Virginia Medicaid Waivers:

Access and ServicesDebra Holloway

Director of Training and Technical Assistance

Achieve with Us.

Different Institution Different Waiver

• Waivers provide funding for a wide variety of services for people of all ages who have disabilities or are elderly so that they may remain in their homes and communities rather than an institutional placement such as a hospital, nursing home or ICFs/MR (intermediate care facility)

Waivers Must be Cost Effective

• Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than compatible institution care.

• The elderly and disabled represent 30% of Medicaid program

recipients.

Different Waivers Have Different Services

Adult Day Health CareAssistive TechnologyCase ManagementCompanion Services Transition ServicesCrisis Intervention/Stabilization Prevocational ServicesDay Support Residential SupportEnvironmental Modifications RespiteFamily Caregiver Training Skilled NursingNursing Service Supported EmploymentNutritional Supplements Therapeutic ConsultationPersonal Care Services Transition CoordinationPersonal Emergency Response System

There are Seven Waivers Administered by the

Commonwealth of Virginia

• Elderly or Disabled with Consumer Direction (EDCD)

• Individual and Family Developmental Disabilities Supports (IFDDS)

• HIV/AIDS • Technology Assisted (Tech) • Intellectual Disabilities Waiver (ID) • Day Support • Alzheimer’s Assisted Living (AAL) Waiver

managed by the Facility and Home-Based Care Unit

• Mental Health Waiver (Demonstration Waiver)

Reviewing Today:Reviewing Today:

• Elderly or Disabled with Consumer Direction Waiver (EDCD)

• Technology Assisted Waiver (Tech)• Individual and Families with

Developmental Disabilities Waiver (DD)

• Intellectual Disabilities Waiver (ID)

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:

– Elderly or Disabled with Consumer-Direction Waiver - Personal Care, RespitePersonal Care, Respite

– Developmental Disabilities Waiver - Personal Care, Personal Care, Respite, CompanionRespite, Companion

– Intellectual Disability Waiver - Personal Assistance, Personal Assistance, Respite, CompanionRespite, Companion

– AIDS Waiver– Personal Care, Respite– Personal Care, 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 staff, how to handle difficult situations, how to complete employment paperwork, etc.

• SF provides list of people who have said they want to work as consumer-directed staff 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 (using a contractor, PPL) pays the attendants, companion aides and respite workers on behalf of the individual

Consumer-Directed Employees

• Consumer-Directed employees may not be -– Parents of minor children or spouses of the

individual receiving consumer-directed services

• If the Consumer-Directed employee lives with the person receiving services -– Service Facilitator must have objective written

documentation as to why there are no other providers available to provide care

Elderly or Disabled with Consumer Direction Waiver

• This waiver is constructed to allow persons to remain in the community that meet nursing facility level of care.

• No waiting list• Screening is conducted by the

Preadmission Screening team made up of a representative from The Department of Health and the Department of Social Services using the Uniform Assessment Instrument (UAI)

Eligibility

• This waiver serves the elderly and persons of all ages with disabilities. The individual may receive this service through a service provider or though consumer direction.

• An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver.

Criteria

• Qualify for Medicaid (individual)• Meet long term care criteria according to

Uniform Assessment Instrument (UAI)Pre-Admission Screening Criteria:

– Functional capacity (the degree of assistance an individual requires to complete activities of daily living); and

– Medical or nursing needs– Risk of nursing facility placement

Examples

• Functional Dependencies:bathing, dressing, toileting, transferring, eating/feeding

• Medical and nursing needs: catheter care, supervision for adequate

nutrition and hydration, therapeutic exercise and positioning, management of those with sensory, metabolic, or circulatory impairment.

Getting Started

• Request for screening, contact your local Health Department/Department of Social Services

• Schedule visit with pre-admission screening teams of the Department of Health & Department of Social Services.

• Completed Medicaid application (child’s information only!)

Services• Adult Day Health Care• Personal Care* (agency or consumer

directed)• Respite* (agency or consumer

directed) • Personal Emergency Response

System (PERS)• Transition Services ($5000 max)• Transition Coordination

Technology Assisted Waiver (Tech)

• No age limit to eligibility

• No waiting list

Eligibility• Serves individuals who need a medical devise

to compensate for the loss of a vital body function and requires substantial and ongoing skilled nursing care to remain safely in their homes.

• Screening: UAI is used for adults and Tech Waiver scoring tool is used for children

• The Department of Medical Assistance Services (DMAS) reviews individual’s private insurance policy for private duty nursing benefits

• Case management provided by DMAS nurses

• Different rules for children and adults

Criteria

• Doctor must certify need for care; and need substantial and ongoing skilled nursing care

• Care must be cost effective

• Primary caregiver must be trained and accept responsibility for 8 hours or more per day

Screening Process• DMAS receives a referral from community

resources, family, other parties.• DMAS completes a Scoring Tool to

determine if the individual meets the specialized care criteria for the waiver.

• If the criteria is met DMAS conducts a home assessment.

• DMAS works with the primary caregiver, referral source to secure appropriate nursing care for the individual in the home.

• DMAS authorizes needed services for the provider agency upon the start of care.

Services • Private Duty Nursing (16 hours

maximum a day, except children may have 24 hours a day for the first 30 days after hospital discharge)

• Personal Care* (adults only)• Respite Care (360 hours) • Environmental Modifications ($5000) • Assistive Technology ($5000)• Durable Medical Equipment• Transition Services ($5000)

Individual and Family Developmental Disabilities

Support Waiver (DD)

• Wait list is maintained by the Department of Medical Assistance Services (DMAS)

• Can be placed on the waiting list at age 5 years 8 months

• 150 new slots July 1, 2011

Eligibility Criteria

• “Related Conditions” Waiver• Must be 6 years of age and over and meet

the related conditions criteria, including autism; and

• Individual must not have a diagnosis of an Intellectual Disability.

• Meet the level of care for admission to an ICF/MR. The individual must meet 2 out of 7 levels of functioning.

Screening

• The Virginia Department of Health Child Development Clinics will screen individuals with the Level of Functioning (LOF) Survey which is the assessment instrument used to determine eligibility to for an ICF/MR

• You can download a copy of the “Request for Screening” from www.dmas.virginia.gov. Compete the form and fax or mail it to the CDC. The psychological assessment is a requirement of the screening determination.

RELATED CONDITIONSalso 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

Transitioning from ID to DD Waiver

• Annually each child receiving ID Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver.

• If the child meets DD Waiver eligibility the child can transition to the DD Waiver.

Services• Adult Companion (CD & Agency)• Assistive Technology ($5000)• Crisis stabilization• Environmental Modifications ($5000)• In-home residential• Prevocational and Day Support • Skilled Nursing• Supported Employment• Therapeutic consultation• PERS - Personal emergency response system• Family/caregiver training (80 hours a year)• Respite care (CD & Agency)• Personal care services• MFP Transition Services ($5000)

Individual with Intellectual Disability Waiver (ID)

• Day-to-day ID waiver operations are managed by the Department of Behavioral Health and Developmental Services (DBHDS)

• Locally, ID Waiver services for individuals are coordinated by case managers employed by Community Services Boards

• 275 New waiver slots, July 1, 2011

Eligibility

• Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning.

• Six and over – a psychological evaluation with a diagnosis as having an intellectual disability.

• Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of intellectual disability or is at developmental risk.

Criteria

• All individuals receiving ID Waiver services must meet the ICF-MR level of care.

• Case Manager completes a “Level of Functioning Survey.” The individual needs to have significant needs in two or more of the survey’s seven categories.

Waiting List

• Urgent

• Non-Urgent

ID WAIVER WAITING LISTSUrgent and Non-urgent

• CSB’s and DBHDS 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 is the most urgent

• 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 ID Waiver, including needing services within 30 days, but don’t meet Urgent criteria

• Planning list = need services in the future

Urgent Criteria for the ID Waiver

• Primary caregivers are both 55 yrs or older (or if 1, is 55 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

Services• Adult Companion Care (CD & Agency)• Assistive Technology ($5000)• Crisis Stabilization• Day Support and prevocational services• Environmental Modifications ($5000) • Residential support (Individual’s home or

group home)• PERS – personal emergency response system• Personal Care (Agency or Consumer Directed)• Skilled Nursing • Respite Care (CD & Agency)• Therapeutic Consultation• Supported Employment• MFP Transition Services ($5000)

Early 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

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

Medical Necessity

• The medical justification for a service must accompany the request for EPSDT treatment services

-Services not coveredRespiteEnvironmental ModificationsVocationalEducational

Health Insurance Premium Payment Program (HIPP)/ HIPP for

Kids• If an individual receiving waiver

services has private health insurance, Medicaid will be the individuals secondary insurance

• DMAS may reimburse the individual for all or a portion of their monthly private health insurance premium

HIPP

• Application must be completed separately from the Medicaid application.

• 1-800-432-5924• Visit www.dmas.virginia.gov scroll to

“Client Services” click on “More Services” then click on “HIPP Information”

Recipient Appeal

• A person may appeal if their benefits are:

-Terminated-Denied-Suspended-Reduced

Medicaid Appeals

• Fair Hearing• Right to challenge decisions and

actions regarding Medicaid• Appeal must be requested within 30

days of the decision or action that you disagree with

• Decision should be issued by the Hearing Officer within 90 days

Steps

• Request an appeal or review (804)-371-8488• Notify appeals division in writing• Be specific about what you want-Results in a hearing-Decision made

MYTH or FACT

• All persons with a disability of ID will qualify for ID Waiver. MYTH

• I can be on a wait list for the DD Waiver or the ID Waiver while I am receiving services from another Waiver. FACT

Waiting ListsID Waiver has 2 waiting listsUrgent and Non-urgent:

CSB determines who is the most urgent to receive available ID Waiver funding

DD Waiver waiting listFirst come, first served with wait list numbers assigned10% of available money allocated for emergency situationsDMAS 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?

Debra HollowayDirector of Training and TechnicalAssistance888-604-2677 ext. 103dholloway@thearcofva.org

www.thearcofva.org