Navigating the New System

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Navigating the New SystemCommunity Care
Waiver,Waiting List Changes, and Individualized
Budgets

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Overview of Presentation

• Who we are
• Three things you will know after tonight
• What Medicaid is
• What the Community Care Waiver is
• How to get services

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What is Medicaid?

• Government funded health insurance program for
  low income children and families, and adults who
  are aged, blind or disabled
• Pays for doctor visits, prescription drug
  coverage, other medical services
• Covers services other insurance often doesnt
  personal care, and long term services supports

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What is the Community Care Waiver

• Funding mechanism for services
• Funds services in group homes, day programs,
  in-home supports
• Federal government contributes to the cost of
  services
• When services are not covered under waiver, the
  state pays the entire cost

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and Why is it Important?

• It allows people to receive services in the
  community rather than in an institution
• It offers a wider variety/range of services
  supports
• Because of the federal funds, it has potential to
  provide more money so the State can serve more
  people

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and Why is it Important?

• And, it is the only way to access long term
  supports and ensure that your son/daughter will
  be properly supported throughout his/her lifetime
• Extensive waiting list

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How Do You Get Services?

• Become DDD eligible
• Get on the Waiver Waiting List
• While you are waiting, you may be eligible for
  non-waiver-funded services
• Contact your DDD case manager to find out what
  services you can get while waiting for a waiver
  slot

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Overview of New System Changes that are Coming

• The only REAL/practical differences are
• The vocabulary
• What you get when you reach the top of the
  waiting list
• You will have more choices in terms of what
  services you can get and from whom

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New System

• Self-direction Option
• Based more on in-home supports
• Funding flows from DDD through Fiscal
  Intermediary
• Waiting list for waiver slot

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New System

• Provider-Managed Option
• Individual chooses a provider agency
• Payment made directly to provider
• Waiting list for waiver slot

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What We Know for Sure

• National Trend
• DDD has stated that this change is already being
  implemented
• Self advocates families will need a new set of
  skills new vocabulary

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How does the Waiver System Work?

• Determination of eligibility for waiver services
• Waiting list criteria
• Reserve capacity within the waiver
• Assessment
• Individual Budget Decision to self-direct or
  not
• Plan Development
• If not eligible, then look at non-waiver waiver
  services funded with state dollars

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What does Self-Direct Mean?

• Support Coordinator assigned
• How do I find service providers?
• Who checks to see if services are being
  delivered?
• How does the money get paid to the provider? How
  much? Can I negotiate?
• What if my needs change?

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Waiver Waiting List

• All move to waiver waiting list if not currently
  enrolled on waiver
• When your name comes up on list, you will receive
  services you need at that time, and be removed
  from list
• If needs change, the changes will be accommodated

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How Waiting List Will Work
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Changes in Need

• If needs change, an updated plan is completed
• Services change to fit the need
• Waiver eligibility is preserved regardless of
  residence
• Waiver is portable

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Review of Covered Services in CCW

• Case Management
• Day Habilitation
• Individual Supports
• Respite
• Supported Employment
• Community Transition Services
• Support Coordination
• Assistive Technology Devices
• Environmental and Vehicle Adaptations
• Personal Emergency Response System (PERS)
• Transportation

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Non-Medicaid Funded Services

• Family Support
• Residential (room board) after contribution to
  care received
• Start-up costs for residential placements, other
  than Transition services
• Discussion of what should be covered by
  state-only funds

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Questions
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Contact

• Start with your Case Manager
• Contact me by email, if possible
• linda.lewis-day_at_dhs.state.nj.us
• 609-631-6502

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Medicaid 101

• What is Medicaid?
• Medical assistance to individuals who are aged,
  blind or disabled and TANF
• Income test
• Resource test

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Medicaid 101

• Services covered under Medicaid
• Mandatory services
• E.g., physician, hospitalization, pharmacy
• Optional services
• E.g., therapy, private duty nursing
• Each state determines scope, duration, and amount

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Waiver 101 or Why Have a Waiver?

• Institutional eligibility vs. in-home eligibility
  for Medicaid
• Non-traditional services needed
• Amendment to the Social Security Act in 1981
• Created 1915 (c) option for states

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Waiver 101

• Home and Community Based Services
• Allows state to limit number of individuals
  enrolled
• Allows state to refuse enrollment if individual
  cost is higher than institutional
• Standards for providers

• Additional waivers requested
• Statewideness
• Amount, duration and scope
• Comparability
• Institutional income

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Waiver 101

• Eligibility
• State specific
• Income
• Resources
• Level of care
• Service need

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CMS Oversight

• Level of Care
• Services
• Plan
• Qualified Providers
• Financial Accountability
• Administrative Oversight by Medicaid Agency

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New Jersey Waivers

• AIDS Community Care Alternatives Program (ACCAP)
• Community Resources for People with Disabilities
  (CRPD)
• combined three model waivers
• Acquired Traumatic Brain Injuries (TBI)

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New Jersey Waivers

• Global Options (GO)
• combined Community Care Program for the
  Elderly and Disabled (CCPED) and Enhanced
  Community Options (ECO)
• Community Care Waiver (CCW)

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Community Care Waiver

• Nationally, the second waiver approved by federal
  government
• Refinanced group home services
• Model used by many other states
• Changes needed to update model

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Revisions to CCW

• Philosophical Changes
• Changed Services
• New Services
• Deleted Services

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Revisions to CCW

• Services where you live
• With family
• Apartment
• Supportive living
• Group home

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Revisions to CCW

• Self-direction
• added as option (includes Real Life Choices,
  Self-Determination, and Olmstead individuals who
  self-direct, and individuals served from Waiting
  List)
• Provider directed model still available
• Essential Life Plan
• added as alternate plan of care for individuals
  who self-direct or have an individual budget

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Revisions to CCW

• Regional Monitor for Individuals who Self-direct
  (new administrative service)
• Assures that the following is completed
• Assessment for waiver eligibility
• Level of care
• Assignment of budget amount
• Review approve service plan
• Assure health safety factors considered
• Approves expenditures

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Revisions to CCW

• Retainer days paid for absences from day program
  and residential supports
• Therapeutic days
• Hospital days related stays in other facilities

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New Service

• Support Coordination
• For persons who self-direct
• Connects people to services
• Providers of Support Coordination are employed by
  agencies other than the Division
• Conflict of Interest provision

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Revisions to CCW

• New individuals enrolled on waiver are assigned
  funding maximum based on the Developmental
  Disability Review Tool (DDRT)
• Remove Psychiatry ITN as a covered service

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New Services

• Transition Services
• For people being discharged from institutional
  settings
• Must be entering a non group home setting
• Pays for deposits, furniture, one time services
  (cleaning, extermination, etc.), moving
• Up to 180 days prior to move

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Revisions to CCW

• Respite changes
• Clarify respite payment cannot be made to
  relative who lives with individual
• Expands eligible providers
• Camp (no out of state)
• ICF/MR
• Group respite at no more than 14 ratio

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Revisions to CCW

• Day Habilitation
• Changed name
• Added hourly units (no more than 25/wk)
• Distance between individuals residence day
  habilitation site is not greater than 38 miles

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Revisions to CCW

• Individual Supports
• Added hourly units (ratio cannot exceed 14)
• Requires drug alcohol testing orientation
  training
• Permits family member residing in home to provide
  services for a limited period (no more than 40
  hours per week for no more than 30 days annually)
  during transition of staff

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Revisions to CCW

• Environmental/Vehicle Modification
• Total expenditure of 11,000 every three years in
  conjunction with
• Assistive Technology Devices (new service)
• Transportation (new service)