Alternatives to Nursing Home Placement MI CHOICE WAIVER REVIEW

Presented by: Patricia E. Kefalas Dudek, CAP Law Office of Patricia E. Kefalas Dudek & Associates Farmington Hills, MI 48334 (248) 254-3462 Email: pdudek@pekdadvocacy.com Website: www.pekdadvocacy.com

What IS the Waiver? A program which allows eligible adult Michigan Residents who meet medical need, income and asset criteria to receive Medicaid covered services, like those provided by nursing homes, but can stay in their own home or another residential settling.

History of “the Waiver” Prior to 1992 Medicaid only paid for Long Term Care in Medicaid certified skilled nursing facilities First introduced in select areas in Michigan in 1992 Originally called the Home and Community Based Services for the Elderly and Disabled (HCBS/ED) waiver program Expanded Statewide in October, 1998 Now known as the MI Choice Waiver Program 2009- Waiver expanded to include any residential setting, including Assisted Livings, Homes for the Aged, and Adult Foster Care Homes

What are the benefits of the Waiver? Do not have to move into a nursing home Allows more Self-Determination Choose Caregivers-sometimes even family members Choose environment – not limited to Medicaid certified skilled nursing facilities Medicaid eligible- no deductible

What Services are Provided by the Waiver ? Community transition services Community living supports Nursing services (preventative nursing) Respite Services (out of home) Adult Day Health (Adult Day Care) Environmental (home) modifications Non-Medical Transportation Medical supplies and equipment not covered under the Medicaid State Plan Chores Services

What Services are Provided by the Waiver (continued)? Personal Emergency Response Systems Private duty nursing Counseling Home Delivered Meals Training in a variety of independent living skills Supports coordination Homemaker services (laundry, shopping assistance & housekeeping)

Sounds Good!! Sign me up!! Not so fast…

How do I get there from here? There is a referral/eligibility process Some eligibility criteria parallels with Nursing Home Medicaid- but not entirely same DO NOT LOOK FOR LOGIC!!

Do Your Homework Consider a location in which your client(s) wants to receive MI Choice Waiver Services. If living in an assisted living or adult foster care: Need to confirm that the facility participates in the Waiver. Need to confirm that the facility is willing to participate in the MI Choice Waiver program for this individual. Many places will say we do not accept Medicaid Gathering this information ahead of time can help avoid a lot of confusion, frustration and disappointment.

Quick Eligibility Comparison Nursing Home Medicaid MI Choice Waiver Age 65+ /or Disabled Michigan Resident Level of Care Determination Asset limit $2,000 single $119,220 max. married Income limit < cost of Nursing Home care Age 65+ /or Disabled Michigan Resident Level of Care Determination Asset limit $2,000 single $119,220 max. married Income limit < $2199/month (300% SSI)

Ready, set, go! Starts with a phone call

Referral Process Contact the Preferred Waiver Agency*** Ask for an Assessment for eligibility for MI Choice Waiver services An intake specialist will conduct a pre-screen over the phone *** If the person passes the pre-screen his or her name will be put on the waiting list*** Once they get to the top of the priority list, the specialist will schedule an in person assessment At the in-person assessment, the Level of Care Determination is made. *** Apply for Medicaid*** *** Opportunities for Advocacy

Referral is Made to MI Choice Every County in Michigan is covered by at least 1 Waiver Agency To Start the process, a referral is made to a Waiver Agency that serves the County where the individual lives. Local Waiver Agencies and more information on MI Choice Waiver can be found at: www.michigan.gov/mdch Click on Health Care Coverage Click on Services for Seniors Click on MI Choice Waiver Program

Waiver Agency Region Map

Advocacy Tips Familiarize yourself with the Waiver Agencies in your area. Get client on the list as soon as possible, hospitalization counts! May have more than one Waiver Agency in Client’s area. May be able to get on more than one waiting list.

Referral Process Contact the Preferred Waiver Agency*** Ask for an Assessment for eligibility for MI Choice Waiver services An intake specialist will conduct a pre-screen over the phone *** If the person passes the pre-screen his or her name will be put on the waiting list*** Once they get to the top of the priority list, the specialist will schedule an in person assessment At the in-person assessment, the Level of Care Determination is made. *** Apply for Medicaid*** *** Opportunities for Advocacy

Intake Guidelines Screening Intended to prescreen applicants, to weed out those who clearly do not qualify for the program This is NOT an eligibility determination. Screening is to determine if the applicant meets nursing facility level of care to demonstrate medical/functional eligibility Newly revised intake criteria established in fall 2014 See Page 5 of handout

Seven Doors Activities of Daily Living (Bed Mobility, Transfers, Toilet Use, Eating) Cognitive Performance Physician Involvement Treatments and Conditions Skilled Rehabilitation Therapies Behavior Service Dependency

MI Choice Intake Guidelines Comprehensive questions specifically formulated to get a more accurate telephonic evaluation. 26 Medically based questions 3 Financially based questions 3 Quality Assessment questions Scoring Algorithm is used to determine waiting list priority.

MI Choice Intake Guidelines & Scoring Algorithm Can be found at: www.michigan.gov/providers >> Providers >>Other Health Care Programs >> MI Choice >> MI Choice Intake Guidelines Interviewer Instructions See Page 5 of handout

Advocacy Tip Remember that this is a telephone prescreen. The intake worker will not see the individual, so detail must be given to the level of need. Review the Intake Guidelines with your client before the phone call. Instruct the applicant to be open and honest about the full extent of his or her needs. Minimizing need can lead to improper screening .

Referral Process Contact the Preferred Waiver Agency*** Ask for an Assessment for eligibility for MI Choice Waiver services An intake specialist will conduct a pre-screen over the phone *** If the person passes the pre-screen his or her name will be put on the waiting list*** Once they get to the top of the priority list, the specialist will schedule an in person assessment At the in-person assessment, the Level of Care Determination is made. *** Apply for Medicaid*** *** Opportunities for Advocacy

Priority Categories CHILDREN’S SPECIAL HEALTH CARE SERVICES (CSHCS) AGE EXPIRATIONS  NURSING FACILITY TRANSITION PARTICIPANTS CURRENT ADULT PROTECTIVE SERVICES (APS) AND DIVERSION APPLICANTS*** CHRONOLOGICAL ORDER BY SERVICE REQUEST DATE *** Opportunities for Advocacy

CHILDREN’S SPECIAL HEALTH CARE SERVICES (CSHCS) AGE EXPIRATIONS   This category includes only those persons who continue to require Private Duty Nursing services at the time such coverage ends due to age restrictions under CSHCS. Advocacy Tip: Consider CMH Services under DD Waiver!

NURSING FACILITY TRANSITION PARTICIPANTS Nursing facility residents who desire to transition to the community and will otherwise meet enrollment requirements for MI Choice qualify for this priority status and are eligible to receive assistance with supports coordination, transition activities, and transition costs. Priority status is not given to applicants whose service and support needs can be fully met by existing State Plan services.

Advocacy Tips This program is designed to assist Nursing Home residents as they transition back into the community. Medicaid must be in place before returning into the community. The referral to this program must be made before returning into the community. WARNING: If timing is wrong, will often be put at the bottom of the chronological list.

CURRENT ADULT PROTECTIVE SERVICES (APS) AND DIVERSION APPLICANTS  An applicant with an active Adult Protective Services (APS) case is given priority when critical needs can be addressed by MI Choice services. It is not expected that MI Choice waiver agencies solicit APS cases, but priority is given when necessary.  An applicant is eligible for diversion priority if they are living in the community or are being released from an acute care setting and are found to be at imminent risk of nursing facility admission. Imminent risk of placement in a nursing facility is determined using the Imminent Risk Assessment (IRA), an evaluation developed by MDHHS. Use of the IRA is essential in providing an objective differentiation between those applicants at risk of a nursing facility placement and those at imminent risk of such a placement. Only applicants found to meet the standard of imminent risk are given priority status on the waiting list. Applicants may request that a subsequent IRA be performed upon a change of condition or circumstance.  Supports coordinators must administer the IRA in person. The design of the tool makes telephone contact insufficient to make a valid determination. Waiver agencies must submit a request for diversion status for an applicant to MDHHS. A final approval of a diversion request is made by MDHHS.

Advocacy Tip Request an IRA (Imminent Risk Assessment) be done on a client that you believe meets that criteria. IRAs can be requested again if the circumstances change. Hospitalization should be enough!!

CHRONOLOGICAL ORDER BY SERVICE REQUEST DATE This category includes applicants who do not meet any of the above priority categories or for whom prioritizing information is not known. As stated, applicants will be placed on the waiting list in the chronological order that they requested services as documented by the date of Telephone intake Guidelines completion or initial nursing facility interview.

Referral Process Contact the Preferred Waiver Agency*** Ask for an Assessment for eligibility for MI Choice Waiver services An intake specialist will conduct a pre-screen over the phone *** If the person passes the pre-screen his or her name will be put on the waiting list*** Once they get to the top of the priority list, the specialist will schedule an in person assessment At the in-person assessment, the Level of Care Determination is made. *** Apply for Medicaid*** *** Opportunities for Advocacy

Level of Care Determination Must meet nursing facility level of care to demonstrate medical/functional eligibility Currently, Waiver Agents must apply the Michigan Medicaid Nursing Facility Level of Care Determination tool to applicants Applicants must pass through one of seven “doors” Review the Doors

Seven Doors Activities of Daily Living (Bed Mobility, Transfers, Toilet Use, Eating) Cognitive Performance Physician Involvement Treatments and Conditions Skilled Rehabilitation Therapies Behavior Service Dependency

Advocacy Tips Make sure your client understands the purpose of this assessment is to determine his or her level of need. If possible, review the Level of Care determination with your client before the assessment. Client should be open and honest about the extent of his or her needs. Intake workers will be inclined to take clients at face value—ie if difficulties are minimized, the applicants needs may not be properly addressed and level of care may be under assessed.

Referral Process Contact the Preferred Waiver Agency*** Ask for an Assessment for eligibility for MI Choice Waiver services An intake specialist will conduct a pre-screen over the phone *** If the person passes the pre-screen his or her name will be put on the waiting list*** Once they get to the top of the priority list, the specialist will schedule an in person assessment At the in-person assessment, the Level of Care Determination is made. *** Apply for Medicaid*** *** Opportunities for Advocacy

Advocacy Tips If the applicant is found to pass through one of the doors, the date of the Assessment is to be considered the Initial Asset Assessment Date (IAA) date for Medicaid purposes The Waiver Agency needs to input that date as the date that the individual meets the Level of Care and is expected to receive care for 30+ days. The attorney should be in contact with the Waiver Agency to coordinate the completion of the application.

Advocacy Tips If the Waiver Agency is not informed of the involvement of the attorney, the Agency may move forward with the application- which may not be to the benefit of the applicant. Communication is key. The application needs to be submitted ASAP. Services will begin after Medicaid has been approved (not always). During the period between Assessment and approval, the Waiver Agency will provide care management services– which is basic oversight of the applicant- not full blown Waiver Services.

Basics of Eligibility: Assets For Married Individuals, need to complete an Assets Declaration (IAA date is Assessment date)*** Common Excluded/Exempt/Not countable Assets: Home (single person equity limit of $552,000), vehicle, personal property, burial space items, funeral expenses. Common Countable Assets: Bank, Credit Union accounts, Stocks, Bonds, Cds, Real Estate (besides homestead), investment accounts, IRAs, Other Retirement Accounts, Savings Bonds, Multiple vehicles

Asset Eligibility Most Eligibility methods that work for Nursing Home Medicaid still work for MI Choice Waiver eligibility, except for methods that increase the income of the applicant. For a single person often looking at spenddown Remember that increase of income for Community Spouse have no affect on MI Choice Waiver eligibility. Most options are still available for Married Couples.

Income For MI Choice Waiver Eligibility, only the income of the applicant is considered Must be below 300% of the SSI amount ($2199 in 2015) Gross income is considered No deductions, or deductibles If approved for the Waiver No “Patient Pay Amount”

After Approval Advocacy for request additional services if necessary Can appeal a number of issues: Amount, duration and scope of services Improper placement in wrong priority category

Resources Michigan Department of Health and Human Services has a lot of information on their website regarding MI Choice Waiver. www.michigan.gov/mdch Medicaid Providers Manual –Insightful for not only MI Choice Waiver but also for other Medicaid issues. Very large document. Bridges Eligibility Manual, Bridges Administrative Manual Minimum Operating Standards for MI Choice Waiver Program Services (Link will presumably be updated eventually with consolidation of agencies)

Resources (continued) NAELA and MiNaela both provide additional training opportunities (conferences, Naela News, etc) Elder Law and Disability Rights Section of the State Bar of Michigan (Fall and Spring Annual conferences, quarterly newsletters, etc) ICLE has a number of publications and Seminar Topics that are helpful (Publications, Seminars, etc)