MEDICAID WAIVER PROGRAMS: Leaving Institutions Behind November - PDF document

MEDICAID WAIVER PROGRAMS:  Leaving Institutions Behind November 2010 1

What Are They? Medicaid Home and Community  Based Services Waivers are programs that enable certain groups of people with disabilities to live in the community instead of in institutions Each program “waives” certain  Medicaid rules. They let targeted groups receive extra services not available to others on Medicaid, to limit the number of people who can receive such services, and provide higher income limits than for most other Medicaid coverage groups. 2

What Do They Have In Common? Each Waiver was designed to  enable eligible people to either leave institutions, or to avoid entering them. Each has a limited number of  service “slots”. Currently, each Waiver is “closed” –  all slots are filled, and not open to people already in the community. Through Money Follows the  Person, each Waiver is still open to people currently receiving institutional services that Medicaid is funding. 3

What Do They Have In Common? Eligibility A person must choose community  services instead of institutional ones  Must not simultaneously be enrolled in another Medicaid Waiver Must qualify for Medicaid through:  SSI, or  TCA, or  By having countable income  below 300% of SSI federal benefit rate ($2,022/month) and countable resources under $2,000 4

What Do They Have In Common? Eligibility Individual considered a household  of one  Each Waiver applies these income exclusions for income eligibility: $20 general income exclusion 1. $65 earned income exclusion 2. ½ of remainder of earned 3. income after $65 exclusion ½ of gross self-employment 4. earnings (unless business expenses are greater than ½ of earnings) ½ of rental income 5. 5

What Do They Have In Common? Eligibility Each Waiver applies these income  exclusions for income eligibility (Continued): BWE’s 6. Any wages, allowances, or 7. reimbursement for transportation and attendant care costs, unless excepted on a case-by-case basis, when received by a blind or disabled person employed in a project under Title VI of the Rehabilitation Act of 1973 6

What Do They Have In Common? Eligibility A home is excluded if it’s occupied  by the participant, his/her spouse, or his/her parent, sibling or child who is financially or medically dependent on the participant Resources that are sold or given  away in order to qualify for Waiver services are counted for five years after disposal Annual financial redetermination  required 7

1. Living at Home Waiver  Alternative to nursing homes  Regulations: COMAR 10.09.55 Who is Eligible?  Must be 18 - 64 years old (or 65 or older if enrolled before age 65)  Must have nursing facility level of care, redetermined annually  Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care) 8

1. Living at Home Waiver Covered Services Attendant care  Environmental assessments  Environmental modifications  Assistive technology  Personal emergency response  systems Consumer training (how to recruit,  select, train, direct, supervise, and fire consumer-employed attendants, as well as money management, budgeting, independent living, meal planning, etc.) 9

1. Living at Home Waiver Covered Services Family training (instruction about  treatment regimens and the use of equipment specified in the plan of service) Transition services (security  deposits, furniture, moving expenses, utility set-up fees and deposits, pest eradication and other health/safety costs)  Medical day services Nursing supervision of attendants  Home-delivered meals   Dietician and nutritionist services Case management  10

1. Living at Home Waiver How to Apply  Contact Area Agency on Aging (AAA) http://www.mdoa.state.md.us/aaa.html or the Living at Home Waiver office (410- 767-7479) to apply.  AAA visits consumer, family and nursing facility staff to educate them about Waiver, complete Medicaid application (CARES 9709), gather financial documents and send to the Division of Eligibility and Waiver Services (DEWS) 11

1. Living at Home Waiver How to Apply  DEWS determines financial eligibility  Adult Evaluation and Review System (AERS) does assessment for nursing facility level of care and physician completes Medical Eligibility Review Form (3871). Forms sent to Key Pro for review.  The Coordinating Center develops Plan of Care 12

2. Older Adults Waiver  Alternative to nursing homes  Regulations: COMAR 10.09.54 Who is Eligible?  Must be at least age 50  Must have nursing facility level of care, redetermined annually  Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care) 13

2. Older Adults Waiver Participant Fees  Paid only by participants in assisted living facilities  Participant pays countable income to assisted living provider  To determine countable income for fees, apply usual exclusions (see slides 5 & 6) plus the following:  Personal needs allowance ($72/mo.)  Room and board paid (not to exceed $420/mo.)  Incurred and unpaid medical expenses  Spousal and/or family maintenance allowance if applicable (for community spouse and dependent children under age 21) 14

2. Older Adults Waiver Covered Services Assisted living  Personal care aide  Senior center plus  Environmental assessments  Environmental modifications  Assistive technology  Personal emergency response  systems Respite care  Behavior consultation  Family or consumer training  Transition services  15

2. Older Adults Waiver Covered Services Medical day services  Nursing supervision of attendants  Home-delivered meals  Dietician and nutritionist services  16

2. Older Adults Waiver How to Apply  Contact Area Agency on Aging (AAA) to apply - http://www.mdoa.state.md.us/aaa.html  AAA visits consumer, family and nursing facility staff to educate them about Waiver, complete Medicaid application (CARES 9709), gather financial documents and send to the Division of Eligibility and Waiver Services (DEWS) 17

2. Older Adults Waiver How to Apply  DEWS determines financial eligibility  Adult Evaluation and Review System (AERS) does assessment for nursing facility level of care and physician completes Medical Eligibility Review Form (3871). Forms sent to Key Pro for review.  AAA develops Plan of Care 18

3. & 4. Community Pathways and New Directions Waivers  Alternative to intermediate care facilities for people with mental retardation (ICF/MR) or nursing facilities  Regulations: COMAR 10.09.26  Community Pathways Waiver provides traditional services  New Directions Waiver provides consumer-controlled services. Consumer hires/fires staff, manages service budget (usually with help of a financial intermediary called a support broker). 19

3. & 4. Community Pathways and New Directions Waivers Who is Eligible?  Must be certified for an ICF-MR level of care  Must be in a:  State Residential Center, or  Nursing facility, but determined to have a developmental disability and to need specialized services  Chronic care facility  Community setting, but at imminent risk of institutionalization (Note: New Waiver eligibility now limited to people in institutions) 20

3. & 4. Community Pathways and New Directions Waivers Participant Fees  Paid only to participants who receive residential habilitation services  Participant pays countable income to residential provider  To determine countable income for fees, apply usual exclusions (see slides 5 & 6) plus the following:  Personal needs allowance ($170/mo.)  Room and board paid ($375/mo.)  Incurred and unpaid medical expenses  Spousal maintenance allowance if applicable 21

3. & 4. Community Pathways and New Directions Waivers Covered Services – Community Pathways  Residential habilitation  Community supported living arrangements  Live-in caregivers  Day habilitation  Community learning services  Medical day services  Employment discovery and customization  Supported employment  Resource coordination 22

3. & 4. Community Pathways and New Directions Waivers Covered Services – Community Pathways  Environmental modifications  Assistive technology  Respite care  Behavioral support services  Family and individual support services  Transition services  Transportation 23

3. & 4. Community Pathways and New Directions Waivers Covered Services – New Directions  Support brokerage  Community supported living arrangements  Live-in caregivers  Day habilitation  Community learning services  Medical day services  Employment discovery and customization  Supported employment  Resource coordination 24

3. & 4. Community Pathways and New Directions Waivers Covered Services – New Directions  Environmental modifications  Assistive technology  Respite care  Behavioral support services  Family and individual support services  Transition services  Transportation 25