Transcript Slide 1

Everything You Need to Know
About Your Medicaid Waiver
The Delaware County Board of
Developmental Disabilities
May 2014
Waiver Growth in Delaware County
Year
2000
2013
# Served # Waivers % Served
750
50
6.7
2251
627
27.8
Waiver Dollars
2000
$ 2,118,424*
2013
$16,432,877*
*DCBDD only pays 40% of these costs
What is a Waiver?
A waiver is a Medicaid funding source that can
help pay for services to keep people with
disabilities in their own homes and prevent
moving to a long-term care facility or nursing
home. The county board is required to pay
approximately 40% of the cost of waiver
services. The federal government pays 60% of
the cost of services
DODD Administered Waivers
Delaware County Board of DD currently administers
three waivers:
• Level One Waiver Allows for minimal paid
support and relies heavily on natural supports
• SELF Waiver Allows for a moderate amount of
support and is Ohio’s first self-directed waiver
• Individual Options Waiver For individuals with
limited or no natural support and who have a
high level of need
Waiting Lists
In order for an individual to receive a waiver,
he/she must make application to be placed on
the waiting list
The waiting list rule OAC 5123:2-1-08 dictates
enrollment based on priority categories
Refer to the Priority Score Sheet for categories
Waiting Lists in Delaware County
In Delaware County, each priority group has a
weighted point value which is used to
determine the individual’s priority score
All waiting lists are ordered first by priority
score, then date and time of application
Currently, only individuals meeting emergency
status will be considered for an IO waiver
Preparing for the Transition to
Waiver Services
Begin search for providers
Providers must be certified by DODD to provide waiver
services
It can take several weeks for a provider to complete the
certification process
Waiver providers will not bill DCBDD for waiver services.
Billing is completed through an on-line application and
payment is made by the State of Ohio
Medicaid Card Service Providers (State Plan Services)
Services
Homemaker Personal Care
(IO and Level One Waiver Only)
• Basic personal care and grooming, including bathing, care of
the hair, and assistance with clothing;
• Assistance with bladder and/or bowel requirements or
problems, including helping the individual to and from the
bathroom
• Assisting the individual with self-medication or provision of
medication administration for prescribed medications and
assisting the individual with, or performing, health care
activities;
• Performing household services essential to the individual's
health and comfort in the home
Services
Homemaker Personal Care, Cont.
• Assessing, monitoring, and supervising the individual to ensure the
individual's safety, health, and welfare;
• Light cleaning tasks in areas of the home used by the individual;
• Preparation of a shopping list appropriate to the individual's dietary
needs and financial circumstances, performance of grocery
shopping activities as necessary, and preparation of meals;
• Personal laundry
• Incidental neighborhood errands as necessary, including
accompanying the individual to medical and other appropriate
appointments and accompanying individual for walks outside the
home.
Services
Transportation
(IO, Level One and SELF Waivers)
A service that enables individuals enrolled in waivers to access
waiver and other community services, activities, and resources
Services
Environmental Accessibility Adaptations
Participant Goods and Services
(IO, Level One and SELF Waivers)
Changes to a home that enable a person to function with greater
independence.
Examples include:
• Installing ramps or grab-bars;
• Widening doorways;
• Modifying bathrooms to be wheelchair-accessible; and,
• Installing specialized electrical or plumbing systems to
accommodate medical equipment;
Services
Adaptive and Assistive Equipment (IO)
Specialized Medical Equipment and Supplies (Level One)
Participant Goods and Services (SELF)
•Devices, controls or appliances that allow people to do daily
living activities or to help them communicate;
•Items necessary for life support and the supplies and
equipment necessary for upkeep; and,
•Durable and non-durable equipment that is not paid for by the
Medicaid State Plan.
Services
Informal Respite
(Level One Only)
Services provided in a person’s home, the home of a friend or
family member of the individual or at sites of community
activities to give relief to the person typically providing care.
Services
Community Inclusion
(SELF only)
Includes supports that promote the individual's participation
in his/her community. The service includes opportunities
and experiences that focus on socialization and/or
therapeutic recreational activities, as well as personal growth
in the home and/or community. Community Inclusion also
can include peer support activities and organization of selfadvocacy events. It is not meant to cover employmentrelated services.
Individual Options Waiver
Services available with the IOW include:
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Homemaker Personal Care
Transportation
Environmental accessibility modifications
Adaptive & Assistive equipment
Adult Day Waiver Services
Remote Monitoring
Community Respite (Specialized Camps)
Residential Respite (Facility-Based Respite)
Adult Family Living*
Adult Foster Care*
Social work*
Interpreter
Home delivered meals
Nutritional services*
*exclusive to the individual options waiver
Self Empowered Life Funding Waiver
Services available with the SELF waiver include:
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Support Brokerage*
Functional Behavioral Assessment*
Community Inclusion*
Participant Directed Goods and Services*
Participant/Family Assistance*
Integrated Employment*
Residential Respite
Community Respite
Remote Monitoring
*exclusive to the SELF waiver
Level One Waiver
Services available with LV1 waiver include:
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Homemaker/Personal Care
$5000 annual cap combined
Community Respite (Camp)
Informal Respite*
Transportation
Personal Emergency Response Systems
Specialized Medical Equipment and Supplies
$7500 cap over
Environmental Accessibility Adaptations
a 3 year period
Home Delivered Meals
Remote Monitoring
Emergency Assistance*
$8000 cap over a 3 year period and
Adult Day Waiver Services
must meet emergency status
*exclusive to the level one waiver
Waiver Service Planning
Complete Individual Support Plan (ISP) with your team
Complete Payment Authorization for Waiver Services (PAWS)
A provider may not provide services or bill without this authorization
Waiver Budget Utilization
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Tracking
Reallocation
Over-utilization
Your ISP is an “All Services Plan” and is to include all waiver,
locally funded, and Medicaid State Plan services
Medicaid
A Medicaid Card is included with the Waiver service package and
may cover therapies, hospital services, nursing services, home
health aides, doctor & dental appointments and medical
equipment
Many of these services are available through Medicaid State
Plan Services
State Plan Services
Home Health Services
Home Health Services include:
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Home Health Nursing
Home Health Aide
Skilled therapies (OT,PT,SLP)
Services must be medically necessary as ordered by the treating
physician and documented by signature.
State Plan Services
Home Health Services
Services anyone can access with a Medicaid card, a
doctor’s order and proof of medical necessity
Available Statewide
No waiting list
Home Health Services
Four hours or less per visit (intermittent service)
No more than 8 hours a day combined nursing, aide
and therapies
No more than 14 hours per week of nursing and
aide services combined
Home Health Services
To meet the requirement of ‘intermittent’, similar
services cannot be ‘stacked’
A two-hour break is required between similar services.
An example of similar services is Home Health Aide
services and Waiver Homemaker/Personal Care
services
Home Health Services
Cannot be billed back to back (stacked) with a similar
service type
For example:
6am-8am (no break) 8am-12pm (no break)12pm-2pm
HH Aide
Waiver HPC Provider
Not Permitted
HH Aide
Home Health Services
MUST have a MINIMUM 2 hour break in services
For example:
6am-10am (break) 1pm-5pm (break) 8pm-10pm
HH Aide
Waiver HPC Provider
HH Aide
Permitted
Home Health Services
Can be billed back to back with a DIFFERENT
service type
For example:
6am-8am (no break) 8am-12pm (no break) 12pm-2pm
Home Health Aide
Home Health Nursing
Permitted
Home Health Aide
Home Health Services
Can be billed back to back with a DIFFERENT service
type
For example:
6am-8am
HH Aide
(no break)
8am-12pm
(no break)
12pm-2pm
Waiver Informal
Respite Provider
Permitted
HH Aide
Home Health Services
Home Health Services cannot be provided for the purposes
of respite.
“Respite care” is the care provided to an individual unable
to care for himself or herself because of the absence or
need for relief of those normally providing care.
Home Health Services
Must be provided in the
person’s place of
residence, in a
licensed day care
center or in an Early
Intervention program
Home Health Services
Home Health Aide Services
Services include:
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Personal Care
Routine catheter/colostomy care
Assistance with routine maintenance exercises and passive ROM
activities in support of skilled therapy goals.
Routine care of prosthetic and orthotic devices
Home Health Services
Home Health Aide Services
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Incidental Services can include: light chores, laundry, light house
cleaning, meal prep and taking out trash
Main purpose of a Home Health Aide visit cannot be solely to
provide incidental services
Incidental services are to be performed only for the eligible
individual
May NOT provide medication administration
Increased Home Health Services
Increased services are available if requires more than 14 hours in a
week of aid and/or nursing services combined or more than 8 hours
per day of aide, therapy and/or nursing services combined
Eligibility:
Up to age 21
Must have a comparable institutional level of care (ILOC, ICF/DD LOC, or SLOC) as
determined by enrollment on a waiver or CareStar will complete assessment for
those with regular Medicaid
Must need at least 1 skilled service a week (nursing or therapy)
Have part-time intermittent needs
(Visits are 4 hours or less with a 2 hour min break in between like services)
Home Health Services
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The SSA will authorize the HHS for those on an DD
waiver
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List all agencies providing home health services (aide,
therapy and nursing)
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Attach care plan from home health agency
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Agency must have Dr.’s prescription, care plan, HHS
worksheet and documentation of medical necessity on
file
Private Duty Nursing Services
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Private Duty Nursing (PDN) is a continuous nursing
service that is more than 4 hours per visit
PDN is required when more than 14 hours of nursing
is needed per week
The service must be provided in the person’s home
unless it is medically necessary for a nurse to
accompany the person into the community
Private Duty Nursing can be provided for the purposes
of respite care
Private Duty Nursing Services
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Once the request is received from the CB, a nurse with
the Ohio Department of Medicaid (ODM) will complete
a face to face assessment to confirm that the person
has a medical condition that requires medically
necessary PDN services
ODM will authorize the amount, scope and duration of
the PDN service
Authorizations require renewal at least annually
State Plan Services
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Prescriptions
Durable Medical Equipment:
http://codes.ohio.gov/oac/5101%3A3-10-03 Appendix A
Doctor and Dental Visits
PT/OT – 30* visits per rolling 12 months
SLP – 30* visits per rolling 12 months
*May be increased with prior authorization
Is a Waiver the Best Option?
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Comparison of Waiver Services and Medicaid Card
Services (State Plan Services)
Medicaid Card (therapies, equipment, doctor
appointments, nursing, etc.)
Can dis-enroll from the waiver at any time if it is not
meeting the need
Contacts and Information
Melinda Draper, DCBDD Waiver Coordinator
[email protected] or 740-201-5808
www.DCBDD.org
http://DODD.Ohio.gov
http://Medicaid.Ohio.gov