Jacqui Downing, RN Program Manager Long Term Care Services Office of Aging and Disability Services May 24, 2016 State of Maine Long Term Care Services

Elderly and Disabled Adults Waiver Adult Family Care Services Consumer Directed Attendant Services Day Health Services Home Health Services Hospice Services Nursing Facility Services Private Duty Nursing Services Long Term Care Services

Section 19- Home and Community Benefits for the Elderly and for Adults with Disabilities

Home and Community Benefits for the Elderly and for Adults with Disabilities (HCB) are in-home care and other services, designed as a package, to assist eligible Members to remain in their homes, or other residential community settings, and thereby avoid or delay institutional nursing facility care. Medical eligibility for these HCB services is established by a medical eligibility determination (MED) assessment, which is conducted by the Department, or its Authorized Entity, the Assessing Services Agency (ASA). All services covered under this Section require prior approval by the Department, or the ASA, and shall be delivered according to the Member’s Authorized Plan of Care. SECTION 19: Home and Community Benefits for the Elderly and for Adults with Disabilities (Waiver)

Section 19 – Home and Community Benefits for the Elderly and for Adults with Disabilities Waivers allow greater state flexibility under federal law because it allows States to “waive” requirements under the Medicaid State plan. OADS manages a 1915(c) waiver which allows the State to provide home and community based services to individuals who meet institutional level of care. Waivers require cost neutrality, which means the State must assure the federal government that the waiver will not cost more than institutional services would cost.

See the MaineCare Benefits Manual, Section 19, for a complete outline of eligibility. Eligibility To be eligible for LTSS, an individual must meet financial eligibility AND medical functional eligibility. OADS oversees the medical/functional eligibility for LTSS. OADS contracts with an independent statewide assessing services agency, Goold Health Systems, to complete LTSS assessments. Financial eligibility for MaineCare Services is determined through the Office of Family Independence (OFI). Financial eligibility for non-MaineCare programs is determined by the contracted agency that administers the particular program, in conjunction with the appropriate State Policy.

Medical Eligibility Medical eligibility requirements for the LTSS programs serving elders and adults with disabilities are based on functional support needs, not diagnosis.

Service Access Point – No Wrong Door Area Agencies on Aging (AAAs) or Aging and Disability Resource Centers (ADRCs) Application to Office of Family Independence Direct referrals to Assessing Services Agency, which commonly come from physicians, hospitals, providers, individuals and family members.

Getting Started - Members Complete Application and submit to OFI Assessment by Goold Health Systems to Determine Eligibility If Eligible Assigned to Services Coordination Agency Select Service Package

Assessment Process Accurate pre-screening to refer individual to appropriate funding and service source. Face to face medical eligibility determinations. Objective medical and functional assessments based on RN clinical judgment and policy parameters. Timely provision of information on LTSS options and development of a community plan of care.

Five Core Areas Need for assistance with ADLS Need for assistance with IADLS Need for nursing and other skilled services CognitionBehaviors

In-Home Services In-home services are primarily provided by Home Health Agencies and Personal Care Agencies. Qualified staff include RNs, LPNs, CNAs and PSSs (Personal Support Specialists) These services are implemented and coordinated through Service Coordination Agencies.

The Functional Assessment Toileting Transferring Bathing Dressing Activities of Daily Living (ADLs) Preparing meals Routine house work Laundry Grocery shopping Instrumental Activities of Daily Living (IADLs) A tool used to determine how much assistance an individual may need for:

Waiver Services Include: Care coordination NursingPersonal care Therapies Adult day services Respite care Transportation Emergency response systems

Accessibility & Modification Home Accessibility Adaptations Equipment Specialized Medical Equipment Communication Aids

Waiver Service Options: This program allows for participant directed as well as agency directed service delivery. The Participant Directed Option allows the participant to direct their own services. Elders and adults with disabilities who meet MaineCare, medical, and functional criteria

LTSS Grant Program: Homeward Bound Maine has implemented a “Money Follows the Person” Rebalancing Demonstration Program (MFP), funded through CMS. This program provides transition assistance and other services to eligible individuals transitioning from qualified institutions back into the community.

Questions? Jacqui Downing, R.N. Office of Aging and Disability Services Maine Department of Health and Human Services 41 Anthony Avenue State House Station 11 Augusta, ME FAX: