Presentation on theme: "Virginia Medicaid Waivers: Access and Services Debra Holloway Director of Training and Technical Assistance Achieve with Us."— Presentation transcript:
Virginia Medicaid Waivers: Access and Services Debra Holloway Director of Training and Technical Assistance Achieve with Us.
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)
Waivers Must be Cost Effective 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.
Different Waivers Have Different Services Adult Day Health Care Assistive Technology Case Management Companion Services Transition Services Crisis Intervention/Stabilization Prevocational Services Day Support Residential Support Environmental Modifications Respite Family Caregiver Training Skilled Nursing Nursing Service Supported Employment Nutritional Supplements Therapeutic Consultation Personal Care Services Transition Coordination Personal Emergency Response System
There are Seven Waivers Administered by the Commonwealth of Virginia Elderly or Disabled with Consumer Direction (EDCD) Individual and Family Developmental Disabilities Supports (IFDDS) HIV/AIDS Technology Assisted (Tech) Intellectual Disabilities Waiver (ID) Day Support Alzheimer’s Assisted Living (AAL) Waiver managed by the Facility and Home-Based Care Unit Mental Health Waiver (Demonstration Waiver)
Reviewing Today: Elderly or Disabled with Consumer Direction Waiver (EDCD) Technology Assisted Waiver (Tech) Individual and Families with Developmental Disabilities Waiver (DD) Intellectual Disabilities Waiver (ID)
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: Personal Care, Respite – Elderly or Disabled with Consumer-Direction Waiver - Personal Care, Respite Personal Care, Respite, Companion – Developmental Disabilities Waiver - Personal Care, Respite, Companion Personal Assistance, Respite, Companion – Intellectual Disability Waiver - Personal Assistance, Respite, Companion – Personal Care, Respite – AIDS Waiver– Personal Care, 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 individual
Consumer-Directed Employees 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. 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)
Eligibility 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.
Criteria 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
Examples Functional Dependencies: bathing, dressing, toileting, transferring, eating/feeding Medical and nursing needs: catheter care, supervision for adequate nutrition and hydration, therapeutic exercise and positioning, management of those with sensory, metabolic, or circulatory impairment.
Getting Started Request for screening, contact your local Health Department/Department of Social Services Schedule visit with pre-admission screening teams of the Department of Health & Department of Social Services. Completed Medicaid application (child’s information only!)
Services Adult Day Health Care Personal Care* (agency or consumer directed) Respite* (agency or consumer directed) Personal Emergency Response System (PERS) Transition Services ($5000 max) Transition Coordination
Technology Assisted Waiver (Tech) No age limit to eligibility No waiting list
Eligibility 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 homes. 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
Criteria Doctor must certify need for care; and need substantial and ongoing skilled nursing care Care must be cost effective 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 waiver. If the criteria is met DMAS conducts a home assessment. 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.
Services Private Duty Nursing (16 hours maximum a day, except children may have 24 hours a day for the first 30 days after hospital discharge) Personal Care* (adults only) Respite Care (360 hours) 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) Can be placed on the waiting list at age 5 years 8 months 150 new slots July 1, 2011
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 an Intellectual Disability. Meet the level of care for admission to an ICF/MR. The individual must meet 2 out of 7 levels of functioning.
Screening 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.www.dmas.virginia.gov
RELATED CONDITIONS also referred to as developmental disability 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 ID to DD Waiver Annually each child receiving ID Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver. If the child meets DD Waiver eligibility the child can transition to the DD Waiver.
Services Adult Companion (CD & Agency) Assistive Technology ($5000) Crisis stabilization Environmental Modifications ($5000) In-home residential Prevocational and Day Support Skilled Nursing Supported Employment Therapeutic consultation PERS - Personal emergency response system Family/caregiver training (80 hours a year) Respite care (CD & Agency) Personal care services MFP Transition Services ($5000)
Individual with Intellectual Disability Waiver (ID) Day-to-day ID waiver operations are managed by the Department of Behavioral Health and Developmental Services (DBHDS) Locally, ID Waiver services for individuals are coordinated by case managers employed by Community Services Boards 275 New waiver slots, July 1, 2011
Eligibility Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning. Six and over – a psychological evaluation with a diagnosis as having an intellectual disability. Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of intellectual disability or is at developmental risk.
Criteria All individuals receiving ID 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 categories.
Waiting List Urgent Non-Urgent
ID WAIVER WAITING LISTS Urgent and Non-urgent CSB’s and DBHDS maintain Urgent and Non-Urgent lists CSB maintains Planning list CSB provides individual with written notice if placed on a waiting list and if there is a change in status to another list CSB determines who is the most urgent Only after all Urgent needs are met statewide will Non-urgent needs be served Slot moves with you to a different town in VA Vacant or new slots are allocated by the CSB unless there is no need in the CSB’s area Non-urgent = meet criteria for the ID Waiver, including needing services within 30 days, but don’t meet Urgent criteria Planning list = need services in the future
Urgent Criteria for the ID Waiver 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 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 or provided by the CSB
Services Adult Companion Care (CD & Agency) Assistive Technology ($5000) Crisis Stabilization Day Support and prevocational services Environmental Modifications ($5000) Residential support (Individual’s home or group home) PERS – personal emergency response system Personal Care (Agency or Consumer Directed) Skilled Nursing Respite Care (CD & Agency) Therapeutic Consultation Supported Employment MFP Transition Services ($5000)
Early 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
EPSDT 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 Respite Environmental Modifications Vocational Educational
Health Insurance Premium Payment Program (HIPP)/ HIPP for Kids 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
HIPP Application must be completed separately from the Medicaid application Visit scroll to “Client Services” click on “More Services” then click on “HIPP Information”www.dmas.virginia.gov
Recipient Appeal A person may appeal if their benefits are: -Terminated -Denied -Suspended -Reduced
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
Steps Request an appeal or review (804) Notify appeals division in writing Be specific about what you want -Results in a hearing -Decision made
MYTH or FACT All persons with a disability of ID will qualify for ID Waiver. MYTH I can be on a wait list for the DD Waiver or the ID Waiver while I am receiving services from another Waiver. FACT
Waiting Lists ID Waiver has 2 waiting lists Urgent and Non-urgent: CSB determines who is the most urgent to receive available ID 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 pace?
Debra Holloway Director of Training and Technical Assistance ext. 103