The Medicaid Waiver Program and Participant-Directed Services

Making Choice and Control a Reality

Waivers

What are they all about?

First, a quick review…

What is a waiver? What are some of the rules? Who can get services through a waiver? What can a waiver cover? What can’t the waiver do?

Waiver

A waiver means permission to set aside or ignore certain rules

The HCBS waiver sets aside certain Medicaid rules about where money can be spent for people

Some important terms: Home and Community-Based Services

(HCBS) waiver = 1915(c)waiver

=Medicaid waiver CMS: The Centers for Medicare and

Medicaid Services (da feds) ICF-MR-intermediate care facility for the

mentally retarded (State developmental centers, private facilities)

Terms

Participant-directed=self-directed=consumer controlled

FMS: Fiscal management service =fiscal intermediary

Home and Community-based Services Waiver

Allows the state to buy community services with money that would have been spent in an institution

How does the state get a waiver?

The state has to apply to the federal government for permission

The state has to follow the federal rules—but there’s a lot of room for creativity

Who decides what the waiver does?

The state waiver committee members give ideas and suggestions to the state about what people want and

need

Who decides what the waiver does? The state makes some decisions too

based on state laws and policies The state submits an application The feds negotiate with the state

(sometime a LOT) The feds approve the application

Who can get waiver services? Federal rules:

– must be eligible for a Medicaid card– must be eligible for services in an ICF-MR

….But that does not mean you have to want to go to an ICF-MR or already live there to get waiver services

Who can get waiver services?

State decides:– What groups to serve-kids, adults, people with certain

conditions – How many people they legislature gives them money

for– Who gets served first, who waits for services

Exactly who gets services and how many people get services depends on decisions made by the state developmental disabilities agency and by the state legislature

Who pays for the waivers?

Medicaid is a state/federal partnership

The federal government “matches” what the state spends

In Illinois the state pays half of the cost and the feds pay half

Who pays for the waivers?

Remember the total amount of money always depends on how much money the state legislature decides to make available for the waiver programs

What can the waiver pay for?

Help to live in your own homeHelp to your family so they can

help youHelp to get a jobWhatever services the state

includes and gets approved

What can’t the waiver do? Federal rules:

– Cannot give cash to families or individuals– Cannot pay for purely “recreational”

activities (the “no fun” rule!)– Cannot pay for services in an ICF-MR or

hospital (unless it is respite)

What can’t the waiver do?

– Cannot pay for things covered by school– Cannot pay for things covered by your

Medicaid card– Cannot pay for services that vocational

rehabilitation should pay for– Cannot pay for services that are not

described and approved in the waiver application

What about directing our own services?The waiver rules allow

people to direct their own services but..

The state has to tell the federal government how they will do it and get permission

And there are rules

Appendix E: Participant Direction of Services

The waiver application

The state has to fill out an application to get the waiver

100 pages with a 300 page “guide” The instructions for just the participant-

directed part, Appendix E, are 28 pages long!

CMS says…

“ Participant direction of waiver services means that the waiver participant has the authority to exercise decision making authority over some or all of her/his waiver services and accepts the responsibility for taking a direct role in managing them.”

Two Basic Approaches

Participant Employer Authority

Participant Budget Authority.

Employer Authority

The waiver participant—or family—not an agency oversees the support workers– Co-Employment. An agency employs workers

recruited by the participant.– Common Law Employer: The participant is the

legally responsible employer of workers whom he or she (or his or her representative) hires, supervises and discharges directly.

Employer Authority means:

The participant must have the power to– Recruit workers– Hire and fire staff (common law employer) or– Refer to the agency for hire and discharge from

providing services (co-employer)– Decide on staff qualifications– Decide staff duties– Schedule staff– Supervise staff– Evaluate staff performance

Budget Authority

Budget Authority means the person has to:

– Determine the amount paid for each service in accordance with the state's policies or rates

– Schedule when services are provided– Identify service providers and refer them for

enrollment– Review and approve provider invoices

Determining Budgets

CMS requires that if the state is using individuals budgets, everyone must understand: – How the amount in the budget is decided– How the method used to set the budget

relates to your needs

The state must “spell-out” how budget are determined.

Determining Budgets

Everyone must understand:

– How information about the budget methodology is made publicly available

– How the method is applied consistently to each waiver participant.

Managing Individual Budgets

There are a lot of ways budgets can be managed– Can allow participant to make changes to

how budget is spent without prior authorization

– Or can require that all changes be approved before they occur

– Must make sure that the person knows how much they have left

Financial Management Services

The HCBS waiver does not allow states to give individuals cash directly.

Can give the money to an agency or organization that “keeps the books” on behalf of the person- a fiscal management service (FMS)

Person has full control over the money but the FMS does the paperwork and pays the bills.

Supports Brokering

Support for individuals (Supports brokering) to self-direct must be available if needed, but:

– Not required if people don’t need it

– Can be done by case managers or by other individuals, agencies, organizations as decided on by the state and stakeholders

Who can provide services?

The state defines who are / what are “qualified providers”

CMS allows states to use all kinds of “non-traditional” people and services

Can use relatives and family if the state allows it

Who can participate in directing their own services? The feds say:

“Participant direction is commonly associated with individuals who live on their own or reside with their families. Participant direction may be less feasible when individuals are served in larger, provider-controlled living arrangements such as group homes. It is up to the state to decide whether participant direction is supported in some or all types of living arrangements.”

Living arrangement and participant direction Best practice nationally:

– Participant direction is available to individuals living in their own home and family home, included supported living

– Individuals living in group homes can manage their day/vocational or other community supports

What services can be participant-directed? State decision... In some states ALL services are

participant-directed (except group homes)

In others, only a few services—like respite or personal care are participant-directed