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

Medicaid Waivers were developed to encourage people with disabilities and the elderly to access services in their homes and communities.

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.

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) (MR Waiver)

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 12,187 Current enrollment 12,187 No waiting list No waiting list

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.

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) Medication Monitoring Medication Monitoring

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

Pre-admission Screening A recipient may qualify for nursing facility level of care or placement in a waiver by meeting one of the following criteria: A recipient may qualify for nursing facility level of care or placement in a waiver by meeting one of the following criteria: -Dependent in 2 to 4 ADL’s, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration; or -Dependent in 2 to 4 ADL’s, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration; or -Dependent in 5 to 7 ADL’s and dependent in mobility; or -Dependent in 5 to 7 ADL’s and dependent in mobility; or -Dependent in 2 to 7 ADL’s plus dependent in behavior and orientation; AND -Dependent in 2 to 7 ADL’s plus dependent in behavior and orientation; AND -Have medical nursing needs -Have medical nursing needs

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 either the local Department of Social Services or the local Health Department Request for screening, contact either the local Department of Social Services or the local Health Department Schedule visit with nurse Schedule visit with nurse Completed Medicaid application (child’s information only!) Completed Medicaid application (child’s information only!) Meet with Home Health Care Agency Meet with Home Health Care Agency

Technology Assisted Waiver (Tech) No age limit to eligibility No age limit to eligibility No waiting list No waiting list Currently serving (2007) 295 individuals. Currently serving (2007) 295 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. Recipients with private insurance which provides PDN as a benefit must exhaust this service prior to waiver service initiation Recipients with private insurance which provides PDN as a benefit must exhaust this service prior to waiver service initiation

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

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

Criteria (younger than 21) Children must depend part of the day on a vent; or require prolonged intravenous nutrition, drugs or peritoneal dialysis; or have a daily dependency on other devise-based respiratory or nutritional support including tracheotomy tube care, oxygen support, or tube feeding; and Children must depend part of the day on a vent; or require prolonged intravenous nutrition, drugs or peritoneal dialysis; or have a daily dependency on other devise-based respiratory or nutritional support including tracheotomy tube care, oxygen support, or tube feeding; and Individuals who have been determined to need substantial and ongoing nursing care as indicated by a score of a minimum of 50 points on the objective scoring criteria Individuals who have been determined to need substantial and ongoing nursing care as indicated by a score of a minimum of 50 points on the objective scoring criteria

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

Individual and Family Developmental Disabilities Support Waiver (DD) DMAS is the administrator of the waiver DMAS is the administrator of the waiver Recipients served FY07 594, and 591 are waiting. Recipients served FY07 594, and 591 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 Home and community-based care services that enables the individual six years of age or over to remain at home rather than being placed in an Intermediate Care Facility (ICF/MR)

Services Adult Companion 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 Respite care (720) Personal attendant services

Criteria 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.

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.

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 12/07 3,893 Wait list - Waiting list as of 12/07 3,893

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.

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

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/Non-Urgent Waiting List Urgent - Needing waiver services immediately Non-urgent – needing waiver services within 30 days

Consumer-Directed The individual consumer or their representative employs and monitors staff providing services exclusive to them. The individual consumer or their representative employs and monitors staff providing services exclusive to them. Public Partnerships, LLC (fiscal agent) Public Partnerships, LLC (fiscal agent)

Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Medicaid’s program for children up to age 21 with a preventative treatment approach Medicaid’s program for children up to age 21 with a preventative treatment approach

Services Screening/Well Child check-ups, lead testing and immunizations Screening/Well Child check-ups, lead testing and immunizations Treatment services to correct a medical condition, make it better, or prevent the child’s health status from worsening Treatment services to correct a medical condition, make it better, or prevent the child’s health status from worsening

Specialized Services: The following services are covered only under EPSDT The following services are covered only under EPSDT All require pre authorization at DMAS All require pre authorization at DMAS -Specialized Medical Treatment -Hearing Aids -Specialized and Substance Abuse Residential Treatment -Personal Care (ADL dependency in 3 areas) -Private Duty Nursing

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 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 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

Examples Fails to take application for medical assistance Fails to take application for medical assistance Personal Care hours are reduced Personal Care hours are reduced EDCD Waiver is terminated for LOC EDCD Waiver is terminated for LOC

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