MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER

Workshop Presented by Maureen Hollowell, Endependence Center June 2007

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HISTORY

MEDICAID



PURPOSE

 Medicaid was established with amendments to the Social Security Act in 1965  Medicaid Buy-In: Medicaid Works  • To provide for health and medical care for certain groups of people who have low income

FLEXIBILITY

• States design their own programs within federal standards

MEDICAID IS A JOINT PROGRAM BETWEEN FEDERAL & STATE GOVERNMENTS

 CENTERS FOR MEDICARE & MEDICAID SERVICES  DEPARTMENT FOR MEDICAL ASSISTANCE SERVICES • • • • Federal agency CMS Previously HCFA cms.hhs.gov

• • • State agency DMAS www.dmas.virginia.gov

VIRGINIA MEDICAID

 DMAS is designated as the single state agency charged with administering Medicaid in Virginia  DMAS contracts or has agreements with other entities for most screening, case management, service and billing related activities  DMAS is responsible for ensuring that the Medicaid program operates in compliance with state and federal laws and regulations

VIRGINIA’S MEDICAID

 Virginia Medicaid budget for fiscal year 2006

$

5,026,980,552

50%

from state funds

50%

from federal funds

 MEDICAID • Federal & state program designed to meet the medical needs of certain people who have low income  SSI • Supplemental Security Income program provides benefits to people who are elderly or disabled who have limited income and resources. Funded with general tax revenues.

 MEDICARE • Federal medical benefits primarily for the elderly financed through the Social Security system  SSDI • Social Security Disability Insurance provides benefits to people who are disabled. Funds are the FICA social security tax paid on workers’ earnings or earnings of their spouses or parents.

MANDATORY

MEDICAID SERVICES

       Inpatient Hospital Services Emergency Hospital Services Outpatient Hospital Services Nursing Facility Care Rural Health Clinics Federally Qualified Health Center Clinic Services Lab and X-Ray Services   Physician Services Home Health Service (if eligible for nursing home)     EPSDT Family Planning Nurse-Midwife Services   Certified Nurse Practitioner Services Transportation Medicare Premiums (Part A) - Hospital ; ( Part B) Supplemental Insurance for Categorically Needy

OPTIONAL

Medicaid Services Provided In Virginia  Other Clinic Services  Podiatrist Services  Optometrist Services  Clinical Psychologist Services  Home Health (if not eligible for nursing home)  PACE  PT, OT & Speech Therapy  Prescribed Drugs  Case Management  Prosthetics  Hospice Services  Mental Health Services  ICF-MR

E arly and P eriodic S creening, D iagnosis and T reatment ( EPSDT )

Medicaid benefits available to children under the age of 21

 

Must be eligible for Medicaid Monitor to prevent health and disability conditions from occurring or worsening, including



services to address such conditions Treatment to “correct or ameliorate conditions,” including maintenance services

EPSDT

         Immunizations Check ups and lab tests Mental health assessment and treatment Health education Eye exams and glasses Hearing exams and hearing aids & implants Dental services Personal care, nursing services Other needed services, treatment and measures for physical and mental illnesses & conditions

Institutional Placements

 Hospitals  Nursing homes  ICFs/MR - Intermediate Care Facility for people with mental retardation or other related conditions    institutions of 4 or more beds for people with MR or other related conditions active treatment and rehabilitation regulated by the federal and state governments  34 ICFs/MR in Virginia  5 large “Training Centers,” several hundred beds at each Center  29 smaller ICFs/MR, ranging from 4 to 88 beds

ELIGIBILITY

Apply at local Department of Social Services

STATE PLAN MEDICAID (Mandatory & Optional Services) Categorical Criteria  Disabled or age 65 or older  Families with children  Pregnant women  Recipients of cash assistance  Low income Medicare beneficiaries Financial Thresholds  Low income and asset guidelines  Thresholds vary by category group  Parental income/resources DO count for minor children  Consideration of exceptionally high medical bills (spend-down) LONG-TERM CARE ( Waivers & Institutions ) Must Need Long-term Care  criteria defined for each Waiver  assessment of need required Financial Thresholds  300% of SSI payment limit for one person ($1,869 per month)  spend-down for 4 of the Waivers  $2000 resource limit  Parent income/resources do NOT count regardless of child’s age Services Required  All Waiver and State Plan (Mandatory and Optional) services you are eligible for

HIPP

 Health Insurance Premium Payment program  DMAS program  May pay a portion or total health insurance premium  Application must be completed separately from the Medicaid application  Application info 800-432-5924

COPAYMENTS

 Some adults may have to pay a copayment for Medicaid services if they do not receive Waiver services.

 People who receive Home and Community Based Medicaid Waiver services

do not

pay copayments for their basic, State Plan Medicaid services.

 However, some people may have to pay a patient-pay for their Waiver services.

PATIENT-PAY RESPONSIBILITIES

$ People may have to pay for some Waiver services if they have income over $1,028 per month (except AIDS and Alzheimer’s Waivers which have no patient-pay) $ Some exceptions for persons who are working (Day Support, DD, EDCD and MR Waivers)

Patient-Pay

Day Support, DD, EDCD and MR Waivers  People may have a patient-pay if income is over $1,028 a month  Can keep earned income up to a total * of 300% of SSI income level if working 20 or more hours/week  Can keep earned income up to a total * of 200% of SSI income level if working 8-20 hours/week  Still have a patient-pay from unearned income for all Waivers except the AIDS and Alzheimer’s Waivers

* total of earned and unearned income

AMERICANS WITH DISABILITIES ACT “A public entity shall administer services, programs, and activities in the

MOST INTEGRATED SETTING

appropriate to the needs of qualified individuals with disabilities.

” 28CFR Section 35.130(d)

OLMSTEAD vs. L.C.

Tommy Olmstead Commissioner Georgia Department of Human Resources Lois Curtis a woman who has mental illness and mental retardation, who was confined to a state psychiatric hospital, and wanted to live outside of the hospital

U. S. SUPREME COURT

 “administer services with an even hand”  “comprehensive, effectively working plan for placing qualified persons with disabilities in less restrictive settings”  “waiting list that moved at a reasonable pace”  www.olmsteadVA.com

WHAT ARE HOME & COMMUNITY BASED MEDICAID WAIVERS?

Waivers give States the flexibility to develop and implement

alternatives to institutionalization

.

WHY WERE HOME & COMMUNITY-BASED WAIVERS ESTABLISHED?

 Slow the growth of Medicaid spending  Institutions are overly restrictive and too highly routine oriented  Permit federal Medicaid funds to be used for community services by people who would otherwise be institutionalized

HOW IS A WAIVER DEVELOPED?

 DMAS develops regulations to implement the Waiver - Public comment is solicited when regulations are proposed  State develops a Waiver application to be submitted to the federal Centers for Medicare and Medicaid Services (CMS) for approval – Task Forces are usually established by DMAS to assist with development of the applications  The Virginia General Assembly allocates funds for Waiver services – Advocates can educate the General Assembly about the need for funds to provide services  Waiver is initially approved by CMS for 3 years and then typically renewed every 5 years – Task Forces are usually established by DMAS to assist with development of the renewal applications

COST EFFECTIVE

To receive approval to implement a Waiver, a State Medicaid agency must assure CMS that it will not cost more to provide home and community based services than providing institutional care would cost

Waiver Must be Cost Effective

 It can be individually cost effective or cost effective in the aggregate • •

Aggregate Cost Effectiveness

The average cost to Medicaid of individuals on the Waiver cannot cost more than the average cost to Medicaid of individuals in the comparable institution

Individual Cost Effectiveness

Cost to Medicaid for the individual in the community can’t exceed the cost in the comparable institution

Medicaid Waivers

Virginia has 7 Home and Community Based Care (1915 (c) ) Waivers State Regulations for the Waivers can be found at: http://leg1.state.va.us/000/reg/TOC12030.HTM#C0120

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12 VAC-30-120-70

Technology Assisted Waiver (Tech Waiver) 

12 VAC-30-120-140

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12 VAC-30-120-210

AIDS Waiver Mental Retardation Waiver (MR Waiver) 

12 VAC-30-120-700

Individual and Family Developmental Disabilities Support Waiver (DD Waiver) 

12 VAC-30-120-900

Elderly or Disabled with Consumer Direction Waiver (EDCD Waiver) 

12 VAC-30-120-1500

Day Support Waiver for Individuals with Mental Retardation (Day Support Waiver)

DIFFERENT INSTITUTION - DIFFERENT WAIVER NURSING HOMES HOSPITAL AIDS Alzheimer’s Elderly or Disabled with Consumer Direction Technology Assisted AIDS Technology Assisted ICF/MR Developmental Disabilities Mental Retardation/ Day Support

Alternative Institutional Placement

 There must be an alternate institutional placement for which Medicaid pays  The individual who is applying for a Waiver must meet the same criteria that is used for admission to the institution  This does not mean that the individual must actually be placed in the institution or make application to an institution

SCREENING PROCESS

Pre-Admission Screening Teams of the Department of Health & Department of Social Services  Elderly or Disabled with Consumer Direction Waiver   AIDS Waiver Alzheimer’s Waiver Department of Medical Assistance Services  Technology Assisted Waiver Community Services Board  MR Waiver (and Day Support Waiver) Department of Health Local Clinics  Developmental Disabilities Waiver

LEVEL OF FUNCTIONING (LOF) SURVEY

 Used for ICF-MR and Day Support, DD and MR Waivers  Completed as part of the screening process  To receive Day Support, DD or MR Waiver services must meet the criteria for admission to an ICF/MR

UNIFORM ASSESSMENT INSTRUMENT (UAI)

 Used for nursing home placement and AIDS, Alzheimer’s, EDCD and Tech Waivers  Completed as part of screening and assessment   Assesses social, physical health and functional abilities To receive AIDS, Alzheimer’s, EDCD or Tech Waiver services must meet criteria for admission to a nursing home

SUPPLEMENT TO SCREENING

DMAS-101A and DMAS-101B

 People who have mental illness, mental retardation or developmental disabilities  Initiated by the nursing home preadmission screening team when screening for nursing home placement and the EDCD Waiver  Preadmission screening team sends supplemental screening request to CSB

PURPOSE OF SUPPLEMENT SCREENING

 Some people with MR or DD have active treatment needs that are not met by nursing homes  Determine the person’s need for active treatment that would not be met by nursing homes

LEVEL II SUPPLEMENT

 Specialized Services  Services Identified By CSB  Responsibility & Entitlement

CASE MANAGEMENT, MR and DD SERVICE

 Ensures development, coordination, implementation, monitoring and modification of the individual’s plan  Links the individual with appropriate community resources and supports  Coordinates service providers  Monitors quality of care

MR WAIVER CASE MANAGEMENT Community Services Boards provide case management services Community Services Boards can also provide other MR waiver services DD WAIVER CASE MANAGEMENT Individual chooses their Case Management organization Various organizations provide Case Management services Case Management organizations cannot provide other DD Waiver services (except Consumer Directed Services Facilitation)

CONSUMER-DIRECTED SERVICES

 Freedom, choice and control remaining with the individual, and sometimes their family • what service is needed • • • • who will provide it when it will be provided where it will be provided how it will be provided In Virginia, CD services were initiated by Centers for Independent Living and the Virginia Board for People with Disabilities in 1989 Virginia Medicaid Waivers have components of consumer direction and self-determination, implementation depends on the individual and their case manager

Consumer-Directed Services

 Virginia offers consumer-directed services in 4 Waivers: • Elderly or Disabled with Consumer-Direction Waiver (since 2005) Personal Care, Respite • Developmental Disabilities Waiver (since 2000) Personal Care, Respite, Companion • • Mental Retardation Waiver (since 2001) Personal Assistance, Respite, Companion AIDS Waiver (began in 2003) – Personal Assistance, Respite

Consumer-Directed Services

 Individual is the employer of record with the IRS     Service Facilitator (SF) writes documentation of need based on information from the individual, monitors the service and provides support as needed to the individual so that the individual can be an employer of their staff SF provides training on recruiting, interviewing and training staff, how to handle difficult situations, how to complete employment paperwork, etc.

SF provides list of attendants, companion aides or respite workers and shows how to place an advertisement for attendants, companion aides and respite workers (the list and ads do not have to be used) Public Partnerships (PPL) acting as a fiscal agent for DMAS pays the attendants, companion aides and respite workers on behalf of the individual

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CONSUMER-DIRECTED STAFF QUALIFICATIONS

Be 18 years old Possess basic math, reading and writing skills Have the required skills to perform job duties Have a valid Social Security number Submit to a criminal history check Willing to attend training requested by the person receiving Waiver services Understand and agree to comply with program requirements TB screening

CONSUMER-DIRECTED STAFF

 Staff (Consumer-Directed employees including attendants, companions, respite workers) • Staff may be related to a consumer, but may not be parents of minor children, spouses, or legal guardians  Exception: Consumer-Directed staff may be other family members or other people who live with the consumer if there is objective written documentation as to why there are no other people available to provide care

CONSUMER INVOLVEMENT

         Person-centered planning Involve people of your choice in developing your Plan Prepare Plan Choose services Choose providers Decide how & when services will be provided Agree to and monitor Plan Quarterly and Annual Review of Plan Right to appeal areas of disagreement

CONSUMER SERVICES PLAN DD and MR WAIVERS

 Written document, signed by the consumer  Addresses all needs of the individual in all life areas  Developed with consumer, providers and others the consumer wants involved CSP will list  services and supports to be provided  who will provide the services and supports  how often the services and supports will be provided

PREPARING FOR CSP

 Who will participate in your meeting  Develop a list of needed supports & services (be honest & frank)  Collect documentation • vocational evaluations • IEPs • • school evaluations medical documentation

HEALTH, SAFETY & WELFARE

Adequate services must be provided Additional or different services should be added if needed to protect health, safety and welfare

Individual and Family Developmental Disabilities Support “DD” Waiver Eligibility Criteria

  “Related Conditions” Waiver Must be 6 years of age and older and meet “related conditions” criteria  Cannot have a diagnosis of mental retardation  Level of Functioning survey used for screening  Call DMAS (804) 786-1465 to request a Request for Screening Form or go to www.dmas.virginia.gov

 There is a waiting list for the DD Waiver

RELATED CONDITIONS

also referred to as developmental disability      Severe chronic disability Attributable to a condition, other than mental illness Manifested before the age of 22 Likely to continue indefinitely Results in substantial limitations in 3 or more areas of major life activity • • • • • • Self-care Understanding and use of language Learning Mobility Self-direction Capacity for independent living

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DD Waiver Services

Adult companion services (CD & agency) (8 hours max day) Assistive technology ($5,000 per year limit) Crisis stabilization (60 day max year) Environmental modifications ($5,000 per year limit) In-home residential support (not congregate) Day Support Skilled Nursing Supported employment Therapeutic consultation Personal emergency response system (PERS) Family/caregiver training (80 hours max year) Respite care (720 hours max year) (CD & agency) Personal assistance services (CD & agency)

DD Waiver Statistics

 Fiscal Year (FY) 2006 Waiver Expenditures (July 2005 through June 2006) = $8,291,641  $21,370 average cost per person FY 2006  388 individuals served FY 2006  Wait list is maintained by DMAS  Approximately 725 people on the wait list  122 new DD Waiver slots available July 2007

MR Waiver Eligibility Criteria

 Must have a diagnosis of mental retardation or be under the age of 6 and at developmental risk  Children on the MR Waiver who do not have a diagnosis of MR at the age of 6, possible transfer to DD Waiver  Screenings are conducted by CSBs  Level of Functioning survey is the screening instrument used   There is a waiting list for the MR Waiver Screening for all Waivers must be provided without any charge to the individual

MR Waiver Services

            Residential support (group home or individual’s home) Day support and prevocational services Supported employment Personal assistance (CD & agency) Respite care (720 hours max/year) (CD & agency) Assistive technology ($5,000 max year) Environmental modifications ($5,000 max year) Skilled nursing services Therapeutic consultation Crisis stabilization (60 days max year) Adult companion (8 hours max day) (CD & agency) Personal emergency response system (PERS)

MR WAIVER WAITING LISTS Urgent and Non-urgent

     CSBs and DMHMRSAS maintain Urgent and Non Urgent lists CSB maintains Planning list CSB provides individual with written notice if placed on a waiting list and if there is a change in status to another list CSB determines who on the Urgent list receives the next available slot Only after all Urgent needs are met statewide will Non-urgent needs be served     Slot moves with you to a different town in VA Vacant or new slots are allocated by the CSB unless there is no need in the CSB’s area Non-urgent = meet criteria for the MR Waiver, including needing services within 30 days, but don’t meet Urgent criteria Planning list = need services in the future

URGENT CRITERIA FOR THE MR WAIVER

      Primary caregiver(s) is/are 55 years or older Living with a primary caregiver who is providing the service voluntarily and without pay and they can’t continue care There is a clear risk of abuse, neglect, or exploitation Primary caregiver has chronic or long term physical or psychiatric condition significantly limiting ability to provide care Individual is aging out of a publicly funded residential placement or otherwise becoming homeless Individual lives with the primary caregiver and there is a risk to the health or safety of the individual, primary caregiver, or other individual living in the home because: • Individual’s behavior presents a risk to himself or others OR physical care or medical needs cannot be managed by the primary caregiver even with generic or specialized support arranged or provided by the CSB

MR Waiver Statistics

 Fiscal Year (FY) 2006 Waiver Expenditures (July 2005 through June 2006) = $325,678,097  $49,353 average cost per person in FY 2006  6,599 individuals served in FY 2006  Wait list is the responsibility of CSBs and DMHMRSAS  Approximately 3,200 people on the waiting lists  330 new MR Waiver slots available July 2007

MENTAL RETARDATION DAY SUPPORT WAIVER

 Only for people now on the MR Waiver Urgent or NonUrgent waiting lists  227 people served in 2006 – 300 slots funded  July 1, 2005 start date  Includes Day Support and Prevocational services  Case Management through the CSBs  People could transition to the MR Waiver

Elderly or Disabled with Consumer Direction Waiver (EDCD) Eligibility Criteria

• • • • Individuals seeking Waiver services are eligible if 65 or older or disabled Must meet nursing home criteria Screening is the conducted by the Preadmission Screening Team using the UAI Questionnaire used to determine if an individual can independently manage Consumer Directed Attendants or if assistance with managing care will be needed

EDCD WAIVER

 Combined E&D and CD-PAS Waivers  Both agency and consumer directed service options available for respite and personal care  Allows for an earned income allowance  42 hour cap per week of CD Personal Care services eliminated

Elderly or Disabled with Consumer Direction Waiver Services

 Services that are available statewide: • • • • Adult Day Health Care Personal Care Services (CD or Agency) Personal Emergency Response System (PERS) Respite (CD, Agency, or Skilled) Individuals can receive up to 720 hours of respite per year Personal assistance services can be provided outside of the individual’s home

EDCD Waiver Statistics

 Fiscal Year (FY) 2006 Waiver Expenditures (July 2005 through June 2006) = $159,629,750  $12,681 average cost per person in FY 2006  12,588 individuals served in FY 2006  No waiting list  Can receive EDCD Waiver while on the waiting list for the DD Waiver or MR Waiver

Technology Assisted Waiver Criteria

 Individual may be eligible if she needs both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing care   Screening: UAI is used for adults and Tech Waiver scoring tool is used for children DMAS reviews individual’s private insurance policy for private duty nursing benefits  Case management provided by DMAS nurses  Different rules for children and adults

Tech Waiver Considerations

ADULTS

   Screening team completes UAI for adults only. DMAS staff follows up to complete the screening for adults Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis Cost effectiveness is compared to nursing facility specialized care

CHILDREN

   DMAS staff completes screening for children Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis; or daily dependence on other device based respiratory or nutritional support Cost effectiveness is compared to hospital costs

Tech Waiver Services

 Services that are available statewide: • • • • Private duty nursing Respite care Durable medical equipment Personal care for individuals over 21 years of age • Environmental Modifications

Tech Waiver Services Limits

• Environmental modifications and Assistive technology provided if medically necessary and cost effective • Respite care has an annual limit of 360 hours per year • Private duty nursing has a limit of 16 hours per day, except • individuals under 21 can receive nursing services 24 hours a day during the first 30 days they receive Tech Waiver services

Tech Waiver Statistics

 Fiscal Year (FY) 2006 Waiver Expenditures (July 2005 through June 2006) = $25,338,140  $85,892 average cost per person in FY 2006  295 individuals served in FY 2006  No waiting list for the Tech Waiver

AIDS Waiver Criteria

 Individuals are eligible for the AIDS Waiver if they have a diagnosis of AIDS or AIDS-Related Complex and would require nursing facility or hospital care  Individuals are screened by a Preadmission Screening Team (DSS social worker, VDH nurse and physician)  Screening tool is the Uniform Assessment Instrument (UAI)

AIDS Waiver Services

 Services that are available statewide: • Case management • • Nutritional supplements Private duty nursing • • Personal assistance/care (CD or Agency) Respite care (CD or Agency) Individuals can receive up to 720 hours of respite per year Personal assistance services can be provided outside of the individual’s home

AIDS Waiver Statistics

 Fiscal Year (FY) 2006 Waiver Expenditures (July 2005 through June 2006) = $738,590  $7,537 average cost per person in FY 2006  98 individuals served in FY 2006  No waiting list for the AIDS Waiver  No patient-pay for the AIDS Waiver

ALZHEIMER’S WAIVER

 For persons with Alzheimer's or related dementia  Must live in a Assisted Living Facility licensed by DSS  Nursing home alternative Waiver  No patient pay  Screening by local DSS or nursing home/hospital staff

SERVICE PROVIDERS

DMAS is responsible for  adequate supply of qualified providers to meet needs of recipients  ensuring the capacity and scope of services are available  ensuring individuals are able to have “provider choice”  enrollment of providers  quality of services

ACCESSING PROVIDERS

 A list of qualified providers for each service in the Consumer Services Plan will be given to you  You have the right to choose your providers  You have the right to visit, interview and research providers  You decide when, where and how you want approved services provided  Case Manager will assist you in locating and choosing providers   You can switch providers if you choose to  Case Manager will contact providers for initiation of services There are shortages of some providers

MEDICAID APPEALS

 Fair Hearing  Right to challenge decisions and actions regarding Medicaid  Request an appeal within 30 days of notice  Decision should be issued by the Hearing Officer within 90 days

RIGHT TO APPEAL WHEN -

 Application of benefits is denied  The agency takes action or proposes to take action which will adversely affect, reduce, or terminate receipt of benefits  Request for a specific benefit is denied; in whole or in part  The agency does not act with reasonable promptness

WAITING LISTS

MR Waiver has 2 waiting lists Urgent and Non-urgent: CSB staff determine who receives available MR Waiver slots DD Waiver waiting list First come, first served with wait list numbers assigned 10% of available money allocated for emergency situations DMAS staff determine who receives available emergency slots No waiting list for AIDS, Alzheimer’s, EDCD and Tech Waiting lists are permissible, but waiting lists must move at a reasonable pace. What is a reasonable pace?