1 Virginia Medicaid Waivers November 2010 Materials developed by the Endependence Center in consultation with DMAS and DBHDS. 75% of the funding to develop this product was provided by the VBPD under the federal DD and Bill of Rights Act. Contact VBPD at or go to

2 Medicaid w HISTORY  1965 Amendments to the Social Security Act  Medicaid Buy-In  Money Follows the Person w PURPOSE Health care for certain groups of people who have low income w FLEXIBILITY States design programs within federal standards

Federal & State Roles w Centers for Medicare & Medicaid Services Federal agency CMS cms.hhs.gov w Department for Medical Assistance Services State agency DMAS 3

Virginia Medicaid w General Assembly determines State funding $ 6,118,574,041 (an increase of $461 million from 2008) 50% from state funds 50% from federal funds 4

Mandated Services All States w EPSDT w Family Planning w Health Clinics w Home Health Service w Hospital Services w Lab and X-Ray Services w Medicare Premiums w Nurse-Midwife Services w Nurse Practitioner w Nursing Facilities w Physician Services w Transportation 5

Optional Services Selected by Virginia w Case Management w Home and Community Based Waivers w Home Health w Hospice w ICF-MR w Mental Health Services w Optometry w PT, OT, Speech Therapy w Podiatry w Prescribed Drugs w Prosthetics w Psychology 6

Early and 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 7

8 EPSDT w Check ups and lab tests w Dental services w Eye glasses w Hearing aids & implants w Immunizations w Mental health assessment and treatment w Personal care, nursing services w Other needed services, treatment and measures for physical and mental illnesses & conditions

9 Children’s Mental Health Waiver Not a Home and Community-Based Waiver w Children under 21 w Parent income not considered w Must currently reside in a PRTF (Psychiatric Residential Treatment Facility) for at least 90 days w Psychiatric diagnosis

Institutional Placements w Hospitals w Nursing facilities n ICFs/MR - Intermediate Care Facility for people with ID or related conditions n institutions of 4 or more beds n active treatment and rehabilitation n regulated by the federal and state governments n 40 ICFs/MR in Virginia n 5 large Training Centers n 35 smaller ICFs/MR, ranging from 4 to 88 beds 10

PACE Program of All-Inclusive Care for the Elderly w Alternative to nursing home and EDCD Waiver w 55 years or older w 7 sites w Managed care of services w dmasva.dmas.virginia.gov/Content_pgs/ltc-pace.aspx 11

Financial Eligibility w Local Department of Social Services w On line application for adults w For Waivers, financial application after screening 12

Long-Term Care Eligibility Process w Screening First w Financial Eligibility Second w Screening for all Waivers must be provided without any charge to the individual 13

Long-Term Care Medicaid HCBC Waivers, PACE & Institutions Must Need Long-term Care  Assessment / screening Financial Thresholds w Monthly income limit $2,022 w “Spend-down” for medical Waivers w $2000 resource limit w Parent income & resources do NOT count regardless of child’s age 14

State Plan Medicaid Regular Medicaid Categorical Criteria w Disabled w 65 or older w Families with children w Pregnant women w Others Financial Thresholds w Low income & resources w Amounts vary by group w Parent income & resources DO count for minor children unless in a facility or receiving a Waiver 15

Special Needs Trusts w Maintain assets for future needs w Protects from disqualifying for public benefits

Medicaid Benefits Once enrolled in a Medicaid Waiver – - Medicaid card - All Waiver and State Plan (Mandatory and Optional) services you are eligible for 17

18 HIPP w Health Insurance Premium Payment w Health Insurance Premium Payment for Kids w May pay a portion or total health insurance premium w Application separate from Medicaid eligibility and filed with DMAS w Call

Patient-Pay $People may have to pay for some Waiver services if they have income over $1,112 per month $No patient-pay for AIDS and Alzheimer’s Waivers $Some exceptions for persons who are working 19

20 Patient-Pay Day Support, DD, EDCD and ID Waivers w May have a patient-pay if income is over $1,112 a month w Can keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/week w Can keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/week w Still have a patient-pay from unearned income for all Waivers except the AIDS and Alzheimer’s Waivers * total of earned and unearned income

Medicaid Works (Medicaid Buy-In) w People with disabilities who work or want to go to work w Available to people enrolled in Waivers w To enroll current monthly income must be less than $722 per month w Enroll before income goes above $722 w Complete an agreement, then work – Income (gross earnings) up to $44,100 a year Resources up to $30,600 21

22 AMERICANS WITH DISABILITIES ACT “A public entity shall administer services, programs, and activities in the MOST INTEGRATED SETTING appropriate to the needs of qualified individuals with disabilities. ” 28CFR Section (d)

23 SUPREME COURT RULING w “administer services with an even hand” w “comprehensive, effectively working plan for placing qualified persons with disabilities in less restrictive settings” w “waiting list that moved at a reasonable pace” w

Why Home & Community Based Care Waivers? w Slow the growth of Medicaid spending w People with disabilities and advocates opposed institutions w Permit federal Medicaid funds to be used for community services by people who would otherwise be institutionalized 24

Home & Community Based Care Waivers Waivers give States the flexibility to develop and implement alternatives to institutionalization. 25

Virginia Home & Community Based Care Waivers State Regulations for the Waivers 12 VAC AIDS Waiver 12 VAC Alzheimer’s and Related Dementias Assisted Living Waiver (Alzheimer’s Waiver) 12 VAC Day Support Waiver for Individuals with Intellectual Disabilities (Day Support Waiver) 12 VAC Elderly or Disabled with Consumer Direction Waiver (EDCD Waiver) 12 VAC Individual and Family Developmental Disabilities Support Waiver (DD Waiver) 12 VAC Intellectual Disabilities Waiver (ID Waiver) 12 VAC Technology Assisted Waiver (Tech Waiver) 26

DD Waiver or ID Waiver? DD Waiver w 6 years or older w Autism, cerebral palsy, spina bifida, brain injury or other disability before the age of 22 w No diagnosis of ID ID Waiver w Any age w Under 6 at developmental risk w Diagnosis of ID (after age of 6) 27

Alternative Placement Options Different Institution – Different Waiver Nursing Home AIDS Waiver Alzheimer’s Waiver EDCD Waiver Tech Waiver Hospital AIDS Waiver Tech Waiver ICF/MR DD Waiver Day Support Waiver ID Waiver 28

29 Screening Pre-Admission Screening Teams of the Department of Health & Department of Social Services w EDCD Waiver w AIDS Waiver w Alzheimer’s Waiver w Tech Waiver Community Services Board w ID Waiver and Day Support Waiver Department of Health Local Clinics/Child Development Clinics w DD Waiver

30 w Medicaid alternate institutional placement w Same criteria used for admission to institution w Do not have to apply for or be placed in an institution Alternative Institutional Placement

Which Waiver Is For Me? maybe more than one… w What is your disability? - AIDS - Alzheimer’s - Developmental Disability (examples: autism, cerebral palsy, spina bifida, brain injury before the age of 21) - Intellectual Disability - Other 31

More Questions w Your age? w Services needed? w Eligible for nursing home? w Eligible for ICF-MR? 32

Waiting Lists w DD and ID Waivers w More people need DD and ID Waiver services than money is allocated for w Be included on a waiting list w Can’t be on both DD and ID Waiver wait lists at the same time 33

34 Level of Functioning (LOF) w Screening tool w Day Support, DD and ID Waivers w Determines the level of care needed w Different form for young children

35 Individual and Family Developmental Disabilities Support (DD) Waiver w 6 years of age or older and have a developmental disability w No diagnosis of intellectual disability w Level of Functioning survey used for screening w Screening request dmasva.dmas.virginia.gov/Content_pgs/ltc-screen.aspx

Developmental Disability w Severe chronic disability w Attributable to a condition, other than mental illness w Manifested before the age of 22 w Likely to continue indefinitely w Results in substantial limitations in 3 or more areas of major life activity Self-care Understanding and use of language Learning Mobility Self-direction Capacity for independent living 36

DD Waiver Services w Adult companion (consumer directed & agency) w Assistive technology ($5,000 per year limit) w Crisis stabilization w Day Support and Prevocational services w Environmental modifications ($5,000 per year limit) w Family/caregiver training w Personal emergency response system (PERS) w Personal assistance services (consumer directed & agency) w Residential (individual’s home) w Respite care (consumer directed & agency) w Skilled Nursing w Supported employment w Therapeutic consultation w MFP Transition Services ($5,000 max in a lifetime) 37

DD Waiver Emergency Criteria w Primary caregiver has a serious illness, has been hospitalized, or has died w DSS determines abused or neglected and in need of immediate waiver services w Individual demonstrates behaviors that present risk to personal or public safety w Individual presents extreme physical, emotional, or financial burden at home, and the family or caregiver is unable to continue to provide care, or w Individual lives in an institutional setting and has a viable discharge plan in place 38

39 Intellectual Disabilities (ID) Waiver w Diagnosis of ID or be under the age of 6 and at developmental risk w Children on the ID Waiver who do not have a diagnosis of ID at the age of 6, possible transfer to DD Waiver w Screenings are conducted by Community Services Boards (CSB) w Level of Functioning used for screening

ID Waiver Services w Adult companion (consumer directed & agency) w Assistive technology ($5,000 per year limit) w Crisis stabilization w Day Support and Prevocational services w Environmental modifications ($5,000 per year limit) w Personal emergency response system (PERS) w Personal assistance services (consumer directed & agency) w Residential support (individual’s home or group home) w Respite care (consumer directed & agency) w Skilled Nursing w Supported employment w Therapeutic consultation w MFP Transition Services ($5,000 max in a lifetime) 40

ID Waiver Waiting Lists Urgent and Non-urgent w CSBs and Dept of Behavioral Health and Developmental Services maintain wait lists w CSB provides written notice if placed on wait list and any change to other wait list w CSB Slot Assignment Committee determines who is most urgent w Non-urgent = meet criteria for the ID Waiver, but not Urgent criteria w Only after all Urgent needs are met statewide will Non-urgent needs be served w Planning list = need services in the future (not Waiver wait list) 41

ID Waiver Urgent Criteria w Primary caregivers are both 55 yrs or older (or if 1, is 55 or older) w Living with a primary caregiver who is providing the service voluntarily and without pay and they can’t continue care w There is a clear risk of abuse, neglect, or exploitation w Primary caregiver has chronic or long term physical or psychiatric condition significantly limiting ability to provide care w Individual is aging out of a publicly funded residential placement or otherwise becoming homeless, or w 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 42

43 Day Support Waiver w For people on the ID Waiver waiting lists w Available to 300 people w Day Support, Prevocational and Supported Employment services w Case Management w People could transition to the ID Waiver

44 Uniform Assessment Instrument (UAI) w Used for nursing home placement and the AIDS, Alzheimer’s, EDCD, and Tech Waivers w Assess social, physical health and functional abilities w Gather info for planning and monitoring needs and eligibility

45 Elderly or Disabled with Consumer Direction (EDCD) Waiver Individuals seeking Waiver services are eligible if 65 or older or disabled Must meet nursing home criteria Screening is conducted by the Preadmission Screening Team using the UAI

Criteria for Nursing Home and Alternative Waivers w Functional Needs Category Combination of - Activities of daily living Behavior and orientation Mobility Joint motion Medication administration w Nursing or Medical Needs Category MUST MEET BOTH CATEGORIES 46

47 EDCD Waiver Services Adult Day Health Care Personal Care Services (CD or Agency) Personal Emergency Response System (PERS) Respite (CD, Agency, or Skilled) For people transitioning with MFP Assistive Technology ($5,000 during the year in MFP) Environmental Modifications ($5,000 during the year in MFP) Transition Services ($5,000 max in a lifetime) Transition Coordination

48 Technology Assisted Waiver w Individual may be eligible if they need both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing care w DMAS reviews individual’s private insurance policy for private duty nursing benefits w Case management provided by DMAS

Tech Waiver Considerations ADULTS w Screening team completes UAI for adults only. DMAS staff follows up to complete the screening for adults w Eligible if depends part of day on vent or complex trach; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis CHILDREN w DMAS staff completes screening for children w Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis; or daily dependence on other device- based respiratory or nutritional support 49

50 Tech Waiver Services  Private duty nursing up to16 hours per day, except - individuals under age 21 can receive nursing services 24 hours a day during the first 30 days they receive Tech Waiver services  Respite care  Environmental Modifications (max $5,000 a year)  Assistive Technology (max $5,000 a year)  MFP Transition Services ($5,000 max)

51 AIDS Waiver w Diagnosis of AIDS or AIDS-Related Complex w Individuals are screened by a Preadmission Screening Team (DSS social worker, VDH nurse and physician) w UAI is the screening tool

52 AIDS Waiver Services Case management Nutritional supplements Private duty nursing Personal assistance/care (CD or Agency) Respite care (CD or Agency) Personal Emergency Response System (PERS) Transitional Services ($5,000 max in a lifetime) AT and EM (if transitioning with MFP)

53 Alzheimer’s Waiver w Reside in assisted living facility w Nursing home care criteria w Must receive an auxiliary grant w Services Nurse evaluation Medication administration Therapeutic and recreation programming

54 Case Management w Development, coordination, implementation, monitoring and modification of Waiver services w Links to other community resources and supports

55 Case Management AIDS Waiver -Provided by an AIDS or related organization Developmental Disability -Individual selects the organization -Organization cannot provide other Waiver services, except CD Facilitation Intellectual Disability -Provided by CSB -CSB can provide Waiver services Tech Waiver -Provided by DMAS

56 Consumer Involvement w Person-centered practices w Involve people of your choice in planning w Choose services w Choose providers w Decide how & when services will be provided w Agree to and monitor services w Quarterly and Annual Review of service plans w Right to appeal areas of disagreement

57 Planning for Services w Who will participate in your meeting w Prepare list of needed supports & services w Honest & frank w Collect documentation vocational evaluations IEPs school evaluations medical documentation

Decision Making w Person receiving services w Power of Attorney w Durable Power of Attorney w Guardianship w Authorized Representative (limited to services through the CSB) w Representative Payee (Social Security funds) 58

59 Health, Safety & Welfare Adequate services must be provided Additional or different services if needed

60 Personal and Attendant Care w Assistance with ADLs and IADLs w Can be provided in any environment w Supervision for up to 8 hours a day when the primary caregiver(s) are working or going to school for all ages (AIDS and EDCD Waiver) w Supervision for children (DD and ID Waivers) w Consumer Directed and Agency service w Nurse delegation of skilled services is allowed

61 Respite w Must have a primary caregiver w Caregiver does not have to live with the individual receiving Waiver services w Annual limits on number of hours w Can be provided in any environment w Consumer Directed and Agency service

62 Companion w Cannot provide any hands on support w Limited to 8 hours in a 24 hour period w Can be provided in any environment w Consumer Directed and Agency service w Person must be - 18 years or older Unable to be alone

63 Consumer Directed Services w Staff hired by the person with a disability w Staff not employed by an agency w Choice and control remains with the individual, and sometimes their family what service is needed who will provide it when it will be provided where it will be provided how it will be provided

Consumer Directed Services AIDS Waiver Personal Assistance, Respite Developmental Disabilities Waiver Personal Care, Respite, Companion Elderly or Disabled with Consumer Direction Waiver Personal Care, Respite Intellectual Disability Waiver Personal Assistance, Respite, Companion 64

65 Consumer Directed Services w Individual receiving services (or someone acting on their behalf) Employer of record with the IRS Hires, supervises, trains and fires employees Must use provided documentation for employment process Approves timesheets for employees to be paid w Service Facilitator Document needs and monitors services Training on services, employment process Provide info as needed w PPL (Medicaid contractor) Enrolls employer with IRS Pays for background checks Pays employees based on approved timesheets Manages tax documentation and unemployment insurance

66 Consumer Directed Employee Qualifications w 18 years or older w Skills to perform job duties w Social Security number w Criminal history check and CPS for children w Annual or routine TB screening

67 Consumer Directed Employees w Employees may not be Parents of minor children or spouses of the individual receiving services w If the employee lives with the person receiving services Objective written documentation why there are no other providers available to provide care

68 Residential Services DD and ID Waivers w Skill building training and supports w Variety of settings: Individual’s or family’s home or apartment (DD and ID Waivers) Sponsored residential placement (ID Waiver) Group home (ID Waiver) Residence with up to 4 unrelated people receiving services (DD Waiver)

69 Supported Employment DD, Day Support and ID Waivers w First exhaust IDEA and Rehab options w Limited to 8 hours a day w Rates adjusted resulting in more providers w Competitive employment w Not sheltered workshops

Prevocational w Preparing for paid or unpaid employment w Not job-task oriented w Skills such as attendance, task completion, problem solving and safety w Must first exhaust IDEA and Rehab options w Limited to 8 hours a day 70

71 Day Support Recreational and social skill building and services Provided outside of the person’s home Variety of settings Integrated in the community Segregated at a center Individual Group Different schedule during school year, weekends, various weekdays

72 Adult Day Health Care w Provided in a congregate setting w Social and recreational activities w Typically used by people who are elderly who cannot be left alone at home w EDCD Waiver service

73 Nursing w Skilled Nursing: through the DD and ID Waivers if not covered by EPSDT or regular Medicaid w Private Duty Nursing: continuous care up to 16 hours a day through the AIDS and Tech Waivers, if not covered by private health insurance w Home Health nursing is provided for periodic support and maintenance (not through a Waiver)

74 Family Caregiver Training w Training and Counseling w Provided to families and caregivers w Provided – Individually Small groups Conferences and Seminars

75 Therapeutic Consultation w Consultation to family or providers to assist them with a plan of care w Psychology, social work, rehabilitation engineering, behavioral analysis, speech therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, or physical therapy or behavior consultation

76 Crisis Stabilization w Direct intervention for persons experiencing serious psychiatric or behavioral challenges w Temporary intensive services and supports to avert emergency psychiatric hospitalization or institutional placement or prevent other out-of- home placement w Stabilize individuals and strengthen the current living situations

77 Personal Emergency Response System w Can include a medication management system w Individual must – Not be able to use a phone in an emergency Be 14 years or older Left alone for a portion of the day Have the cognitive ability to use the device

78 Assistive Technology w Prescription for AT evaluation w Evaluation by qualified professional w Quote by Medicaid AT provider w Delivery after prior authorization w Assistance by Case Manager or Transition Coordinator w Limited to $5,000 per year

Assistive Technology and Environmental Modifications MFP-AIDS and EDCD Waiver w EDCD Waiver only if enrolled in Money Follows the Person (MFP) project w Assistive Technology up to $5,000 w Environmental Modifications up to $5,000 w Provider develops justification w Only available during the year enrolled in MFP w Not an ongoing EDCD Waiver service 79

80 Environmental Modifications w Modifications to primary home Ramps and other access features Fences and other security measures w Modifications to primary vehicle Lifts, ramps, hand controls w Limited to $5,000 per year

81 Money Follows the Person w Transition from institutional settings w DD and ID Waiver slots available w

82 MFP Transition Services w Household set-up expenses w Must be moving from an institution to a private residence w $5,000 per person w Limited to one transition per lifetime w Examples: rent and utility deposits; essential household furnishings; moving expenses

83 Service Providers DMAS is responsible for - w ensuring the capacity and scope of services are available w ensuring individuals are able to have “provider choice” w enrollment of providers w quality of services

Accessing Providers  Switch providers if you choose to  Shortage of some providers  If you have a case manager –  They will assist you in locating and choosing providers  They will contact providers to initiate services  List of qualified providers given to you  Right to choose providers  Right to visit, interview and research providers  You decide when, where and how you want approved services provided (with some limitations)  Shortage of some providers 84

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

86 Right to Appeal When w Application of benefits is denied w The agency takes action or proposes to take action which will adversely affect, reduce, or terminate receipt of benefits w Request for a specific benefit is denied; in whole or in part w The agency does not act with reasonable promptness

87 Waiting Lists ID Waiver has 2 waiting lists Urgent and Non-urgent: CSB Slot Assignment Committee determines who is the most urgent to receive available ID 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?

Waiting List Advocacy w State General Assembly (legislators) decide Waiver funding w Legislators need to understand and be responsive to the need w The Arc of Virginia w Centers for Independent Living 88

89 Future Changes w Increased use of person-centered practices w Waiver Regulations w On hold – Individualized Budgets Consumer Directed Supported Employment w