Exploring Medicaid Waivers

Debra HollowayThe 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 Virginia’s waiver programs for the elderly and disabled are elderly and disabled are expensive but still less costly than expensive but still less costly than compatible institution care.compatible institution care.

The elderly and disabled The elderly and disabled representrepresent

30% of Medicaid program 30% of Medicaid program recipients.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 Elderly or Disabled with Consumer Direction Waiver (EDCD)Direction Waiver (EDCD)

Technology Waiver (tech)Technology Waiver (tech) Individual and families with Individual and families with

Developmental Disabilities Waiver Developmental Disabilities Waiver (DD) (DD)

Mental Retardation WaiverMental Retardation Waiver (MR Waiver) (MR Waiver)

Elderly or Disabled with Consumer Direction Waiver This waiver is constructed to This waiver is constructed to

allow persons to remain in the allow persons to remain in the community that meet nursing community that meet nursing facility level of care.facility level of care.

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

Eligibility

This waiver serves the elderly and This waiver serves the elderly and persons of all ages with disabilities. persons of all ages with disabilities. The individual may receive this The individual may receive this service through a service provider service through a service provider or though consumer direction.or though consumer direction.

An individual can remain on the An individual can remain on the waiting list for another waiver while waiting list for another waiver while being served by the EDCD Waiver.being served by the EDCD Waiver.

Services

Adult Day Health CareAdult Day Health Care Personal Care (agency or Personal Care (agency or

consumer directed)consumer directed) Respite 720 hrs. (agency or Respite 720 hrs. (agency or

consumer directed)consumer directed) Personal Emergency Response Personal Emergency Response

System (PERS)System (PERS) Medication MonitoringMedication Monitoring

Criteria

Qualify for Medicaid (individual)Qualify for Medicaid (individual) Meet long term care criteria according Meet long term care criteria according

to Uniform Assessment Instrument to Uniform Assessment Instrument (UAI)(UAI)

Pre-Admission Screening Criteria:Pre-Admission Screening Criteria:– Functional capacity (the degree of assistance an Functional capacity (the degree of assistance an

individual requires to complete activities of daily individual requires to complete activities of daily living); and living); and

– Medical or nursing needsMedical or nursing needs– Risk of nursing facility placementRisk of nursing facility placement

Pre-admission Screening A recipient may qualify for nursing facility level of care A recipient may qualify for nursing facility level of care

or placement in a waiver by meeting one of the or placement in a waiver by meeting one of the following criteria:following criteria:

-Dependent in 2 to 4 ADL’s, plus semi-dependent or -Dependent in 2 to 4 ADL’s, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in dependent in joint motion or semi-dependent in medication administration; ormedication administration; or

-Dependent in 5 to 7 ADL’s and dependent in mobility; -Dependent in 5 to 7 ADL’s and dependent in mobility; oror

-Dependent in 2 to 7 ADL’s plus dependent in behavior -Dependent in 2 to 7 ADL’s plus dependent in behavior and orientation; ANDand orientation; AND

-Have medical nursing needs-Have medical nursing needs

Examples

Functional Dependencies:Functional Dependencies:bathing, dressing, toileting, bathing, dressing, toileting, transferring, eating/feedingtransferring, eating/feeding

Medical and nursing needs:Medical and nursing needs: catheter care, supervision for catheter care, supervision for

adequate nutrition and hydration, adequate nutrition and hydration, therapeutic exercise and positioning, therapeutic exercise and positioning, management of those with sensory, management of those with sensory, metabolic, or circulatory impairment. metabolic, or circulatory impairment.

Getting Started

Request for screening, contact either Request for screening, contact either the local Department of Social the local Department of Social Services or the local Health Services or the local Health DepartmentDepartment

Schedule visit with nurseSchedule visit with nurse Completed Medicaid application Completed Medicaid application

(child’s information only!)(child’s information only!) Meet with Home Health Care AgencyMeet with Home Health Care Agency

Technology Assisted Waiver (Tech) No age limit to eligibilityNo age limit to eligibility No waiting list No waiting list Currently serving (2007) 295 Currently serving (2007) 295

individuals.individuals.

Eligibility

Serves individuals who need a medical Serves individuals who need a medical devise to compensate for the loss of a devise to compensate for the loss of a vital body function and requires vital body function and requires substantial and ongoing skilled nursing substantial and ongoing skilled nursing care to remain safely in their homes.care to remain safely in their homes.

Recipients with private insurance Recipients with private insurance which provides PDN as a benefit must which provides PDN as a benefit must exhaust this service prior to waiver exhaust this service prior to waiver service initiationservice initiation

Services

Private Duty Nursing (16 hours Private Duty Nursing (16 hours maximum a day, except children may maximum a day, except children may have 24 hours a day for the first 30 have 24 hours a day for the first 30 days after hospital discharge)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 EquipmentDurable Medical Equipment

Criteria

Doctor must certify need for care; Doctor must certify need for care; and need substantial and ongoing and need substantial and ongoing skilled nursing care; andskilled nursing care; and

Care must be cost effective; and Care must be cost effective; and Primary caregiver must be trained Primary caregiver must be trained

and accept responsibility for 8 and accept responsibility for 8 hours or more per dayhours or more per day

Criteria (younger than 21)

Children must depend part of the day on a Children must depend part of the day on a vent; or require prolonged intravenous vent; or require prolonged intravenous nutrition, drugs or peritoneal dialysis; or have nutrition, drugs or peritoneal dialysis; or have a daily dependency on other devise-based a daily dependency on other devise-based respiratory or nutritional support including respiratory or nutritional support including tracheotomy tube care, oxygen support, or tracheotomy tube care, oxygen support, or tube feeding; andtube feeding; and

Individuals who have been determined to Individuals who have been determined to need substantial and ongoing nursing care as need substantial and ongoing nursing care as indicated by a score of a minimum of 50 indicated by a score of a minimum of 50 points on the objective scoring criteria points on the objective scoring criteria

Screening Process

DMAS receives a referral from community DMAS receives a referral from community resources, family, other partiesresources, family, other parties

DMAS completes a Scoring Tool to determine DMAS completes a Scoring Tool to determine if the individual meets the specialized care if the individual meets the specialized care criteria for the waivercriteria for the waiver

If the criteria is met DMAS conducts a home If the criteria is met DMAS conducts a home assessment.assessment.

DMAS works with the primary caregiver, DMAS works with the primary caregiver, referral source to secure appropriate nursing referral source to secure appropriate nursing care for the individual in the homecare for the individual in the home

DMAS authorizes needed services for the DMAS authorizes needed services for the provider agency upon the start of careprovider agency upon the start of care

Individual and Family Developmental Disabilities Support Waiver (DD) DMAS is the administrator of the DMAS is the administrator of the

waiverwaiver Recipients served FY07 594, and Recipients served FY07 594, and

591 are waiting.591 are waiting. Can be placed on the waiting list Can be placed on the waiting list

at age 5 years 8 monthsat 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 Must be 6 years of age and over and meet the related conditions and meet the related conditions criteria, including autism; andcriteria, including autism; and

Individual must not have a Individual must not have a diagnosis of Mental Retardation.diagnosis of Mental Retardation.

Meet the level of care for Meet the level of care for admission to an ICF/MR. The admission to an ICF/MR. The individual must meet 2 out of 7 individual must meet 2 out of 7 levels of functioning.levels of functioning.

Screening

The Virginia Department of Health Child The Virginia Department of Health Child Development Clinics will screen individuals Development Clinics will screen individuals with the Level of Functioning (LOF) Survey with the Level of Functioning (LOF) Survey which is the assessment instrument used to which is the assessment instrument used to determine eligibility to for an ICF/MRdetermine eligibility to for an ICF/MR

You can download a copy of the “Request for You can download a copy of the “Request for Screening” from Screening” from www.dmas.virginia.govwww.dmas.virginia.gov. . Compete the form and fax or mail it to the Compete the form and fax or mail it to the CDC. The psychological assessment is a CDC. The psychological assessment is a requirement of the screening determination.requirement of the screening determination.

Transitioning from MR to DD Waiver Annually each child receiving MR Annually each child receiving MR

Waiver services who will be 6 Waiver services who will be 6 years of age the following year years of age the following year can be up for consideration for can be up for consideration for transfer to the DD Waiver. transfer to the DD Waiver.

If the child meets DD Waiver If the child meets DD Waiver eligibility the child can transition eligibility the child can transition to the DD Waiver.to the DD Waiver.

Mental Retardation Waiver (MR) Day-to-day MR waiver operations are Day-to-day MR waiver operations are

managed by the Department of Mental managed by the Department of Mental Health, Mental Retardation and Health, Mental Retardation and Substance Abuse Services (DMHMRSAS)Substance Abuse Services (DMHMRSAS)

Locally, MR Waiver services for Locally, MR Waiver services for individuals are coordinated by case individuals are coordinated by case managers employed by Community managers employed by Community Services BoardsServices Boards

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

Eligibility

Individuals must have an evaluation that Individuals must have an evaluation that reflects their current level of intellectual reflects their current level of intellectual and adaptive functioning.and adaptive functioning.

Six and over – a psychological evaluation Six and over – a psychological evaluation with a diagnosis of mental retardation.with a diagnosis of mental retardation.

Six and under – either a psychological or Six and under – either a psychological or standardized developmental evaluation standardized developmental evaluation that states the child has a diagnosis of that states the child has a diagnosis of mental retardation or is at developmental mental retardation or is at developmental risk. risk.

Services Adult Companion CareAdult Companion Care Assistive Technology ($5000)Assistive Technology ($5000) Congregate ResidentialCongregate Residential Crisis Stabilization/SupervisionCrisis Stabilization/Supervision Day SupportDay Support Environmental Modifications ($5000)Environmental Modifications ($5000) Family/caregiver TrainingFamily/caregiver Training In-home ResidentialIn-home Residential Medication MonitoringMedication Monitoring PERSPERS Personal Care (Agency or consumer Directed)Personal Care (Agency or consumer Directed) Prevocational ServicesPrevocational 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 ConsultationTherapeutic Consultation Supported EmploymentSupported Employment

Criteria

All individuals receiving MR All individuals receiving MR Waiver services must meet the Waiver services must meet the ICF-MR level of care.ICF-MR level of care.

Case Manager completes a “Level Case Manager completes a “Level of Functioning Survey.” The of Functioning Survey.” The individual needs to have individual needs to have significant needs in two or more significant needs in two or more of the survey’s seven categories.of the survey’s seven categories.

Waiting List

Urgent Urgent Non-UrgentNon-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 The individual consumer or their representative employs and representative employs and monitors staff providing services monitors staff providing services exclusive to them.exclusive to them.

Public Partnerships, LLC (fiscal Public Partnerships, LLC (fiscal agent)agent)

Early Periodic Screening, Diagnosis, and Treatment (EPSDT)

Medicaid’s program for children Medicaid’s program for children up to age 21 with a preventative up to age 21 with a preventative treatment approachtreatment approach

Services

Screening/Well Child check-ups, Screening/Well Child check-ups, lead testing and immunizationslead testing and immunizations

Treatment services to correct a Treatment services to correct a medical condition, make it better, medical condition, make it better, or prevent the child’s health or prevent the child’s health status from worseningstatus from worsening

Specialized Services:

The following services are covered only The following services are covered only under EPSDTunder EPSDT

All require pre authorization at DMASAll require pre authorization at DMAS-Specialized Medical Treatment-Specialized Medical Treatment-Hearing Aids-Hearing Aids-Specialized and Substance Abuse -Specialized and Substance Abuse

Residential TreatmentResidential Treatment-Personal Care (ADL dependency in 3 -Personal Care (ADL dependency in 3

areas)areas)-Private Duty Nursing-Private Duty Nursing

Medical Necessity

The medical justification for a The medical justification for a service must accompany the service must accompany the request for EPSDT treatment request for EPSDT treatment servicesservices

-Services not covered-Services not coveredRespiteRespiteEnvironmental ModificationsEnvironmental ModificationsVocationalVocationalEducationalEducational

Health Insurance Premium Payment Program If an individual receiving waiver If an individual receiving waiver

services has private health services has private health insurance, Medicaid will be the insurance, Medicaid will be the individuals secondary insuranceindividuals secondary insurance

DMAS may reimburse the DMAS may reimburse the individual for all or a portion of individual for all or a portion of their monthly private health their monthly private health insurance premiuminsurance premium

HIPP

1-800-432-59241-800-432-5924 Visit Visit www.dmas.virginia.govwww.dmas.virginia.gov scroll scroll

to “Client Services” click on “More to “Client Services” click on “More Services” then click on “HIPP Services” then click on “HIPP Information”Information”

Recipient Appeal

A person may appeal if their benefits are:

-Terminated-Denied-Suspended-Reduced

Examples

Fails to take application for Fails to take application for medical assistancemedical assistance

Personal Care hours are reducedPersonal Care hours are reduced EDCD Waiver is terminated for EDCD Waiver is terminated for

LOCLOC

Steps

Request an appeal or review Request an appeal or review

(804)-371-8488(804)-371-8488 Notify appeals division in writingNotify appeals division in writing Be specific about what you wantBe specific about what you want

-Results in a hearing-Results in a hearing

-Decision made-Decision made