Long Term Care Division

Long Term Care Division

Alabama Medicaid AgencyLong Term Care Division

Outreach and Education UnitFebruary 2004

P R E S E N T SP R E S E N T S

An Overview OfAn Overview Of

Home and Community Home and Community Based Waiver ServicesBased Waiver Services

What Is A Waiver?What Is A Waiver?

• Under 1915(c) Waiver Under 1915(c) Waiver authority, states can authority, states can provide services not provide services not usually covered by the usually covered by the Medicaid program, as Medicaid program, as long as these services long as these services are required to keep a are required to keep a person from being person from being institutionalized. institutionalized.

Home and Community Based Home and Community Based Service (HCBS) WaiversService (HCBS) Waivers

• In 1981, Congress In 1981, Congress authorized the waiver of authorized the waiver of certain federal certain federal requirements to enable a requirements to enable a state to provide home and state to provide home and community based services community based services (other than room and (other than room and board) to individuals who board) to individuals who would otherwise require would otherwise require SNF, ICF, or ICF/MR services SNF, ICF, or ICF/MR services reimbursable by Medicaid.reimbursable by Medicaid.

HCBS WaiversHCBS Waivers

• The waiver programs are called 1915(c) The waiver programs are called 1915(c) waivers, named after the section of the waivers, named after the section of the Social Security Act that authorized them.Social Security Act that authorized them.

• Under 1915(c) waiver authority, states can Under 1915(c) waiver authority, states can provide services not usually covered by the provide services not usually covered by the Medicaid program, as long as these services Medicaid program, as long as these services are required to keep a person from being are required to keep a person from being institutionalized. institutionalized.

HCBS WaiversHCBS Waivers

• Under HCBS Waiver programs, both the Under HCBS Waiver programs, both the comparability and state wideness comparability and state wideness requirements may be waived to enable states requirements may be waived to enable states to target distinct groups of recipients.to target distinct groups of recipients.

• HCBS Waiver Services can be provided only as HCBS Waiver Services can be provided only as a vehicle to provide an alternative to a vehicle to provide an alternative to institutional care.institutional care.

HCBS WaiversHCBS Waivers

• Initial waivers are approved for three (3) Initial waivers are approved for three (3) years and renewed every five (5) years years and renewed every five (5) years thereafter.thereafter.

What are waiver “slots”?What are waiver “slots”?

• Each waiver program is Each waiver program is allotted a certain allotted a certain number of “slots” to number of “slots” to be filled by clients be filled by clients approved to receive approved to receive waiver services within waiver services within a waiver year.a waiver year.

Distribution of SlotsDistribution of Slots

• Waiver slot distribution will be determined Waiver slot distribution will be determined by the Alabama Medicaid Agency.by the Alabama Medicaid Agency.

Types of waiver slotsTypes of waiver slots

• An An activeactive waiver slot is one in which a waiver slot is one in which a person is actively receiving waiver services person is actively receiving waiver services and is not in a nursing facility.and is not in a nursing facility.

• A A pendingpending waiver slot is one that is pending waiver slot is one that is pending approval for a person to receive waiver approval for a person to receive waiver

servicesservices..

Types of waiver slotsTypes of waiver slots

• A A filledfilled waiver slot is one which has a waiver slot is one which has a person currently receiving waiver services person currently receiving waiver services or who has been receiving waiver services, or who has been receiving waiver services, but had subsequent placement in a nursing but had subsequent placement in a nursing facility has moved or has requested facility has moved or has requested termination from the waiver during the termination from the waiver during the waiver year.waiver year.

More about waiver slotsMore about waiver slots

• A A filledfilled slot cannot be refilled by another slot cannot be refilled by another individual within the same waiver year that individual within the same waiver year that the vacancy occurred, however, the same the vacancy occurred, however, the same individual who previously left the slot may individual who previously left the slot may fill the slot.fill the slot.

When can a When can a waiver slot be refilled?waiver slot be refilled?

• Although a waiver slot cannot be refilled Although a waiver slot cannot be refilled within the same waiver year, available slots within the same waiver year, available slots may be refilled in subsequent waiver years.may be refilled in subsequent waiver years.

Transfer of Waiver SlotsTransfer of Waiver Slots

• If a client transfers from one waiver to If a client transfers from one waiver to another within the same waiver year, the another within the same waiver year, the slot is considered filled and therefore may slot is considered filled and therefore may not be refilled by a different individual.not be refilled by a different individual.

Medicaid Approved Home and Medicaid Approved Home and Community Based WaiversCommunity Based Waivers

• Elderly and Disabled (E&D) Elderly and Disabled (E&D) WaiverWaiver

• Mental Retardation/ Mental Retardation/ Developmentally Disability Developmentally Disability (MRDD) Waiver(MRDD) Waiver

• Living at Home WaiverLiving at Home Waiver

• State of Alabama State of Alabama Independent Living (SAIL) Independent Living (SAIL) WaiverWaiver

• Specialty Care Specialty Care Assisted Living Assisted Living Facility (SCALF) Facility (SCALF) WaiverWaiver

• Technology Technology Assisted (TA) Assisted (TA) Waiver for AdultsWaiver for Adults

• HIV/AIDS WaiverHIV/AIDS Waiver

Administering State AgencyAdministering State Agency

• The Alabama Medicaid The Alabama Medicaid Agency has Agency has administrative administrative authority over the authority over the Home and Community Home and Community Based Waivers.Based Waivers.

Responsibilities of the Responsibilities of the

Alabama Medicaid AgencyAlabama Medicaid Agency

• The Operating Agency adheres to all federal The Operating Agency adheres to all federal guidelines described in the approved waiver guidelines described in the approved waiver document;document;

• The health and welfare of the client is protected;The health and welfare of the client is protected;

• The client has free choice of providers and waiver The client has free choice of providers and waiver service workers;service workers;

• All direct service providers meet the All direct service providers meet the qualifications as outlined in the approved waiver qualifications as outlined in the approved waiver document; and document; and

• The client is aware of their right to express The client is aware of their right to express concerns regarding service provision and/or concerns regarding service provision and/or direct service provider.direct service provider.

Operating State AgenciesOperating State Agencies

• State agencies are charged with the State agencies are charged with the responsibility of operating the home and responsibility of operating the home and community based waiver programs and vary community based waiver programs and vary by each particular waiver.by each particular waiver.

Responsibilities of the Responsibilities of the Operating AgenciesOperating Agencies

• Manage the program by focusing on Manage the program by focusing on improving care for the client;improving care for the client;

• Protect the health and welfare of the Protect the health and welfare of the client;client;

• Give the client free choice of providers Give the client free choice of providers and waiver service workers;and waiver service workers;

• Make sure all direct service providers Make sure all direct service providers meet the qualifications as outlined in meet the qualifications as outlined in the approved waiver document.the approved waiver document.

Elderly and DisabledElderly and Disabled

(E&D) Waiver(E&D) Waiver

E & D WaiverE & D Waiver

• Assists elderly and/or disabled individuals Assists elderly and/or disabled individuals to live in the community who would to live in the community who would otherwise require nursing facility careotherwise require nursing facility care

E & D WaiverE & D Waiver

• Operating Agencies:Operating Agencies:

▪ ▪ Alabama Department of Public HealthAlabama Department of Public Health

▪ ▪ Alabama Department of Senior ServicesAlabama Department of Senior Services

• No age requirementNo age requirement

• 7500 waiver slots7500 waiver slots

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Individuals receiving SSI and/or State Individuals receiving SSI and/or State Supplementation;Supplementation;

• Widows and Widowers under age 60;Widows and Widowers under age 60;

• Widows and Widowers age 60 – 64;Widows and Widowers age 60 – 64;

Financial Eligibility Criteria…Financial Eligibility Criteria…continuedcontinued

• Adult children who lose supplemental security Adult children who lose supplemental security income benefits upon entitlement to the income benefits upon entitlement to the child’s insurance benefits based on disability;child’s insurance benefits based on disability;

• Individuals who would be eligible for Medicaid Individuals who would be eligible for Medicaid in an institution because income from either in an institution because income from either parents or a spouse is not deemed available to parents or a spouse is not deemed available to them (referred to as institutional deeming).them (referred to as institutional deeming).

Medical CriteriaMedical Criteria

• Must meet current level of care admissions Must meet current level of care admissions criteria for nursing facility carecriteria for nursing facility care

Covered ServicesCovered Services

• Case ManagementCase Management• Homemaker ServicesHomemaker Services• Personal Care ServicesPersonal Care Services

• Adult Day Health ServicesAdult Day Health Services

• Respite Care (Skilled and Unskilled)Respite Care (Skilled and Unskilled)

• Adult Companion ServicesAdult Companion Services

• Home Delivered MealsHome Delivered Meals

Mental RetardationMental RetardationDevelopmentally Disability Developmentally Disability

(MRDD) Waiver(MRDD) Waiver

MRDD WaiverMRDD Waiver

• Provides Home and Community Based Provides Home and Community Based Services to Medicaid eligible individuals Services to Medicaid eligible individuals who would otherwise require the level of who would otherwise require the level of care available in an Intermediate Care care available in an Intermediate Care Facility for the Mentally Retarded (ICF/MR)Facility for the Mentally Retarded (ICF/MR)

MRDD WaiverMRDD Waiver

• Operating AgencyOperating Agency• Alabama Department of Mental Health and Alabama Department of Mental Health and

Mental RetardationMental Retardation

• No age requirementNo age requirement

• 5200 waiver slots5200 waiver slots

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Social Security Income (SSI) – protected Social Security Income (SSI) – protected groups deemed to be recipients of SSIgroups deemed to be recipients of SSI

• TANF - (Temporary Assistance to Needy TANF - (Temporary Assistance to Needy Families) low income families with childrenFamilies) low income families with children

• Special home and community based Special home and community based optional categorically needy groups whose optional categorically needy groups whose income is not greater than 300% of the SSI income is not greater than 300% of the SSI federal benefit ratefederal benefit rate

Medical EligibilityMedical Eligibility

• Must meet current level of care admissions Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded)Facility for the Mentally Retarded)

Characteristics of Persons Characteristics of Persons Requiring ICF/MR CareRequiring ICF/MR Care

• Intermediate care services for the mentally Intermediate care services for the mentally retarded are those services which are retarded are those services which are needed because of the severe, chronic needed because of the severe, chronic nature of the mental impairment that nature of the mental impairment that results in substantial functional limitations results in substantial functional limitations in three or more of the following areas of in three or more of the following areas of life activities:life activities:

Characteristics of Persons Characteristics of Persons Requiring ICF/MR Care…Requiring ICF/MR Care…

continuedcontinued

• Self CareSelf Care • Receptive and expressive language Receptive and expressive language

• Learning Learning

• Mobility Mobility

• Self Direction Self Direction

• Capacity for independent livingCapacity for independent living

Covered ServicesCovered Services

• Residential Habilitation Residential Habilitation

TrainingTraining

• Residential Habilitation – Residential Habilitation –

Other Living ArrangementOther Living Arrangement

• Day HabilitationDay Habilitation

• Prevocational ServicesPrevocational Services

• Supported EmploymentSupported Employment

• Occupational Therapy Occupational Therapy

ServicesServices

• Speech and Language Speech and Language

TherapyTherapy

• Physical TherapyPhysical Therapy

• Behavior ManagementBehavior Management

• Companion ServicesCompanion Services

• Respite CareRespite Care

• Personal CarePersonal Care

• Environmental Environmental

Accessibility AdaptationsAccessibility Adaptations

• Medical SuppliesMedical Supplies

• Skilled NursingSkilled Nursing

• Assistive TechnologyAssistive Technology

Living At Home WaiverLiving At Home Waiver

Living At Home WaiverLiving At Home Waiver

• Provides Home and Community Based Provides Home and Community Based Services to Medicaid eligible individuals Services to Medicaid eligible individuals who would otherwise require the level of who would otherwise require the level of care available in an Intermediate Care care available in an Intermediate Care Facility for the Mentally RetardedFacility for the Mentally Retarded

Living At Home WaiverLiving At Home Waiver • Operating AgencyOperating Agency

▪ ▪ Alabama Department of Mental Health and Alabama Department of Mental Health and

Mental RetardationMental Retardation

• 3 years of age and older3 years of age and older

• Waiver SlotsWaiver Slots Year 1 – 204Year 1 – 204 Year 2 – 326Year 2 – 326 Year 3 - 449Year 3 - 449

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Social Security Income (SSI) - protected Social Security Income (SSI) - protected groups deemed to be recipients of SSIgroups deemed to be recipients of SSI

Medical CriteriaMedical Criteria

• Must meet current level of care admissions Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded)Facility for the Mentally Retarded)

Covered ServicesCovered Services

• Residential Residential Habilitation TrainingHabilitation Training

• Day HabilitationDay Habilitation

• Prevocational ServicesPrevocational Services

• Supported Supported EmploymentEmployment

• Occupational TherapyOccupational Therapy

• Speech and Language Speech and Language TherapyTherapy

• Physical TherapyPhysical Therapy

• Behavior TherapyBehavior Therapy

• Respite CareRespite Care

• Personal Care ServicesPersonal Care Services

• Personal Care Personal Care TransportationTransportation

• Environmental Environmental Accessibility AdaptationsAccessibility Adaptations

• Specialized Medical Specialized Medical Equipment and SuppliesEquipment and Supplies

• Skilled NursingSkilled Nursing

• Community SpecialistCommunity Specialist

• Crisis InterventionCrisis Intervention

State of Alabama State of Alabama Independent Living Independent Living

(SAIL) Waiver(SAIL) Waiver

(formerly Homebound Waiver)(formerly Homebound Waiver)

SAIL WaiverSAIL Waiver

• Serves disabled adults with specific medical Serves disabled adults with specific medical diagnoses who are at risk of being diagnoses who are at risk of being institutionalized in a nursing homeinstitutionalized in a nursing home

SAIL WaiverSAIL Waiver

• Operating AgencyOperating Agency ▪ ▪ Alabama Department of Rehabilitation Alabama Department of Rehabilitation

ServicesServices

• 18 years of age or older18 years of age or older

• 550 waiver slots550 waiver slots

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Social Security Income (SSI) -– protected Social Security Income (SSI) -– protected groups deemed to be recipients of SSIgroups deemed to be recipients of SSI

• TANF-(Temporary Assistance to Needy TANF-(Temporary Assistance to Needy Families) low income families with childrenFamilies) low income families with children

• Special home and community based optional Special home and community based optional categorically needy groups whose income is categorically needy groups whose income is not greater than 300% of the SSI federal not greater than 300% of the SSI federal benefit ratebenefit rate

Medical CriteriaMedical Criteria

• Must meet current level of care Must meet current level of care

admissions criteria for nursing facility admissions criteria for nursing facility

care care

Services are provided to, but Services are provided to, but not limited to, persons with a not limited to, persons with a

diagnosis of:diagnosis of:

• QuadriplegiaQuadriplegia• Traumatic Brain InjuryTraumatic Brain Injury• Amyotrophic Lateral SclerosisAmyotrophic Lateral Sclerosis• Multiple SclerosisMultiple Sclerosis

• Spinal Muscular AtrophySpinal Muscular Atrophy

• Severe Cerebral PalsySevere Cerebral Palsy

• StrokeStroke

• Other substantial neurological impairments, Other substantial neurological impairments, severely debilitating diseases, or rare genetic severely debilitating diseases, or rare genetic diseasesdiseases

Covered ServicesCovered Services

• Case Management ServicesCase Management Services

• Personal Care ServicesPersonal Care Services

• Personal Attendant ServicesPersonal Attendant Services

• Environmental Accessibility AdaptationsEnvironmental Accessibility Adaptations

• Personal Emergency Response System Personal Emergency Response System

• Medical SuppliesMedical Supplies

• Assistive TechnologyAssistive Technology

• Evaluation for Assistive TechnologyEvaluation for Assistive Technology

• Assistive Technology RepairsAssistive Technology Repairs

Specialty Care Assisted Specialty Care Assisted Living Facility (SCALF) Living Facility (SCALF)

WaiverWaiver

SCALF WaiverSCALF Waiver

The SCALF Waiver has been approved,

but not yet implemented

SCALF WaiverSCALF Waiver

• The SCALF Waiver is designed to address The SCALF Waiver is designed to address the needs of individuals with a diagnosis of the needs of individuals with a diagnosis of Alzheimer’s and/or Dementia who meet the Alzheimer’s and/or Dementia who meet the nursing facility level of care criteria. nursing facility level of care criteria.

SCALF WaiverSCALF Waiver

• Operating AgencyOperating Agency ▪▪ Alabama Department of Senior Services Alabama Department of Senior Services

(ADSS)(ADSS)

• No age requirementNo age requirement

• Waiver SlotsWaiver Slots ▪ ▪ Year 1 - 500Year 1 - 500 ▪▪ Year 2 - 650Year 2 - 650 ▪▪ Year 3 - 700Year 3 - 700

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Individuals receiving SSI and/or state Individuals receiving SSI and/or state supplementationsupplementation

• Categorically needy groups whose income is Categorically needy groups whose income is not greater than 300% of the SSI federal not greater than 300% of the SSI federal benefit ratebenefit rate

Medical CriteriaMedical Criteria

• Must meet current level of care admission Must meet current level of care admission criteria for nursing facility carecriteria for nursing facility care

Covered ServicesCovered Services

• Assisted LivingAssisted Living

• Case ManagementCase Management

• Medical SuppliesMedical Supplies

Assisted Living ServicesAssisted Living Services

• Personal CarePersonal Care

• HomemakerHomemaker

• ChoreChore

• Attendant CareAttendant Care

• TransportationTransportation

• Companion ServicesCompanion Services

• Medication Oversight Medication Oversight and Administrationand Administration

• Attendant Call SystemAttendant Call System

• Therapeutic and Therapeutic and Recreational Recreational ProgrammingProgramming

Technology Assisted (TA) Technology Assisted (TA) Waiver For AdultsWaiver For Adults

TA WaiverTA Waiver

• The TA Waiver was designed for individuals The TA Waiver was designed for individuals who received private duty nursing services, who received private duty nursing services, through the EPSDT Program under the through the EPSDT Program under the Alabama Medicaid State Plan who will no Alabama Medicaid State Plan who will no longer be eligible for this service upon longer be eligible for this service upon turning age 21.turning age 21.

TA WaiverTA Waiver

• Operating AgencyOperating Agency

▪ ▪ Alabama Medicaid AgencyAlabama Medicaid Agency

• 21 years of age and older21 years of age and older

• Waiver slotsWaiver slots

▪ ▪ Year 1 - 30Year 1 - 30

▪ ▪ Year 2 - 35Year 2 - 35

▪ ▪ Year 3 - 40Year 3 - 40

Case Management AgencyCase Management Agency

• The Alabama Department of Rehabilitation The Alabama Department of Rehabilitation Services provides targeted case management Services provides targeted case management services to individuals served by the TA services to individuals served by the TA Waiver.Waiver.

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Individuals receiving SSI and/or State Individuals receiving SSI and/or State supplementationsupplementation

• Categorically needy groups whose income is Categorically needy groups whose income is not greater than 300% of the SSI federal not greater than 300% of the SSI federal benefit ratebenefit rate

Covered ServicesCovered Services

• Private Duty NursingPrivate Duty Nursing

• Personal Care/Attendant ServicePersonal Care/Attendant Service

• Medical SuppliesMedical Supplies

• Assistive TechnologyAssistive Technology

• Targeted Case Management (TCM) for the Targeted Case Management (TCM) for the TA Waiver is provided under the Medicaid TA Waiver is provided under the Medicaid State planState plan

HIV/AIDS WaiverHIV/AIDS Waiver

HIV/AIDS WaiverHIV/AIDS Waiver

• The HIV / AIDS Waiver is designed to The HIV / AIDS Waiver is designed to address the needs of individuals with a address the needs of individuals with a diagnosis of HIV, AIDS, and related illness diagnosis of HIV, AIDS, and related illness who meet the nursing facility level of care who meet the nursing facility level of care criteria. criteria.

HIV/AIDS WaiverHIV/AIDS Waiver

• Operating AgencyOperating Agency

▪ ▪ Alabama Department of Public HealthAlabama Department of Public Health

• 21 years of age and older21 years of age and older

• Waiver SlotsWaiver Slots Year 1 – 150Year 1 – 150 Year 2 – 150Year 2 – 150 Year 3 - 150Year 3 - 150

Financial Eligibility CriteriaFinancial Eligibility Criteria

• Individuals receiving SSI and/or State Individuals receiving SSI and/or State supplementationsupplementation

• Categorically needy groups whose income is Categorically needy groups whose income is not greater than 300% of the SSI federal not greater than 300% of the SSI federal benefit ratebenefit rate

Medical CriteriaMedical Criteria

• Must meet current level of care admission Must meet current level of care admission criteria for nursing facility carecriteria for nursing facility care

Covered ServicesCovered Services

• Personal CarePersonal Care

• Respite CareRespite Care

• Skilled NursingSkilled Nursing

• Companion ServicesCompanion Services

Additional InformationAdditional Information

If you have further questions regarding If you have further questions regarding Alabama Medicaid Agency, Long Term Care Alabama Medicaid Agency, Long Term Care Programs, please contact:Programs, please contact:

• Wanda Davis, Assistant Director, Long Term Wanda Davis, Assistant Director, Long Term Care Division, 334-242-5018, Care Division, 334-242-5018, wdavis@medicaid.state.al.uswdavis@medicaid.state.al.us