Waiver and More - Community Legal Services of Philadelphia
Download
Report
Transcript Waiver and More - Community Legal Services of Philadelphia
Waiver Programs: Helping
Your Clients Stay at Home
PLAN 2012 Statewide Conference
September 11, 2012
Pamela Walz
Community 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 Waiver
To qualify, must be
Resident of PA and US citizen or qualified
non-citizen
Age 60 or over
Nursing Facility Clinically Eligible (NFCE)
Financially eligible for MA
Aggregate cost of serving all participants
in a waiver must not exceed 80% of cost
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 –
Resources
Resource
limit for single individual is
$8,000 ($2,000 + $6,000 disregard)
Married couples: spousal impoverishment
rules on resource assessment and
spousal share apply
Estate recovery applies for Waiver
recipients age 55 or older
Aging Waiver services
Home
health
Personal care
Attendant care
Respite
Adult Day Care
Transportation
Home modifications
Specialized medical
equipment, supplies
Home delivered
meals
Personal emergency
response
Companion
Aging Waiver services (cont’d)
Prior
to 7/1/12, only AAAs provided care
management. Other providers can now
bid to provide this service, now called
“service coordination”.
Waiver recipients get full MA coverage!
Must meet SLMB or QMB income limits to get
Medicare Part B paid
Living Independently for Elders
(LIFE)
Program
of All-Inclusive Care for the Elderly
(PACE) model
Model of care focused around Adult Day
Care attendance
ALL services are coordinated and provided
by LIFE
LIFE is paid a capitated rate by Medicare, Medicaid,
and/or the Participant (depending on the Participant’s
eligibility for Medicare and Medicaid)
LIFE Eligibility
Must be 55 or older for enrollment in Full-PACE LIFE
Center or 60 or older for enrollment in Pre-PACE LIFE Ctr
NFCE level of care
Available to people with any one of these combinations of
funding:
Medicaid Only
Medicare and Private Pay
Medicare and Medicaid
Private Pay Only
For those seeking Medicaid coverage of LIFE, Waiver
income and resource limits apply and Estate Recovery
applies
Must live in area served by a LIFE program (38 counties)
LIFE Services
Adult
day center
Home support, home health, personal care
Respite
Transportation
Meals
Medical and nursing care
Rehabilitation and restorative therapies
LIFE services (cont’d)
Home
modifications
Social activities and recreation
Social services
Hospital and nursing facility care when
needed
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
Options
State-funded
(not MA)
Services for consumer age 60+
Can be NFCE but not financially eligible
for Waiver OR Nursing Facility Ineligible
(NFI).
Options (cont’d)
Services
are same as Waiver but are
capped at $714.60/month (exception is
available)
Sliding scale cost sharing for consumers
with income greater than 125% of FPL
($1,135/mo. single, $1,532/ mo. couple in
2011)
Waiting 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 Direction
Knowing
the difference between
Participant Centered system and
Participant Direction
Aging Waiver offers choices
the process of choosing amongst the choices
is the Participant “Centeredness” of the
system
the opportunity for the participant to exercise
control over his/her services is Participant
Direction
Participant Direction
Traditional
ways of getting services
through HCBS Waiver = Agency Model
Participant Direction includes
the Employer Model (wherein the waiver
consumer is the employer and hires and fires
staff with the help of a fiscal management
agency, service coordinator, etc.) and
Services My Way – which is the Employer
Model plus budget authority (wherein the
waiver consumer gets decision making ability
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
(cont’d)
Delays
in enrollment:
Maximus (Independent Enrollment Broker for
under-60 Waivers): lengthy waits for
assessments and determinations. Recent
Mosley settlement requires timely actions.
Individualized Service Plan approval delays
Elimination of Community Choice
Christian
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 PPACA
Section 10202. State Balancing Incentive
Payments Program
Section 2401. Community First Choice Option—
Medicaid State Plan Option for Attendant
Services and Supports:
Section 2402. Medicaid Home and Community
Based Services State Plan Option
Others
Questions?
Pam
Walz
Aging and Disabilities Unit
Community Legal Services, Inc.
[email protected]
(215) 227-4798