1. Home and Community Based Medicaid Waivers and Our Pooled Trust Achieve with Us

2. Today’s Presentation An Overview of:  Virginia Medicaid Waivers  The Arc of Northern Virginia Pooled Trust  Planning for the Future of a Child with Disabilities

3. What is a Medicaid Waiver? Medicaid: Medicaid is what pays for the services you can receive from a Medicaid Waiver. Waiver: Waiving the choice of institutional placement and choosing to accept services in the community.

4. Seven Medicaid Waivers in Virginia Elderly or Disabled with Consumer Direction Waiver (EDCD) Technology Waiver (Tech) Individual and Families with Developmental Disabilities Waiver (DD Waiver) Intellectual Disability (Mental Retardation) Waiver (ID/MR Waiver) Day Support Waiver Alzheimer’s Assisted Living Waiver (AAL Waiver) HIV/AIDS Waiver

5. Three Criteria to Determine Eligibility 1) Financial Eligibility Criteria 2) Diagnostic Criteria 3) Functional Criteria

6. Diagnostic Eligibility and Services Each Waiver has its own:  Eligibility criteria  Screening process  List of services

7. Categorical Criteria Categorical Criteria Disabled or age 65 or older Disabled or age 65 or older Families with children Families with children Pregnant women Pregnant women Recipients of cash assistance Recipients of cash assistance Low income Medicare beneficiaries Low income Medicare beneficiaries Financial Thresholds Financial Thresholds Low income and asset guidelines Low income and asset guidelines Thresholds vary by category group Thresholds vary by category group Consideration of exceptionally high medical bills (spend-down) Consideration of exceptionally high medical bills (spend-down) Parental income/resources DO count for minor children Parental income/resources DO count for minor children Eligibility for Regular, State Medicaid

8. Financial Eligibility for Medicaid Long Term Care (Waivers and Institutions) Categorical Criteria Financial Thresholds Categorical Criteria Must meet Long-term Care criteria defined for Waiver Assessment of need required Financial Thresholds $2022 per month (gross income) $2000 resource limit Parent income/resources do NOT count

9. Common Questions and Concerns If I have applied for the Waiver, have I applied for Medicaid? No! If I applied for Medicaid, did I apply for a waiver, too? No! If our household income is too high, does that mean my child cannot have a waiver? No!

10. Diagnostic Eligibility EDCD- Waiver Individuals who have significant medical needs. The criteria used to determine eligibility is the nursing home criteria. Individuals who have significant medical needs. The criteria used to determine eligibility is the nursing home criteria. Day Support Waiver Individuals diagnosed with ID who have been determined to meet two of the Level of Functioning Criteria. Individuals diagnosed with ID who have been determined to meet two of the Level of Functioning Criteria. Technology Waiver Individuals who require ongoing skilled nursing care. Individuals who require ongoing skilled nursing care. Individuals 21 and older who are dependent at least part of each day on a mechanical ventilator or meet complex tracheotomy criteria. Individuals 21 and older who are dependent at least part of each day on a mechanical ventilator or meet complex tracheotomy criteria. Individuals under the age of 21 who meet certain criteria based on various methods of respiratory or nutritional support Individuals under the age of 21 who meet certain criteria based on various methods of respiratory or nutritional support

11. Diagnostic Eligibility ID/MR Waiver Diagnosis of ID or under age of 6 and at developmental risk Diagnosis of ID or under age of 6 and at developmental risk Children on the ID Waiver who do not have a diagnosis of ID at the age of 6, possible transfer to DD Waiver Children on the ID Waiver who do not have a diagnosis of ID at the age of 6, possible transfer to DD Waiver IQ Score & psychological testing is required IQ Score & psychological testing is required a DD Waiver 5 years and 9 months of age and have a developmental disability or “related condition” to apply 5 years and 9 months of age and have a developmental disability or “related condition” to apply Cannot have a diagnosis of ID Cannot have a diagnosis of ID IQ Score & psychological testing is required IQ Score & psychological testing is required

12. Functional Criteria ID, DD and Day Support Waivers: Individuals must meet Intermediate Care Facility (ICF-MR) level of care Individuals must meet Intermediate Care Facility (ICF-MR) level of care Established by meeting dependency level in two or more categories on Level of Functioning Survey Established by meeting dependency level in two or more categories on Level of Functioning Survey Categories: Health Status, Communication, Task Learning Skills, Personal/Self Care, Mobility, Behavior, and Community Living Skills Categories: Health Status, Communication, Task Learning Skills, Personal/Self Care, Mobility, Behavior, and Community Living Skills EDCD, AIDS, Alzheimer’s, and Technology Waivers: Individuals must meet nursing facility eligibility criteria determined by Universal Assessment Instrument (UAI) Individuals must meet nursing facility eligibility criteria determined by Universal Assessment Instrument (UAI) Assesses social, physical health and functional abilities Assesses social, physical health and functional abilities

13. Waiver Services Vary by Waiver Personal / Attendant Care Personal / Attendant Care Respite Care Respite Care Companion Care Companion Care Day Support Day Support In Home Residential Supports In Home Residential Supports Assistive Technology Assistive Technology Environmental Modifications Environmental Modifications Personal Emergency Response System/Medication Monitoring Personal Emergency Response System/Medication Monitoring Money Follows the Person Money Follows the Person Employment (enclave/individual) Employment (enclave/individual) Prevocational services Prevocational services Therapeutic Consultations Therapeutic Consultations

14. WAITING LISTS ID Waiver: Based on need & region population Approximately 8,427 people receiving services 5,762 on ID Waiver waitlist Of those: 3163 are on urgent waiting list 2599 are on non-urgent care waiting list Numbers as of 8/08/10

15. Waiting List DD Waiver: First come, first served 1045 people have DD Waivers App. 1000 people on the waiting list Numbers as of August 2011

16. While on the waiting list, what else can someone do? Depending on level of need & eligibility criteria you can apply for other waivers:  You CANNOT be on both the ID Waiver List and the DD Waiver List.  You CAN be on either the ID Waiver list or the DD Waiver list AND receive EDCD or Technology Waiver services.  You CAN be on the ID Waiver list AND receive the Day Support Waiver. Call your local county for case management and other locally funded services or resources that may be available to you.

17. How Families can ensure that their Child’s Needs are Met and Covered Medicaid Waivers and government benefits are not sufficient to provide for an accustomed level of care and quality of life. Families must plan for the future of their child with disabilities:  Financial, housing, recreational, employment, spiritual plans should be made & documented  How will a family provide for their child’s future when the parents are no longer here? By establishing a (Pooled) Special Needs Trust.

18. Special Needs Trusts Concept simple and based on well thought out public policy The general rule is that trusts are available and income is counted BUT Special Needs Trusts are an exception to the general rule.

19. What Is A Special Needs Trust (SNT)? An SNT is a legal document designed to: An 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.

20. What’s the Purpose of a Special Needs Trust? Provides a manager to meet the needs of the Beneficiary which may arise and cannot otherwise be met by the Beneficiary's personal resources or benefits. Provides a manager to meet the needs of the Beneficiary which may arise and cannot otherwise be met by the Beneficiary's personal resources or benefits. Promotes the dignity, comfort and happiness by providing supplemental care, treatment not otherwise covered. Promotes the dignity, comfort and happiness by providing supplemental care, treatment not otherwise covered.

21. Types of Special Needs Trusts  First Party or Self-Funded Trusts  Funded with disabled individual’s own assets  Third Party or Family-Funded Trusts  Funded with assets that do not belong to individual with disabilities  May be inter vivos or testamentary  Not subject to payback requirement

22. Self-Funded Trusts – d 4 (a) Private 1. Established by the parent, guardian 2. Funded by the individual 3. For the sole benefit of the individual 4. Created by a private attorney or institution

23. Self-Funded Trusts – d 4 (c) Pooled Established by the parent, guardian, court or the individual Established by the parent, guardian, court or the individual Funded by the individual Funded by the individual For the sole benefit of the individual For the sole benefit of the individual Established with a Pooled Trust Program by using a Master Trust Document and Joinder Agreement Established with a Pooled Trust Program by using a Master Trust Document and Joinder Agreement

24. Self-Funded Trusts Most Self-funded accounts established due to: Most Self-funded accounts established due to:  A personal injury settlement  An inheritance  Any other money that threatens benefits  Upon the beneficiary’s death remaining funds in a Self-Funded account AND ONLY A SF ACCT are subject to a Medicaid Payback Provision unless the Trust was established with an authorized non-profit.  In this case, the nonprofit may receive the remainder.

25. Family Funded Trusts – Unfunded or Funded May be setup by parents, grandparents, siblings, aunts and uncles or friends (not the individual). May be setup by parents, grandparents, siblings, aunts and uncles or friends (not the individual). Used frequently by parents to plan for the Future: Used frequently by parents to plan for the Future:  Set up as part of estate planning process with an attorney or an authorized non-profit to protect assets and services that your loved one is receiving  Avoid probate to have funds available immediately  Ensure your loved one has a way to obtain the items, services or the extra’s you want to make sure they have (supplemental needs)  These can be funded during your lifetime or left unfunded until your passing

26. Pooled Trusts  Pooled Trusts  Established by authorized non-profit  Maintain separate accounts for each beneficiary  Established for benefit of individual with disabilities  May be created by individual, parent, grandparent, guardian, or the Court  Third party funds used to create account or  Individual’s funds used to create account

27. An Example of a Pooled Trust The Arc of Northern Virginia manages the Trust providing a professional staff, greater sensitivity and individualized services. The Arc of Northern Virginia manages the Trust providing a professional staff, greater sensitivity and individualized services. SunTrust, the Trustee, offers professional investment management and has developed six investment options from which to choose. SunTrust, the Trustee, offers professional investment management and has developed six investment options from which to choose. There are no minimum or maximum funding requirements. There are no minimum or maximum funding requirements. They are more affordable for families or individuals. They are more affordable for families or individuals.

28. What Are The Trustee’s Roles? Asset Management Asset Management Account Administration Account Administration Account Reporting Account Reporting Tax Reporting Tax Reporting Check Disbursements Check Disbursements

29. The Arc of Northern Virginia & SunTrust Partnership Program Design Two levels of management Two levels of management Funded through living wills, life insurance policies to the trust, gifts, the sale of stocks, property, etc Funded through living wills, life insurance policies to the trust, gifts, the sale of stocks, property, etc Ability to work directly with SunTrust Private Wealth Management Team Ability to work directly with SunTrust Private Wealth Management Team Efficiency in transactions Efficiency in transactions Reduced fees Reduced fees You don’t have to be rich to fund one You don’t have to be rich to fund one

30. Accessing the Funds in the Trust Complete a simple disbursement request form stating the purpose of the request, amount of the request and to whom to send the check. Complete a simple disbursement request form stating the purpose of the request, amount of the request and to whom to send the check. Supporting documentation is needed, such as a receipt or bill. Supporting documentation is needed, such as a receipt or bill. The request form is sent to The Arc of Northern Virginia. We review it and forward it to SunTrust. The request form is sent to The Arc of Northern Virginia. We review it and forward it to SunTrust.

31. An Example of Fees: One-time enrollment fee: $1050.00 One-time enrollment fee: $1050.00 Annual fee for unfunded account: $65.00 Annual fee for unfunded account: $65.00 For funded accounts: For funded accounts:  The Foundation of The Arc of Northern Virginia bills 75 basis points annually of the individuals account. (. 75%) (subject to change)  SunTrust Bank bills 90 basis points annually. (. 90%) (subject to change) Low, competitive fees due to the overall pooled investment. Low, competitive fees due to the overall pooled investment.

32. Where to Go for More Information on Waivers? All Waivers: Virginia Medicaid Waiver Technical Assistance Center 866-323-1088 (toll free) 1-804-786-1465 www.dmas.virginia.gov ID Waiver: http://www.dbhds.virginia.gov/ods-mrwaiver.htm Helpful Tool to better understand the questions asked for the EDCD Waiver: UAI Manual (Universal Assessment Inventory): http://www.dmas.virginia.gov/downloads/pdfs/ltc-UAI_User_Manual.pdf Local Community Services Board Arlington: ages 0-2703-228-1640 ages 3-22703-228-1543 ages over 22703-228-1781 Alexandria: 703-519-5932 Fairfax: 703-383-8500 The Arc of Northern Virginia 703-532-3214 or www.thearcofnova.orgwww.thearcofnova.org

33. For more Information on Medicaid Waivers: Lucy Beadnell: LBeadnell@TheArcofNoVa.org 703-532-3214 Ext 116 The Arc of Northern Virginia 98 N Washington St Falls Church, VA 22046 www.thearcofnova.org Thank you!

34. For more Information on the Pooled Trust: Tia Marsili: tmarsili@thearcofnova.org 703-532-3214 Ext 115 The Arc of Northern Virginia 98 N Washington St Falls Church, VA 22046 www.thearcofnovatrust.org www.thearcofnovatrust.org Thank you!