ADA AND MEDICAID

1
MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER
Funded by Virginia Board for People with
Disabilities
Workshop Presented by Maureen Hollowell,
Endependence Center
Administered by Endependence Center, Norfolk,
VA Fall 2003
2
? MYTH OR FACT ?

• 1. I have to need the level of care provided in
  an institution to qualify for Waiver services.
• 2. Waiver eligibility for children depends on
  parent income.
• 3. Each Waiver offers the same services.
• 4. I can choose my providers from a list of
  qualified providers.
• 5. The administrative appeal process is
  expensive.
• 6. All persons with a disability of mental
  retardation or developmental disability will
  qualify for the MR or DD Waivers.
• 7. I can be on a wait list for the DD Waiver or
  the MR Waiver while I am receiving services
  through another Waiver.

3
MAKING CHANGE

• information is power
• influence and control
• rights must be pursued
• collaboration
• credibility

4

• MEDICAID
• Federal state program designed to meet the
  medical needs of certain people who have low
  income

• MEDICARE
• Federal medical benefits primarily for the
  elderly financed through the Social Security
  system

• SSI
• Supplemental Security Income program provides
  benefits to people who are elderly or disabled
  who have limited income and resources. Funded
  with general tax revenues.

• SSDI
• Social Security Disability Insurance provides
  benefits to people who are disabled. Funds are
  the FICA social security tax paid on workers
  earnings or earnings of their spouses or parents.

5
MEDICAID

• PURPOSE
• To provide for health and medical care for
  certain groups of people who have low income

• HISTORY
• Medicaid was established with amendments to the
  Social Security Act in 1965
• Medicaid Buy-In

• FLEXIBILITY
• States design their own programs within federal
  standards

6
MEDICAID IS A JOINT PROGRAM BETWEEN FEDERAL
STATE GOVERNMENTS

• CENTERS FOR MEDICARE MEDICAID SERVICES
• Federal agency
• CMS
• Previously HCFA
• cms.hhs.gov

• DEPARTMENT FOR MEDICAL ASSISTANCE SERVICES
• State agency
• DMAS
• www.dmas.state.va.us

7
VIRGINIA MEDICAID

• DMAS is designated as the single state agency
  charged with administering Medicaid in Virginia
• DMAS contracts or has agreements with other
  entities for most screening, case management,
  service and billing related activities
• DMAS is responsible for ensuring that the
  Medicaid program operates in compliance with
  state and federal laws and regulations

8
VIRGINIAS MEDICAID

• Virginia Medicaid budget for fiscal year 2002
• 3,784,312,817
• 48.45 from state funds
• 51.55 from federal funds

9
STATE PLANFOR MEDICAL ASSISTANCE

• Periodically updated to reflect changes
• Changes must be approved by CMS

• Details Virginias
• eligibility requirements
• coverage
• reimbursement
• administrative policies

• To add services requires a change to the State
  Plan AND
• Possibly a commitment of dollars from the
  Virginia General Assembly

10
MANDATORY MEDICAID SERVICES

• Inpatient Hospital Services
• Emergency Hospital Services
• Outpatient Hospital Services
• Nursing Facility Care
• Rural Health Clinics
• Federally Qualified Health Center Clinic Services
• Lab and X-Ray Services

• Physician Services
• Home Health Service
• EPSDT
• Family Planning
• Nurse-Midwife Services
• Certified Nurse Practitioner Services
• Transportation
• Medicare Premiums
• (Part A) - Hospital (Part B) - Supplemental
  Insurance for Categorically Needy

11
OPTIONAL Medicaid Services Provided In Virginia

• Other Clinic Services
• Skilled Nursing Facility Services for Individuals
  under 21 years of age
• Podiatrist Services
• Optometrist Services
• Clinical Psychologist Services
• Home Health

• PT, OT, and Speech Therapy
• Prescribed Drugs
• Case Management
• Prosthetics
• Hospice Services
• Mental Health Services
• ICF-MR

12
Early and 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

13
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

14
Institutional Placements

• Hospitals
• Nursing homes

• ICFs/MR - Intermediate Care Facility for people
  with mental retardation or other related
  conditions
• institutions of 4 or more beds for people with
  MR or other related conditions
• active treatment and rehabilitation
• regulated by the federal and state governments
• 24 ICFs/MR in Virginia
• 5 large Training Centers, several hundred beds
  at each Center
• 19 smaller ICFs/MR, ranging from 4 to 88 beds

15
ELIGIBILITY Apply at local Department of Social
Services

• STATE PLAN MEDICAID
• (Mandatory Optional Services)
• Categorical Criteria
• Disabled or age 65 or older
• Families with children
• Pregnant women
• Recipients of cash assistance
• Low income Medicare beneficiaries
• Financial Thresholds
• Low income and asset guidelines
• Thresholds vary by category group
• Parental income/resources DO count for minor
  children
• Consideration of exceptionally high medical bills
  (spend-down)

• LONG-TERM CARE (Waivers Institutions)
• Must Need Long-term Care
• criteria defined for each Waiver
• assessment of need required
• Financial Thresholds
• 300 of SSI payment limit for one person (1,656
  per month)
• spend-down for 4 of the Waivers
• 2000 resource limit
• Parent income/resources do NOT count regardless
  of childs age
• Services Required
• All Waiver and State Plan (Mandatory and
  Optional) services you are eligible for

16
HIPP

• Health Insurance Premium Payment program
• DMAS program
• Pays health insurance premiums
• Application must be completed separately from the
  Medicaid application
• Application info 800-432-5924

17
COPAYMENTS

• Some people may have to pay a copayment for
  Medicaid services if they do not receive Waiver
  services.
• People who receive Home and Community-Based
  Medicaid Waiver services do not pay copayments
  for their basic, State Plan Medicaid services.
• However, some people may have to pay a
  patient-pay for their Waiver services.

18
PATIENT-PAY RESPONSIBILITIES

• People may have to pay for some Waiver services
  if they have income over 552 per month (except
  AIDS Waiver which has no patient-pay)
• Some exceptions for persons who are working
  (CD-PAS, DD and MR Waivers)

19
Patient-PayCD-PAS Waiver, DD Waiver, MR Waiver

• People may have a patient-pay if income is over
  552 a month
• Can keep earned income up to a total of 300 of
  SSI income level if working 20 or more hours/week
• Can keep earned income up to a total of 200 of
  SSI income level if working 8-20 hours/week
• Still have a patient-pay from unearned income for
  all Waivers except the AIDS Waiver
• total of earned and unearned income

20
AMERICANS WITH DISABILITIES ACT

• A public entity shall administer services,
• programs, and activities in the
• MOST INTEGRATED SETTING
• appropriate to the needs of qualified
• individuals with disabilities.
• 28CFR Section 35.130(d)

21
OLMSTEAD vs. L.C.U.S. SUPREME COURT

• Tommy Olmstead
• Commissioner
• Georgia Dept. of Human Resources
• Lois Curtis
• a woman who has
• mental illness and mental
• retardation, who was confined to a
• state psychiatric hospital, wanted to
• live outside of the hospital

22
SUPREME COURT

• administer services with an even hand
• comprehensive, effectively working plan for
  placing qualified persons with disabilities in
  less restrictive settings
• waiting list that moved at a reasonable pace
  No concrete date given by the Supreme Court

23
OLMSTEAD PLAN FOR VIRGINIA

• Task Force
• One Community Final Report of the Task Force
  to Develop an Olmstead Plan for Virginia
• www.olmsteadVA.com

24
WHAT ARE HOME COMMUNITY-BASED MEDICAID WAIVERS?

• Waivers give States the flexibility to develop
  and implement alternatives to institutionalization
  .

25
WHY WERE HOME COMMUNITY-BASED WAIVERS
ESTABLISHED?

• Slow the growth of Medicaid spending
• Institutions are overly restrictive and too
  highly routine oriented
• Permit federal Medicaid funds to be used for
  community services by people who would otherwise
  be institutionalized

26
HOW IS A WAIVER DEVELOPED?

• State develops a Waiver application to be
  submitted to the federal Centers for Medicare and
  Medicaid Services (CMS) for approval Task
  Forces are usually established by DMAS to assist
  with development of the applications
• DMAS develops regulations to implement the Waiver
  - Public comment is solicited when regulations
  are proposed
• The Virginia General Assembly allocates funds for
  Waiver services Advocates can educate the
  General Assembly about the need for funds to
  provide services
• Waiver is initially approved by CMS for 3 years
  and then typically renewed every 5 years Task
  Forces are usually established by DMAS to assist
  with development of the renewal applications

27
COST EFFECTIVE

• To receive approval to
• implement a Waiver, a State
• Medicaid agency must assure
• CMS that it will not cost more
• to provide home and
• community based services
• than providing institutional care
• would cost

28
Waiver Must be Cost Effective

• It can be individually cost effective or cost
  effective in the aggregate

• Aggregate Cost Effectiveness The average
  cost to Medicaid of individuals on the Waiver
  cannot cost more than the average cost to
  Medicaid of individuals in the comparable
  institution
• Individual Cost Effectiveness Cost to
  Medicaid for the individual in the community
  cant exceed the cost in the comparable
  institution

29
Medicaid Waivers

• Virginia has 6 Home and Community Based Care
  (1915 (c) ) Waivers
• State Regulations for the Waivers can be found
  at
• http//leg1.state.va.us/000/reg/TOC12030.HTMC0120
  
• 12 VAC-30-120-10 Elderly Disabled Waiver (ED
  Waiver)
• 12 VAC-30-120-70 Technology Assisted Waiver
  (Tech Waiver)
• 12 VAC-30-120-140 AIDS Waiver
• 12 VAC-30-120-210 Mental Retardation Waiver (MR
  Waiver)
• 12 VAC-30-120-490 Consumer-Directed Personal
  Attendant Services Waiver (CD-PAS Waiver)
• 12 VAC-30-120-700 Individual and Family
  Developmental Disabilities Support Waiver (DD
  Waiver)

30
DIFFERENT INSTITUTION - DIFFERENT WAIVER

• NURSING HOMES
• AIDS
• Elderly and Disabled
• Consumer Directed -PAS
• Technology Assisted

• HOSPITAL
• AIDS
• Technology Assisted

• ICF/MR
• Mental Retardation
• Developmental Disabilities

31
Alternative Institutional Placement

• There must be an alternate institutional
  placement for which Medicaid pays
• The individual who is applying for a Waiver must
  meet the same criteria that is used for admission
  to the institution
• This does not mean that the individual must
  actually be placed in the institution or make
  application to an institution

32
SCREENING PROCESS

• Pre-Admission Screening Teams of the Department
  of Health Department of Social Services
• Elderly and Disabled Waiver
• CD-PAS Waiver
• AIDS Waiver
• Department of Medical Assistance Services
• Technology Assisted Waiver
• Community Services Board
• MR Waiver
• Department of Health Local Clinics
• Developmental Disabilities Waiver

33
LEVEL OF FUNCTIONING (LOF) SURVEY

• Used for DD and MR Waivers
• LOF Survey is completed as part of the screening
  process
• Determines the level of care needed
• To receive DD or MR Waiver services, an
  individual must meet the criteria for admission
  to an ICF/MR

34
UNIFORM ASSESSMENT INSTRUMENT (UAI)

• Used for nursing home placement and the AIDS,
  CD-PAS, ED and Tech Waivers
• Completed as part of screening and assessment
• Assesses social, physical health and functional
  abilities
• Used to gather info for planning and monitoring
  needs and eligibility

35
SUPPLEMENT TO SCREENING

• People who have mental illness, mental
  retardation or developmental disabilities
• Initiated by the nursing home preadmission
  screening team when screening for nursing home
  placement and the CD-PAS and ED Waivers
• Preadmission screening team sends supplement
  screening request to CSB

36
PURPOSE OFSUPPLEMENT SCREENING

• Some people with MR or DD have active treatment
  needs that are not met by nursing homes or
  nursing home-related Waivers
• Determine the persons need for active treatment
  that would not be met by nursing homes or nursing
  home-related Waivers

37
LEVEL II SUPPLEMENT

• Specialized Services
• Services Identified By CSB
• Responsibility Entitlement

38
CASE MANAGEMENT,MR SERVICE
SUPPORT COORDINATION, DD SERVICE

• Ensures development, coordination,
  implementation, monitoring and modification of
  the individuals plan
• Links the individual with appropriate community
  resources and supports
• Coordinates service providers
• Monitors quality of care

39

• DD WAIVER
• SUPPORT
• COORDINATION
• Individual chooses their Support Coordination
  organization
• Various organizations provide Support
  Coordination services
• Support Coordination organizations cannot provide
  other DD Waiver services (except Consumer
  Directed Services Facilitation)

• MR WAIVER
• CASE
• MANAGEMENT
• Community Services Boards provide case
  management services

40
CONSUMER-DIRECTED SERVICES

• Freedom, choice and control remaining with the
  individual, and sometimes their family -
• what service is needed
• who will provide it
• when it will be provided
• where it will be provided
• how it will be provided
• In Virginia, CD services were initiated by
  Centers for Independent Living and the Virginia
  Board for People with Disabilities in 1989
• Virginia Medicaid Waivers have components of
  consumer-direction and self-determination,
  implementation depends on the individual and the
  case manager or support coordinator

41
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
• Consumer-Directed Personal Attendant Services
  Waiver (since 1997) - Attendant
• Developmental Disabilities Waiver (since 2000) -
  Attendant, Respite
• Mental Retardation Waiver (since 2001) -
  Attendant, Respite, Companion
• AIDS Waiver (began in 2003) Attendant, Respite

42
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
  and training staff, how to handle difficult
  situations, how to complete employment paperwork,
  etc.
• SF provides list of attendants, companion aides
  or respite workers 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 (acting as a fiscal agent) and a contractor
  pays the attendants, companion aides and respite
  workers on behalf of the individual

43
CONSUMER-DIRECTED STAFF QUALIFICATIONS

• Be 18 years old
• Possess basic math, reading and writing skills
• Have the required skills to perform job duties
• Have a valid Social Security number
• Submit to a criminal history check
• Willing to attend training requested by the
  person receiving Waiver services
• Willing to register in a CD-staff registry
• Understand and agree to comply with program
  requirements

44
ADDITIONAL REQUIREMENTS OF CONSUMER-DIRECTED STAFF

• AIDS, DD, MR WAIVERS
• Consumer-Directed Staff must receive
• TB screening
• CPR training
• Annual flu shot

45
CONSUMER-DIRECTEDSTAFF

• Staff (Consumer-Directed employees including
  attendants, companions, respite workers)
• Staff may be related to a consumer, but may not
  be members of the immediate family (parents of
  minor children, spouses, or legally responsible
  relatives)
• Exception Payments may be made to other staff
  who are family members when there is objective
  written documentation as to why there are no
  other providers available to provide care

46
CONSUMER INVOLVEMENT

• Person-centered planning
• Involve people of your choice in developing
  your Plan
• Prepare Plan
• Choose services
• Choose providers
• Decide how when services will be provided
• Agree to and monitor Plan
• Quarterly and Annual Review of Plan
• Right to appeal areas of disagreement

47
CONSUMER SERVICES PLANDD and MR WAIVERS

• Written document, signed by the consumer
• Addresses all needs of the individual in all life
  areas
• Developed with consumer, providers and others the
  consumer wants involved

• CSP will list -
• services and supports to be provided
• who will provide the services and supports
• how often the services and supports will
  be provided

48
PREPARING FOR CSP

• Who will participate in your meeting
• Develop a list of needed supports services (be
  honest frank)
• Collect documentation
• vocational evaluations
• IEPs
• school evaluations
• medical documentation

49
WHAT ARE YOUR GOALS FOR COMMUNITY AND INDEPENDENT
LIVING ?
50
TO LIVE IN MY OWN APARTMENT(example)
51
TO LIVE IN MY OWN APARTMENT(example)
52
HEALTH, SAFETY WELFARE

• Adequate services must be provided
• Additional or different services should be added
  if needed to protect health, safety and welfare

53
Individual and Family Developmental Disabilities
Support DD WaiverEligibility Criteria

• Related Conditions Waiver
• Must be 6 years of age and older and meet
  related conditions criteria
• Cannot have a diagnosis of mental retardation
• Level of Functioning survey used for screening
• Call DMAS [phone] to request a Request for
  Screening Form or go to www.dmas.state.va.us

54
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

55
DD Waiver Services

• Adult companion services (8 hrs per day limit)
• Assistive technology (5,000 per year limit)
• Crisis stabilization (60 day max/year)
• Environmental modifications (5,000 per year
  limit)
• In-home residential support (not congregate)
• Day Support
• Skilled Nursing
• Supported employment
• Therapeutic consultation
• Personal emergency response system (PERS)
• Family/caregiver training (80 hours max/year)
• Respite care (CD agency)
• Personal assistance services (CD agency)

56
DD Waiver Statistics

• Fiscal Year (FY) 2002 Waiver Expenditures (July
  2001 through June 2002) 1,176,499
• Other costs (State Plan services drugs,
  doctors visits, etc.) 584,666
• 124 individuals served in FY 2002 323 people
  enrolled in the DD Waiver as of February 2003
• Waiver is cost effective in the aggregate
• About 40 of the individuals requesting a
  screening are not eligible for the DD Waiver
• Wait list is maintained by DMAS

57
DD Waiver Assuring Waiver Cost-Effectiveness
Level 1 55 of Funding
Level 2 40 of Funding
5 of Funding
Plan of Care 25,000 and Less
Plan of Care More than 25,000
Emergencies
5,940,000
4,320,000
540,000
231
92
58
DD Waiver Start Up The Lottery

• Initial 60-day application period (July - August,
  2000) gave individuals an equal chance to apply
• 674 people applied during the initial application
  period. DMAS had slots for 323 individuals in FY
  2002 (July 2001 through June 2002)
• Therefore, the regulations provided for a
  lottery to determine the order in which the 674
  will be served
• The lottery only applies to the first 674 people
  who applied
• Applications from September 1, 2000 forward are
  first come, first served. About 1200 additional
  applications received between September 2000
  July 2003
• Approximately 450 people on the waiting lists

59
MR Waiver Eligibility Criteria

• Must have a diagnosis of mental retardation or be
  under the age of 6 and at developmental risk
• Children on the MR Waiver who do not have a
  diagnosis of MR at the age of 6, possible
  transfer to DD Waiver
• Screenings are conducted by CSBs
• Level of Functioning survey is the screening
  instrument used
• There is a waiting list for the MR Waiver
• Screening for all Waivers must be provided
  without any charge to the individual

60
MR Waiver Services

• Residential support (group home or individuals
  home)
• Day support and prevocational services
• Supported employment
• Personal assistance (CD agency)
• Respite care (720 hours max/year) (CD agency)
• Assistive technology (5,000 max/year)
• Environmental modifications (5,000 max/year)
• Skilled nursing services
• Therapeutic consultation
• Crisis stabilization (60 days max/year)
• Adult companion (8 hours max/day) (CD agency)
• Personal Emergency Response System (PERS)

61
MR WAIVER WAITING LISTSUrgent and Non-urgent

• CSBs and DMHMRSAS 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 on the Urgent list receives
  the next available slot
• 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 CSBs area
• Non-urgent meet criteria for the MR Waiver,
  including needing services within 30 days, but
  dont meet Urgent criteria
• Planning list need services in the future

62
URGENT CRITERIA FOR THE MR WAIVER

• Primary caregiver(s) is/are 55 years or older
• Living with a primary caregiver who is providing
  the service voluntarily and without pay and they
  cant 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
• Individuals 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

63
MR Waiver Statistics

• Fiscal Year (FY) 2002 Waiver Expenditures (July
  2001 through June 2002) 197,686,537
• Other costs (State Plan services drugs,
  doctors visits, etc.) 37,493,074
• 5,367 individuals served in FY 2002
• Waiver is cost effective in the aggregate
• Approximately 2,100 people on the waiting lists

64
INDEPENDENCE PLUS WAIVERIPlus Waiver

• New Waiver being developed by DMAS in
  collaboration with a task force
• For people now receiving DD or MR Waivers
• Would allow for consumer-direction of more Waiver
  services
• Would allow different provider rates within a
  predetermined range
• Lottery likely to be used to determine first 200
  people who would use the IPlus Waiver

65
Consumer-Directed Personal Attendant Services
Waiver (CD-PAS)Eligibility Criteria

• Can be any age
• Must meet nursing home criteria
• Can have a cognitive impairment
• Screening is the conducted by the Preadmission
  Screening Team using the UAI
• Questionnaire used to determine if an individual
  can independently manage attendants or if
  assistance with managing care will be needed

66
RECENT CHANGES TOCD-PAS WAIVER

• CD-PAS Waiver is now available to children.
• No longer have to be 18 or older for the CD-PAS
  Waiver.

• CD-PAS Waiver is now available to people who are
  unable to manage their services.
• Another person can manage their services.

67
CD-PAS Waiver Statistics

• Fiscal Year (FY) 2002 Waiver Expenditures (July
  2001 through June 2002) 2,698,064
• Other costs (State Plan services drugs,
  doctors visits, etc.) 1,047,223
• 191 individuals served in FY 2002
• No waiting list for the CD-PAS Waiver
• CD-PAS Waiver is individually cost effective

68
Elderly and Disabled Waiver Criteria

• Individuals seeking Waiver services are eligible
  if 65 or older or disabled
• Must meet nursing facility criteria
• Individuals are screened by Preadmission
  Screening Team (DSS social worker, VDH nurse and
  physician)
• Screening tool is the Uniform Assessment
  Instrument (UAI)

69
Elderly and Disabled Waiver Services

• Services that are available statewide
• Adult Day Health Care
• Personal Care Services
• Personal Emergency Response System (PERS)
• Respite
• Individuals can receive up to 720 hours of
  respite per year
• Personal assistance services can be provided
  outside of the individuals home
• Generally individuals can receive up to 13 hours
  of personal assistance daily, additional hours
  can be authorized based on individual
  circumstances

70
ED Waiver Statistics

• Fiscal Year (FY) 2002 Waiver Expenditures (July
  2001 through June 2002) 90,176,649
• Other costs (State Plan services drugs,
  doctors visits, etc.) 49,791,342
• 9,271 individuals served in FY 2002
• No waiting list for the ED Waiver
• Waiver is cost effective in the aggregate

71
COMBINING THE CD-PAS AND ED WAIVERS

• The CD-PAS and ED Waivers will be combined.
  Waiver will be based on aggregate
  cost-effectiveness.
• New Waiver will be called Long Term Care Options
  Waiver.

72
LONG TERM CARE OPTIONS WAIVER

• Personal care both agency and consumer directed
  hours based on need.
• Respite care if there is a primary caregiver
  both agency and consumer directed. 720
  hours/year.
• Personal Emergency Response System (includes
  medication monitoring system). Cannot be a
  stand-alone service.
• Adult Day Health Care
• Earned income allowance will be available in
  this Waiver. (Working 20 or more hours can keep
  up to 300 of earned income working 8-20 hours
  can keep up to 200 of earned income. Total
  income cannot exceed 300 of SSI).

73
Technology Assisted Waiver Criteria

• Individual may be eligible if she needs both a
  medical device to compensate for the loss of a
  vital body function and substantial and ongoing
  skilled nursing care
• Screening UAI is used for adults and Tech Waiver
  scoring tool is used for children
• DMAS reviews individuals private insurance
  policy for private duty nursing benefits
• Case management provided by DMAS nurses
• Different rules for children and adults

74
Tech Waiver Considerations

• ADULTS
• Screening team completes UAI for adults only.
  DMAS staff follows up to complete the screening
  for adults
• Eligible if depends part of day on vent or
  requires prolonged intravenous nutrition, drugs,
  or peritoneal dialysis
• Cost effectiveness is compared to nursing
  facility specialized care

• CHILDREN
• DMAS staff completes screening for children
• Eligible if depends part of day on vent or
  requires prolonged intravenous nutrition, drugs,
  or peritoneal dialysis or daily dependence on
  other device-based respiratory or nutritional
  support
• Cost effectiveness is compared to hospital costs

75
Tech Waiver Services

• Services that are available statewide
• Private duty nursing
• Respite care
• Durable medical equipment
• Personal care for individuals over 21 years of
  age
• Environmental Modifications

76
Tech Waiver Services Limits

• Environmental modifications and Assistive
  technology provided if medically necessary and
  cost effective
• Respite care has an annual limit of 360 hours per
  year
• Private duty nursing has a limit of 16 hours per
  day, except -
• individuals under 21 can receive nursing services
  24 hours a day during the first 30 days they
  receive Tech Waiver services

77
Tech Waiver Statistics

• Fiscal Year (FY) 2002 Waiver Expenditures (July
  2001 through June 2002) 17,861,853
• Other costs (State Plan services drugs,
  doctors visits, etc.) 7,994,493
• 308 individuals served in FY 2002
• No waiting list for the Tech Waiver
• Waiver based on individual cost effectiveness

78
AIDS Waiver Criteria

• Individuals are eligible for the AIDS Waiver if
  they have a diagnosis of AIDS or AIDS-Related
  Complex and would require nursing facility or
  hospital care
• Individuals are screened by a Preadmission
  Screening Team (DSS social worker, VDH nurse and
  physician)
• Screening tool is the Uniform Assessment
  Instrument (UAI)

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AIDS Waiver Services

• Services that are available statewide
• Case management
• Consumer-Directed Attendant Care
• Nutritional supplements
• Private duty nursing
• Personal care
• Respite care
• Individuals can receive up to 720 hours of
  respite per year
• Personal assistance services can be provided
  outside of the individuals home

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AIDS Waiver Statistics

• Fiscal Year (FY) 2002 Waiver Expenditures (July
  2001 through June 2002) 1,268,876
• Other costs (State Plan services drugs,
  doctors visits, etc.) 5,910,868
• 337 individuals served in FY 2002
• No waiting list for the AIDS Waiver
• Waiver is cost effective in the aggregate
• No patient-pay for the AIDS Waiver

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BRAIN INJURY WAIVERBEING DEVELOPED

• DMAS is working with a task force to develop a
  new Brain Injury Waiver
• Eligibility, services, providers, and other
  criteria being discussed by DMAS and the task
  force
• Initiation of this new Waiver depends on funding
  provided by the General Assembly
• Brain Injury Association of VA, 804-355-5748

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SERVICE PROVIDERS

• DMAS is responsible for -
• adequate supply of qualified providers to meet
  needs of recipients
• ensuring the capacity and scope of services are
  available
• ensuring individuals are able to have provider
  choice
• enrollment of providers
• quality of services

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ACCESSING PROVIDERS

• A list of qualified providers for each service in
  the Consumer Services Plan will be given to you
• You have the right to choose your providers
• You have the right to visit, interview and
  research providers
• You decide when, where and how you want
  approved services provided

• Case Manager/Support Coordinator will assist you
  in locating and choosing providers
• Case Manager/Support Coordinator will contact
  providers for initiation of services
• You can switch providers if you choose to
• There are shortages of some providers

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MEDICAID APPEALS

• Fair Hearing
• Right to challenge decisions and actions
  regarding Medicaid
• Decision should be issued by the Hearing Officer
  within 90 days

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RIGHT TO APPEAL WHEN -

• Application of benefits is denied
• The agency takes action or proposes to take
  action which will adversely affect, reduce, or
  terminate receipt of benefits
• Request for a specific benefit is denied in
  whole or in part
• The agency does not act with reasonable
  promptness

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WAITING LISTS

• DD and MR Waivers are the only Waivers with
  waiting lists
• MR Waiver has 2 waiting lists
  Urgent and Non-urgent and a planning list
• DD Waiver has 2 waiting lists
  Level I (CSP less than 25,000) and Level II
  (CSP more than 25,000)
• No waiting list for the AIDS, ED, CD-PAS and
  Tech Waivers
• Waiting lists are permissible, but waiting lists
  must move at a reasonable pace
• What is a reasonable pace?