navigating the new system …community care waiver, waiting list changes, and individualized budgets

Navigating the New Navigating the New SystemSystem

…Community Care Waiver,…Community Care Waiver,Waiting List Changes, and Waiting List Changes, and

Individualized BudgetsIndividualized Budgets

2009 - Rev 8/24/092009 - Rev 8/24/09 The Arc of New Jersey & The Arc of New Jersey & NJDHS-DDD NJDHS-DDD

Overview of PresentationOverview of Presentation

Who we areWho we are Three things you will know after Three things you will know after

tonight:tonight:• What Medicaid isWhat Medicaid is• What the Community Care Waiver isWhat the Community Care Waiver is• How to get services How to get services


What is Medicaid?What is Medicaid?

Government funded health insurance Government funded health insurance program for low income children and program for low income children and families, and adults who are aged, blind or families, and adults who are aged, blind or disableddisabled

Pays for doctor visits, prescription drug Pays for doctor visits, prescription drug coverage, other medical servicescoverage, other medical services

Covers services other insurance often Covers services other insurance often doesn’t: personal care, and long term doesn’t: personal care, and long term services & supportsservices & supports


What is the Community Care What is the Community Care Waiver…Waiver…

Funding mechanism for servicesFunding mechanism for services Funds services in group homes, day Funds services in group homes, day

programs, in-home supportsprograms, in-home supports Federal government contributes to Federal government contributes to

the cost of servicesthe cost of services When services are not covered under When services are not covered under

waiver, the state pays the entire costwaiver, the state pays the entire cost


……and Why is it Important?and Why is it Important?

It allows people to receive services in It allows people to receive services in the community rather than in an the community rather than in an institutioninstitution

It offers a wider variety/range of It offers a wider variety/range of services & supportsservices & supports

Because of the federal funds, it has Because of the federal funds, it has potential to provide more money so potential to provide more money so the State can serve more peoplethe State can serve more people


……and Why is it Important?and Why is it Important?

And, it is the only way to access long And, it is the only way to access long term supports and ensure that your term supports and ensure that your son/daughter will be properly son/daughter will be properly supported throughout his/her lifetimesupported throughout his/her lifetime

Extensive waiting listExtensive waiting list


How Do You Get Services?How Do You Get Services?

Become DDD eligibleBecome DDD eligible Get on the Waiver Waiting ListGet on the Waiver Waiting List While you are waiting, you may be While you are waiting, you may be

eligible for non-waiver-funded eligible for non-waiver-funded servicesservices• Contact your DDD case manager to find Contact your DDD case manager to find

out what services you can get while out what services you can get while waiting for a waiver “slot”waiting for a waiver “slot”


Overview of New System & Overview of New System & Changes that are ComingChanges that are Coming

The only REAL/practical differences The only REAL/practical differences are:are:• The vocabularyThe vocabulary• What you get when you reach the top of What you get when you reach the top of

the waiting listthe waiting list• You will have more choices in terms of You will have more choices in terms of

what services you can get and from what services you can get and from whomwhom


New SystemNew System

Self-direction OptionSelf-direction Option• Based more on in-home supportsBased more on in-home supports• Funding flows from DDD through Fiscal Funding flows from DDD through Fiscal

IntermediaryIntermediary• Waiting list for “waiver slot”Waiting list for “waiver slot”


New SystemNew System

Provider-Managed OptionProvider-Managed Option• Individual chooses a provider agencyIndividual chooses a provider agency• Payment made directly to providerPayment made directly to provider• Waiting list for “waiver slot”Waiting list for “waiver slot”


What We Know for SureWhat We Know for Sure

National TrendNational Trend DDD has stated that this change is DDD has stated that this change is

already being implementedalready being implemented Self advocates & families will need a Self advocates & families will need a

new set of skills & new vocabularynew set of skills & new vocabulary


How does the Waiver System How does the Waiver System Work?Work?

Determination of eligibility for waiver Determination of eligibility for waiver servicesservices• Waiting list criteriaWaiting list criteria• Reserve capacity within the waiverReserve capacity within the waiver

AssessmentAssessment Individual Budget – Decision to self-direct Individual Budget – Decision to self-direct

or notor not Plan DevelopmentPlan Development If not eligible, then look at non-waiver & If not eligible, then look at non-waiver &

waiver services funded with state dollarswaiver services funded with state dollars


What does “Self-Direct” Mean?What does “Self-Direct” Mean?

Support Coordinator assignedSupport Coordinator assigned How do I find service providers?How do I find service providers? Who checks to see if services are Who checks to see if services are

being delivered?being delivered? How does the money get paid to the How does the money get paid to the

provider? How much? Can I provider? How much? Can I negotiate?negotiate?

What if my needs change?What if my needs change?


Waiver Waiting ListWaiver Waiting List

All move to waiver waiting list if not All move to waiver waiting list if not currently enrolled on waivercurrently enrolled on waiver

When your name comes up on list, When your name comes up on list, you will receive services you need at you will receive services you need at that time, and be removed from list that time, and be removed from list

If needs change, the changes will be If needs change, the changes will be accommodatedaccommodated


How Waiting List Will WorkHow Waiting List Will Work

Name comes upOn

Priority Waiting List

Enrolled onWaiver; nameRemoved from

WL

Not eligible forwaiver; name re-

moved from WL; Services

provided with state$$

Refuses enrollment;name removed fromWL; some services

provided with Reduced State $$


Changes in NeedChanges in Need

If needs change, an If needs change, an updated plan is updated plan is completedcompleted

Services change to fit Services change to fit the needthe need

Waiver eligibility is Waiver eligibility is preserved regardless preserved regardless of residenceof residence

Waiver is portableWaiver is portable


Review of Covered Services in Review of Covered Services in CCWCCW

Case ManagementCase Management Day HabilitationDay Habilitation Individual SupportsIndividual Supports RespiteRespite Supported EmploymentSupported Employment Community Transition ServicesCommunity Transition Services Support CoordinationSupport Coordination Assistive Technology DevicesAssistive Technology Devices Environmental and Vehicle AdaptationsEnvironmental and Vehicle Adaptations Personal Emergency Response System (PERS) Personal Emergency Response System (PERS) TransportationTransportation


Non-Medicaid Funded ServicesNon-Medicaid Funded Services

Family SupportFamily Support Residential (room & board) after Residential (room & board) after

contribution to care receivedcontribution to care received Start-up costs for residential Start-up costs for residential

placements, other than Transition placements, other than Transition servicesservices

Discussion of what should be covered Discussion of what should be covered by state-only fundsby state-only funds


QuestionsQuestions


Contact Contact

Start with your Case ManagerStart with your Case Manager Contact me by email, if possible:Contact me by email, if possible:

• [email protected]@dhs.state.nj.us• 609-631-6502609-631-6502


Medicaid 101Medicaid 101

What is Medicaid?What is Medicaid?• Medical assistance to individuals who Medical assistance to individuals who

are aged, blind or disabled and TANFare aged, blind or disabled and TANF• Income testIncome test• Resource testResource test


Medicaid 101Medicaid 101

Services covered under MedicaidServices covered under Medicaid• Mandatory servicesMandatory services

E.g., physician, hospitalization, pharmacyE.g., physician, hospitalization, pharmacy

• Optional servicesOptional services E.g., therapy, private duty nursingE.g., therapy, private duty nursing

• Each state determines scope, duration, Each state determines scope, duration, and amountand amount


Waiver 101… orWaiver 101… or Why Have a Waiver? Why Have a Waiver?

• Institutional eligibility vs. in-home Institutional eligibility vs. in-home eligibility for Medicaideligibility for Medicaid

• Non-traditional services neededNon-traditional services needed• Amendment to the Social Security Act in Amendment to the Social Security Act in

19811981• Created 1915 (c) option for statesCreated 1915 (c) option for states


Waiver 101Waiver 101 Home and Community Home and Community

Based ServicesBased Services• Allows state to limit Allows state to limit

number of individuals number of individuals enrolledenrolled

• Allows state to refuse Allows state to refuse enrollment if individual enrollment if individual cost is higher than cost is higher than institutionalinstitutional

• Standards for providers Standards for providers

Additional Additional “waivers” “waivers” requested:requested:• StatewidenessStatewideness• Amount, duration Amount, duration

and scopeand scope• ComparabilityComparability• Institutional incomeInstitutional income


Waiver 101Waiver 101

EligibilityEligibility• State specificState specific• IncomeIncome• ResourcesResources• Level of careLevel of care• Service need Service need


CMS OversightCMS Oversight

Level of Care Level of Care Services Services Plan Plan Qualified ProvidersQualified Providers Financial AccountabilityFinancial Accountability Administrative Oversight by Medicaid Administrative Oversight by Medicaid

AgencyAgency


New Jersey WaiversNew Jersey Waivers

AIDS Community Care Alternatives AIDS Community Care Alternatives Program (ACCAP)Program (ACCAP)

Community Resources for People Community Resources for People with Disabilities (CRPD) with Disabilities (CRPD) • combined three model waiverscombined three model waivers

Acquired Traumatic Brain Injuries Acquired Traumatic Brain Injuries (TBI)(TBI)


New Jersey WaiversNew Jersey Waivers

Global Options (GO) – Global Options (GO) – combined Community Care Program for the combined Community Care Program for the Elderly and Disabled (CCPED) and Elderly and Disabled (CCPED) and

Enhanced Enhanced Community Options (ECO)Community Options (ECO)

Community Care Waiver (CCW)Community Care Waiver (CCW)


CommunityCommunity Care Waiver Care Waiver

Nationally, the second waiver Nationally, the second waiver approved by federal governmentapproved by federal government

Refinanced group home servicesRefinanced group home services Model used by many other statesModel used by many other states Changes needed to update modelChanges needed to update model


Revisions to CCWRevisions to CCW

Philosophical Philosophical ChangesChanges

Changed ServicesChanged Services New ServicesNew Services Deleted ServicesDeleted Services



Services where Services where you liveyou live• With familyWith family• ApartmentApartment• Supportive livingSupportive living• Group homeGroup home



Self-directionSelf-direction• added as option (includes Real Life Choices, added as option (includes Real Life Choices,

Self-Determination, and Olmstead individuals Self-Determination, and Olmstead individuals who self-direct, and individuals served from who self-direct, and individuals served from Waiting List)Waiting List)

• Provider directed model still availableProvider directed model still available Essential Life PlanEssential Life Plan

• added as alternate plan of care for individuals added as alternate plan of care for individuals who self-direct or have an individual budgetwho self-direct or have an individual budget



Regional Monitor for Individuals who Regional Monitor for Individuals who Self-directSelf-direct (new administrative service) (new administrative service) • Assures that the following is completed: Assures that the following is completed:

Assessment for waiver eligibilityAssessment for waiver eligibility Level of careLevel of care Assignment of budget amountAssignment of budget amount Review & approve service planReview & approve service plan Assure health & safety factors consideredAssure health & safety factors considered Approves expendituresApproves expenditures



Retainer days paid for absences from day Retainer days paid for absences from day program and residential supportsprogram and residential supports• ““Therapeutic” daysTherapeutic” days• Hospital days & related stays in other Hospital days & related stays in other

facilitiesfacilities


New ServiceNew Service

Support CoordinationSupport Coordination• For persons who self-directFor persons who self-direct• Connects people to servicesConnects people to services• Providers of Support Coordination are Providers of Support Coordination are

employed by agencies other than the employed by agencies other than the DivisionDivision

• Conflict of Interest provisionConflict of Interest provision


Revisions to CCW Revisions to CCW

New individuals enrolled on waiver New individuals enrolled on waiver are assigned funding maximum are assigned funding maximum based on the Developmental based on the Developmental Disability Review Tool (DDRT)Disability Review Tool (DDRT)

Remove Psychiatry & ITN as a Remove Psychiatry & ITN as a covered servicecovered service


New ServicesNew Services

Transition ServicesTransition Services• For people being discharged from For people being discharged from

institutional settingsinstitutional settings• Must be entering a non group home Must be entering a non group home

settingsetting• Pays for deposits, furniture, one time Pays for deposits, furniture, one time

services (cleaning, extermination, etc.), services (cleaning, extermination, etc.), movingmoving

• Up to 180 days prior to moveUp to 180 days prior to move



Respite changesRespite changes• Clarify respite payment cannot be Clarify respite payment cannot be

made to relative who lives with made to relative who lives with individualindividual

• Expands eligible providersExpands eligible providers Camp (no out of state)Camp (no out of state) ICF/MRICF/MR Group respite at no more than 1:4 ratioGroup respite at no more than 1:4 ratio



Day HabilitationDay Habilitation• Changed nameChanged name• Added hourly units (no more than Added hourly units (no more than

25/wk)25/wk)• Distance between individual’s residence Distance between individual’s residence

& day habilitation site is not greater & day habilitation site is not greater than 38 milesthan 38 miles



Individual SupportsIndividual Supports• Added hourly units (ratio cannot exceed Added hourly units (ratio cannot exceed

1:4)1:4)• Requires drug & alcohol testing & Requires drug & alcohol testing &

orientation trainingorientation training• Permits family member residing in home to Permits family member residing in home to

provide services for a limited period (no provide services for a limited period (no more than 40 hours per week for no more more than 40 hours per week for no more than 30 days annually) during transition of than 30 days annually) during transition of staffstaff



Environmental/Vehicle ModificationEnvironmental/Vehicle Modification• Total expenditure of $11,000 every Total expenditure of $11,000 every

three years in conjunction with three years in conjunction with Assistive Technology Devices (new Assistive Technology Devices (new

service)service) Transportation (new service)Transportation (new service)

navigating the new system …community care waiver, waiting list changes, and individualized budgets

Documents

services funds services

medical services

covers services

nonwaiverfunded services

ddd eligible

long term services

waiver slot slide

waiver slotwaiting list