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MEDICAID WAIVER PROGRAMS: Leaving Institutions Behind
November 2010
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What Are They? Medicaid Home and
Community Based Services Waivers are programs that enable certain groups of people with disabilities to live in the community instead of in institutions
Each program “waives” certain Medicaid rules. They let targeted groups receive extra services not available to others on Medicaid, to limit the number of people who can receive such services, and provide higher income limits than for most other Medicaid coverage groups.
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What Do They Have In Common?
Each Waiver was designed to enable eligible people to either leave institutions, or to avoid entering them.
Each has a limited number of service “slots”.
Currently, each Waiver is “closed” – all slots are filled, and not open to people already in the community.
Through Money Follows the Person, each Waiver is still open to people currently receiving institutional services that Medicaid is funding.
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What Do They Have In Common?
Eligibility A person must choose
community services instead of institutional ones
Must not simultaneously be enrolled in another Medicaid Waiver
Must qualify for Medicaid through:
SSI, or TCA, or By having countable income
below 300% of SSI federal benefit rate ($2,022/month) and countable resources under $2,000
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What Do They Have In Common?
Eligibility
Individual considered a household of one
Each Waiver applies these income exclusions for income eligibility:
1. $20 general income exclusion2. $65 earned income exclusion3. ½ of remainder of earned
income after $65 exclusion4. ½ of gross self-employment
earnings (unless business expenses are greater than ½ of earnings)
5. ½ of rental income
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What Do They Have In Common?
Eligibility
Each Waiver applies these income exclusions for income eligibility (Continued):
6. BWE’s7. Any wages, allowances, or
reimbursement for transportation and attendant care costs, unless excepted on a case-by-case basis, when received by a blind or disabled person employed in a project under Title VI of the Rehabilitation Act of 1973
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What Do They Have In Common?
Eligibility
A home is excluded if it’s occupied by the participant, his/her spouse, or his/her parent, sibling or child who is financially or medically dependent on the participant
Resources that are sold or given away in order to qualify for Waiver services are counted for five years after disposal
Annual financial redetermination required
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1. Living at Home WaiverAlternative to nursing homesRegulations: COMAR
10.09.55
Who is Eligible?
Must be 18 - 64 years old (or 65 or older if enrolled before age 65)
Must have nursing facility level of care, redetermined annually
Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care)
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1. Living at Home Waiver
Covered Services Attendant care Environmental assessments Environmental modifications Assistive technology Personal emergency
response systems Consumer training (how to
recruit, select, train, direct, supervise, and fire consumer-employed attendants, as well as money management, budgeting, independent living, meal planning, etc.)
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1. Living at Home Waiver
Covered Services Family training (instruction
about treatment regimens and the use of equipment specified in the plan of service)
Transition services (security deposits, furniture, moving expenses, utility set-up fees and deposits, pest eradication and other health/safety costs)
Medical day services Nursing supervision of
attendants Home-delivered meals Dietician and nutritionist
services Case management
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1. Living at Home Waiver
How to Apply
Contact Area Agency on Aging (AAA) http://www.mdoa.state.md.us/aaa.html or the Living at Home Waiver office (410-767-7479) to apply.
AAA visits consumer, family and nursing facility staff to educate them about Waiver, complete Medicaid application (CARES 9709), gather financial documents and send to the Division of Eligibility and Waiver Services (DEWS)
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1. Living at Home Waiver
How to Apply
DEWS determines financial eligibility
Adult Evaluation and Review System (AERS) does assessment for nursing facility level of care and physician completes Medical Eligibility Review Form (3871). Forms sent to Key Pro for review.
The Coordinating Center develops Plan of Care
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2. Older Adults WaiverAlternative to nursing homesRegulations: COMAR
10.09.54
Who is Eligible?
Must be at least age 50Must have nursing facility level of
care, redetermined annuallyMust meet cost neutrality
requirements (i.e., needed community services must cost less than nursing home care)
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2. Older Adults Waiver
Participant FeesPaid only by participants in assisted
living facilitiesParticipant pays countable income to
assisted living providerTo determine countable income for
fees, apply usual exclusions (see slides 5 & 6) plus the following: Personal needs allowance
($72/mo.) Room and board paid (not to
exceed $420/mo.) Incurred and unpaid medical
expenses Spousal and/or family
maintenance allowance if applicable (for community spouse and dependent children under age 21)
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2. Older Adults Waiver
Covered Services Assisted living Personal care aide Senior center plus Environmental assessments Environmental modifications Assistive technology Personal emergency
response systems Respite care Behavior consultation Family or consumer training Transition services
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2. Older Adults Waiver
Covered Services
Medical day services Nursing supervision of
attendants Home-delivered meals Dietician and nutritionist
services
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2. Older Adults Waiver
How to Apply
Contact Area Agency on Aging (AAA) to apply - http://www.mdoa.state.md.us/aaa.html
AAA visits consumer, family and nursing facility staff to educate them about Waiver, complete Medicaid application (CARES 9709), gather financial documents and send to the Division of Eligibility and Waiver Services (DEWS)
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2. Older Adults Waiver
How to Apply
DEWS determines financial eligibility
Adult Evaluation and Review System (AERS) does assessment for nursing facility level of care and physician completes Medical Eligibility Review Form (3871). Forms sent to Key Pro for review.
AAA develops Plan of Care
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3. & 4. Community Pathways and New Directions WaiversAlternative to intermediate
care facilities for people with mental retardation (ICF/MR) or nursing facilities
Regulations: COMAR 10.09.26
Community Pathways Waiver provides traditional services
New Directions Waiver provides consumer-controlled services. Consumer hires/fires staff, manages service budget (usually with help of a financial intermediary called a support broker).
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3. & 4. Community Pathways and New Directions Waivers
Who is Eligible?Must be certified for an ICF-MR
level of careMust be in a:
State Residential Center, orNursing facility, but determined
to have a developmental disability and to need specialized services
Chronic care facilityCommunity setting, but at
imminent risk of institutionalization (Note: New Waiver eligibility now limited to people in institutions)
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3. & 4. Community Pathways and New Directions Waivers
Participant FeesPaid only to participants who
receive residential habilitation services
Participant pays countable income to residential provider
To determine countable income for fees, apply usual exclusions (see slides 5 & 6) plus the following: Personal needs allowance
($170/mo.) Room and board paid
($375/mo.) Incurred and unpaid medical
expenses Spousal maintenance allowance
if applicable
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3. & 4. Community Pathways and New Directions Waivers
Covered Services – Community Pathways
Residential habilitationCommunity supported living
arrangementsLive-in caregiversDay habilitationCommunity learning servicesMedical day servicesEmployment discovery and
customizationSupported employmentResource coordination
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3. & 4. Community Pathways and New Directions Waivers
Covered Services – Community Pathways
Environmental modificationsAssistive technologyRespite careBehavioral support servicesFamily and individual support
servicesTransition servicesTransportation
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3. & 4. Community Pathways and New Directions Waivers
Covered Services – New Directions
Support brokerageCommunity supported living
arrangementsLive-in caregiversDay habilitationCommunity learning servicesMedical day servicesEmployment discovery and
customizationSupported employmentResource coordination
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3. & 4. Community Pathways and New Directions Waivers
Covered Services – New Directions
Environmental modificationsAssistive technologyRespite careBehavioral support servicesFamily and individual support
servicesTransition servicesTransportation
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3. & 4. Community Pathways and New Directions Waivers
How to Apply
Service Coordinator/Resource Coordinator completes Waiver information (including Medicaid application (CARES 9709), financial documentation, and level of care form) and submits to DDA regional office (http://dhmh.maryland.gov/dda_md/)
Regional office sends CARES 9709, financial documentation to DEWS, and level of care form to DDA Central Office (Terri Hartman 410-767-5421) for eligibility determinations
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3. & 4. Community Pathways and New Directions Waivers
How to Apply
If applicant does not have a current disability determination from SSA (i.e., for SSI or Title II), DEWS sends forms for physician to complete and return. State Review Team does disability determination.
Service Coordinator/Resource Coordinator develops Individual Plan
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5. Waiver for People with Traumatic Brain Injury (TBI)Alternative to intermediate
care facilities for people with mental retardation (ICF/MR) or nursing facilities
Regulations: COMAR 10.09.46
Fact sheet: http://dhmh.maryland.gov/mha/Miscellaneous/TBI/TBI%20Waiver%20fact%20sheet_09.pdf
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5. Waiver for People with Traumatic Brain Injury (TBI)Who is Eligible?
Must have a traumatic brain injury sustained at age 22 or later
Must have enrolled in Waiver at age 22 - 64
Must have nursing facility or special hospital level of care, redetermined annually
Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care)
Must be able to be served safely and appropriately in the community
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5. Waiver for People with Traumatic Brain Injury (TBI)Who is Eligible?
Ordinarily, must be in:A state psychiatric hospital deemed
inappropriate because the person doesn’t need that level of care, or
A TBI community placement funded by the Mental Hygiene Administration (MHA) with state-only funds, or
A nursing facility owned and operated by the State or an out-of-state rehabilitation facility funded by Medicaid, or
A Maryland licensed special hospital for chronic disease licensed by CARF for inpatient TBI care
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5. Waiver for People with Traumatic Brain Injury (TBI)Who is Eligible?
Currently, while Waiver is closed, must be in:University Specialty Hospital,
orKernan Hospital, orWestern Maryland Hospital
Center, orDeers Head Hospital
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5. Waiver for People with Traumatic Brain Injury (TBI)Covered Services
Residential habilitationDay habilitationSupported employmentIndividual support servicesMedical day services
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5. Waiver for People with Traumatic Brain Injury (TBI)How to Apply
Hospital case manager or social worker makes referral to MHA (410-402-8476)
Completes Medicaid application (CARES form 9709) and submits to DEWS
Physician completes Medical Eligibility Review Form (3871) and sends to Key Pro to review and approve level of care
After eligibility approved, plan of care developed
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Medicaid Waivers and EIDThe preceding 5 Waivers are
compatible with EIDA person enrolled in one of these
Waivers whose income or resources exceed the usual Waiver limits can enroll in EID to keep Waiver services
Countable income limit for an unmarried individual in EID = $2,707/month (usual Waiver limit is $2,022/month)
Countable resource limit for EID = $10,000 (usual Waiver limit is $2,000), plus EID excludes some retirement accounts (Waivers usually count these accounts)
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Other Medicaid WaiversWaiver for Children with Autism
Spectrum Disorder – provides services (residential habilitation, intensive individual supports, therapeutic integration, respite care, family training, environmental modifications and adult life planning) to people with autism aged 1 – 21
Model Waiver – provides services (nursing, certified nursing aides, home health aides, case management and medical day services) for medically fragile children under age 22
These Waivers are NOT COMPATIBLE WITH EID
