1. SW 644: Issues in Developmental Disabilities Supports for Children with Long-Term Support Needs Julie Bryda, MSSW Alice Thorson, MSSW Department of Health Services, Bureau of Long-Term Support, Children’s Section

2. Department of Health Services Bureau of Long-Term Supports Overview of Supports for Children with Long-Term Support Needs

3. Funding Options for Children  Medicaid card  Katie Beckett Program  Birth to 3 Program  Family Support Program  CLTS waivers

4. Eligibility Process Functional Screen is used to determine a child’s “level of care” Child’s disability must result in a substantial functional limitation in three or more of the following five areas: a. Self care b. Receptive or expressive language c. Learning d. Mobility e. Self direction

5. Functional Screen Determines eligibility for:  Family Support Program  Katie Beckett Program (MA Eligibility)  CLTS Waivers  Community Options Program  CCS Services  Mental Health Wrap Around Services Does not determine for:  Birth to 3 Program  Special Education Services  Regional Children with Special Health Care Needs Centers

6. Medicaid Card Ways to access a Medicaid card: Healthy Start, SSI, Badger Care, Katie Beckett Program Healthy Start, SSI, Badger Care, Katie Beckett Program Services must meet the definition of Medical Necessity Services must meet the definition of Medical Necessity Some services require Prior Authorization Some services require Prior Authorization

7. Which Program? If a child is eligible for multiple programs and meets multiple levels of care the county needs to determine which target group, programs, and services are most appropriate to meet the needs of the child. The county will utilize the program most appropriate to the child’s need.

8. The Katie Beckett Program

9.  Special Medicaid eligibility for children under 19 years old with long-term disabilities or complex medical needs, living at home with their families  Must meet Level of Care for DD, PD or SED  Disability determination required

10. The Katie Beckett Program  Child’s income/assets within current MA guidelines  Does not incur a cost at home to the Medicaid Program that exceeds the potential institutional cost  Approximately 5100 children currently enrolled

11. The Family Support Program

12.  Founded on belief that parents of children with severe disabilities know best what they need  Individual services and supports to families with a child with severe disabilities  Offers information and help in finding services, maximizing community resources, connecting families with other families to strengthen natural supports

13. The Family Support Program  Provides flexible funding for up to $3,000 per year per eligible child  Can help fill gaps of other programs by funding needed services & goods that can’t be obtained through other sources  Average FSP allocation $1,500

14. Children’s Long Term Support Waivers

15. CLTS Waivers There are three CLTS Waivers:  Developmental Disabilities (DD)  Severe Emotional Disturbance (SED)  Physical Disabilities (PD)

16. CLTS Waiver Eligibility  Waiver eligible level of care for appropriate target group  DD, PD, or SED  For state matched slots, Disability Determination by Disability Determination Bureau (DHS)  Resides in eligible setting  Meets any applicable residency requirements  Financial Eligibility  Determined to have need for waiver services  Additional criteria for Intensive In-Home Autism Treatment services

17. CLTS Waiver Funding Different ways for a child to receive funding through the CLTS Waivers:  Local match (local dollars)  Family Support Program  Community Options Program  State match

18. CLTS Waiver Services  Specific Services are based on individual need  Experimental or Aversive Services will not be funded

19. CLTS Waiver Services  Adaptive Aids  Child Care & Foster Care Services  only supplemental costs related to meeting additional needs for the child’s disability are eligible to be covered  Communication Aids  Consumer and Family-Directed Supports  Consumer Education and Training  Counseling and Therapeutic Resources  Daily Living Skills Training  Day Services

20. CLTS Waiver Services (continued)  Home Modifications  Intensive In-Home Autism Treatment Services  Personal Emergency Response Systems  Respite Care  Specialized Medical and Therapeutic Supplies  Specialized Transportation  Support and Service Coordination  Supported Employment  Supportive Home Care

21. HISTORY OF CHILDREN’S LONG TERM SUPPORT WAIVERS

22. What is a Waiver?  The Medicaid Home and Community Based Waiver (HCBW) programs were authorized by Congress in 1981, and began in Wisconsin in 1983 with the Community Integration Program for the adult population  The Medicaid waivers represented a significant step, taken to mitigate the Medicaid program’s institutional bias that had led to the extensive development and utilization of nursing homes and Intermediate Care Facilities for the Mentally Retarded (ICF-MR),  Recognizing the problem, Wisconsin had taken its own steps to reverse the trend toward institutionalization with the creation of numerous waiver programs

23. HISTORY OF CLTS Waivers  There are three CLTS Waivers, one waiver for children with:  Developmental Disabilities (DD)  Severe Emotional Disturbance (SED)  Physical Disabilities (PD)  The CLTS Waivers started Jan. 1, 2004  Children are eligible up to age 22 in non- Family Care Counties and age 18 in Family Care Counties

24. History of CLTS Waivers  1997 CLTS Redesign  Review what is working well with the current system and the issues that need to be addressed  Recommend Best Options about how long-term care services for children should be designed and managed  The Children’s Waivers were approved by the federal Centers for Medicare and Medicaid Services (CMS) under the Medicaid rules that permit states to flexibly use Medicaid funds for community supports and services.

25. Why CLTS Waivers?  Other HCBS Waivers written for adults  CLTS Waivers maximize match options for state funded programs (Family Support Program, Community Options Program)  Flexible and family-directed  Provide services beyond what Medicaid fee for service can supply

26. County Responsibilities  On September 15, 2006 the Department of Health and Family Services (DHFS) released DDES Memo 2006-21 directing the counties to implement the CLTS Waivers.  http://dhfs.wisconsin.gov/dsl_info/NumberedMemos/DDES/CY2006/NMemo2006- 21.htm http://dhfs.wisconsin.gov/dsl_info/NumberedMemos/DDES/CY2006/NMemo2006- 21.htm http://dhfs.wisconsin.gov/dsl_info/NumberedMemos/DDES/CY2006/NMemo2006- 21.htm  Every county is required to implement operation of all three CLTS Waivers. The CLTS Waivers must be operated statewide for all target groups per federal HCBSW requirements. A county may choose to have different county departments administer different target groups for the CLTS Waivers, or may choose to contract with another county to offer services for a particular target group.

27. County Responsibilities  For children from any target group whose families contact the county for long-term support services, the county must assess the child's eligibility for services under the CLTS Waivers or other relevant programs including the Family Support and Community Options Program.  If the child is eligible for the CLTS Waiver for any target group, but funding is not available for a slot, the county must create and maintain a waiting list of those children. The county agency does not need to complete a comprehensive assessment until such time that funding is available. This waiting list may be maintained concurrently with the Family Support or Community Options Program wait lists. All policies regarding HCBSW waiting lists may be found in the DHFS Interim HCBS Waiver Manual. DHFS Interim HCBS Waiver Manual.DHFS Interim HCBS Waiver Manual.

28. Progress to Date – Quality of Children’s Services New methods to assure quality services:  Family Outcome Survey  Outcome-based Individual Service Plans

29. Number of Children Served in 2010  Total of 4327 children being served  2262 children in state-funded slots receiving autism services (intensive and ongoing)  1233 children in local match slots  832 children in other state-matched slots  DD-2855 PD-311 SED-1161

30. Funding options for Children with Mental Health needs

31.  Comprehensive Community Services (CCS)  Children’s Long Term Support MH Waiver  Autism Treatment Services  Family Support Program

32. CCS Eligibility  A child is screened using the same functional screen used for CLTS Home and Community Based Waivers  Counties may limit CCS service on the eligibility of the child to receive Medicaid  Additional eligibility criteria identifies functional limits attributed to a diagnosed mental health or substance use condition  Family members may also be eligible for CCS

33. Comprehensive Community Services (CCS) -- HFS 36  Medicaid State Plan Service  Provides services and supports to eligible adults, older adults, children and their families  Services are provided based on need for mental health and or substance abuse services to eligible participants  Available to counties as an option since 2004, 21 counties are currently certified and 8 more are completing applications using technical assistance and start-up funding  The CCS program is not intended for treatment services for children with an autism spectrum disorder since CCS services are considered rehabilitation services. The Center for Medicare and Medicaid Services (CMS) issued a decision that autism treatment is rather a habilitation service. However if the child has another mental health disorder the child may be eligible for the CCS program.

34. The CCS Service Array  Each county chooses services from an array to meet the needs of children and families in their community  Services are identified to be provided within Assessment Domains specified by the CCS rule  Counties may request approval of unique services specific to their county program

35. CCS Services  Assessment  Recovery Planning  Service Facilitation  Communication and Interpersonal Skills Training  Community Skills Development and Enhancement  Diagnostic Evaluations and Specialized Assessments  Employment Related Skill Development  Medication Management  Physical Health and Monitoring  Psycho-education  Psychosocial Rehabilitative Residential Supports  Psychotherapy  Recovery Education and Illness Management  Substance Abuse Treatment  Other: Individually tailored psychosocial rehabilitative service

36. Children’s Long Term Supports Mental Health Waiver

37. CLTS MH Waiver Eligibility Children with Severe Emotional Disturbance must meet all of the following criteria:  Under the age of 22  Emotional disability has persisted at least 6 months except:  If the disability has not persisted 6 months but the nature of the acute episode is such that impairment in functioning is likely to be evident without intensive mental health treatment  Condition expected to persist for more than one year  Diagnosed by a psychiatrist or licensed psychologist using DSM-IV

38. CLTS MH Waiver Eligibility (continued)  Impairment in two or more of the following capacities  Self care  Community involvement  Social relationships  Family relationships  School or work  Impairment is such that the child is at risk of hospitalization  The child is receiving services from two or more of the following service systems: Juvenile justice, Juvenile justice, Child protective services Child protective services Social services Social services  Or one system only if the intensity of treatment needed is three hours or more of MH services

39. CLTS MH Waiver services  Adaptive Aids  Child Care & Foster Care Services  only supplemental costs related to meeting additional needs for the child’s disability are eligible to be covered  Communication Aids  Consumer and Family-Directed Supports  Consumer Education and Training  Counseling and Therapeutic Resources  Daily Living Skills Training  Day Services

40. CLTS MH Waiver Services (continued)  Home Modifications  Intensive In-Home Autism Treatment Services  Personal Emergency Response Systems  Respite Care  Specialized Medical and Therapeutic Supplies  Specialized Transportation  Support and Service Coordination  Supported Employment  Supportive Home Care

41. CLTS MH Waiver Services  Specific Services are based on individual need  Experimental or Aversive Services will not be funded

42. Autism Services  A unique component of the CLTS Waivers is the state funded autism services provided to children with autism, Asperger’s, or Pervasive Developmental Disorders-not otherwise specified (PDD- NOS).  Children referred for this funding must meet specific criteria.

43. Criteria for State-funded Autism Services  Verified DSM IV Axis I diagnosis of one of the three disorders within the Autism Spectrum Disorders Category  One year commitment from family to participate in the intensive services  Qualified provider ready to start serving child  Child must be under 8 years of age prior to be added to the state wait list  Child has not already received 3 years of intensive in- home autism from any funding source  Child meets level of care for DD or SED  Child has been determined disabled by DDB  Child has been a WI resident for at least the last 6 mos.

44. Resources:  CLTS Waiver Manual weblink:  http://dhfs.wisconsin.gov/bdds/waivermanual/index.htm http://dhfs.wisconsin.gov/bdds/waivermanual/index.htm  Appendix E has all the CLTS Waiver forms, policies and procedures  Chapter IV has all the services offered through the CLTS Waivers  CLTS Council weblink:  http://dhfs.wisconsin.gov/bdds/clts/council/index.htm http://dhfs.wisconsin.gov/bdds/clts/council/index.htm  Autism Council weblink:  http://dhfs.wisconsin.gov/bdds/clts/autism/council/index.htm http://dhfs.wisconsin.gov/bdds/clts/autism/council/index.htm  CLTS Functional Screen weblink:  http://dhfs.wisconsin.gov/LTCare/FunctionalScreen/ http://dhfs.wisconsin.gov/LTCare/FunctionalScreen/ See Transcript for Biographical Information