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 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
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
Outline Purpose and Description of Medicaid Waivers 1) Redesigns in 2016 and 2017 2) Eligibility Criteria for all Waivers 3) Waiver Services 4) Application Process 5) Waiting List Navigation 6) Managed Care Intersection 7) SIS, Support Tiers, and Budgets 8) EPSDT 9) 10) Contact information for The Arc of Northern Virginia
Purpose and Description of the Waivers
Purpose of the Waivers Waivers give States the flexibility to offer services to an individual in the community rather than living and receiving services in an institution.
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
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
Current Waiver Cost Sharing Medicaid Waiver Costs Federal Government 50% 50% State Government *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
Waiver Redesigns: 2016 for Developmental Disability Waivers and 2017 for CCC Plus Waiver
Five Waivers in Virginia Disability Waivers Community Living Waiver Developmental Family and Individual Supports Waiver Building Independence Waiver Commonwealth Coordinated Care (CCC) Plus Waiver Formerly EDCD and Tech Waivers, but combined on July 1, 2017 Alzheimer’s Assisted Living Waiver (AAL Waiver)
Comparing Waivers DD Waivers CCC Plus Waiver Need developmental Need disability diagnosis disability diagnosis & medical need Robust menu of Shorter menu of services services for home, aimed at home care and nursing, work, and some nursing, but no community employment/residential Up to 24/7 support 56 hour weekly cap on based on need personal care Case management No case management Long waiting list No waiting list
DD Waiver Redesign Concept Day DD Support ID Waiver Waiver Waiver Family & Individual Building Independence Community Living Waiver Supports Waiver Waiver 24/7 services and supports For individuals living with For adults (18+) able to live for individuals with their families, friends, or in independently in the complex medical and/or their own homes , including community . Individuals own, behavioral support needs supports for those with some lease, or control their own through licensed services. medical or behavioral needs. living arrangements; and Includes residential supports Available to both children supports are complemented by and a full array of medical, and adults. non-waiver-funded rent behavioral, and non-medical subsidies. Supports are supports. Available to adults episodic/periodic in nature. and some children . *Slide content from DBHDS
Waiver Program vs. Waiting List 63% of ID waiver dollars were The majority of people on the waiting list are children and transition-age youth. spent on Congregate Residential Services in FY 2015 I/DD Waiver Waiting List I/DD Waiver (10,288) (11,724) Source: The Department of Behavioral Health and Developmental Services, January 2016, SLIDE FROM DBHDS
CCC Plus Waiver Creation EDCD Waiver CCC Plus Waiver* Tech. Assisted Waiver The CCC Plus Waiver offers all services available under the EDCD and Tech Waivers to all CCC Plus users, based on need
Eligibility for Waivers
Eligibility: Three Criteria 1. Diagnostic Criteria 2. Functional Criteria 3. Financial Criteria
Diagnostic Eligibility for Disability Waivers: DD Diagnosis and IQ “ Developmental disability" means a severe, chronic disability of an individual that: is attributable to a mental or physical impairment, or a combination of mental and (i) physical impairments, other than a sole diagnosis of mental illness; is manifested before the individual reaches 22 years of age; (ii) is likely to continue indefinitely; (iii) results in substantial functional limitations in three or more of the following areas (iv) of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, or economic self- sufficiency; and reflects the individual's need for a combination and sequence of special (v) 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.”
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
Functional Eligibility Disability Waivers: - All individuals must meet/show functional need in three out of 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
Financial Eligibility Thresholds for Medicaid Long Term Care, like Waivers ◊ $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.
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/
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!
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
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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