Medicaid Waiver Overview

Debra Holloway, The Arc of VA Director of Training and Technical Assistance

Lynne Blythe, Infant & Toddler Connection of Rappahannock Rapidan, Local System Manager & Program Manager

Who We Are• The Arc of Virginia is a state chapter of The Arc of the

United States, the nation’s largest and oldest human rights organization for individuals with intellectual and developmental disabilities.

• The Arc’s membership is composed of people with disabilities, family members, community advocates and concerned citizens.

• We are a statewide, non-profit organization composed of 25 local chapters around the Commonwealth. We work to promote and protect the human rights of people with intellectual and developmental disabilities and actively support their full inclusion and participation in the community throughout their lifetime.

Who We Are• Infant & Toddler Connection of Virginia provides Part C

services to children from birth to 36 months. There are 40 Part C programs across Virginia.

• Infant & Toddler Connection of Rappahannock Rapidan provides Part C services in the counties of Culpeper, Fauquier, Madison, Orange, & Rappahannock counties.

• Medicaid Wavier Mentors are a group of approximately 30 people across Virginia that are available to provide information & support to individuals searching for information about Virginia’s Medicaid Waivers.

Today’s Outcomes

The people that work with young children & their families will learn information about how to:

– Direct families to accurate information about Virginia’s Medicaid Waivers.

– Help families learn the steps to apply for the EDCD, ID, or DD Waiver

– Provide families with information about HIPP & EPSDT benefits.

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Different Institution Different Waiver

• Waivers provide funding for a wide variety of services for people of all ages who have disabilities, or are elderly, in order for them to remain in their homes and communities instead of an institutional placement (i.e. hospital, nursing home or ICFs/MR -intermediate care facility).

Waivers Must be Cost Effective

• Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than comparable institutional care.

• Average cost per year – Intellectual Disability Waiver -$74,674 per person/year. Institutional cost is over $150,000 per person/year for the ID Waiver.

• Virginia spends over $262 million/year on state operated institutions for people with intellectual disabilities. Average institutional cost is $250,000 per person, per year.

Department of Justice Settlement

• Individuals with Intellectual and developmental disabilities are unnecessarily institutionalized.

• Total of 4,200 home and community based waivers.• 800 – transition out of institutions• 3,000 on the urgent list• 450 DD• Family supports• Crisis System – START• Case management• Housing• Oversightwww.thearcofva.org http://www.dbhds.virginia.gov/Settlement.htm

• http://www.dbhds.virginia.gov/Settlement.htm

VirginiaHome & Community Based Care

WaiversState Regulations for the Waivers

http://leg1.state.va.us/000/reg/TOC12030.HTM#C0120

12 VAC-30-120-1600 Alzheimer’s and Related Dementias Assisted Living Waiver (Alzheimer’s Waiver)

12 VAC-30-120-1500 Day Support Waiver for Individuals with Intellectual Disabilities (Day Support Waiver)

12 VAC-30-120-900 Elderly or Disabled with Consumer Direction Waiver (EDCD Waiver)

12 VAC-30-120-700 Individual and Family Developmental Disabilities Support Waiver (DD Waiver)

12 VAC-30-120-211 Intellectual Disability Waiver (ID Waiver)

12 VAC-30-120-70 Technology Assisted Waiver (Tech Waiver)

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Reviewing Today:

• Elderly or Disabled with Consumer Direction Waiver (EDCD)

• Individual and Families with Developmental Disabilities Waiver (DD)

• Intellectual Disability Waiver (ID)

Consumer-Directed Services

• Individual or family caregiver directs and controls who, how, and when services are provided.

• Virginia offers consumer-directed services in the following Waivers:

– Elderly or Disabled with Consumer-Direction Waiver - Personal Care, RespitePersonal Care, Respite

– Developmental Disabilities Waiver - Personal Care, Personal Care, Respite, CompanionRespite, Companion

– Intellectual Disability Waiver - Personal Assistance, Personal Assistance, Respite, CompanionRespite, Companion

Consumer-Directed Services

• Individual is the employer of record with the IRS

• Service Facilitator (SF) writes documentation of need based on information from the individual, monitors the service and provides support as needed to the individual so that the individual can be an employer of their staff

• SF provides training on recruiting, interviewing staff, how to handle difficult situations, how to complete employment paperwork, etc.

• SF provides list of people who have said they want to work as consumer-directed staff and shows how to place an advertisement for attendants, companion aides and respite workers (the list and ads do not have to be used)

• DMAS (using a contractor, PPL) pays the attendants, companion aides and respite workers on behalf of the individual

Consumer-Directed Employees

• Consumer-Directed employees may not be -– Parents of minor children or spouses of the

individual receiving consumer-directed services

• If the Consumer-Directed employee lives with the person receiving services -– Service Facilitator must have objective written

documentation as to why there are no other providers available to provide care

Elderly or Disabled with Consumer Direction Waiver

• This waiver is constructed to allow persons to remain in the community that meet nursing facility level of care.

• No waiting list• Screening is conducted by the

Preadmission Screening team made up of a representative from The Department of Health and the Department of Social Services using the Uniform Assessment Instrument (UAI)

Eligibility

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

• An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver. But one person can’t be on waiting lists for ID & DD Waivers.

Criteria• Financial criteria= child’s income is considered,

not the parents’ income. Child’s resources (i.e. savings account) are considered at age 18.

• Meet long term care criteria according to Uniform Assessment Instrument (UAI)

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

individual requires to complete activities of daily living); and

– Medical or nursing needs– Risk of nursing facility placement

Examples

• Functional Capacity:bathing, dressing, toileting, transferring, eating/feeding

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

nutrition and hydration, therapeutic exercise and positioning, management of those with sensory, metabolic, or circulatory impairment. also: speech, occupational, and physical therapy provided through an IFSP or IEP

Getting Started

• Request for screening, contact your local Health Department/Department of Social Services

• Schedule visit with pre-admission screening teams of the Department of Health & Department of Social Services.

• Completed Medicaid application (child’s information only!)

Individual and Family Developmental Disabilities

Support Waiver (IFDDS)• Wait list is maintained by the

Department of Medical Assistance Services (DMAS)

-chronological

• Can be placed on the waiting list at age 5 years 8 months

• 1,000+ individuals on the waiting list

Eligibility Criteria

• “Related Conditions” Waiver• Must be 6 years of age and over and meet the

related conditions criteria, including autism; and

• Individual must not have a diagnosis of having an Intellectual Disability.

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

• Qualify for Medicaid (individual). Child’s income only is considered for financial eligibility.

Screening

• The Virginia Department of Health Child Development Clinics (6 regional clinics) will screen individuals with the Level of Functioning (LOF) Survey which is the assessment instrument used to determine eligibility to for an ICF/MR

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

RELATED CONDITIONSalso referred to as developmental disability

• Severe chronic disability• Attributable to a condition, other than mental

illness• Manifested before the age of 22• Likely to continue indefinitely• Results in substantial limitations in 3 or more

areas of major life activity• Self-care• Understanding and use of language• Learning• Mobility• Self-direction• Capacity for independent living

Transitioning from ID to DD Waiver

• Annually each child receiving ID Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver.

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

Intellectual Disability Waiver (ID)

• Day-to-day ID waiver operations are managed by the Department of Behavioral Health and Developmental Services (DBHDS)

• Locally, ID Waiver services for individuals are coordinated by case managers employed by Community Services Boards

Eligibility

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

• Six and over – a psychological evaluation with a diagnosis as having an intellectual disability.

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

Criteria

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

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

• Financial- only child’s income is considered, not the parents’ income.

ID WAIVER WAITING LISTS

• CSB’s and DBHDS maintain Urgent and Non-Urgent lists

• CSB provides individual with written notice if placed on a waiting list and if there is a change in status to another list

• Only after all Urgent needs are met statewide will Non-urgent needs be served

• Slot moves with you to a different town in VA, not out of the state.

• Non-urgent = meet criteria for the ID Waiver, including needing services within 30 days, but don’t meet Urgent criteria.

Urgent Criteria for the ID Waiver

• Primary caregivers are both 55 yrs or older (or if 1, is 55 or older)

• Living with a primary caregiver who is providing the service voluntarily and without pay and they can’t continue care

• There is a clear risk of abuse, neglect, or exploitation

• Primary caregiver has chronic or long term physical or psychiatric condition significantly limiting ability to provide care

• Individual is aging out of a publicly funded residential placement or otherwise becoming homeless

• Individual lives with the primary caregiver and there is a risk to the health or safety of the individual, primary caregiver, or other individual living in the home because: – Individual’s behavior presents a risk

to himself or others OR physical care or medical needs cannot be managed by the primary caregiver even with generic or specialized support arranged or provided by the CSB

Different Waivers Have Different Services

Adult Day Health Care * Therapeutic ConsultationPersonal Care Services* Family Caregiver Training Personal Emergency Response System Prevocational Services Respite* Residential SupportAssistive Technology Transition CoordinationSupported Employment Transition ServicesTherapeutic Consultation Environmental Modifications Case ManagementCompanion ServicesCrisis Intervention/StabilizationDay Support  

Early Periodic Screening, Diagnosis, and Treatment

(EPSDT)

Medicaid benefits available to children under the age of 21

Must be eligible for Medicaid Monitor to prevent health and disability

conditions from occurring or worsening, including services to address such conditions

Treatment to “correct or ameliorate conditions,” including maintenance services

EPSDT

• Immunizations• Check ups and lab tests• Mental health assessment and treatment• Health education• Eye exams and glasses• Hearing exams and hearing aids & implants• Dental services• Personal care, nursing services• Other needed services, treatment and measures

for physical and mental illnesses & conditions

Medical Necessity

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

-Services not coveredRespiteEnvironmental ModificationsVocationalEducational

Health Insurance Premium Payment Program (HIPP)/ HIPP for

Kids• If an individual receiving waiver

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

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

HIPP

• Application must be completed separately from the Medicaid application.

• 1-800-432-5924• Visit www.dmas.virginia.gov click on

“Client Services” to the left then click on “HIPP Information”

Recipient Appeal

• A person may appeal if their benefits are:

-Terminated-Denied-Suspended-Reduced

Medicaid Appeals

• Fair Hearing• Right to challenge decisions and

actions regarding Medicaid• Appeal must be requested within 30

days of the decision or action that you disagree with

• Decision should be issued by the Hearing Officer within 90 days

Steps

• Request an appeal or review (804)-371-8488• Notify appeals division in writing• Be specific about what you want-Results in a hearing-Decision made-If appeal is lost, can continue through an

Administrative Review in Circuit Court

Debra Holloway, Director of Training and TechnicalAssistance, 804-649-8481 ext. 103,

dholloway@thearcofva.orgwww.thearcofva.org

Lynne Blythe, Infant & Toddler Connection of Rappahannock Rapidan, Local System Manager &

Program Manager, 540-929-7480 ext. 101, lblythe@rrcsb.org