech
Orientation & mobility RX
Respite care
Supported employment
Transition assitance
*up to six beds

40. How to apply for dbmd waiver services
Call and ask for the DB-MD waiver representative.

41. Utilization review/waiting list
Fewer “slots” and number served than other waivers
Provides services similar to other waivers and some services specific to those experiencing multiple disabilities.
Number on waiting list = 262 (3/2010)
Current wait = 2-3 years (3/2010)

42. This program provides home-and community-based services to people who are elderly and to adults with disabilities as a cost-effective alternative to living in a nursing home.
CBA
Community Based Alternatives

43. Eligibility for cba Disability/functional
be at risk of entering a nursing facility,
be 21 or older
Must meet medical necessity for Medicaid nursing home care
Financial
Meet Medicaid income eligibility requirements (300% SSI) and have no more than $2,000 in countable assets
Cost of plan of care may not exceed 200% of the cost of care in a nursing facility

44. Services available in cba
Adaptive aids
Medical supplies
Adult foster care
Assisted living
Emergency response services
Home delivered meals
Minor home mods
Nursing services
OT, PT, Speech
Personal assistance services
Respite care services
Dental services
Unlimited RX
Transition assistance services

45. How to apply for cba services
Call your local Department of Aging and Disability Services Office.
DADS local offices can be found at:
Call 211

46. Utilization review/waiting list
Case management performed by DADS regional staff.
Eligible individuals living in STAR+Plus areas must receive their services through STAR+Plus and are not able to obtain services on fee-for-service basis.
Number on waiting list = 35,278 (3/2010)
Current anticipated wait = 2-3 years (3/2010)

47. The Consolidated Waiver Program provides home and community-based services to people who are eligible for care in a nursing facility or intermediate care facility for persons with intellectual disabilities or a related condition (ICF/MR-RC).
CWP
Consolidated waiver program

48. CWP eligibility No age limit
Must currently be on an interest list in Bexar County for one of the following programs:
Community Based Alternatives
Community Living Assistance and Support Services
Deaf-Blind with Multiple Disabilities
Medically Dependent Children
Home and Community-based Services
Must have a service plan developed by a DADS and the participant using the person-directed planning process.
Must meet specific institutional level of care criteria for an ICF-MR/RC, or
Must meet medical necessity determination for nursing facility services.

49. Services Available in CWP
Adaptive aids
Medical supplies
Assisted living /residential care
Audiology
Behavior communications specialist
Dental
Dietary
Nursing services
Orientation and mobility
Personal assistance svcs. RX
Psychological services
Respite care
Emergency response system
Family surrogate svcs.
Habilitation
Home delivered meals
Independent advocate
Minor home modifications
Social work
OT, PT, speech/language
Transportation
Transition assistance svcs.

50. How to apply for cwp services
Contact local Department of Aging and Disability Services office.
DADS local offices can be found at:
When names “comes up” on one of the other waiting lists in Bexar County, and there is an open slot in CWP, individuals have the option to choose between the standard waiver or the consolidated waiver program
Why it didn’t work – designed to fail.

51. Food for thought…
Waiver services should not be considered an “all you can eat menu.”
Every child should have access to the services they truly need, but those children and families fortunate enough to be receiving waiver services also have a responsibility. It’s not a contest of whoever gets the most, wins.
With tens of thousands waiting for services, every extra dollar used affects how long all the children on the waiting list will have to wait.

52. Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families.
YEs
Youth Empowerment Services

53. Yes Waiver Pilot Pilot Project approved by CMS
Achieves cost neutrality by waiving off of state hospitals
Access through MHMR centers in Bexar and Travis counties
Intended to expand to other parts of Texas if successful
Provides intensive mental/behavioral health services in the community
Intended to prevent hospitalization/residential treatment
Pilot in Travis and Bexar counties only
Administered by DSHS

54. YES Waiver eligibility
Disability/Functional
Be between the ages of 3-18 years;
Reside in Travis or Bexar County;
Reside in a non-institutional setting with the child or adolescent’s Legally Authorized Representative (LAR); or in the child or adolescent’s own home or apartment, if legally emancipated;
Choose, or have the LAR choose, the waiver program services as an alternative to care in an inpatient psychiatric facility;
Meet Department State Health Services (DSHS) clinical criteria (including, but not limited to risk of self-harm, risk of severe disruptive or aggressive behavior, family resources, and risk of challenging school behavior); and
There must be a reasonable expectation that, without Waiver services, the child or adolescent would qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines

55. YES Waiver eligibility cont’d.
Financial
Must be eligible for Medicaid, under a Medicaid Eligibility Group included in the approved waiver; parental income is not counted in financial eligibility;

56. Services available in YES waiver
Respite
Community living supports
Family supports
Transitional services
Adaptive aids
Minor home mods
Professional services
Supportive family-based alternatives
Non-medical transportation
Paraprofessional services

57. How to apply for services
Travis County --
ATCIC’s YES Waiver Interest List Message Line at ,or
ATCIC maintains an interest list for individuals interested in receiving YES waiver services
Bexar County – Center for Health Care Services, (210)

58. yes
Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families.
The waiver is designed to reduce Medicaid psychiatric hospital expenses for children with SED by providing community-based services.

59. Waiver “lite”
This program provides selected essential services and supports to people with mental retardation who live in their family homes or their own homes.
Txhml
Texas Home Living

60. TxHmL waiver eligibility
Disability/Functional
No age limit.
Have a determination of mental retardation made in accordance with state law or have been diagnosed by a physician as having a related condition.
Not be assigned a pervasive plus level of need (LON 9).
Live in their own home or with their family.
Financial
Must meet Medicaid eligibility
Only waiver that considers the family income instead of only the child’s income; many children eligible for HCS are not eligible for TxHmL
Have a plan of care that does not exceed the specific program annual cost limit of $12,000

61. Txhml waiver services Adaptive aids Minor home mods
Specialized therapies
Behavioral support
Dental treatment
Nursing
Respite
Day Habilitation
Employment assistance
Supported employment
Community support

62. Texas home living waiver
Does not have a separate waiting list
HCS waiting list used when slots are available
If TxHmL is accepted, individual’s name remains on HCS waiting list
Only waiver that allows all services to be consumer directed

63. Other non-waiver services / programs
Early Childhood Intervention
School services
DARS employment services
In-Home and Family Support (DADS)
Children with Special Health Care Needs (DSHS)
Community MHMR services
Social Security
Other non-waiver services / programs

64. STAR+Plus Requires waiver from CMS
Provides all waiver services available in CBA with the option to offer more
Provider rates are negotiated with the health plan, not mandated by state
STAR+Plus

65. Star+plus entitlement
Those who are SSI eligible in the STAR+Plus regions have an entitlement to long term services and supports (CBA services).
Those who have income between SSI and 300% of SSI do not have an entitlement and must be placed on the waiting list.
Number waiting for services = 5,743 (3/2010)

66. Service Delivery Options
Consumer directed services is not a service; it’s a way of delivering services
Three options for service delivery
CDS is one mechanism available to enhance opportunities for self-determination/direction
All waivers have some services that can be provided through the CDS options
Not all waiver services can be provided through CDS
Service Delivery Options

67. Three types of service delivery
Agency Model
Agency is responsible for arranging for provision of services
Agency is responsible for recruitment, hiring, training, monitoring
Individual has little say with respect to who provides their care
Direct care workers are employees (or contractors ) of the agency
Service Responsibility Options Model (SRO)
Agency is the employer of record, but client participates in the hiring of attendants and respite providers
Consumer Directed Services Model (CDS)
Individual receiving the services is the employer of record
Client is responsible for recruitment, hiring, training, supervising attendants, respite providers, therapists, nurses

68. Types of services that can be consumer directed
Habilitation
Respite
Intervener
Supported home living
Adjunct support services
Personal assistance services
Professional therapies
Nursing
Note: not all services listed above can be consumer directed in all the waivers. Check with your case manager/service coordinator.

69. Money follows the person
Allows an individual residing in a nursing facility to transition to community services.
An attempt to end the institutional bias in the H&HS system.
Only available to individuals residing in nursing facilities.
Not available for individuals in ICFsMR or state schools (state supported living centers).
Voluntary closure is not the same as money-follows-the-person.
Money follows the person

70. state supported living centers
13 facilities, 4,200 residents at $150,000 per year, per resident
Olmstead – least restrictive setting
Promoting Independence Advisory Committee
Community Living Options Information Process (CLOIP)
No MFP only target population slots
Children in State Schools Workgroup
DOJ Investigation
state supported living centers
Formerly called State Schools

71. Projected $18 billion deficit
5% cuts being implemented
Additional 10% must be identified
Only two ways to cover the deficit – raise more revenue or cut spending
“Everything is on the table except raising taxes”
May provide opportunities for major changes
Items previously “off the table” are now on
Mental health services may be hit harder than others (limited federal match)
The 82nd Legislature

72. If there ever was a time or need for advocacy…it is now!
$18 Billion deficit
Lots of competition for the limited resources
Possibility of major systems changes
Get connected with other parents and advocates
Become informed on the issues
Begin crafting your message(s)
Visit you legislators during the interim
Make a plan

73. Begin your advocacy
Write down three things you’ll do this summer to begin your advocacy efforts. (e.g., make an appointment to meet your legislators, contact advocacy organization, etc.)
Become familiar with this website”
Government was never meant to be a spectator sport.
Barbara Jordon

74. Resources Information about the Medicaid waivers
Texas Medicaid and CHIP in Perspective
Imagine Enterprises
Texas Legislature on Line

75. If you need more information feel free to contact me at: colleen
If you need more information feel free to contact me at:
The End 