Embed Size (px)
Citation preview
MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER
MEDICAID
HISTORY
Medicaid was established with amendments to the Social Security Act in 1965
Medicaid Buy-In
PURPOSE
• To provide for health and medical care for certain groups of people who have low income
FLEXIBILITY
• States design their own programs within federal standards
MEDICAID IS A JOINT PROGRAM BETWEEN FEDERAL & STATE
GOVERNMENTS CENTERS FOR
MEDICARE & MEDICAID SERVICES
• Federal agency• CMS• Previously HCFA• cms.hhs.gov
DEPARTMENT FOR MEDICAL ASSISTANCE SERVICES
• State agency• DMAS• www.dmas.virginia.gov
VIRGINIA MEDICAID
DMAS is designated as the single state agency charged with administering Medicaid in Virginia
DMAS contracts or has agreements with other entities for most screening, case management, service and billing related activities
DMAS is responsible for ensuring that the Medicaid program operates in compliance with state and federal laws and regulations
VIRGINIA’S MEDICAID
Virginia Medicaid budget for fiscal year 2005
$ 4,473,588,930
50% from state funds
50% from federal funds
MANDATORY MEDICAID SERVICES
Inpatient Hospital Services
Emergency Hospital Services
Outpatient Hospital Services
Nursing Facility Care Rural Health Clinics Federally Qualified
Health Center Clinic Services
Lab and X-Ray Services
Physician Services Home Health Service EPSDT Family Planning Nurse-Midwife Services Certified Nurse
Practitioner Services Transportation Medicare Premiums (Part A) - Hospital; (Part B) -
Supplemental Insurance for Categorically Needy
OPTIONAL Medicaid Services Provided In Virginia
Other Clinic Services Skilled Nursing Facility
Services for Individuals under 21 years of age
Podiatrist Services Optometrist Services Clinical Psychologist
Services Home Health
PT, OT, and Speech Therapy
Prescribed Drugs Case Management Prosthetics Hospice Services Mental Health Services ICF-MR
Early and 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
Institutional Placements Hospitals
Nursing homes
ICFs/MR - Intermediate Care Facility for people with mental retardation or other related conditions
institutions of 4 or more beds for people with MR or other related conditions active treatment and rehabilitation regulated by the federal and state governments
32 ICFs/MR in Virginia
5 large “Training Centers,” several hundred beds at each Center 27 smaller ICFs/MR, ranging from 4 to 88 beds
ELIGIBILITY Apply at local Department of Social Services
STATE PLAN MEDICAID (Mandatory & Optional Services)
Categorical Criteria Disabled or age 65 or older Families with children Pregnant women Recipients of cash assistance Low income Medicare beneficiaries
Financial Thresholds Low income and asset guidelines Thresholds vary by category group Parental income/resources DO
count for minor children Consideration of exceptionally high
medical bills (spend-down)
LONG-TERM CARE (Waivers & Institutions)
Must Need Long-term Care criteria defined for each Waiver assessment of need required
Financial Thresholds 300% of SSI payment limit for
one person ($1,809 per month) spend-down for 4 of the Waivers $2000 resource limit Parent income/resources do NOT
count regardless of child’s age Services Required
All Waiver and State Plan (Mandatory and Optional) services you are eligible for
HIPP
Health Insurance Premium Payment program
DMAS program
Pays health insurance premiums
Application must be completed separately from the Medicaid application
Application info 800-432-5924
COPAYMENTS
Some people may have to pay a copayment for Medicaid services if they do not receive Waiver services.
People who receive Home and Community-Based Medicaid Waiver services do not pay copayments for their basic, State Plan Medicaid services.
However, some people may have to pay a patient-pay for their Waiver services.
PATIENT-PAY RESPONSIBILITIES
$ People may have to pay for some Waiver services if they have income over $603 per month (except AIDS Waiver which has no patient-pay)
$ Some exceptions for persons who are working (EDCD, DD and MR Waivers)
Patient-PayEDCD Waiver, DD Waiver, MR Waiver
People may have a patient-pay if income is over $603 a month
Can keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/week
Can keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/week
Still have a patient-pay from unearned income for all Waivers except the AIDS Waiver
* total of earned and unearned income
WHAT ARE HOME & COMMUNITY-BASED MEDICAID WAIVERS?
Waivers give States the flexibility to develop and implement alternatives to institutionalization.
WHY WERE HOME & COMMUNITY-BASED
WAIVERS ESTABLISHED?
Slow the growth of Medicaid spending Institutions are overly restrictive and too highly
routine oriented Permit federal Medicaid funds to be used for
community services by people who would otherwise be institutionalized
HOW IS A WAIVER DEVELOPED? State develops a Waiver application to be submitted to the
federal Centers for Medicare and Medicaid Services (CMS) for approval – Task Forces are usually established by DMAS to assist with development of the applications
DMAS develops regulations to implement the Waiver - Public comment is solicited when regulations are proposed
The Virginia General Assembly allocates funds for Waiver services – Advocates can educate the General Assembly about the need for funds to provide services
Waiver is initially approved by CMS for 3 years and then typically renewed every 5 years – Task Forces are usually established by DMAS to assist with development of the renewal applications
COST EFFECTIVE
To receive approval to
implement a Waiver, a State
Medicaid agency must assure
CMS that it will not cost more
to provide home and
community based services
than providing institutional care
would cost
Waiver Must be Cost Effective It can be individually cost effective or cost effective in
the aggregate
• Aggregate Cost Effectiveness The average cost to Medicaid of individuals on the Waiver cannot cost more than the average cost to Medicaid of individuals in the comparable institution
• Individual Cost Effectiveness Cost to Medicaid for the individual in the community can’t exceed the cost in the comparable institution
Medicaid WaiversVirginia has 6 Home and Community
Based Care (1915 (c) ) WaiversState Regulations for the Waivers can be found
at:http://leg1.state.va.us/000/reg/TOC12030.HTM#C0120
12 VAC-30-120-70 Technology Assisted Waiver (Tech Waiver) 12 VAC-30-120-140 AIDS Waiver 12 VAC-30-120-210 Mental Retardation Waiver (MR Waiver) 12 VAC-30-120-700 Individual and Family Developmental
Disabilities Support Waiver (DD Waiver) 12 VAC-30-120-900 Elderly or Disabled with Consumer
Direction Waiver (EDCD Waiver) 12 VAC-30-120-1500 Day Support Waiver for Individuals with
Mental Retardation (Day Support Waiver)
DIFFERENT INSTITUTION - DIFFERENT WAIVER
NURSING HOMES
AIDS Elderly or Disabled with
Consumer Direction Technology Assisted
HOSPITAL
AIDS Technology Assisted
ICF/MR
Mental Retardation
Developmental Disabilities MR Day Support
There must be an alternate institutional placement for which Medicaid pays
The individual who is applying for a Waiver must meet the same criteria that is used for admission to the institution
This does not mean that the individual must actually be placed in the institution or make application to an institution
Alternative Institutional Placement
SCREENING PROCESSPre-Admission Screening Teams of the Department of
Health & Department of Social Services Elderly or Disabled with Consumer Direction Waiver AIDS Waiver
Department of Medical Assistance Services Technology Assisted Waiver
Community Services Board MR Waiver MR Day Support Waiver
Department of Health Local Clinics Developmental Disabilities Waiver
LEVEL OF FUNCTIONING (LOF) SURVEY
Used for Day Support, DD and MR Waivers LOF Survey is completed as part of the
screening process Determines the level of care needed To receive DD or MR Waiver services, an
individual must meet the criteria for admission to an ICF/MR
UNIFORM ASSESSMENT INSTRUMENT (UAI)
Used for nursing home placement and the AIDS, EDCD, and Tech Waivers
Completed as part of screening and assessment Assesses social, physical health and functional
abilities Used to gather info for planning and monitoring
needs and eligibility
SUPPLEMENT TO SCREENING
People who have mental illness, mental retardation or developmental disabilities
Initiated by the nursing home preadmission screening team when screening for nursing home placement and the EDCD Waiver
Preadmission screening team sends supplement screening request to CSB
PURPOSE OFSUPPLEMENT SCREENING
Some people with MR or DD have active treatment needs that are not met by nursing homes or nursing home-related Waivers
Determine the person’s need for active treatment that would not be met by nursing homes or nursing home-related Waivers
LEVEL II SUPPLEMENT
Specialized Services
Services Identified By CSB
Responsibility & Entitlement
CASE MANAGEMENT,MR and DD SERVICE
Ensures development, coordination, implementation, monitoring and modification of the individual’s plan
Links the individual with appropriate community resources and supports
Coordinates service providers Monitors quality of care
MR WAIVERCASE
MANAGEMENT
Community Services Boards provide case management services
DD WAIVERCASE
MANAGEMENT
Individual chooses their Case Management organization
Various organizations provide Case Management services
Case Management organizations cannot provide other DD Waiver services (except Consumer Directed Services Facilitation)
CONSUMER-DIRECTED SERVICES Freedom, choice and control remaining with the
individual, and sometimes their family -• what service is needed• who will provide it• when it will be provided• where it will be provided• how it will be provided
In Virginia, CD services were initiated by Centers for Independent Living and the Virginia Board for People with Disabilities in 1989
Virginia Medicaid Waivers have components of consumer-direction and self-determination, implementation depends on the individual and their case manager
Consumer-Directed Services Individual or family caregiver directs and controls who,
how, and when services are provided
Virginia offers consumer-directed services in 4 Waivers:
• Elderly or Disabled with Consumer-Direction Waiver (since 2005) - Personal Care, Respite
• Developmental Disabilities Waiver (since 2000) - Personal Care, Respite, Companion
• Mental Retardation Waiver (since 2001) - Personal Assistance, Respite, Companion
• AIDS Waiver (since 2003) – Personal Assistance, Respite
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 and training staff, how to handle difficult situations, how to complete employment paperwork, etc.
SF provides list of attendants, companion aides or respite workers 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 (acting as a fiscal agent) and a contractor pays the attendants, companion aides and respite workers on behalf of the individual
CONSUMER-DIRECTED STAFF QUALIFICATIONS
Be 18 years old Possess basic math, reading and writing skills Have the required skills to perform job duties Have a valid Social Security number Submit to a criminal history check Willing to attend training requested by the person
receiving Waiver services Willing to register in a CD-staff registry Understand and agree to comply with program
requirements TB screening
CONSUMER-DIRECTEDSTAFF
Staff (Consumer-Directed employees including attendants, companions, respite workers)• Staff may be related to a consumer, but may not be
members of the immediate family (parents of minor children, spouses, or legally responsible relatives)
Exception: Payments may be made to other staff who are family members when there is objective written documentation as to why there are no other providers available to provide care
CONSUMER INVOLVEMENT
Person-centered planning Involve people of your choice in developing your Plan Prepare Plan Choose services Choose providers Decide how & when services will be provided Agree to and monitor Plan Quarterly and Annual Review of Plan Right to appeal areas of disagreement
CONSUMER SERVICES PLANDD and MR WAIVERS
Written document, signed by the consumer
Addresses all needs of the individual in all life areas
Developed with consumer, providers and others the consumer wants involved
CSP will list -
services and supports to be provided
who will provide the services and supports
how often the services and supports will be provided
PREPARING FOR CSP
Who will participate in your meeting
Develop a list of needed supports & services (be honest & frank)
Collect documentation• vocational evaluations• IEPs• school evaluations• medical documentation
HEALTH, SAFETY & WELFARE
Adequate services must be provided
Additional or different services should be added if needed to protect health, safety and welfare
Individual and Family Developmental Disabilities Support “DD” Waiver
Eligibility Criteria
“Related Conditions” Waiver Must be 6 years of age and older and meet
“related conditions” criteria Cannot have a diagnosis of mental retardation Level of Functioning survey used for screening Call DMAS (804) 786-1465 to request a Request
for Screening Form or go to www.dmas.virginia.gov
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
DD Waiver Services Adult companion services (CD & agency with 8 hrs
per day limit) Assistive technology ($5,000 per year limit) Crisis stabilization (60 day max/year) Environmental modifications ($5,000 per year limit) In-home residential support (not congregate) Day Support Skilled Nursing Supported employment Therapeutic consultation Personal emergency response system (PERS) Family/caregiver training (80 hours max/year) Respite care (CD & agency) Personal assistance services (CD & agency)
DD Waiver Statistics
Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $6,193,998
338 individuals served in FY 2005 Waiver is cost effective in the aggregate About 40% of the individuals requesting a
screening are not eligible for the DD Waiver Wait list is maintained by DMAS About 2,700 people have requested DD Waiver
services
MR Waiver Eligibility Criteria
Must have a diagnosis of mental retardation or be under the age of 6 and at developmental risk
Children on the MR Waiver who do not have a diagnosis of MR at the age of 6, possible transfer to DD Waiver
Screenings are conducted by CSBs Level of Functioning survey is the screening
instrument used There is a waiting list for the MR Waiver Screening for all Waivers must be provided without
any charge to the individual
MR Waiver Services
Residential support (group home or individual’s home) Day support and prevocational services Supported employment Personal assistance (CD & agency) Respite care (720 hours max/year) (CD & agency) Assistive technology ($5,000 max/year) Environmental modifications ($5,000 max/year) Skilled nursing services Therapeutic consultation Crisis stabilization (60 days max/year) Adult companion (8 hours max/day) (CD & agency) Personal Emergency Response System (PERS)
MR WAIVER WAITING LISTSUrgent and Non-urgent
CSBs and DMHMRSAS maintain Urgent and Non-Urgent lists
CSB maintains Planning list CSB provides individual with
written notice if placed on a waiting list and if there is a change in status to another list
CSB determines who on the Urgent list receives the next available slot
Only after all Urgent needs are met statewide will Non-urgent needs be served
Slot moves with you to a different town in VA
Vacant or new slots are allocated by the CSB unless there is no need in the CSB’s area
Non-urgent = meet criteria for the MR Waiver, including needing services within 30 days, but don’t meet Urgent criteria
Planning list = need services in the future
URGENT CRITERIA FOR THE MR WAIVER
Primary caregiver(s) is/are 55 years 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
MR Waiver Statistics
Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $280,354,624
6,421individuals served in FY 2005
Waiver is cost effective in the aggregate
Approximately 2,600 people on the waiting lists
MENTAL RETARDATIONDAY SUPPORT WAIVER
Only for people now on the MR Waiver Urgent or NonUrgent waiting lists
300 people served July 1, 2005 start date Includes Day Support and Prevocational services Case Management through the CSBs People could transition to the MR Waiver
Elderly or Disabled with Consumer Direction Waiver (EDCD)
Eligibility Criteria
• Individuals seeking Waiver services are eligible if 65 or older or disabled
• Must meet nursing home criteria• Can have a cognitive impairment• Screening is the conducted by the Preadmission
Screening Team using the UAI• Questionnaire used to determine if an individual can
independently manage Consumer Directed Attendants or if assistance with managing care will be needed
Elderly or Disabled with Consumer Direction Waiver Services
Services that are available statewide:• Adult Day Health Care• Personal Care Services (CD or Agency) • Personal Emergency Response System (PERS)• Respite (CD, Agency, or Skilled)
Individuals can receive up to 720 hours of respite per year
Personal assistance services can be provided outside of the individual’s home
Elderly or Disabled with Consumer Direction Waiver Services
Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $137,148,487
11,901individuals served in FY 2005
No waiting list for the EDCD Waiver
Waiver is cost effective in the aggregate
Technology Assisted Waiver Criteria
Individual may be eligible if she needs both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing care
Screening: UAI is used for adults and Tech Waiver scoring tool is used for children
DMAS reviews individual’s private insurance policy for private duty nursing benefits
Case management provided by DMAS nurses
Different rules for children and adults
Tech Waiver Considerations
ADULTS Screening team completes
UAI for adults only. DMAS staff follows up to complete the screening for adults
Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis
Cost effectiveness is compared to nursing facility specialized care
CHILDREN
DMAS staff completes screening for children
Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis; or daily dependence on other device-based respiratory or nutritional support
Cost effectiveness is compared to hospital costs
Tech Waiver Services
Services that are available statewide:
• Private duty nursing• Respite care• Durable medical equipment• Personal care for individuals over 21 years
of age• Environmental Modifications
Tech Waiver Services Limits
• Environmental modifications and Assistive technology provided if medically necessary and cost effective
• Respite care has an annual limit of 360 hours per year
• Private duty nursing has a limit of 16 hours per day, except -
• individuals under 21 can receive nursing services 24 hours a day during the first 30 days they receive Tech Waiver services
Tech Waiver Statistics
Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $24,136,697
363 individuals served in FY 2005
No waiting list for the Tech Waiver
AIDS Waiver Criteria
Individuals are eligible for the AIDS Waiver if they have a diagnosis of AIDS or AIDS-Related Complex and would require nursing facility or hospital care
Individuals are screened by a Preadmission Screening Team (DSS social worker, VDH nurse and physician)
Screening tool is the Uniform Assessment Instrument (UAI)
AIDS Waiver Services
Services that are available statewide:• Case management• Nutritional supplements• Private duty nursing• Personal assistance/care (CD or Agency)• Respite care (CD or Agency)
Individuals can receive up to 720 hours of respite per year
Personal assistance services can be provided outside of the individual’s home
AIDS Waiver Statistics Fiscal Year (FY) 2005 Waiver Expenditures
(July 2004 through June 2005) = $783,297
213 individuals served in FY 2005
No waiting list for the AIDS Waiver
Waiver is cost effective in the aggregate
No patient-pay for the AIDS Waiver
BRAIN INJURY WAIVERnot quite yet
DMAS worked with a task force to develop an outline for a new Brain Injury Waiver
Eligibility, services, providers, and other criteria being discussed by DMAS and the task force
Initiation of this new Waiver depends on funding provided by the General Assembly
Brain Injury Association of VA, 804-355-5748
SERVICE PROVIDERS
DMAS is responsible for -
adequate supply of qualified providers to meet needs of recipients
ensuring the capacity and scope of services are available
ensuring individuals are able to have “provider choice”
enrollment of providers
quality of services
ACCESSING PROVIDERS
Case Manager will assist you in locating and choosing providers
Case Manager will contact providers for initiation of services
You can switch providers if you choose to
There are shortages of some providers
A list of qualified providers for each service in the Consumer Services Plan will be given to you
You have the right to choose your providers
You have the right to visit, interview and research providers
You decide when, where and how you want approved services provided
MEDICAID APPEALS
Fair Hearing
Right to challenge decisions and actions regarding Medicaid
Decision should be issued by the Hearing Officer within 90 days
RIGHT TO APPEAL WHEN - Application of benefits is denied
The agency takes action or proposes to take action which will adversely affect, reduce, or terminate receipt of benefits
Request for a specific benefit is denied; in whole or in part
The agency does not act with reasonable promptness
WAITING LISTS DD and MR Waivers are the only Waivers with
waiting lists MR Waiver has 2 waiting lists:
Urgent and Non-urgent and a planning list DD Waiver has 2 waiting lists:
Level I (CSP less than $25,000) and Level II (CSP more than $25,000)
No waiting list for the AIDS, EDCD and Tech Waivers
Waiting lists are permissible, but waiting lists must move at a reasonable pace
What is a reasonable pace?
