Presentation on theme: "Waiver Programs: Helping Your Clients Stay at Home PLAN 2012 Statewide Conference September 11, 2012 Pamela Walz Community Legal Services."— Presentation transcript:
Waiver Programs: Helping Your Clients Stay at Home PLAN 2012 Statewide Conference September 11, 2012 Pamela Walz Community Legal Services
Home and Community Based Services Medical and non-medical services to allow elderly and people with disabilities to live independently in their homes and communities. Most but not all programs are Medicaid funded through waiver programs
Waiver Programs Section 1915(c) of the Social Security Act: permits certain Medicaid provisions to be waived to allow states to offer enhanced services to particular populations at risk of institutionalization permits use of spousal impoverishment rules to determine financial eligibility
Waiver Programs (cont’d) Must meet eligibility requirements of a specific waiver In PA, the Office of Long Term Living administers most waiver programs (Office of Developmental Programs administers the rest).
HCBS Waivers in PA PDA (Aging) Waiver Attendant Care Waiver AIDS Waiver Autism Waiver (for adults 21and over with autism) COMMCARE Waiver (for individuals with traumatic brain injury) Independence Waiver (for individuals 18-59 with physical disability but not intellectual disability or mental illness as primary diagnosis)
HCBS Waivers in PA (cont’d) Living Independently for the Elderly (LIFE) OBRA Waiver (individuals 18-59 with severe developmental physical disability) Consolidated Waiver (age 3 or older with Intellectual Disability and recommended for ICF/MR level of care) Person Family Directed Support Waiver (age 3 or older with Intellectual Disability and recommended for ICF/MR level of care but do not need residential services)
PDA Waiver To qualify, must be Resident of PA and US citizen or qualified non-citizen Age 60 or over Nursing Facility Clinically Eligible (NFCE) Financially eligible for MA Aggregate cost of serving all participants in a waiver must not exceed 80% of cost to serve same group in nursing facility.
Nursing Facility Clinically Eligible (NFCE) Individual has diagnosed illness, injury, disability or medical condition; As result, requires care and services above level of room and board; Physician certified individual is NFCE; and Care and services are either: Skilled or Intermediate level care.
Financial eligibility for Waiver – Income Income limit for 2012 is $2,094 (300% of the federal SSI rate) Spouses’ income is not counted in determining income eligibility Can spend down to SSI level ($698), but not to $2,094.
Financial eligibility for Waiver – Resources Resource limit for single individual is $8,000 ($2,000 + $6,000 disregard) Married couples: spousal impoverishment rules on resource assessment and spousal share apply Estate recovery applies for Waiver recipients age 55 or older
Aging Waiver services Home health Personal care Attendant care Respite Adult Day Care Transportation Home modifications Specialized medical equipment, supplies Home delivered meals Personal emergency response Companion
Aging Waiver services (cont’d) Prior to 7/1/12, only AAAs provided care management. Other providers can now bid to provide this service, now called “service coordination”. Waiver recipients get full MA coverage! Must meet SLMB or QMB income limits to get Medicare Part B paid Must meet SLMB or QMB income limits to get Medicare Part B paid
Living Independently for Elders (LIFE) Program of All-Inclusive Care for the Elderly (PACE) model Model of care focused around Adult Day Care attendance ALL services are coordinated and provided by LIFE LIFE is paid a capitated rate by Medicare, Medicaid, and/or the Participant (depending on the Participant’s eligibility for Medicare and Medicaid) LIFE is paid a capitated rate by Medicare, Medicaid, and/or the Participant (depending on the Participant’s eligibility for Medicare and Medicaid)
LIFE Eligibility Must be 55 or older for enrollment in Full-PACE LIFE Center or 60 or older for enrollment in Pre-PACE LIFE Ctr NFCE level of care Available to people with any one of these combinations of funding: Medicaid Only Medicaid Only Medicare and Private Pay Medicare and Private Pay Medicare and Medicaid Medicare and Medicaid Private Pay Only Private Pay Only For those seeking Medicaid coverage of LIFE, Waiver income and resource limits apply and Estate Recovery applies Must live in area served by a LIFE program (38 counties)
LIFE Services Adult day center Home support, home health, personal care Respite Transportation Meals Medical and nursing care Rehabilitation and restorative therapies
LIFE services (cont’d) Home modifications Social activities and recreation Social services Hospital and nursing facility care when needed
Attendant Care Waiver Eligibility requirements: Resident of PA Between 18 and 59 years old NFCE Financially eligible for MA Diagnosis of physical impairment expected to last at least 1 year Capable of hiring, firing, supervising attendant care workers and managing financial/legal affairs
Options State-funded (not MA) Services for consumer age 60+ Can be NFCE but not financially eligible for Waiver OR Nursing Facility Ineligible (NFI).
Options (cont’d) Services are same as Waiver but are capped at $714.60/month (exception is available) Sliding scale cost sharing for consumers with income greater than 125% of FPL ($1,135/mo. single, $1,532/ mo. couple in 2011) Waiting lists
Act 150 Program State-funded attendant care program (not MA funded) Same eligibility requirements as Attendant Care Waiver except need not be financially eligible for MA Minimal copayment if income >125% FPL No estate recovery
Domiciliary Care Provides home-like living arrangement in community for individuals who need help with ADLs and unable to live independently In dom care provider’s own home
Dom Care Eligibility 18 or older with difficulties with ADLs which prevents independent living Cannot be NFCE Mobile or –semi-mobile Generally low-income (dom care supplement available)
Dom Care Services AAA develops care plan Assistance with ADLs 3 meals/day Medication Administration
Family Caregiver Support Program Purpose is to support individuals providing care in the home Governed by state and federal law Act 112 of 2011 made revisions: caregiver no longer needs to be related to person receiving care
FCSP Eligibility Must be primary caregiver Care receiver must be functionally dependent older adult or other adult with chronic dementia Services available to caregivers whose care receiver’s households are under 200% of FPL or to those between 200-380% with sliding scale contribution. No benefits if care receiver household income >380% FPL.
FCSP Services Counseling, education and training Assessment Home chore services Modest financial assistance with expenses including respite care and incontinence supplies Grants for home modifications (not to exceed $2,000)
FCSP services (cont’d) Maximum monthly grant is $200, but Act 112 increases it to $500 in cases of documented need. However, if local AAA average grant is >$300/month across entire FCSP caseload, maximum is $200.
Process to Obtain Aging Waiver Services Level of care assessment by AAA Prescription from physician indicating NFCE Individual Service Plan (ISP) development – must be approved by OLTL Supports coordinator contacts agencies, arranges and manages services If waiver services inadequate or denied, applicant may appeal and have fair hearing before ALJ Recipient participation in process
Participant Direction Knowing the difference between Participant Centered system and Participant Direction Aging Waiver offers choices the process of choosing amongst the choices is the Participant “Centeredness” of the system the process of choosing amongst the choices is the Participant “Centeredness” of the system the opportunity for the participant to exercise control over his/her services is Participant Direction the opportunity for the participant to exercise control over his/her services is Participant Direction
Participant Direction Traditional ways of getting services through HCBS Waiver = Agency Model Participant Direction includes the Employer Model (wherein the waiver consumer is the employer and hires and fires staff with the help of a fiscal management agency, service coordinator, etc.) and the Employer Model (wherein the waiver consumer is the employer and hires and fires staff with the help of a fiscal management agency, service coordinator, etc.) and Services My Way – which is the Employer Model plus budget authority (wherein the waiver consumer gets decision making ability over how to spend budgeted amount) Services My Way – which is the Employer Model plus budget authority (wherein the waiver consumer gets decision making ability over how to spend budgeted amount)
Common Problems for Waiver clients Inability to spend down to Waiver Loss of eligibility due to failure to comply with redetermination requirements Denial of particular service (e.g. adult day care) or number of hours Waiting lists (CommCare, OBRA, Act 150)
Common problems for Waiver Clients (cont’d) Delays in enrollment: Maximus (Independent Enrollment Broker for under-60 Waivers): lengthy waits for assessments and determinations. Recent Mosley settlement requires timely actions. Maximus (Independent Enrollment Broker for under-60 Waivers): lengthy waits for assessments and determinations. Recent Mosley settlement requires timely actions. Individualized Service Plan approval delays Individualized Service Plan approval delays Elimination of Community Choice Elimination of Community Choice Christian Financial debacle
Problems, cont’d Act 22 HCBS regulations: Set provider rates which may create access problems and reduce consumer direction Narrowed scope of Aging waiver care management function (now called service coordination) Reduced nursing oversight in Aging waiver Eliminated several services from Aging waiver What happened to rebalancing???
New HCBS Opportunities Under PPACA Section 10202. State Balancing Incentive Payments Program Section 2401. Community First Choice Option— Medicaid State Plan Option for Attendant Services and Supports: Section 2402. Medicaid Home and Community Based Services State Plan Option Others
Questions? Pam Walz Aging and Disabilities Unit Community Legal Services, Inc. firstname.lastname@example.org (215) 227-4798