MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER

1. MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER Funded by Virginia Board for People with Disabilities Workshop Presented by Maureen Hollowell, Endependence Center Administered by Endependence Center, Norfolk, VA Fall 2003

2. ? MYTH OR FACT ? 1. I have to need the level of care provided in an institution to qualify for Waiver services. 2. Waiver eligibility for children depends on parent income. 3. Each Waiver offers the same services. 4. I can choose my providers from a list of qualified providers. 5. The administrative appeal process is expensive. 6. All persons with a disability of mental retardation or developmental disability will qualify for the MR or DD Waivers. 7. I can be on a wait list for the DD Waiver or the MR Waiver while I am receiving services through another Waiver.

3. MAKING CHANGE • information is power • influence and control • rights must be pursued • collaboration • credibility

4. MEDICAID • Federal & state program designed to meet the medical needs of certain people who have low income • MEDICARE • Federal medical benefits primarily for the elderly financed through the Social Security system • 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. • 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.

5. MEDICAID • HISTORY • Medicaid was established with amendments to the Social Security Act in 1965 • Medicaid Buy-In • PURPOSE • 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

6. CENTERS FOR MEDICARE & MEDICAID SERVICES Federal agency CMS Previously HCFA cms.hhs.gov DEPARTMENT FOR MEDICAL ASSISTANCE SERVICES State agency DMAS www.dmas.state.va.us MEDICAID IS A JOINT PROGRAM BETWEEN FEDERAL & STATE GOVERNMENTS

7. 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

8. VIRGINIA’S MEDICAID • Virginia Medicaid budget for fiscal year 2002 $ 3,784,312,817 48.45% from state funds 51.55% from federal funds

9. STATE PLANFOR MEDICAL ASSISTANCE • Details Virginia’s • eligibility requirements • coverage • reimbursement • administrative policies • Periodically updated to reflect changes • Changes must be approved by CMS • To add services requires a change to the State Plan AND • Possibly a commitment of dollars from the Virginia General Assembly

10. 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 EPSDT Family Planning Nurse-Midwife Services Certified Nurse Practitioner Services Transportation Medicare Premiums (Part A) - Hospital; (Part B) - Supplemental Insurance for Categorically Needy MANDATORYMEDICAID SERVICES

11. Other Clinic Services Skilled Nursing Facility Services for Individuals under 21 years of age Podiatrist Services Optometrist Services Clinical Psychologist Services Home Health PT, OT, and Speech Therapy Prescribed Drugs Case Management Prosthetics Hospice Services Mental Health Services ICF-MR OPTIONALMedicaid Services Provided In Virginia

12. Early and Periodic Screening, Diagnosis and Treatment (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

13. 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

14. 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 • 24 ICFs/MR in Virginia • 5 large “Training Centers,” several hundred beds at each Center • 19 smaller ICFs/MR, ranging from 4 to 88 beds

15. STATE PLANMEDICAID (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 ($1,656 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 ELIGIBILITY Apply at local Department of Social Services

16. HIPP • Health Insurance Premium Payment program • DMAS program • Pays health insurance premiums • Application must be completed separately from the Medicaid application • Application info 800-432-5924

17. COPAYMENTS • Some people 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.

18. PATIENT-PAY RESPONSIBILITIES • People may have to pay for some Waiver services if they have income over $552 per month (except AIDS Waiver which has no patient-pay) • Some exceptions for persons who are working (CD-PAS, DD and MR Waivers)

19. Patient-PayCD-PAS Waiver, DD Waiver, MR Waiver • People may have a patient-pay if income is over $552 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 Waiver * total of earned and unearned income

20. 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)

21. OLMSTEAD vs. L.C.U.S. SUPREME COURT Tommy Olmstead Commissioner Georgia Dept. of Human Resources Lois Curtis a woman who has mental illness and mental retardation, who was confined to a state psychiatric hospital, wanted to live outside of the hospital

22. 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” No concrete date given by the Supreme Court

23. OLMSTEAD PLAN FOR VIRGINIA • Task Force • “One Community – Final Report of the Task Force to Develop an Olmstead Plan for Virginia” • www.olmsteadVA.com

24. WHAT ARE HOME & COMMUNITY-BASED MEDICAID WAIVERS? Waivers give States the flexibility to develop and implement alternatives to institutionalization.

25. 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

26. HOW IS A WAIVER DEVELOPED? • 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 • DMAS develops regulations to implement the Waiver - Public comment is solicited when regulations are proposed • 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

27. 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

28. Waiver Must be Cost Effective • It can be individually cost effective or cost effective in the aggregate • Aggregate Cost EffectivenessThe 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

29. Medicaid Waivers Virginia has 6 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 • 12 VAC-30-120-10 Elderly & Disabled Waiver (E&D Waiver) • 12 VAC-30-120-70 Technology Assisted Waiver (Tech Waiver) • 12 VAC-30-120-140 AIDS Waiver • 12 VAC-30-120-210 Mental Retardation Waiver (MR Waiver) • 12 VAC-30-120-490 Consumer-Directed Personal Attendant Services Waiver (CD-PAS Waiver) • 12 VAC-30-120-700 Individual and Family Developmental Disabilities Support Waiver (DD Waiver)

30. DIFFERENT INSTITUTION - DIFFERENT WAIVER • HOSPITAL • AIDS • Technology Assisted NURSING HOMES • AIDS • Elderly and Disabled • Consumer Directed -PAS • Technology Assisted • ICF/MR • Mental Retardation • Developmental Disabilities

31. 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

32. SCREENING PROCESS Pre-Admission Screening Teams of the Department of Health & Department of Social Services • Elderly and Disabled Waiver • CD-PAS Waiver • AIDS Waiver Department of Medical Assistance Services • Technology Assisted Waiver Community Services Board • MR Waiver Department of Health Local Clinics • Developmental Disabilities Waiver

33. LEVEL OF FUNCTIONING (LOF) SURVEY • Used for DD and MR Waivers • LOF Survey is completed as part of the screening process • Determines the level of care needed • To receive DD or MR Waiver services, an individual must meet the criteria for admission to an ICF/MR

34. UNIFORM ASSESSMENT INSTRUMENT (UAI) • Used for nursing home placement and the AIDS, CD-PAS, E&D and Tech Waivers • Completed as part of screening and assessment • Assesses social, physical health and functional abilities • Used to gather info for planning and monitoring needs and eligibility

35. SUPPLEMENT TO SCREENING • 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 CD-PAS and E&D Waivers • Preadmission screening team sends supplement screening request to CSB

36. PURPOSE OFSUPPLEMENT SCREENING • Some people with MR or DD have active treatment needs that are not met by nursing homes or nursing home-related Waivers • Determine the person’s need for active treatment that would not be met by nursing homes or nursing home-related Waivers

37. LEVEL II SUPPLEMENT • Specialized Services • Services Identified By CSB • Responsibility & Entitlement

38. CASE MANAGEMENT,MR SERVICE SUPPORT COORDINATION, 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

39. MR WAIVER CASE MANAGEMENT Community Services Boards provide case management services DD WAIVER SUPPORT COORDINATION Individual chooses their Support Coordination organization Various organizations provide Support Coordination services Support Coordination organizations cannot provide other DD Waiver services (except Consumer Directed Services Facilitation)

40. 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 the case manager or support coordinator

41. Consumer-Directed Services • Individual or family caregiver directs and controls who, how, and when services are provided • Virginia offers consumer-directed services in 4 Waivers: • Consumer-Directed Personal Attendant Services Waiver (since 1997) - Attendant • Developmental Disabilities Waiver (since 2000) - Attendant, Respite • Mental Retardation Waiver (since 2001) - Attendant, Respite, Companion • AIDS Waiver (began in 2003) – Attendant, Respite

42. 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) • DMAS (acting as a fiscal agent) and a contractor pays the attendants, companion aides and respite workers on behalf of the individual

43. 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 • Willing to register in a CD-staff registry • Understand and agree to comply with program requirements

44. ADDITIONAL REQUIREMENTS OF CONSUMER-DIRECTED STAFF AIDS, DD, & MR WAIVERS Consumer-Directed Staff must receive: TB screening CPR training Annual flu shot

45. CONSUMER-DIRECTEDSTAFF • Staff (Consumer-Directed employees including attendants, companions, respite workers) • Staff may be related to a consumer, but may not be members of the immediate family (parents of minor children, spouses, or legally responsible relatives) • Exception: Payments may be made to other staff who are family members when there is objective written documentation as to why there are no other providers available to provide care

46. 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

47. CONSUMER SERVICES PLANDD 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

48. 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

49. WHAT ARE YOUR GOALS FOR COMMUNITY AND INDEPENDENT LIVING ?

50. TO LIVE IN MY OWN APARTMENT(example)