Waiver Programs: Helping Waiver Programs: Helping Your Clients Stay at HomeYour Clients Stay at Home

PLAN 2012 Statewide ConferencePLAN 2012 Statewide ConferenceSeptember 11, 2012September 11, 2012

Pamela WalzPamela WalzCommunity Legal ServicesCommunity Legal Services

Home and Community Based Services

Medical and non-medical services to allow elderly and people with disabilities to live independently in their homes and communities.

Most but not all programs are Medicaid funded through waiver programs

Waiver Programs

Section 1915(c) of the Social Security Act: permits certain Medicaid provisions to be

waived to allow states to offer enhanced services to particular populations at risk of institutionalization

permits use of spousal impoverishment rules to determine financial eligibility

Waiver Programs (cont’d)

Must meet eligibility requirements of a specific waiver

In PA, the Office of Long Term Living administers most waiver programs (Office of Developmental Programs administers the rest).

HCBS Waivers in PA

PDA (Aging) Waiver Attendant Care Waiver AIDS Waiver Autism Waiver (for adults 21and over with

autism) COMMCARE Waiver (for individuals with

traumatic brain injury) Independence Waiver (for individuals 18-59 with

physical disability but not intellectual disability or mental illness as primary diagnosis)

HCBS Waivers in PA (cont’d)

Living Independently for the Elderly (LIFE) OBRA Waiver (individuals 18-59 with severe

developmental physical disability) Consolidated Waiver (age 3 or older with

Intellectual Disability and recommended for ICF/MR level of care)

Person Family Directed Support Waiver (age 3 or older with Intellectual Disability and recommended for ICF/MR level of care but do not need residential services)

PDA WaiverPDA Waiver

To qualify, must beTo qualify, must be Resident of PA and US citizen or qualified Resident of PA and US citizen or qualified

non-citizen non-citizen Age 60 or over Age 60 or over Nursing Facility Clinically Eligible (NFCE)Nursing Facility Clinically Eligible (NFCE) Financially eligible for MAFinancially eligible for MA AggregateAggregate cost of serving all participants cost of serving all participants

in a waiver must not exceed 80% of cost in a waiver must not exceed 80% of cost to serve same group in nursing facility.to serve same group in nursing facility.

Nursing Facility Clinically Eligible (NFCE)

Individual has diagnosed illness, injury, disability or medical condition;

As result, requires care and services above level of room and board;

Physician certified individual is NFCE; and Care and services are either:

Skilled or Intermediate level care.

Financial eligibility for Waiver – Income

Income limit for 2012 is $2,094 (300% of the federal SSI rate)

Spouses’ income is not counted in determining income eligibility

Can spend down to SSI level ($698), but not to $2,094.

Financial eligibility for Waiver –Financial eligibility for Waiver –ResourcesResources

Resource limit for single individual is Resource limit for single individual is $8,000 ($2,000 + $6,000 disregard)$8,000 ($2,000 + $6,000 disregard)

Married couples: spousal impoverishment Married couples: spousal impoverishment rules on resource assessment and rules on resource assessment and spousal share applyspousal share apply

Estate recovery applies for Waiver Estate recovery applies for Waiver recipients age 55 or olderrecipients age 55 or older

Aging Waiver servicesAging Waiver services

Home healthHome health Personal carePersonal care Attendant careAttendant care RespiteRespite Adult Day CareAdult Day Care TransportationTransportation Home modificationsHome modifications

Specialized medical Specialized medical equipment, suppliesequipment, supplies

Home delivered Home delivered mealsmeals

Personal emergency Personal emergency responseresponse

CompanionCompanion

Aging Waiver services (cont’d)Aging Waiver services (cont’d)

Prior to 7/1/12, only AAAs provided care Prior to 7/1/12, only AAAs provided care management. Other providers can now management. Other providers can now bid to provide this service, now called bid to provide this service, now called “service coordination”.“service coordination”.

Waiver recipients get full MA coverage!Waiver recipients get full MA coverage! Must meet SLMB or QMB income limits to get Must meet SLMB or QMB income limits to get

Medicare Part B paidMedicare Part B paid

Living Independently for Elders Living Independently for Elders (LIFE)(LIFE)

Program of All-Inclusive Care for the Elderly Program of All-Inclusive Care for the Elderly (PACE) model(PACE) model

Model of care focused around Adult Day Model of care focused around Adult Day Care attendanceCare attendance

ALL services are coordinated and provided ALL services are coordinated and provided by LIFEby LIFE LIFE is paid a capitated rate by Medicare, Medicaid, LIFE is paid a capitated rate by Medicare, Medicaid,

and/or the Participant (depending on the Participant’s and/or the Participant (depending on the Participant’s eligibility for Medicare and Medicaid)eligibility for Medicare and Medicaid)

LIFE EligibilityLIFE Eligibility Must be 55 or older for enrollment in Full-PACE LIFE Must be 55 or older for enrollment in Full-PACE LIFE

Center or 60 or older for enrollment in Pre-PACE LIFE CtrCenter or 60 or older for enrollment in Pre-PACE LIFE Ctr NFCE level of careNFCE level of care Available to people with any one of these combinations of Available to people with any one of these combinations of

funding:funding: Medicaid OnlyMedicaid Only Medicare and Private PayMedicare and Private Pay Medicare and Medicaid Medicare and Medicaid Private Pay OnlyPrivate Pay Only

For those seeking Medicaid coverage of LIFE, Waiver For those seeking Medicaid coverage of LIFE, Waiver income and resource limits apply and Estate Recovery income and resource limits apply and Estate Recovery appliesapplies

Must live in area served by a LIFE program (38 counties)Must live in area served by a LIFE program (38 counties)

LIFE ServicesLIFE Services

Adult day centerAdult day center Home support, home health, personal careHome support, home health, personal care RespiteRespite TransportationTransportation MealsMeals Medical and nursing careMedical and nursing care Rehabilitation and restorative therapiesRehabilitation and restorative therapies

LIFE services (cont’d)LIFE services (cont’d)

Home modificationsHome modifications Social activities and recreationSocial activities and recreation Social servicesSocial services Hospital and nursing facility care when Hospital and nursing facility care when

neededneeded

Attendant Care Waiver

Eligibility requirements: Resident of PA Between 18 and 59 years old NFCE Financially eligible for MA Diagnosis of physical impairment expected to

last at least 1 year Capable of hiring, firing, supervising attendant

care workers and managing financial/legal affairs

OptionsOptions

State-funded (not MA)State-funded (not MA) Services for consumer age 60+Services for consumer age 60+ Can be NFCE but not financially eligible Can be NFCE but not financially eligible

for Waiver OR Nursing Facility Ineligible for Waiver OR Nursing Facility Ineligible (NFI).(NFI).

Options (cont’d)Options (cont’d)

Services are same as Waiver but are Services are same as Waiver but are capped at $714.60/month (exception is capped at $714.60/month (exception is available)available)

Sliding scale cost sharing for consumers Sliding scale cost sharing for consumers with income greater than 125% of FPL with income greater than 125% of FPL ($1,135/mo. single, $1,532/ mo. couple in ($1,135/mo. single, $1,532/ mo. couple in 2011)2011)

Waiting listsWaiting lists

Act 150 Program

State-funded attendant care program (not MA funded)

Same eligibility requirements as Attendant Care Waiver except need not be financially eligible for MA

Minimal copayment if income >125% FPL No estate recovery

Domiciliary Care

Provides home-like living arrangement in community for individuals who need help with ADLs and unable to live independently

In dom care provider’s own home

Dom Care Eligibility

18 or older with difficulties with ADLs which prevents independent living

Cannot be NFCE Mobile or –semi-mobile Generally low-income (dom care

supplement available)

Dom Care Services

AAA develops care plan Assistance with ADLs 3 meals/day Medication Administration

Family Caregiver Support Program

Purpose is to support individuals providing care in the home

Governed by state and federal law Act 112 of 2011 made revisions: caregiver

no longer needs to be related to person receiving care

FCSP Eligibility

Must be primary caregiver Care receiver must be functionally dependent

older adult or other adult with chronic dementia Services available to caregivers whose care

receiver’s households are under 200% of FPL or to those between 200-380% with sliding scale

contribution. No benefits if care receiver household income

>380% FPL.

FCSP Services

Counseling, education and training Assessment Home chore services Modest financial assistance with expenses

including respite care and incontinence supplies

Grants for home modifications (not to exceed $2,000)

FCSP services (cont’d)

Maximum monthly grant is $200, but Act 112 increases it to $500 in cases of documented need.

However, if local AAA average grant is >$300/month across entire FCSP caseload, maximum is $200.

Process to Obtain Aging Waiver Services

Level of care assessment by AAA Prescription from physician indicating NFCE Individual Service Plan (ISP) development –

must be approved by OLTL Supports coordinator contacts agencies,

arranges and manages services If waiver services inadequate or denied,

applicant may appeal and have fair hearing before ALJ

Recipient participation in process

Participant DirectionParticipant Direction Knowing the difference between Knowing the difference between

Participant Centered system and Participant Centered system and Participant DirectionParticipant Direction

Aging Waiver offers choices Aging Waiver offers choices the process of choosing amongst the choices the process of choosing amongst the choices

is the Participant “Centeredness” of the is the Participant “Centeredness” of the systemsystem

the opportunity for the participant to exercise the opportunity for the participant to exercise control over his/her services is Participant control over his/her services is Participant DirectionDirection

Participant DirectionParticipant Direction Traditional ways of getting services Traditional ways of getting services

through HCBS Waiver = Agency Modelthrough HCBS Waiver = Agency Model Participant Direction includes Participant Direction includes

the Employer Model (wherein the waiver the Employer Model (wherein the waiver consumer is the employer and hires and fires consumer is the employer and hires and fires staff with the help of a fiscal management staff with the help of a fiscal management agency, service coordinator, etc.) andagency, service coordinator, etc.) and

Services My Way – which is the Employer Services My Way – which is the Employer Model plus budget authority (wherein the Model plus budget authority (wherein the waiver consumer gets decision making ability waiver consumer gets decision making ability over how to spend budgeted amount)over how to spend budgeted amount)

Common Problems for Waiver clients

Inability to spend down to Waiver Loss of eligibility due to failure to comply

with redetermination requirements Denial of particular service (e.g. adult day

care) or number of hours Waiting lists (CommCare, OBRA, Act 150)

Common problems for Waiver Clients Common problems for Waiver Clients (cont’d)(cont’d)

Delays in enrollment: Delays in enrollment: Maximus (Independent Enrollment Broker for Maximus (Independent Enrollment Broker for

under-60 Waivers): lengthy waits for under-60 Waivers): lengthy waits for assessments and determinations. Recent assessments and determinations. Recent MosleyMosley settlement requires timely actions. settlement requires timely actions.

Individualized Service Plan approval delays Individualized Service Plan approval delays Elimination of Community ChoiceElimination of Community Choice

Christian Financial debacleChristian Financial debacle

Problems, cont’d

Act 22 HCBS regulations: Set provider rates which may create access

problems and reduce consumer direction Narrowed scope of Aging waiver care

management function (now called service coordination)

Reduced nursing oversight in Aging waiver Eliminated several services from Aging waiver

What happened to rebalancing???

New HCBS Opportunities Under PPACANew HCBS Opportunities Under PPACA

Section 10202. State Balancing Incentive Section 10202. State Balancing Incentive Payments ProgramPayments Program

Section 2401. Community First Choice Option—Section 2401. Community First Choice Option—Medicaid State Plan Option for Attendant Medicaid State Plan Option for Attendant Services and Supports:Services and Supports:

Section 2402. Medicaid Home and Community Section 2402. Medicaid Home and Community Based Services State Plan OptionBased Services State Plan Option

OthersOthers

Questions?

Pam Walz

Aging and Disabilities Unit

Community Legal Services, Inc.

pwalz@clsphila.org

(215) 227-4798