An Overview of Home and Community-Based Waiver Services

1. An Overview of Home and Community-Based Waiver Services Alabama Medicaid Agency Long Term Care Division Revised: December 2007

2. Home Community-Based Service (HCBS) Waivers • In 1981, Congress authorized the waiver of certain federal requirements to enable a state to provide home and community-based services (other than room and board) to individuals who would otherwise require SNF, ICF, or ICF/MR services reimbursable by Medicaid.

3. HCBS Waivers • The waiver programs are called 1915(c) waivers, named after the section of the Social Security Act that authorized them. • Under 1915(c) waiver authority, states can provide services not usually covered by the Medicaid program, as long as these services are required to keep a person from being institutionalized.

4. HCBS Waivers • Under HCBS Waiver programs, both the comparability and statewideness requirements may be waived to enable states to target distinct groups of recipients. • HCBS Waiver Services can be provided only as a vehicle to provide an alternative to institutional care.

5. HCBS Waivers • Initial waivers are approved for three (3) years and renewed every five (5) years thereafter.

6. What are waiver “slots”? • Each waiver program is allotted a certain number of “slots” to be filled by clients approved to receive waiver services within a waiver year.

7. Types of waiver slots • An active waiver slot is one in which a person is actively receiving waiver services and is not in a nursing facility. • A pending waiver slot is one that is pending approval for a person to receive waiver services.

8. Types of waiver slots • A filled waiver slot is one which has a person currently receiving waiver services or who has been receiving waiver services, but had subsequent placement in a nursing facility, has moved or has requested termination from the waiver during the waiver year.

9. More about waiver slots • A filled slot cannot be refilled by another individual within the same waiver year that the vacancy occurred; however, the same individual who previously left the slot may fill the slot.

10. When can a waiver slot be refilled? • Although a waiver slot cannot be refilled within the same waiver year, available slots may be refilled in subsequent waiver years.

11. Transfer of Waiver Slots • If a client transfers from one waiver to another within the same waiver year, the slot that was left vacant is considered filled, and therefore may not be refilled by a different individual. For example, the client is on the MR Waiver and transfers to the LAHW, the MR Waiver slot cannot be refilled until the next waiver year.

12. Elderly and Disabled (E&D) Waiver State of Alabama Independent Living (SAIL) Waiver Mentally Retarded (MR) Waiver Living At Home Waiver HIV/AIDS Waiver Technology Assisted (TA) Waiver for Adults Medicaid Approved Home and Community-Based Waivers

13. Administering State Agency • The Alabama Medicaid Agency has administrative authority over the Home and Community-Based Waivers.

14. Responsibilities of the Alabama Medicaid Agency To assure Centers for Medicaid and Medicare Services that: • The Operating Agency adheres to all federal guidelines described in the approved waiver document; • The health and welfare of the client is protected; • The client has free choice of providers and waiver service workers; • All direct service providers meet the qualifications as outlined in the approved waiver document; and • The client is aware of their right to express concerns regarding service provision and/or direct service provider.

15. Operating State AgenciesResponsibility • State agencies are charged with the responsibility of operating the home and community-based waiver programs.

16. Responsibilities of the Operating Agencies • Manage the program by focusing on improving care for the client; • Protect the health and welfare of the client; • Give the client free choice of providers and waiver service workers; • Make sure all direct service providers meet the qualifications as outlined in the approved waiver document.

17. Elderly and Disabled(E&D) Waiver(Since 1982)

18. E & D Waiver • Assists elderly and/or disabled individuals to live in the community who would otherwise require nursing facility care.

19. E & D Waiver • Operating Agencies: ▪ Alabama Department of Public Health ▪ Alabama Department of Senior Services • No age requirement • 9,205 waiver slots

20. Financial Eligibility Criteria • Individuals receiving SSI and/or State Supplementation; • Widows and Widowers under age 60; • Widows and Widowers age 60 – 64; • Adult children who lose supplemental security income benefits upon entitlement to the child’s insurance benefits based on disability;

21. Financial Eligibility Criteria…continued • SSI related protected groups deemed to be eligible for SSI/Medicaid; • Individuals who would be eligible for Medicaid in an institution because income from either parents or a spouse is not deemed available to them (referred to as institutional deeming).

22. Medical Criteria • Must meet current level of care admissions criteria for nursing facility care.

23. Covered Services • Case Management • Homemaker Services • Personal Care • Adult Day Health • Respite Care (Skilled and Unskilled) • Adult Companion Services • Home Delivered Meals

24. Mentally Retarded(MR) Waiver(Since 1981)

25. MR Waiver • Provides Home and Community-Based Services to Medicaid eligible individuals who would otherwise require the level of care available in an Intermediate Care Facility for the Mentally Retarded (ICF/MR).

26. MR Waiver • Operating Agency • Alabama Department of Mental Health and Mental Retardation • 3 years of age and above • 5260 waiver slots

27. Financial Eligibility Criteria • Social Security Income (SSI) – protected groups deemed to be recipients of SSI • Special home and community-based optional categorically needy groups whose income is not greater than 300% of the SSI federal benefit rate.

28. Medical Eligibility • Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded) Facility.

29. Characteristics of Persons Requiring ICF/MR Care • Intermediate care services for the mentally retarded are those services which are needed because of the severe, chronic nature of the mental impairment that results in substantial functional limitations in three or more of the following areas of life activities:

30. Characteristics of Persons Requiring ICF/MR Care…continued • Self Care • Receptive and expressive language • Learning • Mobility • Self Direction • Capacity for independent living

31. Residential Habilitation Training Residential Habilitation – Other Living Arrangement Day Habilitation – Levels 1-4 Day Habilitation with Transportation – Levels 1-4 Prevocational Services Supported Employment Occupational Therapy Services Speech and Language Therapy Physical Therapy Behavior Therapy – Levels 1-3 In-Home Respite Care Out-of-Home Respite Care Institutional Respite Care Personal Care Personal Care on Worksite Personal Care Transportation Environmental Accessibility Adaptations Specialized Medical Equipment and Supplies Skilled Nursing Assistive Technology Adult Companion Services Crisis Intervention Community Specialist Services Covered Services

32. Living At Home Waiver(Since 2002)

33. Living At Home Waiver • Provides Home and Community-Based Services to Medicaid eligible individuals who would otherwise require the level of care available in an Intermediate Care Facility for the Mentally Retarded.

34. Living At Home Waiver • Operating Agency ▪ Alabama Department of Mental Health and Mental Retardation • 3 years of age and older • 569 waiver slots

35. Financial Eligibility Criteria • Social Security Income (SSI) - protected groupsdeemed to be recipients of SSI.

36. Medical Criteria • Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded)

37. Residential Habilitation In-Home Day Habilitation – Level 1-4 Day Habilitation with Transportation – Level 1-4 Prevocational Services Supported Employment Occupational Therapy Services Speech and Language Therapy Physical Therapy Behavior Therapy – Level 1-3 In-Home Respite Out-of-Home Respite Personal Care Personal Care on Worksite Personal Care Transportation Environmental Accessibility Adaptations Specialized Medical Equipment and Supplies Skilled Nursing Community Specialist Crisis Intervention Covered Services

38. State of Alabama Independent Living (SAIL) Waiver (Since 1992)

39. Operating Agency • Alabama Department of Rehabilitation Services

40. Target Population • The SAIL Waiver is approved to serve disabled adults with specific medical diagnosis who are at risk of being institutionalized in a nursing home.

41. SAIL Waiver Services are provided to, but not limited to persons with the following diagnoses: Quadriplegia Traumatic brain injury Amyotrophic Lateral Sclerosis Multiple Sclerosis Muscular Dystrophy Spinal Muscular Atrophy Severe Cerebral Palsy Stroke Other substantial neurological impairments, severely debilitating diseases, or rare genetic diseases (such as Lesch-Nyhan disease). Target Population

42. Waiver Slots • The SAIL Waiver is approved to serve 660 individuals.

43. Financial Eligibility Criteria • Individuals receiving SSI; • Individuals receiving State Supplementation; • SSI related protected groups deemed to be eligible for SSI/Medicaid; • Special HCBS Waiver disabled individuals whose income is not greater than 300% of the SSI Federal Benefit Rate.

44. Covered Services • Case Management* • Personal Care Services • Environmental Accessibility Adaptations* • Personal Emergency Response System (Initial Set-up) • Personal Emergency Response System (Monthly) • Medical Supplies • Minor Assistive Technology • Assistive Technology • Evaluation for Assistive Technology* • Assistive Technology Repairs • Personal Assistance Services *Includes Transitional Services

45. HIV/AIDS Waiver(Since 2003)

46. Operating State Agency • Alabama Department of Public Health

47. Target Population • The HIV / AIDS Waiver is designed to address the needs of individuals with a diagnosis of HIV, AIDS, and related illness who meet the nursing facility level of care criteria.

48. Waiver Slots • The HIV/AIDS Waiver is approved to serve 150 individuals.

49. Financial Eligibility Criteria • Individuals receiving SSI • Disabled individuals with income up to 300% of the SSI income level.

50. Covered Services • Case Management • Personal Care • Homemaker Services • Respite Care • Skilled Nursing • Companion Services