Long Term Care Division

1. Long Term Care Division Alabama Medicaid Agency Long Term Care Division February 2008

2. MEDICAID HCBS WAIVERS MADE EASY

3. Medicaid vs. Medicare • Medicaid is a program that provides medical assistance for certain individuals and families with low income and resources. • Medicare is a Health Insurance Program for people 65 years of age and older, some people with disabilities under age 65, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

4. Comparisons

5. Funding Formula • The federal-state funding ratio for Medicaid varies from state to state based on each state’s per capita income. • During FY 2006, the formula was approximately 70/30. For every $30 the state spent, the federal government contributed $70.

6. Eligibility for Medicaid • Persons receiving Supplemental Security Income (SSI) from the Social Security Administration are automatically eligible for Medicaid in Alabama. • Persons approved for “Medicaid for Low Income Families” through the Alabama Medicaid Agency are eligible for Medicaid.

7. Eligibility for Medicaid • Pregnant women and children under six years of age with family income which does not exceed 133% of the federal poverty level are covered by Medicaid. • Persons who are residents of medical institutions (nursing homes, hospitals, or facilities for the mentally retarded) for a period of 30 continuous days and meet very specific income, resource and medical criteria may be Medicaid eligible.

8. Dual Eligibles • Qualified Medicare Beneficiaries (QMBs) have low income. Persons in this group may be eligible to have their Medicare premiums, deductibles, and coinsurance paid by Medicaid. • Specified Low-income Medicare Beneficiaries (SLMBs) and Qualifying Indiviudals-1 (QI-1) have low income above the QMB limit. Persons in this group may be eligible to have their Medicare Part B premiums paid by Medicaid.

9. State Plan Services • The Medicaid State Plan is a written plan submitted by the Medicaid Agency to Centers for Medicare and Medicaid Services (CMS) describing the nature and scope of its Medicaid program. • State Plan Services must be made available to Medicaid eligible individuals who meet the criteria for the specific service or program.

10. 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.

11. 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.

12. HCBS Waivers • Under HCBS Waiver programs, both the comparability and state wideness 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.

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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. Transfer of Waiver Slots • If a client transfers from one waiver to another within the same waiver year, the slot is considered filled and therefore may not be refilled by a different individual.

20. Alabama Medicaid Approved HCBS Waivers • Elderly and Disabled (E&D Waiver) • Mental Retardation Waiver • State of Alabama Independent Living (SAIL) Waiver • Living at Home Waiver • HIV/AIDS Waiver • Technology Assisted (TA) Waiver for Adults

21. Administering State Agency • The Alabama Medicaid Agency has administrative authority over the Home and Community Based Waiver programs.

22. Elderly and Disabled Waiver

23. Operating State Agencies State agencies that operate the Elderly and Disabled Waiver program are: • Alabama Department of Public Health • Alabama Department of Senior Services

24. Target Population • The E&D Waiver is approved to provide Home and Community Based Services to assist elderly and disabled individuals to live in the community who would otherwise require nursing facility care.

25. Waiver Slots • The Elderly and Disabled Waiver is approved to serve 9,205 individuals.

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

27. Mental Retardation Waiver

28. Operating State Agency • Alabama Department of Mental Health and Mental Retardation

29. Target Population • The MR Waiver is approved to provide 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.

30. Waiver Slots • The MR Waiver is approved to serve 5,260 individuals.

31. Residential Habilitation Day Habilitation Respite Care Personal Care Prevocational Services Occupational Therapy Speech Therapy Physical Therapy Supported Employment Companion Services Skilled Nursing Assistive Technology Behavior Therapy Environmental Accessibility Adaptations Specialized Medical Supplies and Equipment Covered Services

32. State of Alabama Independent Living (SAIL) Waiver

33. Operating Agency • Alabama Department of Rehabilitation Services

34. 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.

35. 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 Target Population

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

37. Covered Services • Case Management • Personal Care Services • Environmental Accessibility Adaptations • Personal Emergency Response System (Initial Set-up) • Personal Emergency Response System (Monthly) • Medical Supplies • Assistive Technology • Assistive Technology Repairs • Personal Assistance Services

38. Living At Home Waiver

39. Operating State Agency • Alabama Department of Mental Health and Mental Retardation

40. Target Population • The Living at Home Waiver is approved to provide 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.

41. Waiver Slots Available slots for the Living at Home Waiver is as follows: • 569

42. Residential Habilitation Training Day Habilitation Prevocational Services Supported Employment Occupational Therapy Services Speech and Language Therapy Physical Therapy Behavior Therapy In-Home Respite Out-of-Home Respite Personal Care Personal Care Transportation Environmental Accessibility Adaptations Specialized Medical Equipment and Supplies Skilled Nursing Community Specialist Crisis Intervention Covered Services

43. HIV / AIDS Waiver

44. Operating State Agency • Alabama Department of Public Health

45. 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.

46. Waiver Slots Available slots for the HIV / AIDS Waiver is as follows: • 150

47. Covered Services • Personal Care • Respite Care • Skilled Nursing • Companion Services

48. Technology Assisted Waiver for Adults

49. Operating State Agency • Alabama Medicaid Agency

50. Target Population • Individuals who received private duty nursing services through the Early Periodic Screening Diagnostic Test (EPSDT) Program under the Alabama Medicaid State Plan, who will no longer be eligible for this service upon turning age 21 and for whom private duty nursing services continues to be medically necessary based upon approved private duty nursing criteria.