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Working to Create “A Life Like Yours” (ALLY) Home and Community Based Medicaid Waivers.

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Presentation on theme: "Working to Create “A Life Like Yours” (ALLY) Home and Community Based Medicaid Waivers."— Presentation transcript:

1 Working to Create “A Life Like Yours” (ALLY) Home and Community Based Medicaid Waivers

2 The Arc of Northern Virginia: Who we are and What we do History Advocacy Education Information and Referral DD Waiver Case Management Guardianship Pooled Special Needs Trusts

3 Outline 1) Purpose and Description of Medicaid Waivers 2) Eligibility Criteria 3) Waiver Services Definitions 4) Waiver Services for each Waiver 5) Screening Process/Summary & Criteria 6) Other Steps

4 Waivers give States the flexibility to offer services to an individual in the community rather than living and receiving services in an institution. Purpose of the Waivers

5 What is a Medicaid Waiver? Medicaid: Medicaid is what pays for the services you can receive from a Medicaid Waiver Waiver: Waiving the choice of institutional placement and choosing to accept services in the community

6 Six Waivers in Virginia Elderly or Disabled with Consumer Direction Waiver (EDCD)- now include the HIV/AIDS Waiver Elderly or Disabled with Consumer Direction Waiver (EDCD)- now include the HIV/AIDS Waiver Individual and Families with Developmental Disabilities Waiver (DD Waiver) Individual and Families with Developmental Disabilities Waiver (DD Waiver) Intellectual Disability/formerly Mental Retardation Waiver (ID/MR Waiver) Intellectual Disability/formerly Mental Retardation Waiver (ID/MR Waiver) Day Support Waiver Day Support Waiver Technology Assisted Waiver (Tech) Technology Assisted Waiver (Tech) Alzheimer’s Assisted Living Waiver (AAL Waiver) Alzheimer’s Assisted Living Waiver (AAL Waiver)

7 Three Criteria to Determine Eligibility 1) Financial Eligibility Criteria 2) Diagnostic Criteria 3) Functional Criteria

8 Financial Eligibility for State Plan Medicaid Categorical Criteria Categorical Criteria Disabled or age 65 or older Disabled or age 65 or older Families with children Families with children Pregnant women Pregnant women Recipients of cash assistance Recipients of cash assistance Low income Medicare beneficiaries Low income Medicare beneficiaries Financial Thresholds Financial Thresholds Low income and asset guidelines (up to 80%) of Federal Poverty Level Low income and asset guidelines (up to 80%) of Federal Poverty Level Thresholds vary by category group Thresholds vary by category group Consideration of exceptionally high medical bills (spend- down) Consideration of exceptionally high medical bills (spend- down) Parental income/resources DO count for minor children Parental income/resources DO count for minor children

9 Categorical Criteria Must Need Long-term Care Criteria defined for each Waiver Assessment of need required Financial Thresholds $2130 per month (gross income) Spend-down for 4 of the Waivers $2000 resource limit Parent income/resources do NOT count regardless of child’s age Financial Eligibility for Medicaid Long Term Care (Waivers and Institutions)

10 Financial Eligibility If someone has applied for the Waiver, does this mean they have applied for Medicaid? No! These are two separate process! To apply for Medicaid, contact the local Department of Social Services!

11 Financial Eligibility The household income is too high to qualify for Medicaid, should the individual still apply for a waiver? Yes! You CAN be on the waiting lists without receiving Medicaid benefits. Once a slot becomes available, you can apply for Medicaid under the “Long Term Care/Institutional Rules”. And remember, different rules apply when it is State Plan Medicaid versus “long term care” Medicaid! And remember, different rules apply when it is State Plan Medicaid versus “long term care” Medicaid!

12 Explore a Special Needs Trust Like The Arc of Northern VA’s Pooled Trust A SNT is a legal document designed to: A SNT is a legal document designed to: Provide benefit to & protect the assets of a person with a disability while allowing the individual to be qualified for and receive government benefits, such as Medicaid, Medicaid Waivers and Supplemental Security Income. For more information, contact: Tia Marsili, Director of Trusts (703) x115

13 Diagnostic Eligibility EDCD Waiver Individuals who have significant medical needs. The criteria used to determine eligibility is the nursing home criteria. Individuals who have significant medical needs. The criteria used to determine eligibility is the nursing home criteria. Day Support Waiver Individuals with ID/MR who have been determined to meet two of the Level of Functioning Criteria. Individuals with ID/MR who have been determined to meet two of the Level of Functioning Criteria. Technology Assisted Waiver Individuals who require ongoing skilled nursing care. Individuals who require ongoing skilled nursing care. Individuals 21 and older who are dependent at least part of each day on a mechanical ventilator or meet complex tracheotomy criteria. Individuals 21 and older who are dependent at least part of each day on a mechanical ventilator or meet complex tracheotomy criteria. Individuals under the age of 21 who meet certain criteria based on various methods of respiratory or nutritional support Individuals under the age of 21 who meet certain criteria based on various methods of respiratory or nutritional support

14 Diagnostic Eligibility ID Waiver Must have a diagnosis of ID or be under the age of 6 and at developmental risk Must have a diagnosis of ID or be under the age of 6 and at developmental risk Children on the ID Waiver who do not have a diagnosis of ID/MR at the age of 6, possible transfer to DD Waiver Children on the ID Waiver who do not have a diagnosis of ID/MR at the age of 6, possible transfer to DD Waiver IQ Score (70 or below) and psychological testing is required! IQ Score (70 or below) and psychological testing is required! a DD Waiver Must be 5 years and 9 months of age and have a developmental disability or “related condition” to apply Must be 5 years and 9 months of age and have a developmental disability or “related condition” to apply Cannot have a diagnosis of an intellectual disability Cannot have a diagnosis of an intellectual disability IQ Score (71 or above) and psychological testing is required! IQ Score (71 or above) and psychological testing is required!

15 Functional Criteria ID, DD, and Day Support Waivers: - All individuals must meet the Intermediate Care Facility- Intellectual Disability (ICF-ID) level of care. This is established by meeting the indicated dependency level in two or more of the categories on the Level of Functioning Survey. -Categories include: Health Status, Communication, Task Learning Skills, Personal/Self Care, Mobility, Behavior, and Community Living Skills. -View the LOF Survey online: - EDCD, Alzheimer’s, and Technology Waivers: - Individuals must meet the nursing facility eligibility criteria determined by using the Universal Assessment Instrument (UAI) - Assesses social, physical health and functional abilities

16 Waiver Services Definitions Personal / Attendant Care Personal / Attendant Care Respite Care Respite Care Companion Care Companion Care Day Support Day Support In Home Residential In Home Residential Assistive Technology Assistive Technology Environmental Modifications Environmental Modifications Personal Emergency Response Personal Emergency Response Transition Services Transition Services

17 Waiver Services Definitions Options of Care Agency Directed Agency Directed ◦Care that is rendered by a Medicaid approved agency ◦The agency hires and manages and pays the workers ◦The agency submits the paperwork necessary for payment to DMAS Consumer Directed Consumer Directed ◦Workers are directly hired and managed by the individual receiving the DD Waiver support services ◦The individual, or their family if the client is a child or is unable to manage the task, is responsible for managing all aspects of the employment relationship, including recruiting, hiring, training, supervising, ensuring payment through DMAS, and firing if needed ◦There is a service facilitator to assist you with this process

18 Waiver Services Offered by the EDCD Waiver No Case Management Service DMAS Contracted Providers including institution, facility, agency, partnership, corporation, or association Personal Care Aide Services Personal Care Aide Services Adult Day Health Care Adult Day Health Care Respite Care Respite Care Personal Emergency Response System (PERS) Personal Emergency Response System (PERS) Medication Monitoring Medication Monitoring Consumer-Directed Services Consumer-Directed Services Transition Services Transition Services

19 Waiver Services Offered by the Tech Waiver Case Managed by DMAS Personal care (Adults Only) Personal care (Adults Only) Private duty nursing Private duty nursing Respite care Respite care Environmental Modifications Environmental Modifications Assistive Technology Assistive Technology Personal Emergency Response System Personal Emergency Response System

20 Waiver Services Offered by the Day Support Waiver Case Management by the Local CSBs Day support services Prevocational services Supportive Employment

21 Waiver Services Offered by the ID Waiver In addition to these the ID Waiver also offers Residential support (group home, sponsored placement, 24 hour-care) Residential support (group home, sponsored placement, 24 hour-care) Support Coordination provided by local CSB Day support Day support Supported employment Supported employment Personal or Attendant Care Personal or Attendant Care Respite care Respite care In-Home Residential Support In-Home Residential Support Adult Companion Care Adult Companion Care Assistive technology Assistive technology Environmental modifications Environmental modifications Therapeutic consultations Therapeutic consultations Personal Emergency Response System (PERS) Personal Emergency Response System (PERS) Transition Services (from institution to community via Money Follows the Person Program) Transition Services (from institution to community via Money Follows the Person Program)

22 Waiver Services Offered by the DD Waiver Case Managed by Private Non-Profit Organizations contracted with DMAS, such as The Arc of Northern Virginia Supported employment Supported employment Day Support Day Support Personal or Attendant Care Personal or Attendant Care Respite care Respite care In-Home Residential Support In-Home Residential Support Adult Companion Care Adult Companion Care Assistive technology Assistive technology Environmental modifications Environmental modifications Therapeutic consultations Therapeutic consultations Personal Emergency Response System (PERS) Personal Emergency Response System (PERS) Transition coordination from an institution to the community Transition coordination from an institution to the community

23 Screening Processes EDCD Waiver EDCD Waiver Call your local Department of Health or Department of Social Services for intake Call your local Department of Health or Department of Social Services for intake Alexandria ( ), Arlington ( ), Fairfax ( ) Alexandria ( ), Arlington ( ), Fairfax ( ) Set up Screening and intake appointment with Social Worker Set up Screening and intake appointment with Social Worker Schedule visit with the nurse Schedule visit with the nurse Meet with local County case worker Meet with local County case worker Meet with Home Health Care Agency or Service Facilitator Meet with Home Health Care Agency or Service Facilitator Waiting List None – just the process of intake None – just the process of intake

24 Screening Processes Technology Assisted Waiver Technology Assisted Waiver DMAS conducts the screenings for individuals under the age of 21 who request Tech Waiver services DMAS conducts the screenings for individuals under the age of 21 who request Tech Waiver services Call or local Health Department or Department of Social Services Call or local Health Department or Department of Social Services If hospitalized, the hospital social worker or discharge planner can assist in coordinating a screening with DMAS If hospitalized, the hospital social worker or discharge planner can assist in coordinating a screening with DMAS Waiting List None – just the process of intake None – just the process of intake

25 Screening Processes Day Support Waiver Steps: Contact the local CSB for Screening information Contact the local CSB for Screening information Waiting List Limited number of slots (300) Limited number of slots (300) First come, first serve First come, first serve Allocated by state office of ID Services Allocated by state office of ID Services

26 Screening Processes ID Waiver Screenings are conducted by the local CSBs Arlington: Alexandria: Fairfax: (refer to ID Services) Steps: 1) Call your local CSB to complete a screening process 2) Complete application they send to you 3) Make and attend intake process at the CSB

27 Waiting List ID Waiver Urgent Criteria Primary Caregiver (s) is/are 55 years 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 exploitation. 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 homeless. 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 by the CSB.

28 Recap of ID Waiver ID Waiver: In Virginia the ID Waiver waiting list is served based on need and region population In Virginia the ID Waiver waiting list is served based on need and region population Approximately 9,457 people have ID Waivers. Approximately 9,457 people have ID Waivers. Approximately 6,529 people are on the waiting lists. Approximately 6,529 people are on the waiting lists. Over 3,762 of those are on the urgent care waiting list Over 3,762 of those are on the urgent care waiting list The waiting list grows at a rate of one person per day The waiting list grows at a rate of one person per day Numbers as of 10/01/13

29 Screening Processes DD Waiver Steps: 1) Complete the Screening Request Form Available on or 1) Complete the Screening Request Form Available on or Send form to Regional Child Development Center: Alexandria -, Health Center - P: (703) Alexandria - Veronica Aberle, Health Center - P: (703) F: (703) Arlington - Margaret Jones, Arlington HS P: (703) F: (703) Fairfax - Terri Morris, Fairfax Co. Health Dept P: (703) F: Fairfax - Terri Morris, Fairfax Co. Health Dept P: (703) F: (703) ) Have an appointment with local Child Developmental Center (CDC) for Screening 3) Receive letter from CDC stating eligibility 4) Choose a Case Management Agency 5) Complete Plan of Care with Case Manager ***You are NOT on the waiting list until your screening and Plan of Care are completed!

30 Waiting List DD Waiver: The DD Waiver waiting list is served on a first come, first serve basis. The DD Waiver waiting list is served on a first come, first serve basis. 948 people have DD Waivers 948 people have DD Waivers 1,295 people are on the waiting list 1,295 people are on the waiting list Numbers from DMAS as of 08/13

31 Medicaid Waiver Services (Source: VA Department of Medical Assistance Services 8/13) Slot/Wait List Summary EDCDIDDDTECHDAY SUPPORT ALZ Approved Slots 33,5079, Current Enrollment 26,0109, Current Wait List 6,4881,295

32 While on the waiting list what else can you do? Depending on level of need and eligibility criteria, you can apply for other waivers: ◦You can NOT be on both the ID Waiver List and the DD Waiver List. ◦You CAN be on either the ID Waiver list OR the DD Waiver list AND Receive or be on the list for the Elderly or Disabled with Consumer Directed Services Waiver (EDCD), Day Support or the Technology Waivers. Call your county for case management and other locally funded services or resources that may be available to you. Utilize the Individuals and Families Support Program Funding Up to $3,000 per year for supports to serve you in the community Read more at Available September 3, 2013 and subsequently on July 1 each year Access START Crisis Services- 24 hour crisis response and respite for people with ID/DD and behavioral or mental health needs who are over 18 years old START

33 Become a Member of The Arc of Northern Virginia! Follow our lead in advocating for the needs of your loved one. Sign up for our newsletter!

34 Where Do I Go For More Information? All Waivers: All Waivers: Virginia Medicaid Waiver Technical Assistance Center (toll free) ID Waiver: UAI Manual (Universal Assessment Instrument): UAI Manual (Universal Assessment Instrument): Local Community Services Board Local Community Services Board Arlington: Alexandria: Fairfax:

35 Thank you! The Arc of Northern Virginia 2755 Hartland Road Falls Church, VA Ext 108


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