Presentation on theme: "MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER"— Presentation transcript:
1 MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER Funded by Virginia Board for People with DisabilitiesWorkshop Presented byMaureen Hollowell, Endependence CenterAdministered by Endependence Center, Norfolk, VAFall 2003
2 ? MYTH OR FACT ?1. I have to need the level of care provided in an institution to qualify for Waiver services.2. Waiver eligibility for children depends on parent income.3. Each Waiver offers the same services.4. I can choose my providers from a list of qualified providers.5. The administrative appeal process is expensive.6. All persons with a disability of mental retardation or developmental disability will qualify for the MR or DD Waivers.7. I can be on a wait list for the DD Waiver or the MR Waiver while I am receiving services through another Waiver.
3 MAKING CHANGE information is power influence and control rights must be pursuedcollaborationcredibility
4 MEDICAID MEDICARE SSI SSDI Federal & state program designed to meet the medical needs of certain people who have low incomeMEDICAREFederal medical benefits primarily for the elderly financed through the Social Security systemSSISupplemental Security Income program provides benefits to people who are elderly or disabled who have limited income and resources. Funded with general tax revenues.SSDISocial Security Disability Insurance provides benefits to people who are disabled. Funds are the FICA social security tax paid on workers’ earnings or earnings of their spouses or parents.
5 MEDICAIDPURPOSETo provide for health and medical care for certain groups of people who have low incomeHISTORYMedicaid was established with amendments to the Social Security Act in 1965Medicaid Buy-InFLEXIBILITYStates design their own programs within federal standards
6 MEDICAID IS A JOINT PROGRAM BETWEEN FEDERAL & STATE GOVERNMENTS CENTERS FOR MEDICARE & MEDICAID SERVICESFederal agencyCMSPreviously HCFAcms.hhs.govDEPARTMENT FOR MEDICAL ASSISTANCE SERVICESState agencyDMAS
7 VIRGINIA MEDICAIDDMAS is designated as the single state agency charged with administering Medicaid in VirginiaDMAS contracts or has agreements with other entities for most screening, case management, service and billing related activitiesDMAS is responsible for ensuring that the Medicaid program operates in compliance with state and federal laws and regulations
8 VIRGINIA’S MEDICAID $ 3,784,312,817 48.45% from state funds Virginia Medicaid budget for fiscal year 2002$ 3,784,312,81748.45% from state funds51.55% from federal funds
9 STATE PLAN FOR MEDICAL ASSISTANCE Periodically updated to reflect changesChanges must be approved by CMSDetails Virginia’seligibility requirementscoveragereimbursementadministrative policiesTo add services requires a change to the State Plan ANDPossibly a commitment of dollars from the Virginia General Assembly
10 MANDATORY MEDICAID SERVICES Inpatient Hospital ServicesEmergency Hospital ServicesOutpatient Hospital ServicesNursing Facility CareRural Health ClinicsFederally Qualified Health Center Clinic ServicesLab and X-Ray ServicesPhysician ServicesHome Health ServiceEPSDTFamily PlanningNurse-Midwife ServicesCertified Nurse Practitioner ServicesTransportationMedicare Premiums(Part A) - Hospital; (Part B) - Supplemental Insurance for Categorically Needy
11 OPTIONAL Medicaid Services Provided In Virginia Other Clinic ServicesSkilled Nursing Facility Services for Individuals under 21 years of agePodiatrist ServicesOptometrist ServicesClinical Psychologist ServicesHome HealthPT, OT, and Speech TherapyPrescribed DrugsCase ManagementProstheticsHospice ServicesMental Health ServicesICF-MR
12 Early and 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
13 EPSDT Immunizations Check ups and lab tests Mental health assessment and treatmentHealth educationEye exams and glassesHearing exams and hearing aids & implantsDental servicesPersonal care, nursing servicesOther needed services, treatment and measures for physical and mental illnesses & conditions
14 Institutional Placements HospitalsNursing homesICFs/MR - Intermediate Care Facility for people with mental retardation or other related conditionsinstitutions of 4 or more beds for people with MR or other related conditionsactive treatment and rehabilitationregulated by the federal and state governments24 ICFs/MR in Virginia5 large “Training Centers,” several hundred beds at each Center19 smaller ICFs/MR, ranging from 4 to 88 beds
15 ELIGIBILITY Apply at local Department of Social Services STATE PLAN MEDICAID(Mandatory & Optional Services)Categorical CriteriaDisabled or age 65 or olderFamilies with childrenPregnant womenRecipients of cash assistanceLow income Medicare beneficiariesFinancial ThresholdsLow income and asset guidelinesThresholds vary by category groupParental income/resources DO count for minor childrenConsideration of exceptionally high medical bills (spend-down)LONG-TERM CARE (Waivers & Institutions)Must Need Long-term Carecriteria defined for each Waiverassessment of need requiredFinancial Thresholds300% of SSI payment limit for one person ($1,656 per month)spend-down for 4 of the Waivers$2000 resource limitParent income/resources do NOT count regardless of child’s ageServices RequiredAll Waiver and State Plan (Mandatory and Optional) services you are eligible for
16 HIPP Health Insurance Premium Payment program DMAS program Pays health insurance premiumsApplication must be completed separately from the Medicaid applicationApplication info
17 COPAYMENTSSome people may have to pay a copayment for Medicaid services if they do not receive Waiver services.People who receive Home and Community-Based Medicaid Waiver services do not pay copayments for their basic, State Plan Medicaid services.However, some people may have to pay a patient-pay for their Waiver services.
18 PATIENT-PAY RESPONSIBILITIES People may have to pay for some Waiver services if they have income over $552 per month (except AIDS Waiver which has no patient-pay)Some exceptions for persons who are working (CD-PAS, DD and MR Waivers)
19 Patient-Pay CD-PAS Waiver, DD Waiver, MR Waiver People may have a patient-pay if income is over $552 a monthCan keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/weekCan keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/weekStill have a patient-pay from unearned income for all Waivers except the AIDS Waiver* total of earned and unearned incomeNobody can keep more than $300% of the SSI income level - current federal regs.
20 AMERICANS WITH DISABILITIES ACT “A public entity shall administer services,programs, and activities in theMOST INTEGRATED SETTINGappropriate to the needs of qualifiedindividuals with disabilities.”28CFR Section (d)
21 OLMSTEAD vs. L.C. U.S. SUPREME COURT Tommy OlmsteadCommissionerGeorgia Dept. of Human ResourcesLois Curtisa woman who hasmental illness and mentalretardation, who was confined to astate psychiatric hospital, wanted tolive outside of the hospital
22 SUPREME COURT “administer services with an even hand” “comprehensive, effectively working plan for placing qualified persons with disabilities in less restrictive settings”“waiting list that moved at a reasonable pace” No concrete date given by the Supreme Court
23 OLMSTEAD PLAN FOR VIRGINIA Task Force“One Community – Final Report of the Task Force to Develop an Olmstead Plan for Virginia”
24 WHAT ARE HOME & COMMUNITY-BASED MEDICAID WAIVERS? Waivers give States the flexibility to develop and implement alternatives to institutionalization.
25 WHY WERE HOME & COMMUNITY-BASED WAIVERS ESTABLISHED? Slow the growth of Medicaid spendingInstitutions are overly restrictive and too highly routine orientedPermit federal Medicaid funds to be used for community services by people who would otherwise be institutionalized
26 HOW IS A WAIVER DEVELOPED? State develops a Waiver application to be submitted to the federal Centers for Medicare and Medicaid Services (CMS) for approval – Task Forces are usually established by DMAS to assist with development of the applicationsDMAS develops regulations to implement the Waiver - Public comment is solicited when regulations are proposedThe Virginia General Assembly allocates funds for Waiver services – Advocates can educate the General Assembly about the need for funds to provide servicesWaiver is initially approved by CMS for 3 years and then typically renewed every 5 years – Task Forces are usually established by DMAS to assist with development of the renewal applications
27 COST EFFECTIVE To receive approval to implement a Waiver, a State Medicaid agency must assureCMS that it will not cost moreto provide home andcommunity based servicesthan providing institutional carewould cost
28 Waiver Must be Cost Effective It can be individually cost effective or cost effective in the aggregateAggregate Cost Effectiveness The average cost to Medicaid of individuals on the Waiver cannot cost more than the average cost to Medicaid of individuals in the comparable institutionIndividual Cost Effectiveness Cost to Medicaid for the individual in the community can’t exceed the cost in the comparable institution
29 Medicaid WaiversVirginia has 6 Home and Community Based Care (1915 (c) ) WaiversState Regulations for the Waivers can be found at:12 VAC Elderly & Disabled Waiver (E&D Waiver)12 VAC Technology Assisted Waiver (Tech Waiver)12 VAC AIDS Waiver12 VAC Mental Retardation Waiver (MR Waiver)12 VAC Consumer-Directed Personal Attendant Services Waiver (CD-PAS Waiver)12 VAC Individual and Family Developmental Disabilities Support Waiver (DD Waiver)The reference is to the beginning of each waiver section. For specific waiver sections, refer to the VAC. At DMAS this is on the intranet - Policy - regulations.7
30 DIFFERENT INSTITUTION - DIFFERENT WAIVER NURSING HOMESAIDSElderly and DisabledConsumer Directed -PASTechnology AssistedHOSPITALAIDSTechnology AssistedICF/MRMental RetardationDevelopmental Disabilities
31 Alternative Institutional Placement There must be an alternate institutional placement for which Medicaid paysThe individual who is applying for a Waiver must meet the same criteria that is used for admission to the institutionThis does not mean that the individual must actually be placed in the institution or make application to an institutionIn order to understand some of HCFA’s concerns, it is necessary to discuss alternative institutional placement of individuals on the waiver.
32 SCREENING PROCESSPre-Admission Screening Teams of the Department of Health & Department of Social ServicesElderly and Disabled WaiverCD-PAS WaiverAIDS WaiverDepartment of Medical Assistance ServicesTechnology Assisted WaiverCommunity Services BoardMR WaiverDepartment of Health Local ClinicsDevelopmental Disabilities Waiver
33 LEVEL OF FUNCTIONING (LOF) SURVEY Used for DD and MR WaiversLOF Survey is completed as part of the screening processDetermines the level of care neededTo receive DD or MR Waiver services, an individual must meet the criteria for admission to an ICF/MR
34 UNIFORM ASSESSMENT INSTRUMENT (UAI) Used for nursing home placement and the AIDS, CD-PAS, E&D and Tech WaiversCompleted as part of screening and assessmentAssesses social, physical health and functional abilitiesUsed to gather info for planning and monitoring needs and eligibility
35 SUPPLEMENT TO SCREENING People who have mental illness, mental retardation or developmental disabilitiesInitiated by the nursing home preadmission screening team when screening for nursing home placement and the CD-PAS and E&D WaiversPreadmission screening team sends supplement screening request to CSB
36 PURPOSE OF SUPPLEMENT SCREENING Some people with MR or DD have active treatment needs that are not met by nursing homes or nursing home-related WaiversDetermine the person’s need for active treatment that would not be met by nursing homes or nursing home-related Waivers
37 LEVEL II SUPPLEMENT Specialized Services Services Identified By CSB Responsibility & Entitlement
38 CASE MANAGEMENT, MR SERVICE SUPPORT COORDINATION,DD SERVICEEnsures development, coordination, implementation, monitoring and modification of the individual’s planLinks the individual with appropriate community resources and supportsCoordinates service providersMonitors quality of care
39 DD WAIVER SUPPORT COORDINATION MR WAIVER CASE MANAGEMENT Individual chooses their Support Coordination organizationVarious organizations provide Support Coordination servicesSupport Coordination organizations cannot provide other DD Waiver services (except Consumer Directed Services Facilitation)MR WAIVERCASEMANAGEMENTCommunity Services Boards provide case management services
40 CONSUMER-DIRECTED SERVICES Freedom, choice and control remaining with the individual, and sometimes their family -what service is neededwho will provide itwhen it will be providedwhere it will be providedhow it will be providedIn Virginia, CD services were initiated by Centers for Independent Living and the Virginia Board for People with Disabilities in 1989Virginia Medicaid Waivers have components of consumer-direction and self-determination, implementation depends on the individual and the case manager or support coordinator
41 Consumer-Directed Services Individual or family caregiver directs and controls who, how, and when services are providedVirginia offers consumer-directed services in 4 Waivers:Consumer-Directed Personal Attendant Services Waiver (since 1997) - AttendantDevelopmental Disabilities Waiver (since 2000) - Attendant, RespiteMental Retardation Waiver (since 2001) - Attendant, Respite, CompanionAIDS Waiver (began in 2003) – Attendant, Respite
42 Consumer-Directed Services Individual is the employer of record with the IRSService 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 staffSF provides training on recruiting, interviewing and training staff, how to handle difficult situations, how to complete employment paperwork, etc.SF provides list of attendants, companion aides or respite workers 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 (acting as a fiscal agent) and a contractor pays the attendants, companion aides and respite workers on behalf of the individualCurrently the number of maximum hours per week of CD-PAS services is 42.
43 CONSUMER-DIRECTED STAFF QUALIFICATIONS Be 18 years oldPossess basic math, reading and writing skillsHave the required skills to perform job dutiesHave a valid Social Security numberSubmit to a criminal history checkWilling to attend training requested by the person receiving Waiver servicesWilling to register in a CD-staff registryUnderstand and agree to comply with program requirements
44 ADDITIONAL REQUIREMENTS OF CONSUMER-DIRECTED STAFF AIDS, DD, & MR WAIVERSConsumer-Directed Staff must receive:TB screeningCPR trainingAnnual flu shot
45 CONSUMER-DIRECTED STAFF Staff (Consumer-Directed employees including attendants, companions, respite workers)Staff may be related to a consumer, but may not be members of the immediate family (parents of minor children, spouses, or legally responsible relatives)Exception: Payments may be made to other staff who are family members when there is objective written documentation as to why there are no other providers available to provide care
46 CONSUMER INVOLVEMENT Person-centered planning Involve people of your choice in developing your PlanPrepare PlanChoose servicesChoose providersDecide how & when services will be providedAgree to and monitor PlanQuarterly and Annual Review of PlanRight to appeal areas of disagreement
47 CONSUMER SERVICES PLAN DD and MR WAIVERS Written document, signed by the consumerAddresses all needs of the individual in all life areasDeveloped with consumer, providers and others the consumer wants involvedCSP will list -services and supports to be providedwho will provide the services and supportshow often the services and supports will be provided
48 PREPARING FOR CSP Who will participate in your meeting Develop a list of needed supports & services (be honest & frank)Collect documentationvocational evaluationsIEPsschool evaluationsmedical documentation
49 WHAT ARE YOUR GOALS FOR COMMUNITY AND INDEPENDENT LIVING ?
52 HEALTH, SAFETY & WELFARE Adequate services must be providedAdditional or different services should be added if needed to protect health, safety and welfare
53 Individual and Family Developmental Disabilities Support “DD” Waiver Eligibility Criteria “Related Conditions” WaiverMust be 6 years of age and older and meet “related conditions” criteriaCannot have a diagnosis of mental retardationLevel of Functioning survey used for screeningCall DMAS (804) to request a Request for Screening Form or go toVirginia already has a waiver that serves children with developmental disabilities up to age 6. That is the MR Waiver. People on the MR waiver waiting list could have filled all the slots and there would still have been no services for people with developmental disabilities without a diagnosis of MR.Add the AAMR definitionOne issue that we will need to address is how children transition from the MR Waiver to the DD waiver if there is not a diagnosis of mental retardation at age 6.(1) Cerebral palsy, epilepsy or autism; or(2) Any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons.(B) It is manifested before the person reaches age 22.(C) It is likely to continue indefinitely.(D) It results in substantial functional limitations in three or more of the following areas of major life activity:(1) Self-care.(2) Understanding and use of language.(3) Learning.(4) Mobility.(5) Self-direction.(6) Capacity for independent living
54 RELATED CONDITIONS also referred to as developmental disability Severe chronic disabilityAttributable to a condition, other than mental illnessManifested before the age of 22Likely to continue indefinitelyResults in substantial limitations in 3 or more areas of major life activitySelf-careUnderstanding and use of languageLearningMobilitySelf-directionCapacity for independent living
55 DD Waiver Services Adult companion services (8 hrs per day limit) Assistive technology ($5,000 per year limit)Crisis stabilization (60 day max/year)Environmental modifications ($5,000 per year limit)In-home residential support (not congregate)Day SupportSkilled NursingSupported employmentTherapeutic consultationPersonal emergency response system (PERS)Family/caregiver training (80 hours max/year)Respite care (CD & agency)Personal assistance services (CD & agency)
56 DD Waiver StatisticsFiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $1,176,499Other costs (State Plan services – drugs, doctors’ visits, etc.) = $584,666124 individuals served in FY 2002 – 323 people enrolled in the DD Waiver as of February 2003Waiver is cost effective in the aggregateAbout 40% of the individuals requesting a screening are not eligible for the DD WaiverWait list is maintained by DMASMany of the individuals served in FY 2001 will be the same individuals served in FY 2002.
57 DD Waiver Assuring Waiver Cost-Effectiveness Level 155% of FundingLevel 240% of Funding5% of FundingPlan of Care $25,000 and LessPlan of Care More than $25,000Emergencies$5,940,000$4,320,000$540,00023192
58 DD Waiver “Start Up” The Lottery Initial 60-day application period (July - August, 2000) gave individuals an equal chance to apply674 people applied during the initial application period. DMAS had slots for 323 individuals in FY 2002 (July 2001 through June 2002)Therefore, the regulations provided for a “lottery” to determine the order in which the 674 will be servedThe lottery only applies to the first 674 people who appliedApplications from September 1, 2000 forward are first come, first served. About 1200 additional applications received between September 2000 – July 2003Approximately 450 people on the waiting listsDon’t like to use the term lottery to apply to people and to services that could affect their lives, but it is a term that people understand.
59 MR Waiver Eligibility Criteria Must have a diagnosis of mental retardation or be under the age of 6 and at developmental riskChildren on the MR Waiver who do not have a diagnosis of MR at the age of 6, possible transfer to DD WaiverScreenings are conducted by CSBsLevel of Functioning survey is the screening instrument usedThere is a waiting list for the MR WaiverScreening for all Waivers must be provided without any charge to the individualThere is no medically needy program for ICFs/MR, therefore, there is no medically needy program for the MR Waiver.
60 MR Waiver ServicesResidential support (group home or individual’s home)Day support and prevocational servicesSupported employmentPersonal assistance (CD & agency)Respite care (720 hours max/year) (CD & agency)Assistive technology ($5,000 max/year)Environmental modifications ($5,000 max/year)Skilled nursing servicesTherapeutic consultationCrisis stabilization (60 days max/year)Adult companion (8 hours max/day) (CD & agency)Personal Emergency Response System (PERS)
61 MR WAIVER WAITING LISTS Urgent and Non-urgent CSBs and DMHMRSAS maintain Urgent and Non-Urgent listsCSB maintains Planning listCSB provides individual with written notice if placed on a waiting list and if there is a change in status to another listCSB determines who on the Urgent list receives the next available slotOnly after all Urgent needs are met statewide will Non-urgent needs be servedSlot moves with you to a different town in VAVacant or new slots are allocated by the CSB unless there is no need in the CSB’s areaNon-urgent = meet criteria for the MR Waiver, including needing services within 30 days, but don’t meet Urgent criteriaPlanning list = need services in the future
62 URGENT CRITERIA FOR THE MR WAIVER Primary caregiver(s) is/are 55 years or olderLiving with a primary caregiver who is providing the service voluntarily and without pay and they can’t continue careThere is a clear risk of abuse, neglect, or exploitationPrimary caregiver has chronic or long term physical or psychiatric condition significantly limiting ability to provide careIndividual is aging out of a publicly funded residential placement or otherwise becoming homelessIndividual 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
63 MR Waiver StatisticsFiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $197,686,537Other costs (State Plan services – drugs, doctors’ visits, etc.) = $37,493,0745,367 individuals served in FY 2002Waiver is cost effective in the aggregateApproximately 2,100 people on the waiting listsWhen reporting annual average costs to CMS, the average cost per waiver recipient was $36,300. This was our highest cost waiver.
64 INDEPENDENCE PLUS WAIVER IPlus Waiver New Waiver being developed by DMAS in collaboration with a task forceFor people now receiving DD or MR WaiversWould allow for consumer-direction of more Waiver servicesWould allow different provider rates within a predetermined rangeLottery likely to be used to determine first 200 people who would use the IPlus Waiver
65 Consumer-Directed Personal Attendant Services Waiver (CD-PAS) Eligibility Criteria Can be any ageMust meet nursing home criteriaCan have a cognitive impairmentScreening is the conducted by the Preadmission Screening Team using the UAIQuestionnaire used to determine if an individual can independently manage attendants or if assistance with managing care will be needed
66 RECENT CHANGES TO CD-PAS WAIVER CD-PAS Waiver is now available to children.No longer have to be 18 or older for the CD-PAS Waiver.CD-PAS Waiver is now available to people who are unable to manage their services.Another person can manage their services.
67 CD-PAS Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $2,698,064Other costs (State Plan services – drugs, doctors’ visits, etc.) = $1,047,223191 individuals served in FY 2002No waiting list for the CD-PAS WaiverCD-PAS Waiver is individually cost effectiveWhen reporting annual average costs to CMS, the average cost per waiver recipient was $11,975
68 Elderly and Disabled Waiver Criteria Individuals seeking Waiver services are eligible if 65 or older or disabledMust meet nursing facility criteriaIndividuals are screened by Preadmission Screening Team (DSS social worker, VDH nurse and physician)Screening tool is the Uniform Assessment Instrument (UAI)
69 Elderly and Disabled Waiver Services Services that are available statewide:Adult Day Health CarePersonal Care ServicesPersonal Emergency Response System (PERS)RespiteIndividuals can receive up to 720 hours of respite per yearPersonal assistance services can be provided outside of the individual’s homeGenerally individuals can receive up to 13 hours of personal assistance daily, additional hours can be authorized based on individual circumstances
70 E&D Waiver StatisticsFiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $90,176,649Other costs (State Plan services – drugs, doctors’ visits, etc.) = $49,791,3429,271 individuals served in FY 2002No waiting list for the E&D WaiverWaiver is cost effective in the aggregateWhen reporting annual average costs to CMS, the average cost per waiver recipient was $13,500.
71 COMBINING THE CD-PAS AND E&D WAIVERS The CD-PAS and E&D Waivers will be combined. Waiver will be based on aggregate cost-effectiveness.New Waiver will be called “Long Term Care Options Waiver.”
72 LONG TERM CARE OPTIONS WAIVER Personal care – both agency and consumer directed – hours based on need.Respite care if there is a primary caregiver – both agency and consumer directed hours/year.Personal Emergency Response System (includes medication monitoring system). Cannot be a stand-alone service.Adult Day Health CareEarned income allowance will be available in this Waiver. (Working 20 or more hours can keep up to 300% of earned income; working 8-20 hours can keep up to 200% of earned income. Total income cannot exceed 300% of SSI).
73 Technology Assisted Waiver Criteria Individual may be eligible if she needs both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing careScreening: UAI is used for adults and Tech Waiver scoring tool is used for childrenDMAS reviews individual’s private insurance policy for private duty nursing benefitsCase management provided by DMAS nursesDifferent rules for children and adults
74 Tech Waiver Considerations ADULTSScreening team completes UAI for adults only. DMAS staff follows up to complete the screening for adultsEligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysisCost effectiveness is compared to nursing facility specialized careCHILDRENDMAS staff completes screening for childrenEligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis; or daily dependence on other device-based respiratory or nutritional supportCost effectiveness is compared to hospital costs
75 Tech Waiver Services Services that are available statewide: Private duty nursingRespite careDurable medical equipmentPersonal care for individuals over 21 years of ageEnvironmental ModificationsMost of the funds for this waiver are for private duty nursing.
76 Tech Waiver Services Limits Environmental modifications and Assistive technology provided if medically necessary and cost effectiveRespite care has an annual limit of 360 hours per yearPrivate duty nursing has a limit of 16 hours per day, except -individuals under 21 can receive nursing services 24 hours a day during the first 30 days they receive Tech Waiver services
77 Tech Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $17,861,853Other costs (State Plan services – drugs, doctors’ visits, etc.) = $7,994,493308 individuals served in FY 2002No waiting list for the Tech WaiverWaiver based on individual cost effectivenessWhen reporting annual average costs to CMS, the average cost per waiver recipient was $92,200
78 AIDS Waiver CriteriaIndividuals are eligible for the AIDS Waiver if they have a diagnosis of AIDS or AIDS-Related Complex and would require nursing facility or hospital careIndividuals are screened by a Preadmission Screening Team (DSS social worker, VDH nurse and physician)Screening tool is the Uniform Assessment Instrument (UAI)
79 AIDS Waiver Services Services that are available statewide: Case managementConsumer-Directed Attendant CareNutritional supplementsPrivate duty nursingPersonal careRespite careIndividuals can receive up to 720 hours of respite per yearPersonal assistance services can be provided outside of the individual’s home
80 AIDS Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $1,268,876Other costs (State Plan services – drugs, doctors’ visits, etc.) = $5,910,868337 individuals served in FY 2002No waiting list for the AIDS WaiverWaiver is cost effective in the aggregateNo patient-pay for the AIDS WaiverThe highest “other” cost for this population is pharmacy (approx. $5.4 million).When reporting annual average costs to CMS, the average cost per waiver recipient was $18,800.
81 BRAIN INJURY WAIVER BEING DEVELOPED DMAS is working with a task force to develop a new Brain Injury WaiverEligibility, services, providers, and other criteria being discussed by DMAS and the task forceInitiation of this new Waiver depends on funding provided by the General AssemblyBrain Injury Association of VA,
82 DMAS is responsible for - SERVICE PROVIDERSDMAS is responsible for -adequate supply of qualified providers to meet needs of recipientsensuring the capacity and scope of services are availableensuring individuals are able to have “provider choice”enrollment of providersquality of services
83 ACCESSING PROVIDERSA list of qualified providers for each service in the Consumer Services Plan will be given to youYou have the right to choose your providersYou have the right to visit, interview and research providersYou decide when, where and how you want approved services providedCase Manager/Support Coordinator will assist you in locating and choosing providersCase Manager/Support Coordinator will contact providers for initiation of servicesYou can switch providers if you choose toThere are shortages of some providers
84 MEDICAID APPEALS Fair Hearing Right to challenge decisions and actions regarding MedicaidDecision should be issued by the Hearing Officer within 90 days
85 RIGHT TO APPEAL WHEN - Application of benefits is denied The agency takes action or proposes to take action which will adversely affect, reduce, or terminate receipt of benefitsRequest for a specific benefit is denied; in whole or in partThe agency does not act with reasonable promptness
86 What is a reasonable pace? WAITING LISTSDD and MR Waivers are the only Waivers with waiting listsMR Waiver has 2 waiting lists: Urgent and Non-urgent and a planning listDD Waiver has 2 waiting lists: Level I (CSP less than $25,000) and Level II (CSP more than $25,000)No waiting list for the AIDS, E&D, CD-PAS and Tech WaiversWaiting lists are permissible, but waiting lists must move at a reasonable paceWhat is a reasonable pace?