Exploring Medicaid Waivers Debra Holloway The Arc of Virginia Family Involvement Project

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)

Medicaid Means “Low income” – Wrong! Waiver eligibility is not dependent on income.

Waiver Must be Cost Effective Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than compatible institution care. Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than compatible institution care. The elderly and disabled represent The elderly and disabled represent 30% of Medicaid program recipients. 30% of Medicaid program recipients.

What are the services? Different Waivers have different services. Adult Day Health Care Assistive Technology Case Management Companion Services Crisis Intervention/Stabilization Day Support Environmental Modifications Family Caregiver Training Nursing Services Nutritional Supplements Personal Care Services Personal Emergency Response System Prevocational Services Residential Support Respite Skilled Nursing Supported Employment Therapeutic Consultation Transition Coordination Transition Services

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) Mental Retardation (MR) Day Support Alzheimer’s Assisted Living (AAL) Waiver managed by the Facility and Home-Based Care Unit Mental Health Waiver (Demonstration Waiver)

Elderly or Disabled with Consumer Direction Waiver (EDCD) Elderly or Disabled with Consumer Direction Waiver (EDCD) Technology Waiver (Tech) Technology Waiver (Tech) Individual and families with Developmental Disabilities Waiver (DD) Individual and families with Developmental Disabilities Waiver (DD) Mental Retardation Waiver Mental Retardation Waiver (MR Waiver, ID or intellectually disabled) (MR Waiver, ID or intellectually disabled)

Consumer-Directed Services Individual or family caregiver directs and controls who, how, and when services are provided Individual or family caregiver directs and controls who, how, and when services are provided Virginia offers consumer-directed services in 4 Waivers: Virginia offers consumer-directed services in 4 Waivers: –Elderly or Disabled with Consumer-Direction Waiver (since 2005) - Personal Care, Respite –Developmental Disabilities Waiver (since 2000) - Personal Care, Respite, Companion –Mental Retardation Waiver (since 2001) - Personal Assistance, Respite, Companion –AIDS Waiver (since 2003) – Personal Assistance, Respite

Consumer-Directed Services Individual is the employer of record with the IRS 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 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 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) 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 DMAS (using a contractor, PPL) pays the attendants, companion aides and respite workers on behalf of the individual

Consumer-Directed Employees Attendants, Companions, Respite Workers Consumer-Directed employees may not be - 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 - 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. This waiver is constructed to allow persons to remain in the community that meet nursing facility level of care. Current enrollment 14,034 Current enrollment 14,034 No waiting list 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) 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. 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. An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver.

Criteria Qualify for Medicaid (individual) Qualify for Medicaid (individual) Meet long term care criteria according to Uniform Assessment Instrument (UAI) 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: Functional Dependencies: bathing, dressing, toileting, transferring, eating/feeding Medical and nursing needs: 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. 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 Request for screening, contact your local Health Department Schedule visit with pre-admission screening teams of the Department of Health & 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!) Completed Medicaid application (child’s information only!)

Services Adult Day Health Care Adult Day Health Care Personal Care (agency or consumer directed) Personal Care (agency or consumer directed) Respite 720 hrs. (agency or consumer directed) Respite 720 hrs. (agency or consumer directed) Personal Emergency Response System (PERS) Personal Emergency Response System (PERS) Transition Services ($5000 max) Transition Services ($5000 max) Transition Coordination Transition Coordination

Technology Assisted Waiver (Tech) No age limit to eligibility No age limit to eligibility No waiting list No waiting list Currently serving 319 individuals. Currently serving 319 individuals.

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. 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 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 The Department of Medical Assistance Services (DMAS) reviews individual’s private insurance policy for private duty nursing benefits Case management provided by DMAS nurses Case management provided by DMAS nurses Different rules for children and adults Different rules for children and adults

Criteria Doctor must certify need for care; and need substantial and ongoing skilled nursing care; and Doctor must certify need for care; and need substantial and ongoing skilled nursing care; and Care must be cost effective; and Care must be cost effective; and Primary caregiver must be trained and accept responsibility for 8 hours or more per day 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 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 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. 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 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 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) 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) Personal Care (adults only) Respite Care (360) Respite Care (360) Environmental Modifications ($5000) Environmental Modifications ($5000) Assistive Technology ($5000) Assistive Technology ($5000) Durable Medical Equipment Durable Medical Equipment Transition Services ($5000) Transition Services ($5000)

Individual and Family Developmental Disabilities Support Waiver (DD) Wait list is maintained by the Department of Medical Assistance Services (DMAS) Wait list is maintained by the Department of Medical Assistance Services (DMAS) Recipients served FY07 594, and 640 are waiting. Recipients served FY07 594, and 640 are waiting. Can be placed on the waiting list at age 5 years 8 months Can be placed on the waiting list at age 5 years 8 months

Eligibility Criteria “Related Conditions” Waiver “Related Conditions” Waiver Must be 6 years of age and over and meet the related conditions criteria, including autism; and Must be 6 years of age and over and meet the related conditions criteria, including autism; and Individual must not have a diagnosis of Mental Retardation. Individual must not have a diagnosis of Mental Retardation. Meet the level of care for admission to an ICF/MR. The individual must meet 2 out of 7 levels of functioning. 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 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. 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.

RELATED CONDITIONS also referred to as developmental disability Severe chronic disability Severe chronic disability Attributable to a condition, other than mental illness Attributable to a condition, other than mental illness Manifested before the age of 22 Manifested before the age of 22 Likely to continue indefinitely Likely to continue indefinitely Results in substantial limitations in 3 or more areas of major life activity Results in substantial limitations in 3 or more areas of major life activity Self-care Self-care Understanding and use of language Understanding and use of language Learning Learning Mobility Mobility Self-direction Self-direction Capacity for independent living Capacity for independent living

Transitioning from MR to DD Waiver Annually each child receiving MR Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver. Annually each child receiving MR 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. If the child meets DD Waiver eligibility the child can transition to the DD Waiver.

Services Adult Companion (CD & Agency/up to 8 hours a day) Assistive Technology ($5000) Crisis stabilization Crisis supervision Environmental Modifications ($5000) In-home residential Prevocational Companion Care Day support Skilled nursing Supported employment Therapeutic consultation PERS Family/caregiver training (80 hours a year) Respite care (720) Personal attendant services Transition Services ($5000)

Mental Retardation Waiver (MR) Day-to-day MR waiver operations are managed by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) Day-to-day MR waiver operations are managed by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) Locally, MR Waiver services for individuals are coordinated by case managers employed by Community Services Boards Locally, MR Waiver services for individuals are coordinated by case managers employed by Community Services Boards Wait list - Waiting list as of 12/08 4,375 Wait list - Waiting list as of 12/08 4,375 7,942 waivers approved 7,942 waivers approved 400 new MR Waiver slots funded, 200 available 400 new MR Waiver slots funded, 200 available July 1, 2009, 200 available January 1, 2010 July 1, 2009, 200 available January 1, 2010

Eligibility Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning. Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning. Six and over – a psychological evaluation with a diagnosis of mental retardation. Six and over – a psychological evaluation with a diagnosis of mental retardation. Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of mental retardation or is at developmental risk. Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of mental retardation or is at developmental risk.

Criteria All individuals receiving MR Waiver services must meet the ICF-MR level of care. All individuals receiving MR 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. 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 Urgent Non-Urgent Non-Urgent

Urgent Criteria for the MR Waiver Primary caregivers are both 55 yrs or older (or if 1, is 55 or older) 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 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 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 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 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 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

MR WAIVER WAITING LISTS Urgent and Non-urgent CSBs and DMHMRSAS maintain Urgent and Non- Urgent lists CSBs and DMHMRSAS maintain Urgent and Non- Urgent lists CSB maintains Planning list 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 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 CSB determines who is the most urgent Only after all Urgent needs are met statewide will Non- urgent needs be served Only after all Urgent needs are met statewide will Non- urgent needs be served Slot moves with you to a different town in VA 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 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 MR Waiver, including needing services within 30 days, but don’t meet Urgent criteria Non-urgent = meet criteria for the MR Waiver, including needing services within 30 days, but don’t meet Urgent criteria Planning list = need services in the future Planning list = need services in the future

Services Adult Companion Care Adult Companion Care Assistive Technology ($5000) Assistive Technology ($5000) Congregate Residential Congregate Residential Crisis Stabilization/Supervision Crisis Stabilization/Supervision Day Support Day Support Environmental Modifications ($5000) Environmental Modifications ($5000) Family/caregiver Training Family/caregiver Training In-home Residential In-home Residential Medication Monitoring Medication Monitoring PERS PERS Personal Care (Agency or Consumer Directed) Personal Care (Agency or Consumer Directed) Prevocational Services Prevocational Services Private Duty Nursing/Skilled Nursing Private Duty Nursing/Skilled Nursing Respite Care (720) (Agency or Consumer Directed) Respite Care (720) (Agency or Consumer Directed) Therapeutic Consultation Therapeutic Consultation Supported Employment Supported Employment Transition Services ($5000) 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 Immunizations Check ups and lab tests Check ups and lab tests Mental health assessment and treatment Mental health assessment and treatment Health education Health education Eye exams and glasses Eye exams and glasses Hearing exams and hearing aids & implants Hearing exams and hearing aids & implants Dental services Dental services Personal care, nursing services Personal care, nursing services Other needed services, treatment and measures for physical and mental illnesses & conditions 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 The medical justification for a service must accompany the request for EPSDT treatment services -Services not covered Respite Environmental Modifications VocationalEducational

Health Insurance Premium Payment Program (HIPP) If an individual receiving waiver services has private health insurance, Medicaid will be the individuals secondary insurance 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 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. Application must be completed separately from the Medicaid application Visit scroll to “Client Services” click on “More Services” then click on “HIPP Information” Visit scroll to “Client Services” click on “More Services” then click on “HIPP Information”

Recipient Appeal A person may appeal if their benefits are: -Terminated -Denied -Suspended -Reduced

Medicaid Appeals Fair Hearing Fair Hearing Right to challenge decisions and actions regarding Medicaid Right to challenge decisions and actions regarding Medicaid Appeal must be requested within 30 days of the decision or action that you disagree with 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 Decision should be issued by the Hearing Officer within 90 days

Steps Request an appeal or review Request an appeal or review (804) (804) Notify appeals division in writing Notify appeals division in writing Be specific about what you want Be specific about what you want -Results in a hearing -Decision made

MYTH or FACT All persons with a disability of MR/ID will qualify for MR Waiver. MYTH I can be on a wait list for the DD Waiver or the MR Waiver while I am receiving services from another Waiver. FACT

Waiting Lists MR Waiver has 2 waiting lists Urgent and Non-urgent: CSB determines who is the most urgent to receive available MR 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?

The Arc of Virginia Family Involvement Project Debra Holloway Family Involvement Project Manager ext. 103 The Arc of Virginia