Understanding

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Understanding the Waiver Tiers
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Understanding the Waiver Tiers
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• APD is committed to protecting the health and
  safety of the people it serves by helping them
  receive services and supports.
• There are many changes to the Medicaid waiver
  program.
• On October 15, 2008, APD will implement the
  legislatively-mandated and federally-approved
  Medicaid waiver tiers.

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What This Means

• In 2007, the Florida Legislature passed
  legislation requiring the four-tiered waiver
  system for individuals receiving services through
  the Developmental Disabilities Waiver, the Family
  and Supported Living Waiver, and the Consumer
  Directed Care Plus Program.
• There are now four separate waivers three of
  them having financial caps.
• The Legislature also created eligibility criteria
  for these waivers.
• Personal Care Assistance for customers under 21
  will be funded by the Medicaid state plannot
  affected by the waiver tiers cap.

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Specific Criteria for Waivers

• Tier 1 Waiver (Formerly the Developmental
  Disabilities Waiver, no dollar cap)
• The individual has intensive medical or adaptive
  needs that are essential for avoiding
  institutionalization, and the individuals needs
  cannot be met in Tier 2, 3, or 4.
• The individual has behavioral problems that are
  exceptional in intensity, duration, or frequency
  and present a substantial risk of harm to
  themselves or others, and the individuals needs
  cannot be met in Tier 2, 3, or 4.

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Specific Criteria for Waivers

• Tier 2 Waiver (A new waiver capped at 55,000 a
  year)
• The individuals service needs include placement
  in a licensed residential facility and
  authorization for standard residential
  habilitation services at the moderate level or
  higher, or behavior-focused residential
  habilitation services at the minimal level or
  higher.
• The individual is in supported living and is
  authorized to receive more than six hours a day
  of in-home support services.
• The individual can be any age, but cannot live in
  the family home.

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Specific Criteria for Waivers

• Tier 3 Waiver (A new waiver capped at 35,000 a
  year)
• Intended for people who
• reside in a licensed residential facility and are
  not eligible for Tier 1 or 2
• are 21 or older, reside in their own home, and
  receive In-Home Support Services, and are not
  eligible for Tier 1 or 2
• are 21 or older and authorized to receive
  Personal Care Assistance services at standard or
  moderate level of support as defined in the
  Developmental Disabilities Handbook
• are 21 or older, authorized to receive Skilled or
  Private Duty Nursing Services, and are not
  eligible for Tier 1 or 2

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Specific Criteria for Waivers

• Tier 3 Waiver (continued, more examples)
• Intended for people who
• are 22 or older and authorized to receive
  services of a behavior analyst and/or a behavior
  assistant
• are under the age of 22, and authorized to
  receive the combined services of a behavior
  analyst and/or a behavior assistant for more than
  60 hours a month and not eligible for the Tier 1
  or Tier 2
• are 21 or older and authorized to receive at
  least one of the following services Occupational
  Therapy, Physical Therapy, Speech Therapy, or
  Respiratory Therapy

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Specific Criteria for Waivers

• Tier 4 Waiver (Formerly the Family and Supported
  Living Waiver, capped at 14,792 a year)
• Intended for people who are
• not eligible for assignment to Tier 1, 2, or 3
• currently on the FSL waiver
• are under the age of 21 and residing in their own
  home or the family home
• dependent children who reside in residential
  facilities licensed by the Department of Children
  and Families

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• Tier 4 Waiver
• Specific Services
• Adult Day Training
• Behavior Analysis
• Behavior Assistance
• Consumable Medical Supplies
• Durable Medical Equipment
• Environmental Accessibility Adaptations
• In-Home Support Services
• Personal Emergency Response System

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• Respite Care
• Support Coordination
• Supported Employment
• Supported Living Coaching
• Transportation

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Special Note

• If you are in Tier 4 and CDC
• You are not limited to the services listed in the
  previous slide.
• Select from any of the services that are
  available under the CDC program.
• The Tier 4 cap of 14,792 still applies.
• The CDC adjustment to your purchasing plan still
  applies.

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Notification of Tier Assignment

• Each individual enrolled in the DD/HCBS waiver,
  the FSL waiver, and the CDC program will receive
  a letter in the mail informing them of their tier
  assignment.
• The letter will contain information on how to
  file an appeal if the tier assignment may have
  been made in error.
• The individual should immediately consult with
  his or her waiver support coordinator to
  determine if changes need to be made to services.
• The Area Office must receive changes to the
  individuals cost plan by September 24, 2008.
• It is critical that individuals work directly
  with their waiver support coordinator to make
  necessary changes.

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Notification of Tier Assignment

• Not all individuals will need to make changes.
  The letter will explain if changes to the cost
  plan are required.
• The tier implementation is an automatic action
  caused by a change in state law. Due process does
  not require a hearing for tier assignments.
  However, if an error has occurred in the tier
  assignment, he or she may be entitled to a
  hearing.
• If APD determines the individual has a right to a
  hearing, the individual may use legal counsel, a
  relative, friend, or other spokesperson in a
  hearing.
• If you are not representing yourself, proof of
  guardianship or other documentation of the
  representatives authority to act on your behalf
  is required. A letter signed by you is
  acceptable.

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Need Assistance?

• If a waiver assignment results in a spending
  limit lower than the amount that has been spent
  annually, work with the waiver support
  coordinator to prioritize the services so they do
  not exceed the limit, and so the most important
  services are supported.
• APD is supplying waiver support coordinators
  with information on how to help customers
  reprioritize, if necessary.

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Reprioritizing Your Services

• Some things to consider when reviewing and
  reprioritizing services
• Identify services that are not being used to the
  anticipated amount.
• Review services to see if there is any overlap.
  For example, supported living coaching and
  in-home supports might be adjusted because both
  services have similar goals.
• Review one-time expenditures for equipment, etc.,
  and determine if the need still exists or if
  other services are a higher priority.

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Reprioritizing Your Services

• More examples
• Review cost plans to determine if the service can
  be provided at a lower rate. For example,
  transportation has a negotiated rate so some
  providers may charge less.
• Maximize the use of stepped rates for services
  such as companion or in-home supports. The
  service will be less costly at the 13 ratio than
  the 11 ratio.
• Discuss the use of Limited Support Coordination
  for adults, including the reduced role of the
  support coordinator.
• Help build and encourage the use of nonpaid
  supports in the community to maximize available
  natural supports.

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Reprioritizing Your Services

• Review services that could be provided by other
  agencies or community and natural supports.
• Medication Reviews By a doctor or pharmacist
  for free
• Dental Through the County Health Department
• Transportation Family members, friends, and
  neighbors may be paid for limited transportation
  at the state mileage rate.
• Supported Employment Re-evaluate the need for
  coaching to provide only the amount of service
  necessary. Other people in the workplace could
  help.
• Specialized Mental Health Services Through
  community mental health agencies

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What happens Next?

• After the individual and waiver support
  coordinator have revised the cost plan services,
  the WSC will update the support plan and prepare
  an Amendment Request Form.
• This form is submitted by the WSC to the Area
  Office. All Amendment Request Forms are due to
  the Area Office by September 24, 2008.
• The Area Office will review the form and make
  changes to the cost plan.
• The Area Office will notify the WSC that the cost
  plan has been changed and approved.
• The WSC will provide the person with a copy of
  the approved cost plan, review its changes, and
  provide a notice of hearing rights.
• The WSC will issue new service authorizations to
  providers.

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• APD has additional information about the Waiver
  Tiers on its Web site
• www.apdcares.org
• Please check this site regularly for the most
  current information regarding the implementation
  of the tier assignments.
• Individuals and families can find specific group
  home vacancy information for the various APD
  areas, service- specific information, and FAQs.
  The Web site also contains important information
  about planning resources and will be updated when
  new information becomes available.

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Family Care Council

• The Family Care Council of Florida provides
  families with accurate information from a family
  perspective. The FCCF maintains a toll-free
  information line and has members available who
  can speak to you in both English and Spanish.
• 1-800-470-8101
• The FCCF maintains a Web site with information
  about area meetings. Attend and participate in
  Family Care Council meetings and activities! The
  Web address is
• www.fccflorida.org

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• Agency for Persons with Disabilities
• 4030 Esplanade Way, Suite 380
• Tallahassee, FL 32399-0950
• 1-866-APD-CARES
• (1-866-273-2273)
• Click on the Area Offices tab on our Web Site
  for contact information on our area offices.
• www.apdcares.org