Working to Create “A Life Like Yours” (ALLY)

Working to Create “A Life Like Yours” (ALLY)
Home and Community Based Medicaid Waivers and Managed Care

The Arc of Northern Virginia’s Work
History Advocacy Education Information and Referral Case Management for the DD Waivers Public Guardianship of Last Resort Special Needs Trusts Beneficiary Advocate

Outline Purpose and Description of Medicaid Waivers Managed Care
Redesign from 2016 and CCC Plus Waiver Eligibility Criteria for all Waivers Waiver Services Application Process Waiting List Navigation SIS, Support Tiers, and Budgets EPSDT

Purpose and Description of the Waivers

Purpose of the Waivers Waivers give States the flexibility to offer services to an individual in the community rather than living and receiving services in an institution.

Origins of the Term “Medicaid Waiver”
Medicaid: Medicaid is the insurance that pays for Waiver services Waiver: Waiving the requirement that all Medicaid services be offered to everyone in the state, and allowing a special group to get extra long term care supports

Current Waiver Cost Sharing
*Proposals to change the Affordable Care Act included cuts and caps to Medicaid. If they are re-introduced and succeed, this will be fundamentally altered. Visit to learn more and get involved.

Managed Care- Commonwealth Coordinated Care (CCC) Plus

What is Managed Care/CCC Plus?
Old System New System Medicaid enrolls providers Providers bill for each unit of service Medicaid reimburses providers for each service DMAS Medicaid (DMAS) contracts with managed care orgs. DMAS pays certain rate per enrollee per month MCO Individuals enroll with managed care organizations (MCOs) MCOs process monthly claims for providers Provider Providers enroll with individual MCOs Providers bill MCOs monthly for services provided

Enrollment in CCC Plus Medicaid enrollees in Northern Virginia were notified in Oct about enrollment beginning on December 1, 2017 One of the six providers will be randomly assigned unless you are currently affiliated with a plan/provider Not all hospitals are covered under each plan Non-Waiver transportation will have various vendors Managed care provider will work with your Waiver team and is paid by DMAS Care coordinator will serve as “medical case manager” and look at medical needs as well as whole life quality, like food and housing

Who Will be Enrolled in CCC Plus?
Most Medicaid users, including DD Waiver users People 65 years and older People using the CCC Plus (formerly EDCD) Waiver Most people in nursing homes

Who Will NOT be Enrolled in CCC Plus?
Some Medicare users FAMIS/Medicaid Medallion users People using Money Follow the Person People enrolled in HIPP for more info Individuals living in ICF/IIDs People receiving hospice care

What is Included in CCC Plus?
Managed Care Not Managed Care CCC Plus (formerly EDCD and Tech) Waiver All Medicaid medical AND Waiver services starting 12/1/2017 Ineligible populations Developmental Disability Waivers All Medicaid medical services starting 12/1/2017 All Waiver services until further notice

Protections Available Under CCC Plus
90 days to continue care with all current Medicaid providers (starting 12/1/17) MCO must pay for out of network options if their existing network cannot offer needed services May change plans each year during open enrollment (Oct-Dec) May change plans anytime for “good cause” reasons (e.g., poor care, no continuity of care) Appeals

Available CCC Plus MCOs
Aetna Better Health Anthem HealthKeepers Plus Magellan Complete Care of VA Optima Health Community Care United Healthcare Community Plan Virginia Premier Health Plan

Visit https://cccplusva.com/choose for more information

Waivers: 2016 Redesign of Developmental Disability Waivers and 2017 CCC Plus Waiver

Why Look at Waivers? Offer a menu of services and designed to be a “one stop shop” for most people, even with a wide range of needs Lifelong supports Only public funding stream for ongoing support services Free or very low cost for the individual with a disability

Five Waivers in Virginia
Community Living Waiver Family and Individual Supports Waiver Building Independence Waiver Commonwealth Coordinated Care (CCC) Plus Waiver Formerly EDCD and Tech Waivers, but combined on July 1, 2017 Alzheimer’s Assisted Living Waiver (AAL Waiver) Developmental Disability Waivers HIV/AIDS Waiver Overview of HIV/AIDS Waiver The HIV/AIDS Waiver was developed in This waiver provides services to individuals who are diagnosed with the human immunodeficiency virus (HIV), who are experiencing the symptoms associated with acquired immune deficiency syndrome (AIDS), and who would otherwise require care provided in a nursing facility or a hospital. Available services include: Case management Nutritional supplements Private duty nursing Personal care (agency or consumer-directed options) Respite care (agency or consumer-directed options) Who qualifies for services? Individuals must have a diagnosis of HIV or AIDS and be experiencing medical and functional symptoms associated with the disease that require hospital or nursing facility care to receive services under the waiver. Individuals must meet Medicaid eligibility criteria as determined by the local department of social services. Individuals who are found to be eligible for the HIV/AIDS Waiver and choose to receive services may apply for Medicaid using special rules which allow the individual to receive a higher income and still qualify for Medicaid. Who can help initiate services? Call the local department of social services in your area to schedule an appointment to be screened for long-term care services or if hospitalized, request a screening from the hospital social worker or discharge planner. There is no cost to be screened to determine the eligibility for the waiver. Individuals found eligible for waiver services must apply and be found eligible for Medicaid. The DSS worker who processes the Medicaid application will use special rules that apply to individuals found eligible for the HIV/AIDS waiver. Alzheimer's Assisted Living (AAL) Waiver Overview of AAL Waiver Waiver The 2004 General Assembly mandated that DMAS develop a home- and community-based care waiver for individuals with Alzheimer’s disease or a related dementia. This waiver became a reality in 2005 and will initially serve 200 individuals. Participants must reside in an assisted living facility (ALF) licensed by the Virginia Department of Social Services, be in a safe and secure environment, meet Virginia’s criteria for nursing facility placement and be receiving an Auxiliary Grant (AG). In order to participate in the program, the ALF must meet certain criteria. The individual must not have a diagnosis of mental retardation or serious mental illness. It is estimated that the waiver would be approximately $50 a day per participant. Individuals eligible to be placed on this waiver are currently either 1) remaining at home where an adult child is typically serving as primary caregiver; 2) residing in an ALF without the benefit of specialized services, which are not provided in the base $50 per day rate; or c) residing in a more expensive institutionalized nursing facility setting. Through the Alzheimer’s Assisted Living Waiver, recipients would be able to receive an appropriate level of care within special care units of ALFs. To initiate services, call the local department of social services to schedule an appointment to be screened for long-term care services. If hospitalized, request a screening from the hospital social worker or discharge planner. There is no cost to be screened to determine eligibility for the waiver. Individuals receiving AAL Wavier services must also be receiving an Auxiliary Grant (AG) and have no patient pay for waiver services. DSS determines eligibility for the AG program. Enrollment is limited to 200 individuals and once 200 individuals have enrolled, DMAS will begin a waiting list. Services available in the AAL waiver are: Assisted Living: Assistance with activities of daily living, housekeeping, and supervision. Medication Administration: Medication administered by a licensed professional. Nursing evaluations: Evaluation by a registered nurse. Therapeutic and Recreational Programming: Weekly activity program based on needs and interests. Individuals receiving AAL Waiver services also receive services through the Medicaid program. Examples include medications (for those individuals not covered under Medicare), physician visits, acute care hospitalizations, and certain therapies.

Comparing Waivers DD Waivers CCC Plus Waiver
Need developmental disability diagnosis Robust menu of services for home, nursing, work, and community Up to 24/7 support based on need Case management Long waiting list Need disability diagnosis & medical need Shorter menu of services aimed at home care and some nursing, but no employment/residential 56 hour weekly cap on personal care No case management No waiting list

DD Waiver Redesign Concept
Day Support Waiver DD Waiver ID Waiver Building Independence Waiver For adults (18+) able to live independently in the community. Individuals own, lease, or control their own living arrangements; and supports are complemented by non-waiver-funded rent subsidies. Supports are episodic/periodic in nature. Family & Individual Supports Waiver For individuals living with their families, friends, or in their own homes, including supports for those with some medical or behavioral needs. Available to both children and adults. Community Living Waiver 24/7 services and supports for individuals with complex medical and/or behavioral support needs through licensed services. Includes residential supports and a full array of medical, behavioral, and non-medical supports. Available to adults and some children. *Slide content from DBHDS

Waiver Program vs. Waiting List
63% of ID waiver dollars were spent on Congregate Residential Services in FY 2015 The majority of people on the waiting list are children and transition-age youth. I/DD Waiver (11,724) I/DD Waiver Waiting List (10,288) Source: The Department of Behavioral Health and Developmental Services, January 2016, SLIDE FROM DBHDS

CCC Plus Waiver Creation
EDCD Waiver Tech. Assisted Waiver CCC Plus Waiver* The CCC Plus Waiver offers all services available under the EDCD and Tech Waivers to all CCC Plus users, based on need

Eligibility for Waivers

Eligibility: Three Criteria
1. Diagnostic Criteria 2. Functional Criteria 3. Financial Criteria

Diagnostic Eligibility for Disability Waivers: DD Diagnosis and IQ
“Developmental disability" means a severe, chronic disability of an individual that: is attributable to a mental or physical impairment, or a combination of mental and physical impairments, other than a sole diagnosis of mental illness; is manifested before the individual reaches 22 years of age; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self-sufficiency; and reflects the individual's need for a combination and sequence of special interdisciplinary or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and 2 of 3 are individually planned and coordinated. An individual from birth through age nine who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described in clauses (i) through (v) if the individual, without services and supports, has a high probability of meeting those criteria later in life.”

Diagnostic Eligibility for CCC Plus Waiver
Individuals who have significant medical needs. The criteria used to determine eligibility is the nursing home criteria. Self assessment to determine possible eligibility can be found here Enrollment process unchanged from former EDCD process New manual under development .

Functional Eligibility
Disability Waivers: All individuals must meet/show functional need in three out of eight categories on the Virginia Intellectual and Developmental Disabilities Eligibility Survey (VIDES) Different versions for ages 0-3, 3-18, and 18+ Categories include: Health Status, Communication, Task Learning Skills, Personal/Self Care, Mobility, Behavior, Community Living Skills, and Financial Self-Sufficiency CCC Plus Waiver: Individuals must meet the nursing facility eligibility criteria determined by using the Uniform Assessment Instrument (UAI) Focus on personal care and medical care needs

Financial Eligibility Thresholds for Medicaid Long Term Care, like Waivers
• $2,250 per month income cap (300% of 2018 SSI amount) • Patient pay begins once someone is earning $1212/month • $2000 resource limit for adults • No resource limit for children • Parent income/resources do NOT EVER count* *2017 Session Update: DMAS to develop a proposal for cost sharing requirements based on family income and submit to CMS to determine if such a proposal is feasible.

Applying for Medicaid Q: If someone has applied for the Waiver, does this mean they have applied for Medicaid? A: No! These are two separate process! To apply for Medicaid, visit

Financial Eligibility Q: The household income is too high to qualify for Medicaid, should the individual still apply for a waiver? A: Yes! You CAN be on the waiting lists without receiving Medicaid benefits. Once a slot becomes available, you can apply for Medicaid under the “Long Term Care/Institutional Rules”. And remember, different rules apply when it is State Plan Medicaid versus “long term care” Medicaid! Differences in adult….and children…

Explore a Special Needs Trust Like The Arc of Northern VA’s Trust
A SNT is a legal document designed to: Provide benefit to & protect the assets of a person with a disability while allowing the individual to be qualified for and receive government benefits, such as Medicaid, Medicaid Waivers and Supplemental Security Income. For more information, contact: Tia Marsili, Director of Trusts (703) x115

Let’s Talk About Services
Bear in mind, services will vary by person based upon need. Most people use multiple services and have changes in their support plans over time.

Service Category and Description
Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs CCC Plus Waiver- For people with medical and disability needs Residential Group Homes- 24/7 staffed home where 3+ people with disabilities live. Homes usually have 4-7 residents and staff that rotate around the clock on shifts. X Shared Living- Individual lives with someone without a disability who is reimbursed for room and board in exchange for companionship Independent Living- Supports brought into the home focused on skill building and preparing for greater independence Sponsored Residential- Option where person with disability lives with a paid caregiver in the home of the caregiver. Supported Living- Residence owned by a support provider that offers up to 24/7 help with support needs

Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs CCC Plus Waiver- For people with medical and disability needs Day & Employment Community Engagement- Service focused on ability to improve skills for employability and independence using the community as the environment X Supported Employment (Group and Individual)- Supports on the job to allow people to work in competitive employment Day Support- Either center or community based supports that are typically unpaid and involve skill development Workplace Assistance Services- Services for someone who needs to fill the gap between initial job training and following along services Community Coaching*- 1:1 support to build a specific skill or break a barrier to employment and community engagement Benefits Planning*- Services to help individuals receiving social security benefits understand the impact of work on those benefits

Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs CCC Plus Waiver- For people with medical and disability needs In Home In-home Support Services (up to 24/7)- 1:1 services in the home focused on life skills X Companion Services- 1:1 service in the home focused to monitor for safety Respite- Supplemental annual hours of personal care to provide relief to the unpaid caregiver Environmental Modifications- Up to $5000 per year to modify a primary home or vehicle to better adapt it to the needs of the individual X Personal Emergency Response System- Electronic safety monitoring system to link to emergency services

Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs CCC Plus Waiver- For people with medical and disability needs Community Supports Electronic Home-Based Supports- Good and services to be used in the home for greater independence in lieu of paid staff X Assistive Technology- Up to $5000 per year on portable items to assist the individual with safety, communication, and independence. Must work with Medicaid approved provider on eval. X Crisis Supports (center and community based)- crisis prevention and stabilization Community Guide*- Direct assistance in promoting and developing community relationships that promote integration and self-determination Non-medical transportation*- Reimbursement for transport to locations associated with an individual’s support plan and goals

X X Service Category and Description
Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs CCC Plus Waiver- For people with medical and disability needs Medical Private Duty Nursing- 1:1 continuous care nursing for people with complex medical needs X X Skilled Nursing- Intermittent nursing related to a specific medical care need Other Therapeutic Consultations- Limited consultations with therapists in qualifying areas Transition Services- Funding and supports to assist people with leaving institutional settings Individual and Family/Caregiver Training- Education and training on disability related issues for the primary caregiver or family of the individual

Agency and Consumer Directed Staffing Options
Agency Directed Care that is rendered by a Medicaid approved agency The agency hires, manages, and pays the workers The agency submits the paperwork necessary for payment to MCO Available with all Waivers Consumer Directed Workers are directly hired and managed by the individual receiving the Waiver support services Responsibility for managing all aspects of the employment relationship, including recruiting, hiring, training, supervising, ensuring payment, and firing if needed There is a service facilitator to assist you with this process

Application Process

Applying for all Developmental Disability Waivers
Screenings are conducted by the local CSBs Arlington: Alexandria: Fairfax: Loudoun: Steps: 1) Call your local CSB to complete a screening process 2) Complete application they send to you 3) Complete the process with the VIDES assessment, in person planning meeting, and get a letter confirming you’re on the waiting list

Screening and Application Process: CCC Plus Waiver
Call your local Department of Social Services for intake Alexandria ( ), Arlington: Birth to 3 (703) yrs to 21yrs (703) , 21yrs and older (703) ; Fairfax ( ); Loudoun (703) Set up Screening and intake appointment with Social Worker Schedule visit with the nurse Meet with local County case worker Meet with Home Health Care Agency or Service Facilitator NO WAITING LIST

Waiting List Navigation

Disability Waiver Waiting Lists
All of the DD Waivers have a shared waiting list Wait time is unpredictable since it is based upon urgency of need People’s urgency is constantly in flux The waiting list is managed by Community Services Boards A Regional Waiver Slot Assignment Committee reviews applications when slots are available There should be emergency/reserve Waivers that are accessed when APS/CPS involvement is present, and/or when primary caregiver(s) have passed away and the person needs help to care for themselves

Will need waiver services within one year and meets specific criteria
Waiting List Tiers Priority One Status Priority Two Status Priority Three Status Will need waiver services within one year and meets specific criteria (Supplemental Critical Needs Summary Questions will be asked) May require waiver services in one to five years and meets specific criteria May not present for waiver services in over five years as long as the current supports and services remain *DBHDS Slide. NOTE- You can appeal your tier if it doesn’t reflect your need

Waivers Added in the 2017 Session
Type of Waiver Slots Added Community Living Waiver 90 Family and Individual Supports Waiver 344 Building Independence Waiver 60 TOTAL 494

While on the waiting list what else can you do?
Depending on level of need and eligibility criteria, you can apply for other waivers: You CAN be the DD Waiver list AND receive services through the CCC Plus Waiver Call your county for case management and other locally funded services or resources that may be available to you. Utilize the Individuals and Families Support Program Funding Up to $1,000 per year for supports to serve you in the community Read more at Open though November 23, 2017 Access REACH Crisis Services- 24 hour crisis response and respite for people with ID/DD and behavioral or mental health needs who are over 18 years old For children under 18 years old, CR2 is available 844-N-CRISIS Crisis Assistance Grant Supports Other Waivers

SIS, Support Tiers, and Budgets

Once You Receive a DD Waiver
You will be contacted by the Community Services Board and should be offered a choice of Case Manager You will take the Supports Intensity Scale (SIS) assessment then and every three years thereafter You will develop a plan for the services you need with the Case Manager

Your SIS Score Gives a Support Level 1-7
Level 1 = Tier 1 Level 2 = Tier 2 Level 3 and 4 = Tier 3 Levels 5, 6 and 7 = Tier 4

Most People will be in Middle Tiers
*Individually negotiated rates are possible for people with truly exceptional needs

For some services, SIS affects reimbursement rates

Reimbursement Decreases with More People in a Housing or Employment Situation
*This graphic and the previous graphic were created by The Arc of Virginia

EPSDT and Waivers

Early Periodic Screening Diagnosis and Treatment
Available to all children under 21 with Medicaid EPSDT provides any treatment or procedure that fits within any of the categories of Medicaid-covered services if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.

EPSDT Service Examples
Physician, nurse practitioner and hospital services Physical, speech/language, and occupational therapies Home health services, including medical equipment, supplies, and appliances Treatment for vision, hearing and dental diseases and disorders

Mandate to Use EPSDT First for some DD Waiver Services*
Personal Care/Personal Assistance Dependent in three or more ADLs - Bathing, dressing, transferring, ambulation, eating, toileting and continence. Doctor must fill out one form and service facilitator or RN fill out two Private Duty Nursing Doctor must fill out two forms Assistive Technology Doctor or relevant therapist must write evaluation Doctor must write letter of medical necessity Quote from a vendor needed *Change began November 1, 2017 for DD Waiver users, coming soon for CCC+ Waiver. FORMS MUST BE FILLED OUT BY MEDICAID PHYSICIAN!

EPSDT Changes If someone does not meet EPSDT criteria for the requested service, DD Waivers will not fund it either You must use another stand alone Waiver service every 90 days to keep your Waiver active (e.g., Respite)* DMAS starting process of “Individual Consideration” before denials or reductions You can appeal decisions *New list of stand alone services coming soon from DMAS

Where Do I Go For More Information?
All Waivers: Waiver Hotline Developmental Disability Waivers Websites The Arc of NOVA’s webpage- Local Community Services Boards Arlington: Alexandria: Fairfax: Loudoun: Where Do I Go For More Information?

Please Become a Member of The Arc of Northern Virginia!
Follow our lead in advocating for the needs of your loved one. Sign up for our newsletter!

Thank you! The Arc of Northern Virginia 2755 Hartland Road
Falls Church, VA Ext 116

Working to Create “A Life Like Yours” (ALLY)

Similar presentations

Presentation on theme: "Working to Create “A Life Like Yours” (ALLY)"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Working to Create “A Life Like Yours” (ALLY)

Similar presentations

Presentation on theme: "Working to Create “A Life Like Yours” (ALLY)"— Presentation transcript:

Similar presentations

About project

Feedback