Transcript ODMRDD Waivers

Everything You Need to Know
About
Your Medicaid Waiver
Delaware County Board of Developmental Disabilities
November 2009
1
What is a Waiver?
A waiver is another way that Medicaid can pay for
services to keep people with disabilities in their
homes so they do not have to move to a long-term
care facility or nursing home. The local county board
is required to pay 40% of the cost of waiver services
and Medicaid pays the remainder (also known as
HCBS waiver)
In order for an individual to receive a waiver, they
must make application to be placed on the waiting
list
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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.
3
Waiting Lists in Delaware County
In Delaware County, each priority group has a
weighted point value which is used to determine
the individuals priority score
All waiting lists are ordered first by priority score
and then date and time of application
One must have a minimum score of 2 in order to
meet priority for the Level One Waiver. This
increases to a minimum score of 11 in order to
meet priority for the Individual Options Waiver
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Why do I want a waiver?
Comparison Charts for local funding
Medicaid Card (therapies, equipment, doctor
appointments, nursing)
Can disenroll from the waiver at any time if it is
not meeting the need
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Applying for a Waiver
A person must be Medicaid eligible to be eligible for a waiver
Adults on the waiting lists should apply for Medicaid if his/her
name is on the waiting list (JFS 7200)
Medicaid eligibility is determined by the local Job & Family
Services office and takes into consideration:
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Income
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Assets
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Disability and age
Children will need to wait until a slot is available and assigned
before applying for Medicaid due to household income
inclusions
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Applying for a Waiver continued…
Delaware County Board of DD will send the
Medicaid and Waiver applications to the family (7200
and 2300)
The family will complete the applications and send
them to DCJFS. DCJFS will set an appointment and
send notification to the family
A person must remain eligible for Medicaid to receive
waiver services
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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
IO and LV1 providers will not bill DCBDD for waiver services.
Billing is completed through the MBS on-line application and
payment is made by DODD
Medicaid Card Service (State Plan/CORE) providers are listed at
http://www.ohiohcp.org/
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Waiver Enrollment
Ages 5 and Under
Reports from EI Specialists, school staff or therapists that
document delays in at least three of six areas (reports must
be less than 6 months old). Delay areas include (OAC
5101:3-3-07(D)(2)):
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Adaptive behavior
Physical development or maturation, fine and gross motor skills, growth
Cognition
Communication
Social or emotional development
Sensory Development
Protective Level of Care
Ohio Developmental Disability Profile*
*exclusive to the individual options waiver
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Waiver Enrollment
Ages 6 and Over
Functional Assessment
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Ages 6-8 Attachment C
Ages 9-11 Attachment D
Ages 12-15 Attachment E
Ages 16+ Attachment F
Protective Level Of Care
Medical Evaluation
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Not time sensitive
Must contain relevant information and confirm diagnosis
Psychological report
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Not time sensitive
Must contain relevant information and confirm diagnosis
Ohio Developmental Disability Profile*
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*exclusive to the individual options waiver
Individual Options
Services available with the IOW include:
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Homemaker Personal Care
Transportation
Environmental accessibility modifications
Adaptive & Assistive equipment
Social work*
Interpreter*
Home delivered meals*
Nutritional services*
Adult Day Waiver Services
*exclusive to the individual options waiver
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Level One
Services available with LV1 waiver include:
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Homemaker/Personal Care
Informal Respite*
$5000 annual cap combined
Institutional Respite
Transportation
Personal Emergency Response Systems
$6000 cap
Specialized Medical Equipment and Supplies
over a 3
yr. period
Environmental Accessibility Adaptations
Emergency Assistance*
$8000 cap over a 3 yr period – must meet
emergency status to access this service.
Adult Day Waiver Services
*exclusive to the level one waiver
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Waiver Service Planning
Complete Individual Support Plan (ISP) with your team
Complete Payment Authorization for Waiver Services (PAWS)
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Read and understand your PAWS (refer to sample PAWS)
Waiver 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 card services
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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
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State Plan Services
Home Health Services
(OAC 5101:3-12-01)
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Services anyone with a Medicaid card and a
Doctor’s order can access
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Available Statewide
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No waiting list
Home Health Services
Home Health Services include:
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Home Health Nursing
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Home Health Aide
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Skilled therapies (OT,PT,SLP)
Services must be medically necessary as ordered
by the treating physician.
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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/aide
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Home Health Services
To meet the requirement of ‘intermittent’, similar
services cannot be ‘stacked’
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For example—2 consecutive hours of service
cannot be authorized as 1 hour of Home
Health Services aide and 1 hour as Waiver
HPC provider.
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A 2 hour break is required.
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
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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
Permitted
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HH Aide
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
Waiver Nursing
Permitted
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Home Health Aide
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
HH Aide
Waiver Informal
Respite Provider
Permitted
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HH Aide
Home Health Services
Home Health Services
cannot be provided for
the purposes of respite
or habilitative care
23
Home Health Services
Per OAC 5101:3-12-01 (D) (4) (c)
“Respite care” is the care provided to a
consumer unable to care for himself or herself
because of the absence or need for relief of
those normally providing care.
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Home Health Services
Must be provided in the
consumer’s place of
residence or in a
licensed day care, or
in an Early Intervention
program .
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Home Health Services
Home Health Aide Services
Per OAC 5101-3-12-01(F)(2)(e)
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
Per OAC 5101-3-12-01(F)(2)(f)
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Incidental Services can include: light chores, laundry, light
house cleaning, meal prep and taking out trash
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Main purpose of a Home Health Aide visit cannot be solely to
provide incidental services
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Incidental services are to be performed only for the consumer
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May NOT provide medication administration
Home Health Services Worksheet
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The SSA will complete the HHS worksheet for those
on an MRDD waiver (DCBDD form)
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List all agencies providing home health services
(aide, therapy and nursing less than 14 hours per
week)
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Attach care plan from home health agency
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Agency must have Dr’s script, care plan and HHS
worksheet on file
Increased Home Health
Eligibility:
Up to age 21
Must have a comparable institutional level of care (ILOC, ICF
MR/DD LOC, or SLOC)
Must need at least 1 skilled service a week (nursing or therapy)
Have part-time intermittent needs
(Visits must continue to be 4 hours or less with 2 hour min break in
between like services)
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Home Health Services
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Must be reflected on service plan for children enrolled on a
DODD-administered waiver. (Use worksheet)
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For children on ODJFS-administered waivers, the case
manager authorizes these services via the service
planning process.
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Provider Type---Medicare Certified Home Health Agency
providers are listed at http://www.ohiohcp.org/
Home Health Services Crosswalk
Services at a Glance
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Types of services
Separated into age
groups
Eligibility
Providers
State Plan Therapies
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SLP, OT, PT
Fee for Service
HHA
Hospital
Physician
IPs (not available for all
services)
Private Duty Nursing Services
OAC 5101:3-12-02
Private Duty Nursing is continuous nursing that is more than 4
hours per visit.
PDN is required when more than 14 hours of nursing is needed
per week.
Must be provided in the consumer’s place of residence unless it is
medically necessary for a nurse to accompany the consumer
into the community.
The Private Duty Nursing Service can be provided for the
purposes of respite care.
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Private Duty Nursing
ODJFS shall complete a face-to-face assessment to confirm
that the consumer has a medical condition that requires
medically necessary PDN services once they receive the
request form from the CB.
ODJFS will authorize the amount scope and duration of PDN
services.
Authorized for no more than 1 year for consumers enrolled on
an DODD-administered waiver
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Durable Medical Equipment
Rule:
5101:3-10-03 "Medicaid Supply List“
List of supplies:
http://www.registerofohio.state.oh.us/pdfs/5101/3/10/5101$3-1003_PH_FF_A_APP1_20090320_1057.pdf
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Any Questions?
Ohio Department of Developmental Disabilities
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http://dodd.ohio.gov/
Delaware County Board of DD
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www.dcbdd.org
Ohio Department of Job & Family Services
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http://jfs.ohio.gov/
Questions?
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Melinda Draper
Roxanne Richardson
Waiver Coordinator
[email protected]
740-368-5802 ext 506
Support Administrator
[email protected]
740-368-5801 ext 308