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Everything You Need to Know About Your Medicaid Waiver The Delaware County Board of Developmental Disabilities May 2014.

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Presentation on theme: "Everything You Need to Know About Your Medicaid Waiver The Delaware County Board of Developmental Disabilities May 2014."— Presentation transcript:

1 Everything You Need to Know About Your Medicaid Waiver The Delaware County Board of Developmental Disabilities May 2014

2 Waiver Growth in Delaware County Year # Served # Waivers % Served Waiver Dollars 2000$ 2,118,424* 2013$16,432,877* *DCBDD only pays 40% of these costs

3 What is a Waiver? A waiver is a Medicaid funding source that can help pay for services to keep people with disabilities in their own homes and prevent moving to a long-term care facility or nursing home. The county board is required to pay approximately 40% of the cost of waiver services. The federal government pays 60% of the cost of services

4 DODD Administered Waivers Delaware County Board of DD currently administers three waivers: Level One Waiver Allows for minimal paid support and relies heavily on natural supports SELF Waiver Allows for a moderate amount of support and is Ohio’s first self-directed waiver Individual Options Waiver For individuals with limited or no natural support and who have a high level of need

5 Waiting Lists In order for an individual to receive a waiver, he/she must make application to be placed on the waiting list The waiting list rule OAC 5123: dictates enrollment based on priority categories Refer to the Priority Score Sheet for categories

6 Waiting Lists in Delaware County In Delaware County, each priority group has a weighted point value which is used to determine the individual’s priority score All waiting lists are ordered first by priority score, then date and time of application Currently, only individuals meeting emergency status will be considered for an IO waiver

7 Preparing for the Transition to Waiver Services Begin search for providers Providers must be certified by DODD to provide waiver services It can take several weeks for a provider to complete the certification process Waiver providers will not bill DCBDD for waiver services. Billing is completed through an on-line application and payment is made by the State of Ohio Medicaid Card Service Providers (State Plan Services)

8 Services Homemaker Personal Care (IO and Level One Waiver Only) Basic personal care and grooming, including bathing, care of the hair, and assistance with clothing; Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom Assisting the individual with self-medication or provision of medication administration for prescribed medications and assisting the individual with, or performing, health care activities; Performing household services essential to the individual's health and comfort in the home

9 Services Homemaker Personal Care, Cont. Assessing, monitoring, and supervising the individual to ensure the individual's safety, health, and welfare; Light cleaning tasks in areas of the home used by the individual; Preparation of a shopping list appropriate to the individual's dietary needs and financial circumstances, performance of grocery shopping activities as necessary, and preparation of meals; Personal laundry Incidental neighborhood errands as necessary, including accompanying the individual to medical and other appropriate appointments and accompanying individual for walks outside the home.

10 Services Transportation (IO, Level One and SELF Waivers) A service that enables individuals enrolled in waivers to access waiver and other community services, activities, and resources

11 Services Environmental Accessibility Adaptations Participant Goods and Services (IO, Level One and SELF Waivers) Changes to a home that enable a person to function with greater independence. Examples include: Installing ramps or grab-bars; Widening doorways; Modifying bathrooms to be wheelchair-accessible; and, Installing specialized electrical or plumbing systems to accommodate medical equipment;

12 Services Adaptive and Assistive Equipment (IO) Specialized Medical Equipment and Supplies (Level One) Participant Goods and Services (SELF) Devices, controls or appliances that allow people to do daily living activities or to help them communicate; Items necessary for life support and the supplies and equipment necessary for upkeep; and, Durable and non-durable equipment that is not paid for by the Medicaid State Plan.

13 Services Informal Respite (Level One Only) Services provided in a person’s home, the home of a friend or family member of the individual or at sites of community activities to give relief to the person typically providing care.

14 Services Community Inclusion (SELF only) Includes supports that promote the individual's participation in his/her community. The service includes opportunities and experiences that focus on socialization and/or therapeutic recreational activities, as well as personal growth in the home and/or community. Community Inclusion also can include peer support activities and organization of self- advocacy events. It is not meant to cover employment- related services.

15 Individual Options Waiver Services available with the IOW include: Homemaker Personal Care Transportation Environmental accessibility modifications Adaptive & Assistive equipment Adult Day Waiver Services Remote Monitoring Community Respite (Specialized Camps) Residential Respite (Facility-Based Respite) Adult Family Living* Adult Foster Care* Social work* Interpreter Home delivered meals Nutritional services* *exclusive to the individual options waiver

16 Self Empowered Life Funding Waiver Services available with the SELF waiver include: Support Brokerage* Functional Behavioral Assessment* Community Inclusion* Participant Directed Goods and Services* Participant/Family Assistance* Integrated Employment* Residential Respite Community Respite Remote Monitoring *exclusive to the SELF waiver

17 Level One Waiver Services available with LV1 waiver include:  Homemaker/Personal Care  Community Respite (Camp)  Informal Respite*  Transportation  Personal Emergency Response Systems  Specialized Medical Equipment and Supplies  Environmental Accessibility Adaptations  Home Delivered Meals  Remote Monitoring  Emergency Assistance*  Adult Day Waiver Services *exclusive to the level one waiver $5000 annual cap combined $7500 cap over a 3 year period $8000 cap over a 3 year period and must meet emergency status

18 Waiver Service Planning Complete Individual Support Plan (ISP) with your team Complete Payment Authorization for Waiver Services (PAWS) A provider may not provide services or bill without this authorization Waiver Budget Utilization – Tracking – Reallocation – Over-utilization Your ISP is an “All Services Plan” and is to include all waiver, locally funded, and Medicaid State Plan services

19 Medicaid A Medicaid Card is included with the Waiver service package and may cover therapies, hospital services, nursing services, home health aides, doctor & dental appointments and medical equipment Many of these services are available through Medicaid State Plan Services

20 State Plan Services Home Health Services Home Health Services include:  Home Health Nursing  Home Health Aide  Skilled therapies (OT,PT,SLP) Services must be medically necessary as ordered by the treating physician and documented by signature.

21 State Plan Services Home Health Services Services anyone can access with a Medicaid card, a doctor’s order and proof of medical necessity Available Statewide No waiting list

22 Home Health Services Four hours or less per visit (intermittent service) No more than 8 hours a day combined nursing, aide and therapies No more than 14 hours per week of nursing and aide services combined

23 Home Health Services To meet the requirement of ‘intermittent’, similar services cannot be ‘stacked’ A two-hour break is required between similar services. An example of similar services is Home Health Aide services and Waiver Homemaker/Personal Care services

24 Home Health Services Cannot be billed back to back (stacked) with a similar service type For example: 6am-8am (no break) 8am-12pm (no break) 12pm-2pm HH Aide Waiver HPC Provider HH Aide Not Permitted

25 Home Health Services MUST have a MINIMUM 2 hour break in services For example: 6am-10am (break) 1pm-5pm (break) 8pm-10pm HH Aide Waiver HPC Provider HH Aide Permitted

26 Home Health Services Can be billed back to back with a DIFFERENT service type For example: 6am-8am (no break) 8am-12pm (no break) 12pm-2pm Home Health Aide Home Health Nursing Home Health Aide Permitted

27 Home Health Services Can be billed back to back with a DIFFERENT service type For example: 6am-8am (no break) 8am-12pm (no break) 12pm-2pm HH Aide Waiver Informal HH Aide Respite Provider Permitted

28 Home Health Services Home Health Services cannot be provided for the purposes of respite. “Respite care” is the care provided to an individual unable to care for himself or herself because of the absence or need for relief of those normally providing care.

29 Home Health Services Must be provided in the person’s place of residence, in a licensed day care center or in an Early Intervention program

30 Home Health Services Home Health Aide Services Services include:  Personal Care  Routine catheter/colostomy care  Assistance with routine maintenance exercises and passive ROM activities in support of skilled therapy goals.  Routine care of prosthetic and orthotic devices

31 Home Health Services Home Health Aide Services  Incidental Services can include: light chores, laundry, light house cleaning, meal prep and taking out trash  Main purpose of a Home Health Aide visit cannot be solely to provide incidental services  Incidental services are to be performed only for the eligible individual  May NOT provide medication administration

32 Increased Home Health Services Increased services are available if requires more than 14 hours in a week of aid and/or nursing services combined or more than 8 hours per day of aide, therapy and/or nursing services combined Eligibility: Up to age 21 Must have a comparable institutional level of care (ILOC, ICF/DD LOC, or SLOC) as determined by enrollment on a waiver or CareStar will complete assessment for those with regular Medicaid Must need at least 1 skilled service a week (nursing or therapy) Have part-time intermittent needs (Visits are 4 hours or less with a 2 hour min break in between like services)

33 Home Health Services  The SSA will authorize the HHS for those on an DD waiver  List all agencies providing home health services (aide, therapy and nursing)  Attach care plan from home health agency  Agency must have Dr.’s prescription, care plan, HHS worksheet and documentation of medical necessity on file

34 Private Duty Nursing Services  Private Duty Nursing (PDN) is a continuous nursing service that is more than 4 hours per visit  PDN is required when more than 14 hours of nursing is needed per week  The service must be provided in the person’s home unless it is medically necessary for a nurse to accompany the person into the community  Private Duty Nursing can be provided for the purposes of respite care

35 Private Duty Nursing Services  Once the request is received from the CB, a nurse with the Ohio Department of Medicaid (ODM) will complete a face to face assessment to confirm that the person has a medical condition that requires medically necessary PDN services  ODM will authorize the amount, scope and duration of the PDN service  Authorizations require renewal at least annually

36 State Plan Services  Prescriptions  Durable Medical Equipment: Appendix Ahttp://codes.ohio.gov/oac/5101%3A  Doctor and Dental Visits  PT/OT – 30* visits per rolling 12 months  SLP – 30* visits per rolling 12 months *May be increased with prior authorization

37 Is a Waiver the Best Option? Comparison of Waiver Services and Medicaid Card Services (State Plan Services) Medicaid Card (therapies, equipment, doctor appointments, nursing, etc.) Can dis-enroll from the waiver at any time if it is not meeting the need

38 Contacts and Information Melinda Draper, DCBDD Waiver Coordinator or


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