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Navigating the New System …Community Care Waiver, Waiting List Changes, and Individualized Budgets.

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Presentation on theme: "Navigating the New System …Community Care Waiver, Waiting List Changes, and Individualized Budgets."— Presentation transcript:

1 Navigating the New System …Community Care Waiver, Waiting List Changes, and Individualized Budgets

2 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Overview of Presentation Who we are Who we are Three things you will know after tonight: Three things you will know after tonight: What Medicaid isWhat Medicaid is What the Community Care Waiver isWhat the Community Care Waiver is How to get servicesHow to get services

3 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD What is Medicaid? Government funded health insurance program for low income children and families, and adults who are aged, blind or disabled Government funded health insurance program for low income children and families, and adults who are aged, blind or disabled Pays for doctor visits, prescription drug coverage, other medical services Pays for doctor visits, prescription drug coverage, other medical services Covers services other insurance often doesnt: personal care, and long term services & supports Covers services other insurance often doesnt: personal care, and long term services & supports

4 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD What is the Community Care Waiver… Funding mechanism for services Funding mechanism for services Funds services in group homes, day programs, in-home supports Funds services in group homes, day programs, in-home supports Federal government contributes to the cost of services Federal government contributes to the cost of services When services are not covered under waiver, the state pays the entire cost When services are not covered under waiver, the state pays the entire cost

5 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD …and Why is it Important? It allows people to receive services in the community rather than in an institution It allows people to receive services in the community rather than in an institution It offers a wider variety/range of services & supports It offers a wider variety/range of services & supports Because of the federal funds, it has potential to provide more money so the State can serve more people Because of the federal funds, it has potential to provide more money so the State can serve more people

6 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD …and Why is it Important? And, it is the only way to access long term supports and ensure that your son/daughter will be properly supported throughout his/her lifetime And, it is the only way to access long term supports and ensure that your son/daughter will be properly supported throughout his/her lifetime Extensive waiting list Extensive waiting list

7 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD How Do You Get Services? Become DDD eligible Become DDD eligible Get on the Waiver Waiting List Get on the Waiver Waiting List While you are waiting, you may be eligible for non-waiver-funded services While you are waiting, you may be eligible for non-waiver-funded services Contact your DDD case manager to find out what services you can get while waiting for a waiver slotContact your DDD case manager to find out what services you can get while waiting for a waiver slot

8 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Overview of New System & Changes that are Coming The only REAL/practical differences are: The only REAL/practical differences are: The vocabularyThe vocabulary What you get when you reach the top of the waiting listWhat you get when you reach the top of the waiting list You will have more choices in terms of what services you can get and from whomYou will have more choices in terms of what services you can get and from whom

9 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD New System Self-direction Option Self-direction Option Based more on in-home supportsBased more on in-home supports Funding flows from DDD through Fiscal IntermediaryFunding flows from DDD through Fiscal Intermediary Waiting list for waiver slotWaiting list for waiver slot

10 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD New System Provider-Managed Option Provider-Managed Option Individual chooses a provider agencyIndividual chooses a provider agency Payment made directly to providerPayment made directly to provider Waiting list for waiver slotWaiting list for waiver slot

11 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD What We Know for Sure National Trend National Trend DDD has stated that this change is already being implemented DDD has stated that this change is already being implemented Self advocates & families will need a new set of skills & new vocabulary Self advocates & families will need a new set of skills & new vocabulary

12 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD How does the Waiver System Work? Determination of eligibility for waiver services Determination of eligibility for waiver services Waiting list criteriaWaiting list criteria Reserve capacity within the waiverReserve capacity within the waiver Assessment Assessment Individual Budget – Decision to self-direct or not Individual Budget – Decision to self-direct or not Plan Development Plan Development If not eligible, then look at non-waiver & waiver services funded with state dollars If not eligible, then look at non-waiver & waiver services funded with state dollars

13 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD What does Self-Direct Mean? Support Coordinator assigned Support Coordinator assigned How do I find service providers? How do I find service providers? Who checks to see if services are being delivered? Who checks to see if services are being delivered? How does the money get paid to the provider? How much? Can I negotiate? How does the money get paid to the provider? How much? Can I negotiate? What if my needs change? What if my needs change?

14 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Waiver Waiting List All move to waiver waiting list if not currently enrolled on waiver All move to waiver waiting list if not currently enrolled on waiver When your name comes up on list, you will receive services you need at that time, and be removed from list When your name comes up on list, you will receive services you need at that time, and be removed from list If needs change, the changes will be accommodated If needs change, the changes will be accommodated

15 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD How Waiting List Will Work Name comes up On Priority Waiting List Enrolled on Waiver; name Removed from WL Not eligible for waiver; name re- moved from WL; Services provided with state $$ Refuses enrollment; name removed from WL; some services provided with Reduced State $$

16 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Changes in Need If needs change, an updated plan is completed If needs change, an updated plan is completed Services change to fit the need Services change to fit the need Waiver eligibility is preserved regardless of residence Waiver eligibility is preserved regardless of residence Waiver is portable Waiver is portable

17 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Review of Covered Services in CCW Case Management Case Management Day Habilitation Day Habilitation Individual Supports Individual Supports Respite Respite Supported Employment Supported Employment Community Transition Services Community Transition Services Support Coordination Support Coordination Assistive Technology Devices Assistive Technology Devices Environmental and Vehicle Adaptations Environmental and Vehicle Adaptations Personal Emergency Response System (PERS) Personal Emergency Response System (PERS) Transportation Transportation

18 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Non-Medicaid Funded Services Family Support Family Support Residential (room & board) after contribution to care received Residential (room & board) after contribution to care received Start-up costs for residential placements, other than Transition services Start-up costs for residential placements, other than Transition services Discussion of what should be covered by state-only funds Discussion of what should be covered by state-only funds

19 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Questions

20 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Contact Start with your Case Manager Start with your Case Manager Contact me by , if possible: Contact me by , if possible:

21 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Medicaid 101 What is Medicaid? What is Medicaid? Medical assistance to individuals who are aged, blind or disabled and TANFMedical assistance to individuals who are aged, blind or disabled and TANF Income testIncome test Resource testResource test

22 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Medicaid 101 Services covered under Medicaid Services covered under Medicaid Mandatory servicesMandatory services E.g., physician, hospitalization, pharmacy E.g., physician, hospitalization, pharmacy Optional servicesOptional services E.g., therapy, private duty nursing E.g., therapy, private duty nursing Each state determines scope, duration, and amountEach state determines scope, duration, and amount

23 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Waiver 101… or Why Have a Waiver? Institutional eligibility vs. in-home eligibility for MedicaidInstitutional eligibility vs. in-home eligibility for Medicaid Non-traditional services neededNon-traditional services needed Amendment to the Social Security Act in 1981Amendment to the Social Security Act in 1981 Created 1915 (c) option for statesCreated 1915 (c) option for states

24 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Waiver 101 Home and Community Based Services Home and Community Based Services Allows state to limit number of individuals enrolledAllows state to limit number of individuals enrolled Allows state to refuse enrollment if individual cost is higher than institutionalAllows state to refuse enrollment if individual cost is higher than institutional Standards for providersStandards for providers Additional waivers requested: Additional waivers requested: Statewideness Amount, duration and scope Comparability Institutional income

25 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Waiver 101 Eligibility Eligibility State specificState specific IncomeIncome ResourcesResources Level of careLevel of care Service needService need

26 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD CMS Oversight CMS Oversight Level of Care Level of Care Services Services Plan Plan Qualified Providers Qualified Providers Financial Accountability Financial Accountability Administrative Oversight by Medicaid Agency Administrative Oversight by Medicaid Agency

27 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD New Jersey Waivers AIDS Community Care Alternatives Program (ACCAP) AIDS Community Care Alternatives Program (ACCAP) Community Resources for People with Disabilities (CRPD) Community Resources for People with Disabilities (CRPD) combined three model waiverscombined three model waivers Acquired Traumatic Brain Injuries (TBI) Acquired Traumatic Brain Injuries (TBI)

28 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD New Jersey Waivers Global Options (GO) – Global Options (GO) – combined Community Care Program for the Elderly and Disabled (CCPED) and Enhanced Community Options (ECO) Community Care Waiver (CCW) Community Care Waiver (CCW)

29 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Community Care Waiver Nationally, the second waiver approved by federal government Nationally, the second waiver approved by federal government Refinanced group home services Refinanced group home services Model used by many other states Model used by many other states Changes needed to update model Changes needed to update model

30 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Philosophical Changes Philosophical Changes Changed Services Changed Services New Services New Services Deleted Services Deleted Services

31 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Services where you live Services where you live With familyWith family ApartmentApartment Supportive livingSupportive living Group homeGroup home

32 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Self-direction Self-direction added as option (includes Real Life Choices, Self-Determination, and Olmstead individuals who self-direct, and individuals served from Waiting List)added as option (includes Real Life Choices, Self-Determination, and Olmstead individuals who self-direct, and individuals served from Waiting List) Provider directed model still availableProvider directed model still available Essential Life Plan Essential Life Plan added as alternate plan of care for individuals who self-direct or have an individual budgetadded as alternate plan of care for individuals who self-direct or have an individual budget

33 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Regional Monitor for Individuals who Self-direct (new administrative service) Regional Monitor for Individuals who Self-direct (new administrative service) Assures that the following is completed:Assures that the following is completed: Assessment for waiver eligibility Assessment for waiver eligibility Level of care Level of care Assignment of budget amount Assignment of budget amount Review & approve service plan Review & approve service plan Assure health & safety factors considered Assure health & safety factors considered Approves expenditures Approves expenditures

34 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Retainer days paid for absences from day program and residential supports Retainer days paid for absences from day program and residential supports Therapeutic daysTherapeutic days Hospital days & related stays in other facilitiesHospital days & related stays in other facilities

35 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD New Service Support Coordination Support Coordination For persons who self-directFor persons who self-direct Connects people to servicesConnects people to services Providers of Support Coordination are employed by agencies other than the DivisionProviders of Support Coordination are employed by agencies other than the Division Conflict of Interest provisionConflict of Interest provision

36 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW New individuals enrolled on waiver are assigned funding maximum based on the Developmental Disability Review Tool (DDRT) New individuals enrolled on waiver are assigned funding maximum based on the Developmental Disability Review Tool (DDRT) Remove Psychiatry & ITN as a covered service Remove Psychiatry & ITN as a covered service

37 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD New Services Transition Services Transition Services For people being discharged from institutional settingsFor people being discharged from institutional settings Must be entering a non group home settingMust be entering a non group home setting Pays for deposits, furniture, one time services (cleaning, extermination, etc.), movingPays for deposits, furniture, one time services (cleaning, extermination, etc.), moving Up to 180 days prior to moveUp to 180 days prior to move

38 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Respite changes Respite changes Clarify respite payment cannot be made to relative who lives with individualClarify respite payment cannot be made to relative who lives with individual Expands eligible providersExpands eligible providers Camp (no out of state) Camp (no out of state) ICF/MR ICF/MR Group respite at no more than 1:4 ratio Group respite at no more than 1:4 ratio

39 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Day Habilitation Day Habilitation Changed nameChanged name Added hourly units (no more than 25/wk)Added hourly units (no more than 25/wk) Distance between individuals residence & day habilitation site is not greater than 38 milesDistance between individuals residence & day habilitation site is not greater than 38 miles

40 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Individual Supports Individual Supports Added hourly units (ratio cannot exceed 1:4)Added hourly units (ratio cannot exceed 1:4) Requires drug & alcohol testing & orientation trainingRequires drug & alcohol testing & orientation training Permits family member residing in home to provide services for a limited period (no more than 40 hours per week for no more than 30 days annually) during transition of staffPermits family member residing in home to provide services for a limited period (no more than 40 hours per week for no more than 30 days annually) during transition of staff

41 Rev 8/24/09 The Arc of New Jersey & NJDHS-DDD Revisions to CCW Environmental/Vehicle Modification Environmental/Vehicle Modification Total expenditure of $11,000 every three years in conjunction withTotal expenditure of $11,000 every three years in conjunction with Assistive Technology Devices (new service) Assistive Technology Devices (new service) Transportation (new service) Transportation (new service)


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