1. MEDICAID WAIVER PROGRAMS: Leaving Institutions Behind November 2010 1

2. 2 What Are They? Medicaid Home and Community Based Services Waivers are programs that enable certain groups of people with disabilities to live in the community instead of in institutions Each program “waives” certain Medicaid rules. They let targeted groups receive extra services not available to others on Medicaid, to limit the number of people who can receive such services, and provide higher income limits than for most other Medicaid coverage groups.

3. 3 What Do They Have In Common? Each Waiver was designed to enable eligible people to either leave institutions, or to avoid entering them. Each has a limited number of service “slots”. Currently, each Waiver is “closed” – all slots are filled, and not open to people already in the community. Through Money Follows the Person, each Waiver is still open to people currently receiving institutional services that Medicaid is funding.

4. 4 What Do They Have In Common? Eligibility A person must choose community services instead of institutional ones Must not simultaneously be enrolled in another Medicaid Waiver Must qualify for Medicaid through: SSI, or TCA, or By having countable income below 300% of SSI federal benefit rate ($2,022/month) and countable resources under $2,000

5. 5 What Do They Have In Common? Eligibility Individual considered a household of one Each Waiver applies these income exclusions for income eligibility: 1. $20 general income exclusion 2. $65 earned income exclusion 3. ½ of remainder of earned income after $65 exclusion 4. ½ of gross self-employment earnings (unless business expenses are greater than ½ of earnings) 5. ½ of rental income

6. 6 What Do They Have In Common? Eligibility Each Waiver applies these income exclusions for income eligibility (Continued): 6. BWE’s 7. Any wages, allowances, or reimbursement for transportation and attendant care costs, unless excepted on a case-by-case basis, when received by a blind or disabled person employed in a project under Title VI of the Rehabilitation Act of 1973

7. 7 What Do They Have In Common? Eligibility A home is excluded if it’s occupied by the participant, his/her spouse, or his/her parent, sibling or child who is financially or medically dependent on the participant Resources that are sold or given away in order to qualify for Waiver services are counted for five years after disposal Annual financial redetermination required

8. 8 1. Living at Home Waiver Alternative to nursing homes Regulations: COMAR 10.09.55 Who is Eligible? Must be 18 - 64 years old (or 65 or older if enrolled before age 65) Must have nursing facility level of care, redetermined annually Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care)

9. 9 1. Living at Home Waiver Covered Services Attendant care Environmental assessments Environmental modifications Assistive technology Personal emergency response systems Consumer training (how to recruit, select, train, direct, supervise, and fire consumer-employed attendants, as well as money management, budgeting, independent living, meal planning, etc.)

10. 10 1. Living at Home Waiver Covered Services Family training (instruction about treatment regimens and the use of equipment specified in the plan of service) Transition services (security deposits, furniture, moving expenses, utility set-up fees and deposits, pest eradication and other health/safety costs) Medical day services Nursing supervision of attendants Home-delivered meals Dietician and nutritionist services Case management

11. 11 1. Living at Home Waiver How to Apply Contact Area Agency on Aging (AAA) http://www.mdoa.state.md.us/aaa.html or the Living at Home Waiver office (410- 767-7479) to apply. http://www.mdoa.state.md.us/aaa.html AAA visits consumer, family and nursing facility staff to educate them about Waiver, complete Medicaid application (CARES 9709), gather financial documents and send to the Division of Eligibility and Waiver Services (DEWS)

12. 12 1. Living at Home Waiver How to Apply DEWS determines financial eligibility Adult Evaluation and Review System (AERS) does assessment for nursing facility level of care and physician completes Medical Eligibility Review Form (3871). Forms sent to Key Pro for review. The Coordinating Center develops Plan of Care

13. 13 2. Older Adults Waiver Alternative to nursing homes Regulations: COMAR 10.09.54 Who is Eligible? Must be at least age 50 Must have nursing facility level of care, redetermined annually Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care)

14. 14 2. Older Adults Waiver Participant Fees Paid only by participants in assisted living facilities Participant pays countable income to assisted living provider To determine countable income for fees, apply usual exclusions (see slides 5 & 6) plus the following: Personal needs allowance ($72/mo.) Room and board paid (not to exceed $420/mo.) Incurred and unpaid medical expenses Spousal and/or family maintenance allowance if applicable (for community spouse and dependent children under age 21)

15. 15 2. Older Adults Waiver Covered Services Assisted living Personal care aide Senior center plus Environmental assessments Environmental modifications Assistive technology Personal emergency response systems Respite care Behavior consultation Family or consumer training Transition services

16. 16 2. Older Adults Waiver Covered Services Medical day services Nursing supervision of attendants Home-delivered meals Dietician and nutritionist services

17. 17 2. Older Adults Waiver How to Apply Contact Area Agency on Aging (AAA) to apply - http://www.mdoa.state.md.us/aaa.html http://www.mdoa.state.md.us/aaa.html AAA visits consumer, family and nursing facility staff to educate them about Waiver, complete Medicaid application (CARES 9709), gather financial documents and send to the Division of Eligibility and Waiver Services (DEWS)

18. 18 2. Older Adults Waiver How to Apply DEWS determines financial eligibility Adult Evaluation and Review System (AERS) does assessment for nursing facility level of care and physician completes Medical Eligibility Review Form (3871). Forms sent to Key Pro for review. AAA develops Plan of Care

19. 19 3. & 4. Community Pathways and New Directions Waivers Alternative to intermediate care facilities for people with mental retardation (ICF/MR) or nursing facilities Regulations: COMAR 10.09.26 Community Pathways Waiver provides traditional services New Directions Waiver provides consumer-controlled services. Consumer hires/fires staff, manages service budget (usually with help of a financial intermediary called a support broker).

20. 20 3. & 4. Community Pathways and New Directions Waivers Who is Eligible? Must be certified for an ICF-MR level of care Must be in a: State Residential Center, or Nursing facility, but determined to have a developmental disability and to need specialized services Chronic care facility Community setting, but at imminent risk of institutionalization (Note: New Waiver eligibility now limited to people in institutions)

21. 21 3. & 4. Community Pathways and New Directions Waivers Participant Fees Paid only to participants who receive residential habilitation services Participant pays countable income to residential provider To determine countable income for fees, apply usual exclusions (see slides 5 & 6) plus the following: Personal needs allowance ($170/mo.) Room and board paid ($375/mo.) Incurred and unpaid medical expenses Spousal maintenance allowance if applicable

22. 22 3. & 4. Community Pathways and New Directions Waivers Covered Services – Community Pathways Residential habilitation Community supported living arrangements Live-in caregivers Day habilitation Community learning services Medical day services Employment discovery and customization Supported employment Resource coordination

23. 23 3. & 4. Community Pathways and New Directions Waivers Covered Services – Community Pathways Environmental modifications Assistive technology Respite care Behavioral support services Family and individual support services Transition services Transportation

24. 24 3. & 4. Community Pathways and New Directions Waivers Covered Services – New Directions Support brokerage Community supported living arrangements Live-in caregivers Day habilitation Community learning services Medical day services Employment discovery and customization Supported employment Resource coordination

25. 25 3. & 4. Community Pathways and New Directions Waivers Covered Services – New Directions Environmental modifications Assistive technology Respite care Behavioral support services Family and individual support services Transition services Transportation

26. 26 3. & 4. Community Pathways and New Directions Waivers How to Apply Service Coordinator/Resource Coordinator completes Waiver information (including Medicaid application (CARES 9709), financial documentation, and level of care form) and submits to DDA regional office (http://dhmh.maryland.gov/dda_md/)http://dhmh.maryland.gov/dda_md/ Regional office sends CARES 9709, financial documentation to DEWS, and level of care form to DDA Central Office (Terri Hartman 410-767-5421) for eligibility determinations

27. 27 3. & 4. Community Pathways and New Directions Waivers How to Apply If applicant does not have a current disability determination from SSA (i.e., for SSI or Title II), DEWS sends forms for physician to complete and return. State Review Team does disability determination. Service Coordinator/Resource Coordinator develops Individual Plan

28. 28 5. Waiver for People with Traumatic Brain Injury (TBI) Alternative to intermediate care facilities for people with mental retardation (ICF/MR) or nursing facilities Regulations: COMAR 10.09.46 Fact sheet: http://dhmh.maryland.gov/mha/Mis cellaneous/TBI/TBI%20Waiver%20fa ct%20sheet_09.pdf http://dhmh.maryland.gov/mha/Mis cellaneous/TBI/TBI%20Waiver%20fa ct%20sheet_09.pdf

29. 29 5. Waiver for People with Traumatic Brain Injury (TBI) Who is Eligible? Must have a traumatic brain injury sustained at age 22 or later Must have enrolled in Waiver at age 22 - 64 Must have nursing facility or special hospital level of care, redetermined annually Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care) Must be able to be served safely and appropriately in the community

30. 30 5. Waiver for People with Traumatic Brain Injury (TBI) Who is Eligible? Ordinarily, must be in: A state psychiatric hospital deemed inappropriate because the person doesn’t need that level of care, or A TBI community placement funded by the Mental Hygiene Administration (MHA) with state-only funds, or A nursing facility owned and operated by the State or an out-of-state rehabilitation facility funded by Medicaid, or A Maryland licensed special hospital for chronic disease licensed by CARF for inpatient TBI care

31. 31 5. Waiver for People with Traumatic Brain Injury (TBI) Who is Eligible? Currently, while Waiver is closed, must be in: University Specialty Hospital, or Kernan Hospital, or Western Maryland Hospital Center, or Deers Head Hospital

32. 32 5. Waiver for People with Traumatic Brain Injury (TBI) Covered Services Residential habilitation Day habilitation Supported employment Individual support services Medical day services

33. 33 5. Waiver for People with Traumatic Brain Injury (TBI) How to Apply Hospital case manager or social worker makes referral to MHA (410-402-8476) Completes Medicaid application (CARES form 9709) and submits to DEWS Physician completes Medical Eligibility Review Form (3871) and sends to Key Pro to review and approve level of care After eligibility approved, plan of care developed

34. 34 Medicaid Waivers and EID The preceding 5 Waivers are compatible with EID A person enrolled in one of these Waivers whose income or resources exceed the usual Waiver limits can enroll in EID to keep Waiver services Countable income limit for an unmarried individual in EID = $2,707/month (usual Waiver limit is $2,022/month) Countable resource limit for EID = $10,000 (usual Waiver limit is $2,000), plus EID excludes some retirement accounts (Waivers usually count these accounts)

35. 35 Other Medicaid Waivers Waiver for Children with Autism Spectrum Disorder – provides services (residential habilitation, intensive individual supports, therapeutic integration, respite care, family training, environmental modifications and adult life planning) to people with autism aged 1 – 21 Model Waiver – provides services (nursing, certified nursing aides, home health aides, case management and medical day services) for medically fragile children under age 22 These Waivers are NOT COMPATIBLE WITH EID