Home and Community Based Medicaid Waivers and EPSDT This webinar is - - PowerPoint PPT Presentation

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Home and Community Based Medicaid Waivers and EPSDT This webinar is - - PowerPoint PPT Presentation

Working to Create A Life Like Yours (ALLY) Home and Community Based Medicaid Waivers and EPSDT This webinar is made possible by a sponsorship from Anthem HealthKeepers Plus. The Arc of Northern Virginia is grateful for their support. To


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Working to Create “A Life Like Yours” (ALLY)

Home and Community Based Medicaid Waivers and EPSDT

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This webinar is made possible by a sponsorship from Anthem HealthKeepers Plus.

The Arc of Northern Virginia is grateful for their support.

To keep workshops, trainings, and webinars FREE for families, we seek sponsors from companies or professional and community organizations.

For more information on sponsoring a workshop or webinar, please contact:

  • Howard Stregack, Director of Development, at 703-208-1119 x102 or HStregack@TheArcofNoVA.org
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The Arc of Northern Virginia’s Work

 History  Advocacy  Education  Information and Referral  Case Management for the DD Waivers  Public Guardianship of Last Resort  Special Needs Trusts  Beneficiary Advocate

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Outline

1)

Purpose and Description of Medicaid Waivers

2)

Redesigns in 2016 and 2017

3)

Eligibility Criteria for all Waivers

4)

Waiver Services

5)

Application Process

6)

Waiting List Navigation

7)

Managed Care Intersection

8)

SIS, Support Tiers, and Budgets

9)

EPSDT

10) Contact information for The Arc of Northern

Virginia

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Purpose and Description of the Waivers

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Waivers give States the flexibility to

  • ffer services to an individual in the

community rather than living and receiving services in an institution.

Purpose of the Waivers

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Origins of the Term “Medicaid Waiver”

Medicaid: Medicaid is the insurance that pays for Waiver services Waiver: Waiving the requirement that all Medicaid services be offered to everyone in the state, and allowing a special group to get extra long term care supports

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Why Look at Waivers?

 Offer a menu of services and designed to

be a “one stop shop” for most people, even with a wide range of needs

 Lifelong supports  Only public funding stream for ongoing

support services

 Free or very low cost for the individual

with a disability

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Current Waiver Cost Sharing

*Proposals to change the Affordable Care Act included cuts and caps to

  • Medicaid. If they are re-introduced and succeed, this will be

fundamentally altered. Visit www.thearc.org to learn more and get involved

50% 50%

Medicaid Waiver Costs

Federal Government State Government

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Waiver Redesigns:

2016 for Developmental Disability Waivers and 2017 for CCC Plus Waiver

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Five Waivers in Virginia

 Community Living Waiver  Family and Individual Supports Waiver  Building Independence Waiver  Commonwealth Coordinated Care (CCC)

Plus Waiver

 Formerly EDCD and Tech Waivers, but combined

  • n July 1, 2017

 Alzheimer’s Assisted Living Waiver (AAL

Waiver)

Developmental Disability Waivers

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Comparing Waivers

DD Waivers CCC Plus Waiver

 Need developmental

disability diagnosis

 Robust menu of

services for home, nursing, work, and community

 Up to 24/7 support

based on need

 Case management  Long waiting list  Need disability diagnosis

& medical need

 Shorter menu of services

aimed at home care and some nursing, but no employment/residential

 56 hour weekly cap on

personal care

 No case management  No waiting list

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DD Waiver Redesign Concept

Day Support Waiver

Building Independence Waiver

For adults (18+) able to live independently in the

  • community. Individuals own,

lease, or control their own living arrangements; and supports are complemented by non-waiver-funded rent

  • subsidies. Supports are

episodic/periodic in nature.

DD Waiver

Family & Individual Supports Waiver

For individuals living with their families, friends, or in their own homes, including supports for those with some medical or behavioral needs. Available to both children and adults.

ID Waiver

Community Living Waiver

24/7 services and supports for individuals with complex medical and/or behavioral support needs through licensed services. Includes residential supports and a full array of medical, behavioral, and non-medical

  • supports. Available to adults

and some children.

*Slide content from DBHDS

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Waiver Program vs. Waiting List

63% of ID waiver dollars were

spent on Congregate Residential Services in FY 2015 The majority of people on the waiting list are children and transition-age youth.

Source: The Department of Behavioral Health and Developmental Services, January 2016, SLIDE FROM DBHDS

I/DD Waiver Waiting List

(10,288)

I/DD Waiver

(11,724)

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CCC Plus Waiver Creation

EDCD Waiver

Tech. Assisted Waiver

CCC Plus Waiver*

The CCC Plus Waiver offers all services available under the EDCD and Tech Waivers to all CCC Plus users, based on need

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Eligibility for Waivers

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Eligibility: Three Criteria

  • 1. Diagnostic Criteria
  • 2. Functional Criteria
  • 3. Financial Criteria
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Diagnostic Eligibility for Disability Waivers: DD Diagnosis and IQ

“Developmental disability" means a severe, chronic disability of an individual that:

(i)

is attributable to a mental or physical impairment, or a combination of mental and physical impairments, other than a sole diagnosis of mental illness;

(ii)

is manifested before the individual reaches 22 years of age;

(iii)

is likely to continue indefinitely;

(iv)

results in substantial functional limitations in three or more of the following areas

  • f major life activity: self-care, receptive and expressive language, learning,

mobility, self-direction, capacity for independent living, or economic self- sufficiency; and

(v)

reflects the individual's need for a combination and sequence of special interdisciplinary or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and 2 of 3 are individually planned and coordinated. An individual from birth through age nine who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described in clauses (i) through (v) if the individual, without services and supports, has a high probability of meeting those criteria later in life.”

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Diagnostic Eligibility for CCC Plus Waiver

CCC Plus Waiver

 Individuals who have significant medical needs. The criteria used to

determine eligibility is the nursing home criteria.

 Self assessment to determine possible eligibility can be found here

http://www.home-phone.com/momsinmotion/Registration.asp?#

 Enrollment process unchanged from former EDCD process  New manual under development

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Functional Eligibility

Disability Waivers:

  • All individuals must meet/show functional need in three out
  • f eight categories on the Virginia Individual Developmental

Disabilities Eligibility Survey (VIDES)

  • Different versions for ages 0-3, 3-18, and 18+
  • Categories include: Health Status, Communication, Task Learning Skills,

Personal/Self Care, Mobility, Behavior, Community Living Skills, and Financial Self-Sufficiency

CCC Plus Waiver:

  • Individuals must meet the nursing facility eligibility criteria

determined by using the Uniform Assessment Instrument (UAI) http://tinyurl.com/zdwfrl5

  • Focus on personal care and medical care needs
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◊ $2,250 per month income cap (300% of 2018 SSI amount) ◊ Patient pay begins once someone is earning $1237/month ◊ $2000 resource limit for adults ◊ No resource limit for children ◊ Parent income/resources do NOT EVER count*

*2017 Session Update: DMAS to develop a proposal for cost sharing requirements based on family income and submit to CMS to determine if such a proposal is feasible.

Financial Eligibility Thresholds for Medicaid Long Term Care, like Waivers

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Applying for Medicaid Q: If someone has applied for the Waiver, does this mean they have applied for Medicaid?

A: No!

These are two separate process! To apply for Medicaid, visit https://commonhelp.virginia.gov/

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Financial Eligibility

Q: The household income is too high to qualify for Medicaid, should the individual still apply for a waiver?

A: Yes!

You CAN be on the waiting lists without receiving Medicaid

  • benefits. Once a slot becomes available, you can apply for

Medicaid under the “Long Term Care/Institutional Rules”. And remember, different rules apply when it is State Plan Medicaid versus “long term care” Medicaid!

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Explore a Special Needs Trust

Like The Arc of Northern VA’s Trust

A SNT is a legal document designed to: Provide benefit to & protect the assets of a person with a disability while allowing the individual to be qualified for and receive government benefits, such as Medicaid, Medicaid Waivers and Supplemental Security Income. For more information, contact: Tia Marsili, Director of Trusts tmarsili@thearcofnova.org (703) 208-1119 x115 www.thearcofnovatrust.com

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Let’s Talk About Services

Bear in mind, services will vary by person based upon

  • need. Most people use multiple services and have

changes in their support plans over time.

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Service Category and Description Community Living Waiver-

Designed for people with higher needs

Family Supports Waiver-

Designed for people with moderate needs

Building Indep. Waiver-

Designed for people with lower needs

CCC Plus Waiver-

For people with medical and disability needs

Residential

Group Homes- 24/7 staffed home where 3+ people with disabilities live. Homes usually have 4-7 residents and staff that rotate around the clock on shifts. X

Residential

Shared Living- Individual lives with someone without a disability who is reimbursed for room and board in exchange for companionship X X X

Residential

Independent Living- Supports brought into the home focused on skill building and preparing for greater independence X

Residential

Sponsored Residential- Option where person with disability lives with a paid caregiver in the home of the caregiver. X

Residential

Supported Living- Residence owned by a support provider that offers up to 24/7 help with support needs X X

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Service Category and Description Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs

CCC Plus Waiver-

For people with medical and disability needs Day & Employment

Community Engagement- Service focused on ability to improve skills for employability and independence using the community as the environment

X X X

Day & Employment

Supported Employment (Group and Individual)- Supports on the job to allow people to work in competitive employment

X X X

Day & Employment

Day Support- Either center or community based supports that are typically unpaid and involve skill development

X X X

Day & Employment

Workplace Assistance Services- Services for someone who needs to fill the gap between initial job training and following along services

X X

Day & Employment

Community Coaching*- 1:1 support to build a specific skill or break a barrier to employment and community engagement

X X X

Day & Employment

Benefits Planning*- Services to help individuals receiving social security benefits understand the impact of work on those benefits

X X X

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Service Category and Description Community Living Waiver-

Designed for people with higher needs

Family Supports Waiver-

Designed for people with moderate needs

Building Indep. Waiver-

Designed for people with lower needs

CCC Plus Waiver-

For people with medical and disability needs

In Home

In-home Support Services (up to 24/7)- 1:1 services in the home focused on life skills X X

In Home

Companion Services- 1:1 service in the home focused to monitor for safety X X

In Home

Respite- Supplemental annual hours of personal care to provide relief to the unpaid caregiver X X X

In Home

Environmental Modifications- Up to $5000 per year to modify a primary home or vehicle to better adapt it to the needs of the individual X X X X

In Home

Personal Emergency Response System- Electronic safety monitoring system to link to emergency services X X X X

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Service Category and Description Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs

CCC Plus Waiver-

For people with medical and disability needs

Community Supports

Electronic Home-Based Supports- Good and services to be used in the home for greater independence in lieu of paid staff

X X X

Community Supports

Assistive Technology- Up to $5000 per year

  • n portable items to assist the individual

with safety, communication, and

  • independence. Must work with Medicaid

approved provider on eval.

X X X X

Community Supports

Crisis Supports (center and community based)- crisis prevention and stabilization

X X X

Community Supports

Community Guide*- Direct assistance in promoting and developing community relationships that promote integration and self-determination

X X X

Community Supports

Non-medical transportation*- Reimbursement for transport to locations associated with an individual’s support plan and goals

X X X

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Service Category and Description Community Living Waiver- Designed for people with higher needs Family Supports Waiver- Designed for people with moderate needs Building Indep. Waiver- Designed for people with lower needs CCC Plus Waiver- For people with medical and disability needs Medical Private Duty Nursing- 1:1 continuous care nursing for people with complex medical needs

X X X

Medical Skilled Nursing- Intermittent nursing related to a specific medical care need

X X X

Other Therapeutic Consultations- Limited consultations with therapists in qualifying areas

X X

Other Transition Services- Funding and supports to assist people with leaving institutional settings

X X X X

Other Individual and Family/Caregiver Training- Education and training on disability related issues for the primary caregiver or family of the individual

X

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Agency and Consumer Directed Staffing Options

 Agency Directed

  • Care that is rendered by a Medicaid approved agency
  • The agency hires, manages, and pays the workers
  • The agency submits the paperwork necessary for payment to

MCO

  • Available with all Waivers

 Consumer Directed

  • Workers are directly hired and managed by the individual

receiving the Waiver support services

  • Responsibility for managing all aspects of the employment

relationship, including recruiting, hiring, training, supervising, ensuring payment, and firing if needed

  • There is a service facilitator to assist you with this process
  • Available with all Waivers
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Application Process

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Applying for all Developmental Disability Waivers

Screenings are conducted by the local CSBs

Arlington: 703-228-1700 Alexandria: 703-746-3400 Fairfax: 703-324-4400 Loudoun: 703-777-0377

Steps:

1) Call your local CSB to complete a screening process

2) Complete application they send to you 3) Complete the process with the VIDES assessment, in person planning meeting, and get a letter confirming you’re

  • n the waiting list
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Screening and Application Process: CCC Plus Waiver

  • Call your local Department of Social Services for

intake

  • Alexandria (703-746-5700)
  • Arlington: Birth to 3 (703) 228-1640, 3yrs to 21yrs (703)

228-1510, 21yrs and older (703) 228-1769

  • Fairfax (703-324-7948)
  • Loudoun (703) 777-0353

Set up Screening and intake appointment with Social Worker

Schedule visit with the nurse

Meet with local County case worker

Meet with Home Health Care Agency or Service Facilitator

NO WAITING LIST

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Waiting List Navigation for the DD Waivers

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Disability Waiver Waiting Lists

  • All of the DD Waivers have a shared waiting list
  • Wait time is unpredictable since it is based upon urgency
  • f need
  • The waiting list is managed by Community Services

Boards

  • A Regional Waiver Slot Assignment Committee reviews

applications when slots are available

  • There should be emergency/reserve Waivers that are

accessed when APS/CPS involvement is present, and/or when primary caregiver(s) have passed away and the person needs help to care for themselves

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Will need waiver services within

  • ne year and

meets specific criteria

(Supplemental Critical Needs Summary Questions will be asked)

Priority One Status

Waiting List Tiers

Priority Two Status Priority Three Status

May require waiver services in one to five years and meets specific criteria May not present for waiver services in

  • ver five years as

long as the current supports and services remain

*DBHDS Slide. NOTE- You can appeal your tier if it doesn’t reflect your need

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Waivers Added in the 2018 Session

Type of Waiver Slots Added Community Living Waiver 129 Family and Individual Supports Waiver 414 Building Independence Waiver TOTAL 543

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While on the waiting list what else can you do?

Depending on level of need and eligibility criteria, you can apply for other waivers:

  • You CAN be the DD Waiver list AND receive services through the CCC

Plus Waiver

  • Call your county for case management and other locally funded

services or resources that may be available to you. Utilize the Individuals and Families Support Program Funding

Up to $1,000 per year for supports to serve you in the community

Apply online https://ifsponline.dbhds.virginia.gov

Open now until November 8, 2018 Access REACH Crisis Services- 24 hour crisis response and respite for people with ID/DD and behavioral or mental health needs who are over 18 years old

885-897-8278 For children under 18 years old, CR2 is available

844-N-CRISIS

Crisis Assistance Grant Supports Other Waivers

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Managed Care:

Commonwealth Coordinated Care (CCC) Plus

https://thearcofnova.org/programs-services/library/#ccc-plus to learn more and get information on selecting a plan

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What is Included in CCC Plus?

Managed Care Not Managed Care CCC Plus (formerly EDCD and Tech) Waiver All Medicaid medical AND Waiver services starting 12/1/2017 Ineligible populations Developmental Disability Waivers All Medicaid medical services starting 12/1/2017 All Waiver services until further notice

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Available CCC Plus MCOs

  • 1. Aetna Better Health
  • 2. Anthem HealthKeepers Plus
  • 3. Magellan Complete Care of VA
  • 4. Optima Health Community Care
  • 5. United Healthcare Community Plan
  • 6. Virginia Premier Health Plan
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SIS, Support Tiers, and Budgets

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Once You Receive a DD Waiver

 You will be contacted by the Community

Services Board and should be offered a choice of Case Manager

 You will take the Supports Intensity Scale

(SIS) assessment then and every three years thereafter

 You will develop a plan for the services

you need with the Case Manager

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Your SIS Score Gives a Support Level 1-7

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Most People will be in Middle Tiers

*Individually negotiated rates are possible for people with truly exceptional needs

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For some services, SIS affects reimbursement rates

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Reimbursement Decreases with More People in a Housing or Employment Situation

*This graphic and the previous graphic were created by The Arc of Virginia

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EPSDT and Waivers

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Early Periodic Screening Diagnosis and Treatment

 Available to all children under 21 with

Medicaid

 EPSDT provides any treatment or

procedure that fits within any of the categories of Medicaid-covered services if that treatment or service is necessary to “correct or ameliorate” defects and physical and mental illnesses or conditions.

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EPSDT Service Examples

 Physician, nurse practitioner and hospital

services

 Physical, speech/language, and

  • ccupational therapies

 Home health services, including medical

equipment, supplies, and appliances

 Treatment for vision, hearing and dental

diseases and disorders

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Mandate to Use EPSDT First for some DD Waiver Services*

 Personal Care/Personal

Assistance

  • Dependent in three or

more ADLs - Bathing, dressing, transferring, ambulation, eating, toileting and continence.

  • Doctor must fill out one

form and service facilitator or RN fill out two

 Private Duty Nursing

  • Doctor must fill out two

forms  Assistive Technology

  • Doctor or relevant

therapist must write evaluation

  • Doctor must write letter of

medical necessity

  • Quote from a vendor

needed *Change began November 1, 2017 for DD Waiver users and September 1, 2018 for CCC Plus Waiver users.

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EPSDT Changes

 If someone does not meet EPSDT criteria

for the requested service, DD Waivers will not fund it either

 You must use another stand alone Waiver

service every 90 days to keep your Waiver active (e.g., Respite, Employment, Residential)*

 DMAS process of “Individual

Consideration” before denials or reductions

 You can appeal decisions

*New list of stand alone services coming soon from DMAS

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Where Do I Go For More Information?

 All Waivers:

Waiver Hotline- 1-844-603-9248

 Developmental Disability Waivers Websites

http://www.mylifemycommunityvirginia.org/ The Arc of NOVA’s webpage- https://thearcofnova.org/programs/waivers/

 Local Community Services Boards

Arlington: 703-228-1700 Alexandria: 703-746-3400 Fairfax: 703-324-4400 Loudoun: 703-777-0377

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Please Become a Member of The Arc of Northern Virginia!

Follow our lead in advocating for the needs

  • f your loved one.

www.thearcofnova.org

Sign up for our newsletter!

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Thank you!

The Arc of Northern Virginia 2755 Hartland Road Falls Church, VA 22043 www.thearcofnova.org

Visit www.thearcofnova.org/answers anytime with questions!