Medicaid waiver programs
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MEDICAID WAIVER PROGRAMS:. Leaving Institutions Behind November 2010. 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

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Medicaid waiver programs

MEDICAID WAIVER PROGRAMS:

  • Leaving Institutions Behind

    November 2010


What are they

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.

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What do they have in common

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.

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What do they have in common1

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

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What do they have in common2

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

$65 earned income exclusion

½ of remainder of earned income after $65 exclusion

½ of gross self-employment earnings (unless business expenses are greater than ½ of earnings)

½ of rental income

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What do they have in common3

What Do They Have In Common?

Eligibility

Each Waiver applies these income exclusions for income eligibility (Continued):

BWE’s

Any wages, allowances, or 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

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What do they have in common4

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

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1 living at home waiver

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)

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1 living at home waiver1

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.)

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1 living at home waiver2

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

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1 living at home waiver3

1. Living at Home Waiver

How to Apply

Contact Area Agency on Aging (AAA) http://www.mdoa.state.md.us/aaa.htmlor 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)

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1 living at home waiver4

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

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2 older adults waiver

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)

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2 older adults waiver1

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)

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2 older adults waiver2

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

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2 older adults waiver3

2. Older Adults Waiver

Covered Services

Medical day services

Nursing supervision of attendants

Home-delivered meals

Dietician and nutritionist services

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2 older adults waiver4

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)

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2 older adults waiver5

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

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3 4 community pathways and new directions waivers

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).

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3 4 community pathways and new directions waivers1

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)

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3 4 community pathways and new directions waivers2

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

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3 4 community pathways and new directions waivers3

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

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3 4 community pathways and new directions waivers4

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

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3 4 community pathways and new directions waivers5

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

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3 4 community pathways and new directions waivers6

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

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3 4 community pathways and new directions waivers7

3. & 4. Community Pathways and New Directions Waivers

How to Apply

Service Coordinator/Resource Coordinator completes Waiver information (including Medicaid application (CARES 9709), financial documentation, and level of care form) and submits to DDA regional office (http://dhmh.maryland.gov/dda_md/)

Regional office sends CARES 9709, financial documentation to DEWS, and level of care form to DDA Central Office (Terri Hartman 410-767-5421) for eligibility determinations

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3 4 community pathways and new directions waivers8

3. & 4. Community Pathways and New Directions Waivers

How to Apply

If applicant does not have a current disability determination from SSA (i.e., for SSI or Title II), DEWS sends forms for physician to complete and return. State Review Team does disability determination.

Service Coordinator/Resource Coordinator develops Individual Plan

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5 waiver for people with traumatic brain injury tbi

5. Waiver for People with Traumatic Brain Injury (TBI)

Alternative to intermediate care facilities for people with mental retardation (ICF/MR) or nursing facilities

Regulations: COMAR 10.09.46

Fact sheet: http://dhmh.maryland.gov/mha/Miscellaneous/TBI/TBI%20Waiver%20fact%20sheet_09.pdf

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5 waiver for people with traumatic brain injury tbi1

5. Waiver for People with Traumatic Brain Injury (TBI)

Who is Eligible?

Must have a traumatic brain injury sustained at age 22 or later

Must have enrolled in Waiver at age 22 - 64

Must have nursing facility or special hospital level of care, redetermined annually

Must meet cost neutrality requirements (i.e., needed community services must cost less than nursing home care)

Must be able to be served safely and appropriately in the community

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5 waiver for people with traumatic brain injury tbi2

5. Waiver for People with Traumatic Brain Injury (TBI)

Who is Eligible?

Ordinarily, must be in:

A state psychiatric hospital deemed inappropriate because the person doesn’t need that level of care, or

A TBI community placement funded by the Mental Hygiene Administration (MHA) with state-only funds, or

A nursing facility owned and operated by the State or an out-of-state rehabilitation facility funded by Medicaid, or

A Maryland licensed special hospital for chronic disease licensed by CARF for inpatient TBI care

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5 waiver for people with traumatic brain injury tbi3

5. Waiver for People with Traumatic Brain Injury (TBI)

Who is Eligible?

Currently, while Waiver is closed, must be in:

University Specialty Hospital, or

Kernan Hospital, or

Western Maryland Hospital Center, or

Deers Head Hospital

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5 waiver for people with traumatic brain injury tbi4

5. Waiver for People with Traumatic Brain Injury (TBI)

Covered Services

Residential habilitation

Day habilitation

Supported employment

Individual support services

Medical day services

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5 waiver for people with traumatic brain injury tbi5

5. Waiver for People with Traumatic Brain Injury (TBI)

How to Apply

Hospital case manager or social worker makes referral to MHA (410-402-8476)

Completes Medicaid application (CARES form 9709) and submits to DEWS

Physician completes Medical Eligibility Review Form (3871) and sends to Key Pro to review and approve level of care

After eligibility approved, plan of care developed

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Medicaid waivers and eid

Medicaid Waivers and EID

The preceding 5 Waivers are compatible with EID

A person enrolled in one of these Waivers whose income or resources exceed the usual Waiver limits can enroll in EID to keep Waiver services

Countable income limit for an unmarried individual in EID = $2,707/month (usual Waiver limit is $2,022/month)

Countable resource limit for EID = $10,000 (usual Waiver limit is $2,000), plus EID excludes some retirement accounts (Waivers usually count these accounts)

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Other medicaid waivers

Other Medicaid Waivers

Waiver for Children with Autism Spectrum Disorder – provides services (residential habilitation, intensive individual supports, therapeutic integration, respite care, family training, environmental modifications and adult life planning) to people with autism aged 1 – 21

Model Waiver – provides services (nursing, certified nursing aides, home health aides, case management and medical day services) for medically fragile children under age 22

These Waivers are NOT COMPATIBLE WITH EID

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