Medicaid Waiver: A Primer

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Medicaid Waiver A Primer

• Presentation by
• Randy Laya, M.S.
• Federal Programs, Manager
• Regional Center of Orange County (RCOC)
• and
• Suzanne Butler
• RCOC Insurance and Benefits Specialist

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What are Home and Community-Based Services (HCBS)
Waivers?

• Medi-Cal waivers are programs under Medi-Cal
  that
• Provide additional services to specific groups of
  individuals,
• Limit services to specific geographic areas of
  the state, and
• Provide medical coverage to individuals who may
  not otherwise be eligible under Medicaid rules. 
• Currently there are ten Waiver programs in
  California.  

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A few of the HCBS Medi-Cal Waiver programs
currently authorized in CA

• A. Home and Community Based Services Waiver for
  Individuals with Developmental Disabilities AKA
  the Medicaid Waiver or the DDS Waiver
• B. In-Home Operations
• 1. Nursing Facility/Acute Hospital (NF/AH) Waiver
• 2. In-Home Operations Waiver
• C. Multipurpose Senior Service Program (MSSP)
  Waiver
• D. Acquired Immune Deficiency Syndrome (AIDS)
  Waiver

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Role and Responsibilities of the Regional
Centers The 21 regional centers are charged with
the responsibility to coordinate, provide,
arrange or purchase services and supports for
persons with developmental disabilities in
California. The regional centers were created
under the Lanterman Act and receive their funding
through contract with DDS. DDS has delegated
responsibility to the regional centers for
assuring that HCBS Waiver requirements are met.
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The Medicaid Waiver (MW)

• Allows California to claim Medi-Cal reimbursement
  for specific Regional Center services
• Regional centers must meet consumers needs
• The major purpose of the Medicaid Waiver program
  is to bring federal dollars into the state of CA

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What are the Medicaid Waiver program
requirements?
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• Meet the Lanterman Act definition of
  developmental disability
• A developmental disability means
• A disability which begins before age 18,
• Is expected to continue indefinitely,
• Presents a substantial disability for the
  individual, and
• Is due to mental retardation, cerebral palsy,
  epilepsy, autism or a disabling condition closely
  related to mental retardation or requiring
  treatment similar to that required for
  individuals with mental retardation.
• The definition expressly excludes other
  handicapping conditions that are solely learning
  disabilities, psychiatric disorders or physical
  in nature.

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• 2. Be an active regional center consumer
• Regional Centers administer three programs
  Prevention, Early Intervention, and On-Going
  (Active) each with their own eligibility criteria
• To be active, the individual must have a
  developmental disability and have an open case
  with regional center

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• 3. Have full-scope Medi-Cal benefits,
• Be eligible to access all services available
• through Medi-Cal, or
• Meet the requirements for institutional deeming
  (well discuss this later)

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• 4. Have substantial limitations in adaptive
  functioning which qualifies the consumer for the
  level of care provided in an ICF-DD, intermediate
  care facility for the developmentally
  disabled-Habilitation (ICF/DD-H), or intermediate
  care facility for the developmentally
  disabled-Nursing (ICF/DD-N).
• Evaluation of each consumers level of care needs
  is based on his/her ability to perform activities
  of daily living and community participation.
• Provides funding for services only to individuals
  who, but for the provision of these services,
  would require the level of care provided in an
  ICF-DD
• This determination is typically made through two
  CDER (Client Development and Evaluation Report)
  deficits or two medical deficits or one of each

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• 5. Not be concurrently enrolled in another
• HCBS Waiver
• Individuals may occasionally qualify for two or
  more Waiver programs, such as NF/AH Waiver (for
  medical technology dependency) and the Medicaid
  Waiver
• Can only be enrolled in one Waiver program at a
  time

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• 6. Choose to participate and receive services
  through the HCBS Waiver and to reside in a
  community setting.
• Consumer needs to have a MW qualifying service
  in place that directly addresses one of the CDER
  deficits
• Must use a MW qualifying service at least once
  every twelve month
• 1000 per month

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Services that qualify for the DDS Waiver program

• Homemaker
• Home Health Aide Services
• Respite Care
• Habilitation
• Residential habilitation for children services
• Day habilitation
• Prevocational services
• Supported employment services
• Environmental Accessibility Adaptations
• Skilled Nursing
• Transportation
• Specialized Medical Equipment / Supplies
• Chore Services

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Services that qualify for the DDS Waiver program

• Personal Emergency Response System (PERS)
• Family Training
• Adult Residential Care
• Adult Foster Care
• Assisted Living
• Supported Living Services
• Vehicle Adaptations
• Communication Aides
• Crisis Intervention
• Crisis Intervention Facility Services
• Mobile Crisis Intervention
• Nutritional Consultation
• Behavior Intervention Services
• Specialized Therapeutic Services
• Transition / Set-Up Expenses
• Habilitation
• http//www.dhcs.ca.gov/services/ltc/Pages/DD.aspx

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• Each regional center contracts directly with DDS
  to provide services that meet the needs of their
  DD population
• Not all MW qualifying services are offered by all
  regional centers
• Each regional center develops their own Purchase
  of Services guidelines
• These guidelines are
• Approved by each regional centers Board of
  Directors, and
• Approved by DDS

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Legislative changes

• In 2009, the state legislature passed Trailer
  Bill Language (TBL) mandating that regional
  centers utilize generic resources when available
• The TBL also mandated that regional centers
  reduce their services, if a generic resource is
  available, whether the consumer chooses to use
  the generic resource or not

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Any questions about the MW program?
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Institutional Deeming Medi-Cal
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What is Institutional Deeming?

• Institutional deeming means that "the individual
  is assessed to be Medi-Cal eligible as if
  he/she were in a long-term care facility".  
•  
• If the familys income/property/assets exceeds
  regular Medi-Cal limits, then only the
  income/property/assets of the child or the
  disabled adult spouse is considered under
  institutional deeming.

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Who is eligible for ID Medi-Cal?

• Consumers who meet the criteria of the HCBS
  Waiver program
• Consumers who are citizens or in the US with
  satisfactory immigration status
• Typically a consumer with an income of less than
  620/mo and with assets that total less than
  2000.
• Consumer in the family home up to the age of 21
  y.o. who does not otherwise qualify for regular
  Medi-Cal childs income is the only income
  counted
• However, if the consumer has income and
  resources of his/her own such as a trust fund or
  court-appointed child support, the consumer may
  be assessed with a share of cost or may be denied
  eligibility

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How does a consumer obtain ID Medi-Cal?

• Service Coordinator starts the process by
  confirming that the consumer meets the
  eligibility criteria to be added to the MW
  program.
• The Regional Center sends the DDS Waiver Referral
  form to the Medi-Cal office.
• The Medi-Cal office assigns a Medi-Cal worker to
  the childs case.
• The family is sent a Medi-Cal application to
  complete.
• The familys income/assets/property is
  disregarded in the eligibility determination for
  the child if it exceeds Medi-Cals limits BUT
• The family must complete the Medi-Cal application
  and submit their financial, property, and
  citizenship information or the childs
  application will be denied.
• Once the application is completed an eligibility
  determination is made by the Medi-Cal worker. If
  the family is eligible for regular Medi-Cal, the
  child will be added to that program and not the
  ID Medi-Cal program.

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What are the advantages of having ID Medi-Cal?

• FCPP (Family Cost Participation Program) assessed
  for regional center services is waived with Full
  Scope Medi-Cal
• Medi-Cal offers services/supports that may not be
  covered by private insurance
• Diapers Shift nursing through EPSDT Durable
  Medical Equipment
• Dental Vision IHSS Mental Health
• Medi-Cal serves as a secondary insurance for the
  consumer that has private insurance.
• Medi-Cal will cover certain co-pays that are the
  familys responsibility once the private
  insurance has paid their portion
• Medications Hospitals DME

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What causes the ID Medi-Cal case to be denied or
to close?

• The Medi-Cal application with the required
  documentation was not submitted to the Medi-Cal
  office in a timely manner
• The consumer has unsatisfactory immigration
  status
• Excess income/assets/property
• The annual redetermination paperwork was not
  received by the Medi-Cal office
• Family moved and didnt leave forwarding address
• Family didnt realize that paperwork needed to be
  resubmitted each year
• The consumer is no longer residing in CA
• The consumer becomes eligible for regular
  Medi-Cal
• The consumer is no longer eligible for the MW
  program

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Questions?