Long Term Care Division

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Long Term Care Division
Alabama Medicaid Agency Long Term Care
Division Outreach and Education Unit February 2004
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MEDICAID HCBS WAIVERS MADE EASY
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Medicaid vs. Medicare

• Medicaid is a program that provides medical
  assistance for certain individuals and families
  with low income and resources.
• Medicare is a Health Insurance Program for people
  65 years of age and older, some people with
  disabilities under age 65, and people with
  End-Stage Renal Disease (permanent kidney failure
  requiring dialysis or a transplant).

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Comparisons
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Funding Formula

• The federal-state funding ratio for Medicaid
  varies from state to state based on each states
  per capita income.
• During FY 2002, the formula was approximately
  70/30. For every 30 the state spent, the federal
  government contributed 70.

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Eligibility for Medicaid

• Persons receiving Supplemental Security Income
  (SSI) from the Social Security Administration are
  automatically eligible for Medicaid in Alabama.
• Persons approved for Medicaid for Low Income
  Families through the Alabama Medicaid Agency are
  eligible for Medicaid.

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Eligibility for Medicaid

• Pregnant women and children under six years of
  age with family income which does not exceed 133
  of the federal poverty level are covered by
  Medicaid.
• Persons who are residents of medical institutions
  (nursing homes, hospitals, or facilities for the
  mentally retarded) for a period of 30 continuous
  days and meet very specific income, resource and
  medical criteria may be Medicaid eligible.

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Dual Eligibles

• Qualified Medicare Beneficiaries (QMBs) have low
  income. Persons in this group may be eligible to
  have their Medicare premiums, deductibles, and
  coinsurance paid by Medicaid.
• Specified Low-income Medicare Beneficiaries
  (SLMBs) and Qualifying Indiviudals-1 (QI-1) have
  low income above the QMB limit. Persons in this
  group may be eligible to have their Medicare Part
  B premiums paid by Medicaid.

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State Plan Services

• The Medicaid State Plan is a written plan
  submitted by the Medicaid Agency to Centers for
  Medicare and Medicaid Services (CMS) describing
  the nature and scope of its Medicaid program.
• State Plan Services must be made available to
  Medicaid eligible individuals who meet the
  criteria for the specific service or program.

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Home Community Based Service (HCBS) Waivers

• In 1981, Congress authorized the waiver of
  certain federal requirements to enable a state to
  provide home and community based services (other
  than room and board) to individuals who would
  otherwise require SNF, ICF, or ICF/MR services
  reimbursable by Medicaid.

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HCBS Waivers

• The Waiver programs are called 1915(c) waivers,
  named after the section of the Social Security
  Act that authorized them.
• Under 1915(c) waiver authority, states can
  provide services not usually covered by the
  Medicaid program, as long as these services are
  required to keep a person from being
  institutionalized.

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HCBS Waivers

• Under HCBS Waiver programs, both the
  comparability and state wideness requirements may
  be waived to enable states to target distinct
  groups of recipients.
• HCBS Waiver Services can be provided only as a
  vehicle to provide an alternative to
  institutional care.

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HCBS Waivers

• Initial waivers are approved for three (3) years
  and renewed every five (5) years thereafter.

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What are waiver slots?

• Each waiver program is allotted a certain number
  of slots to be filled by clients approved to
  receive waiver services within a waiver year.

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Types of waiver slots

• An active waiver slot is one in which a person is
  actively receiving waiver services and is not in
  a nursing facility.
• A pending waiver slot is one that is pending
  approval for a person to receive waiver services.

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Types of waiver slots

• A filled waiver slot is one which has a person
  currently receiving waiver services or who has
  been receiving waiver services, but had
  subsequent placement in a nursing facility has
  moved or has requested termination from the
  waiver during the waiver year.

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More about waiver slots

• A filled slot cannot be refilled by another
  individual within the same waiver year that the
  vacancy occurred, however, the same individual
  who previously left the slot may fill the slot.

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When can a waiver slot be refilled?

• Although a waiver slot cannot be refilled within
  the same waiver year, available slots may be
  refilled in subsequent waiver years.

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Transfer of Waiver Slots

• If a client transfers from one waiver to another
  within the same waiver year, the slot is
  considered filled and therefore may not be
  refilled by a different individual.

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Alabama Medicaid Approved HCBS Waivers

• Elderly and Disabled (ED Waiver)
• Mental Retardation/Developmentally Disability
  (MRDD) Waiver
• State of Alabama Independent Living (SAIL) Waiver
• Living at Home Waiver
• Specialty Care Assisted Living Facility (SCALF)
  Waiver
• HIV/AIDS Waiver
• Technology Assisted (TA) Waiver for Adults

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Administering State Agency

• The Alabama Medicaid Agency has administrative
  authority over the Home and Community Based
  Waiver programs.

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Elderly and Disabled Waiver
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Operating State Agencies

• State agencies that operate the Elderly and
  Disabled Waiver program are
• Alabama Department of Public Health
• Alabama Department of Senior Services

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Target Population

• The ED Waiver is approved to provide Home and
  Community Based Services to assist elderly and
  disabled individuals to live in the community who
  would otherwise require nursing facility care.

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Waiver Slots

• The Elderly and Disabled Waiver is approved to
  serve 7,500 individuals.

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Covered Services

• Case Management
• Homemaker
• Personal Care Services
• Respite Care (Skilled and Unskilled)
• Adult Day Health
• Adult Companion Services
• Home Delivered Meals

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Mental Retardation - Developmentally
Disability Waiver
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Operating State Agency

• Alabama Department of Mental Health and
• Mental Retardation

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Target Population

• The MRDD Waiver is approved to provide Home and
  Community Based Services to Medicaid eligible
  individuals who would otherwise require the level
  of care available in an intermediate care
  facility for the mentally retarded.

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Waiver Slots

• The MRDD Waiver is approved to serve 5,200
  individuals.

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Covered Services

• Residential Habilitation
• Day Habilitation
• Respite Care
• Personal Care
• Prevocational Services
• Occupational Therapy
• Speech Therapy
• Physical Therapy

• Supported Employment
• Companion Services
• Skilled Nursing
• Assistive Technology
• Behavior Therapy
• Environmental Accessibility Adaptations
• Specialized Medical Supplies and Equipment

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State of Alabama Independent Living (SAIL)
Waiver
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Operating Agency

• Alabama Department of Rehabilitation Services

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Target Population

• The SAIL Waiver is approved to serve disabled
  adults with specific medical diagnosis who are at
  risk of being institutionalized in a nursing
  home.

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Target Population

• Quadriplegia
• Traumatic brain injury
• Amyotrophic lateral sclerosis
• Multiple sclerosis
• Muscular dystrophy
• Spinal muscular atrophy
• Severe cerebral palsy
• Stroke
• Other substantial neurological impairments,
  severely debilitating diseases, or rare genetic
  diseases

• SAIL Waiver Services are provided to, but not
  limited to persons with the following diagnoses

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Waiver Slots

• The SAIL Waiver is approved to serve 550
  individuals.

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Covered Services

• Case Management
• Personal Care Services
• Environmental Accessibility Adaptations
• Personal Emergency Response System (Initial
  Set-up)
• Personal Emergency Response System (Monthly)
• Medical Supplies
• Assistive Technology
• Assistive Technology Repairs
• Personal Assistance Services

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Living At Home Waiver
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Operating State Agency

• Alabama Department of Mental Health and Mental
  Retardation

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Target Population

• The Living at Home Waiver is approved to provide
  Home and Community Based Services to Medicaid
  eligible individuals who would otherwise require
  the level of care available in an intermediate
  care facility for the mentally retarded.

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Waiver Slots

• Available slots for the Living at Home Waiver
  increases over a three (3) year period as
  follows
• Year 1 204
• Year 2 326
• Year 3 449

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Covered Services

• Residential Habilitation Training
• Day Habilitation
• Prevocational Services
• Supported Employment
• Occupational Therapy Services
• Speech and Language Therapy
• Physical Therapy
• Behavior Therapy
• In-Home Respite

• Out-of-Home Respite
• Personal Care
• Personal Care Transportation
• Environmental Accessibility Adaptations
• Specialized Medical Equipment and Supplies
• Skilled Nursing
• Community Specialist
• Crisis Intervention

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Specialty Care Assisted Living Facility Waiver
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SCALF Waiver has been approved by CMS, but not
yet implemented
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The SCALF Waiver has been approved by CMS, but
not yet implemented
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Operating State Agency

• Alabama Department of Senior Services

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Target Population

• The SCALF Waiver is designed to address the needs
  of individuals with a diagnosis of Alzheimers
  and/or Dementia who meet the nursing facility
  level of care criteria.

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Waiver Slots

• Available slots for the SCALF Waiver increases
  over a three (3) year period as follows
• Year 1 500
• Year 2 650
• Year 3 700

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Covered Services

• The SCALF Waiver provides the following
  services
• Assisted Living Service
• Case Management
• Medical Supplies

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Assisted Living Service

• Activities included in the Assisted Living
  Service component include
• Personal Care
• Homemaker
• Chore
• Attendant Care
• Companion Services
• Medication Oversight Administration
• Attendant Call System
• Therapeutic and Recreational Programming
• Transportation

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HIV / AIDS Waiver
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Operating State Agency

• Alabama Department of Public Health

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Target Population

• The HIV / AIDS Waiver is designed to address the
  needs of individuals with a diagnosis of HIV,
  AIDS, and related illness who meet the nursing
  facility level
• of care criteria.

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Waiver Slots

• Available slots for the HIV / AIDS Waiver
  increases over a three (3) year period as
  follows
• Year 1 150
• Year 2 150
• Year 3 150

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Covered Services

• Personal Care
• Respite Care
• Skilled Nursing
• Companion Services

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Technology Assisted Waiver for Adults
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Operating State Agency

• Alabama Medicaid Agency

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Target Population

• Individuals who received private duty nursing
  services through the Early Periodic Screening
  Diagnostic Test (EPSDT) Program under the Alabama
  Medicaid State Plan, who will no longer be
  eligible for this service upon turning age 21 and
  for whom private duty nursing services continues
  to be medically necessary based upon approved
  private duty nursing criteria.

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Waiver Slots

• Available slots for the TA Waiver increases over
  a three (3) year period as follows
• Year 1 30
• Year 2 35
• Year 3 40

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Covered Services

• Private Duty Nursing
• Personal Care/Attendant Services
• Medical Supplies
• Assistive Technology
• Targeted Case Management (TCM)
• TCM for the Technology Assisted (TA) Waiver for
  Adults is under the Medicaid State Plan

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Additional Information

• If you have further questions regarding Alabama
  Medicaid Agency Long Term Care Programs, please
  contact
• Wanda Davis, Assistant Director, Long Term Care
  Division, 334-242-5018, wdavis_at_medicaid.state.al.u
  s