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MEDICAID - PowerPoint PPT Presentation

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MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER. MEDICAID. HISTORY Medicaid was established with amendments to the Social Security Act in 1965 Medicaid Buy-In. PURPOSE To provide for health and medical care for certain groups of people who have low income. FLEXIBILITY

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Medicaid l.jpg


  • Medicaid was established with amendments to the Social Security Act in 1965

  • Medicaid Buy-In


    • To provide for health and medical care for certain groups of people who have low income


    • States design their own programs within federal standards

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Federal agency


Previously HCFA


State agency



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  • DMAS is designated as the single state agency charged with administering Medicaid in Virginia

  • DMAS contracts or has agreements with other entities for most screening, case management, service and billing related activities

  • DMAS is responsible for ensuring that the Medicaid program operates in compliance with state and federal laws and regulations

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  • Virginia Medicaid budget for fiscal year 2005

    $ 4,473,588,930

    50% from state funds

    50% from federal funds

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Inpatient Hospital Services

Emergency Hospital Services

Outpatient Hospital Services

Nursing Facility Care

Rural Health Clinics

Federally Qualified Health Center Clinic Services

Lab and X-Ray Services

Physician Services

Home Health Service


Family Planning

Nurse-Midwife Services

Certified Nurse Practitioner Services


Medicare Premiums

(Part A) - Hospital; (Part B) - Supplemental Insurance for Categorically Needy


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Other Clinic Services

Skilled Nursing Facility Services for Individuals under 21 years of age

Podiatrist Services

Optometrist Services

Clinical Psychologist Services

Home Health

PT, OT, and Speech Therapy

Prescribed Drugs

Case Management


Hospice Services

Mental Health Services


OPTIONALMedicaid Services Provided In Virginia

E arly and p eriodic s creening d iagnosis and t reatment epsdt l.jpg
Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Medicaid benefits available to children under the age of 21

Must be eligible for Medicaid

 Monitor to prevent health and disability conditions from occurring or worsening, including services to address such conditions

 Treatment to “correct or ameliorate conditions,” including maintenance services

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  • Immunizations

  • Check ups and lab tests

  • Mental health assessment and treatment

  • Health education

  • Eye exams and glasses

  • Hearing exams and hearing aids & implants

  • Dental services

  • Personal care, nursing services

  • Other needed services, treatment and measures for physical and mental illnesses & conditions

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Institutional Placements

  • Hospitals

  • Nursing homes

  • ICFs/MR - Intermediate Care Facility for people with mental retardation or other related conditions

  • institutions of 4 or more beds for people with MR or other related conditions

  • active treatment and rehabilitation

  • regulated by the federal and state governments

    • 32 ICFs/MR in Virginia

      • 5 large “Training Centers,” several hundred beds at each Center

      • 27 smaller ICFs/MR, ranging from 4 to 88 beds

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(Mandatory & Optional Services)

Categorical Criteria

Disabled or age 65 or older

Families with children

Pregnant women

Recipients of cash assistance

Low income Medicare beneficiaries

Financial Thresholds

Low income and asset guidelines

Thresholds vary by category group

Parental income/resources DO count for minor children

Consideration of exceptionally high medical bills (spend-down)

LONG-TERM CARE (Waivers & Institutions)

Must Need Long-term Care

criteria defined for each Waiver

assessment of need required

Financial Thresholds

300% of SSI payment limit for one person ($1,809 per month)

spend-down for 4 of the Waivers

$2000 resource limit

Parent income/resources do NOT count regardless of child’s age

Services Required

All Waiver and State Plan (Mandatory and Optional) services you are eligible for

ELIGIBILITY Apply at local Department of Social Services

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  • Health Insurance Premium Payment program

  • DMAS program

  • Pays health insurance premiums

  • Application must be completed separately from the Medicaid application

  • Application info 800-432-5924

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  • Some people may have to pay a copayment for Medicaid services if they do not receive Waiver services.

  • People who receive Home and Community-Based Medicaid Waiver services do not pay copayments for their basic, State Plan Medicaid services.

  • However, some people may have to pay a patient-pay for their Waiver services.

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  • People may have to pay for some Waiver services if they have income over $603 per month (except AIDS Waiver which has no patient-pay)

  • Some exceptions for persons who are working (EDCD, DD and MR Waivers)

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Patient-PayEDCD Waiver, DD Waiver, MR Waiver

  • People may have a patient-pay if income is over $603 a month

  • Can keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/week

  • Can keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/week

  • Still have a patient-pay from unearned income for all Waivers except the AIDS Waiver

    * total of earned and unearned income

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Waivers give States the flexibility to develop and implement alternatives to institutionalization.

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  • Slow the growth of Medicaid spending

  • Institutions are overly restrictive and too highly routine oriented

  • Permit federal Medicaid funds to be used for community services by people who would otherwise be institutionalized

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  • State develops a Waiver application to be submitted to the federal Centers for Medicare and Medicaid Services (CMS) for approval – Task Forces are usually established by DMAS to assist with development of the applications

  • DMAS develops regulations to implement the Waiver - Public comment is solicited when regulations are proposed

  • The Virginia General Assembly allocates funds for Waiver services – Advocates can educate the General Assembly about the need for funds to provide services

  • Waiver is initially approved by CMS for 3 years and then typically renewed every 5 years – Task Forces are usually established by DMAS to assist with development of the renewal applications

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To receive approval to

implement a Waiver, a State

Medicaid agency must assure

CMS that it will not cost more

to provide home and

community based services

than providing institutional care

would cost

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Waiver Must be Cost Effective

  • It can be individually cost effective or cost effective in the aggregate

  • Aggregate Cost EffectivenessThe average cost to Medicaid of individuals on the Waiver cannot cost more than the average cost to Medicaid of individuals in the comparable institution

  • Individual Cost Effectiveness Cost to Medicaid for the individual in the community can’t exceed the cost in the comparable institution

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Medicaid Waivers

Virginia has 6 Home and Community Based Care (1915 (c) ) Waivers

State Regulations for the Waivers can be found at:

  • 12 VAC-30-120-70 Technology Assisted Waiver (Tech Waiver)

  • 12 VAC-30-120-140 AIDS Waiver

  • 12 VAC-30-120-210 Mental Retardation Waiver (MR Waiver)

  • 12 VAC-30-120-700 Individual and Family Developmental Disabilities Support Waiver (DD Waiver)

  • 12 VAC-30-120-900 Elderly or Disabled with Consumer Direction Waiver (EDCD Waiver)

  • 12 VAC-30-120-1500 Day Support Waiver for Individuals with Mental Retardation (Day Support Waiver)

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  • AIDS

  • Technology Assisted


  • AIDS

  • Elderly or Disabled with Consumer Direction

  • Technology Assisted

  • ICF/MR

  • Mental Retardation

  • Developmental Disabilities

  • MR Day Support

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Alternative Institutional Placement

  • There must be an alternate institutional placement for which Medicaid pays

  • The individual who is applying for a Waiver must meet the same criteria that is used for admission to the institution

  • This does not mean that the individual must actually be placed in the institution or make application to an institution

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Pre-Admission Screening Teams of the Department of Health & Department of Social Services

  • Elderly or Disabled with Consumer Direction Waiver

  • AIDS Waiver

    Department of Medical Assistance Services

  • Technology Assisted Waiver

    Community Services Board

  • MR Waiver

  • MR Day Support Waiver

    Department of Health Local Clinics

  • Developmental Disabilities Waiver

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  • Used for Day Support, DD and MR Waivers

  • LOF Survey is completed as part of the screening process

  • Determines the level of care needed

  • To receive DD or MR Waiver services, an individual must meet the criteria for admission to an ICF/MR

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  • Used for nursing home placement and the AIDS, EDCD, and Tech Waivers

  • Completed as part of screening and assessment

  • Assesses social, physical health and functional abilities

  • Used to gather info for planning and monitoring needs and eligibility

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  • People who have mental illness, mental retardation or developmental disabilities

  • Initiated by the nursing home preadmission screening team when screening for nursing home placement and the EDCD Waiver

  • Preadmission screening team sends supplement screening request to CSB

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  • Some people with MR or DD have active treatment needs that are not met by nursing homes or nursing home-related Waivers

  • Determine the person’s need for active treatment that would not be met by nursing homes or nursing home-related Waivers

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  • Specialized Services

  • Services Identified By CSB

  • Responsibility & Entitlement

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  • Ensures development, coordination, implementation, monitoring and modification of the individual’s plan

  • Links the individual with appropriate community resources and supports

  • Coordinates service providers

  • Monitors quality of care

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Community Services Boards provide case management services




Individual chooses their Case Management organization

Various organizations provide Case Management services

Case Management organizations cannot provide other DD Waiver services (except Consumer Directed Services Facilitation)

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  • Freedom, choice and control remaining with the individual, and sometimes their family -

    • what service is needed

    • who will provide it

    • when it will be provided

    • where it will be provided

    • how it will be provided

      In Virginia, CD services were initiated by Centers for Independent Living and the Virginia Board for People with Disabilities in 1989

      Virginia Medicaid Waivers have components of consumer-direction and self-determination, implementation depends on the individual and their case manager

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Consumer-Directed Services

  • Individual or family caregiver directs and controls who, how, and when services are provided

  • Virginia offers consumer-directed services in 4 Waivers:

    • Elderly or Disabled with Consumer-Direction Waiver (since 2005) - Personal Care, Respite

    • Developmental Disabilities Waiver (since 2000) - Personal Care, Respite, Companion

    • Mental Retardation Waiver (since 2001) - Personal Assistance, Respite, Companion

    • AIDS Waiver (since 2003) – Personal Assistance, Respite

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Consumer-Directed Services

  • Individual is the employer of record with the IRS

  • Service Facilitator (SF) writes documentation of need based on information from the individual, monitors the service and provides support as needed to the individual so that the individual can be an employer of their staff

  • SF provides training on recruiting, interviewing and training staff, how to handle difficult situations, how to complete employment paperwork, etc.

  • SF provides list of attendants, companion aides or respite workers and shows how to place an advertisement for attendants, companion aides and respite workers (the list and ads do not have to be used)

  • DMAS (acting as a fiscal agent) and a contractor pays the attendants, companion aides and respite workers on behalf of the individual

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  • Be 18 years old

  • Possess basic math, reading and writing skills

  • Have the required skills to perform job duties

  • Have a valid Social Security number

  • Submit to a criminal history check

  • Willing to attend training requested by the person receiving Waiver services

  • Willing to register in a CD-staff registry

  • Understand and agree to comply with program requirements

  • TB screening

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  • Staff (Consumer-Directed employees including attendants, companions, respite workers)

    • Staff may be related to a consumer, but may not be members of the immediate family (parents of minor children, spouses, or legally responsible relatives)

  • Exception: Payments may be made to other staff who are family members when there is objective written documentation as to why there are no other providers available to provide care

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  • Person-centered planning

  • Involve people of your choice in developing your Plan

  • Prepare Plan

  • Choose services

  • Choose providers

  • Decide how & when services will be provided

  • Agree to and monitor Plan

  • Quarterly and Annual Review of Plan

  • Right to appeal areas of disagreement

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  • Written document, signed by the consumer

  • Addresses all needs of the individual in all life areas

  • Developed with consumer, providers and others the consumer wants involved

CSP will list -

  • services and supports to be provided

  • who will provide the services and supports

  • how often the services and supports will be provided

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  • Who will participate in your meeting

  • Develop a list of needed supports & services (be honest & frank)

  • Collect documentation

    • vocational evaluations

    • IEPs

    • school evaluations

    • medical documentation

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  • Adequate services must be provided

  • Additional or different services should be added if needed to protect health, safety and welfare

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Individual and Family Developmental Disabilities Support “DD” WaiverEligibility Criteria

  • “Related Conditions” Waiver

  • Must be 6 years of age and older and meet “related conditions” criteria

  • Cannot have a diagnosis of mental retardation

  • Level of Functioning survey used for screening

  • Call DMAS (804) 786-1465 to request a Request for Screening Form or go to

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RELATED CONDITIONS “DD” Waiveralso referred to as developmental disability

  • Severe chronic disability

  • Attributable to a condition, other than mental illness

  • Manifested before the age of 22

  • Likely to continue indefinitely

  • Results in substantial limitations in 3 or more areas of major life activity

    • Self-care

    • Understanding and use of language

    • Learning

    • Mobility

    • Self-direction

    • Capacity for independent living

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DD Waiver Services “DD” Waiver

  • Adult companion services (CD & agency with 8 hrs per day limit)

  • Assistive technology ($5,000 per year limit)

  • Crisis stabilization (60 day max/year)

  • Environmental modifications ($5,000 per year limit)

  • In-home residential support (not congregate)

  • Day Support

  • Skilled Nursing

  • Supported employment

  • Therapeutic consultation

  • Personal emergency response system (PERS)

  • Family/caregiver training (80 hours max/year)

  • Respite care (CD & agency)

  • Personal assistance services (CD & agency)

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DD Waiver Statistics “DD” Waiver

  • Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $6,193,998

  • 338 individuals served in FY 2005

  • Waiver is cost effective in the aggregate

  • About 40% of the individuals requesting a screening are not eligible for the DD Waiver

  • Wait list is maintained by DMAS

  • About 2,700 people have requested DD Waiver services

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MR Waiver Eligibility Criteria “DD” Waiver

  • Must have a diagnosis of mental retardation or be under the age of 6 and at developmental risk

  • Children on the MR Waiver who do not have a diagnosis of MR at the age of 6, possible transfer to DD Waiver

  • Screenings are conducted by CSBs

  • Level of Functioning survey is the screening instrument used

  • There is a waiting list for the MR Waiver

  • Screening for all Waivers must be provided without any charge to the individual

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MR Waiver Services “DD” Waiver

  • Residential support (group home or individual’s home)

  • Day support and prevocational services

  • Supported employment

  • Personal assistance (CD & agency)

  • Respite care (720 hours max/year) (CD & agency)

  • Assistive technology ($5,000 max/year)

  • Environmental modifications ($5,000 max/year)

  • Skilled nursing services

  • Therapeutic consultation

  • Crisis stabilization (60 days max/year)

  • Adult companion (8 hours max/day) (CD & agency)

  • Personal Emergency Response System (PERS)

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CSBs and DMHMRSAS maintain Urgent and Non-Urgent lists “DD” Waiver

CSB maintains Planning list

CSB provides individual with written notice if placed on a waiting list and if there is a change in status to another list

CSB determines who on the Urgent list receives the next available slot

Only after all Urgent needs are met statewide will Non-urgent needs be served

Slot moves with you to a different town in VA

Vacant or new slots are allocated by the CSB unless there is no need in the CSB’s area

Non-urgent = meet criteria for the MR Waiver, including needing services within 30 days, but don’t meet Urgent criteria

Planning list = need services in the future

MR WAIVER WAITING LISTSUrgent and Non-urgent

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  • Primary caregiver(s) is/are 55 years or older

  • Living with a primary caregiver who is providing the service voluntarily and without pay and they can’t continue care

  • There is a clear risk of abuse, neglect, or exploitation

  • Primary caregiver has chronic or long term physical or psychiatric condition significantly limiting ability to provide care

  • Individual is aging out of a publicly funded residential placement or otherwise becoming homeless

  • Individual lives with the primary caregiver and there is a risk to the health or safety of the individual, primary caregiver, or other individual living in the home because:

    • Individual’s behavior presents a risk to himself or others OR physical care or medical needs cannot be managed by the primary caregiver even with generic or specialized support arranged or provided by the CSB

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MR Waiver Statistics “DD” Waiver

  • Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $280,354,624

  • 6,421individuals served in FY 2005

  • Waiver is cost effective in the aggregate

  • Approximately 2,600 people on the waiting lists

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  • Only for people now on the MR Waiver Urgent or NonUrgent waiting lists

  • 300 people served

  • July 1, 2005 start date

  • Includes Day Support and Prevocational services

  • Case Management through the CSBs

  • People could transition to the MR Waiver

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Elderly or Disabled with Consumer Direction Waiver (EDCD) “DD” WaiverEligibility Criteria

  • Individuals seeking Waiver services are eligible if 65 or older or disabled

  • Must meet nursing home criteria

  • Can have a cognitive impairment

  • Screening is the conducted by the Preadmission Screening Team using the UAI

  • Questionnaire used to determine if an individual can independently manage Consumer Directed Attendants or if assistance with managing care will be needed

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Elderly or Disabled with Consumer Direction Waiver Services “DD” Waiver

  • Services that are available statewide:

    • Adult Day Health Care

    • Personal Care Services (CD or Agency)

    • Personal Emergency Response System (PERS)

    • Respite (CD, Agency, or Skilled)

      Individuals can receive up to 720 hours of respite per year

      Personal assistance services can be provided outside of the individual’s home

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Elderly or Disabled with Consumer Direction Waiver Services “DD” Waiver

  • Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $137,148,487

  • 11,901individuals served in FY 2005

  • No waiting list for the EDCD Waiver

  • Waiver is cost effective in the aggregate

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Technology Assisted Waiver Criteria “DD” Waiver

  • Individual may be eligible if she needs both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing care

  • Screening: UAI is used for adults and Tech Waiver scoring tool is used for children

  • DMAS reviews individual’s private insurance policy for private duty nursing benefits

  • Case management provided by DMAS nurses

  • Different rules for children and adults

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ADULTS “DD” Waiver

Screening team completes UAI for adults only. DMAS staff follows up to complete the screening for adults

Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis

Cost effectiveness is compared to nursing facility specialized care


DMAS staff completes screening for children

Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis; or daily dependence on other device-based respiratory or nutritional support

Cost effectiveness is compared to hospital costs

Tech Waiver Considerations

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Tech Waiver Services “DD” Waiver

  • Services that are available statewide:

    • Private duty nursing

    • Respite care

    • Durable medical equipment

    • Personal care for individuals over 21 years of age

    • Environmental Modifications

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Tech Waiver Services Limits “DD” Waiver

  • Environmental modifications and Assistive technology provided if medically necessary and cost effective

  • Respite care has an annual limit of 360 hours per year

  • Private duty nursing has a limit of 16 hours per day, except -

    • individuals under 21 can receive nursing services 24 hours a day during the first 30 days they receive Tech Waiver services

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Tech Waiver Statistics “DD” Waiver

  • Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $24,136,697

  • 363 individuals served in FY 2005

  • No waiting list for the Tech Waiver

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AIDS Waiver Criteria “DD” Waiver

  • Individuals are eligible for the AIDS Waiver if they have a diagnosis of AIDS or AIDS-Related Complex and would require nursing facility or hospital care

  • Individuals are screened by a Preadmission Screening Team (DSS social worker, VDH nurse and physician)

  • Screening tool is the Uniform Assessment Instrument (UAI)

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AIDS Waiver Services “DD” Waiver

  • Services that are available statewide:

    • Case management

    • Nutritional supplements

    • Private duty nursing

    • Personal assistance/care (CD or Agency)

    • Respite care (CD or Agency)

      Individuals can receive up to 720 hours of respite per year

      Personal assistance services can be provided outside of the individual’s home

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AIDS Waiver Statistics “DD” Waiver

  • Fiscal Year (FY) 2005 Waiver Expenditures (July 2004 through June 2005) = $783,297

  • 213 individuals served in FY 2005

  • No waiting list for the AIDS Waiver

  • Waiver is cost effective in the aggregate

  • No patient-pay for the AIDS Waiver

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BRAIN INJURY WAIVER “DD” Waivernot quite yet

  • DMAS worked with a task force to develop an outline for a new Brain Injury Waiver

  • Eligibility, services, providers, and other criteria being discussed by DMAS and the task force

  • Initiation of this new Waiver depends on funding provided by the General Assembly

  • Brain Injury Association of VA, 804-355-5748

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DMAS is responsible for - “DD” Waiver

adequate supply of qualified providers to meet needs of recipients

ensuring the capacity and scope of services are available

ensuring individuals are able to have “provider choice”

enrollment of providers

quality of services


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  • A list of qualified providers for each service in the Consumer Services Plan will be given to you

  • You have the right to choose your providers

  • You have the right to visit, interview and research providers

  • You decide when, where and how you want approved services provided

  • Case Manager will assist you in locating and choosing providers

  • Case Manager will contact providers for initiation of services

  • You can switch providers if you choose to

  • There are shortages of some providers

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  • Fair Hearing

  • Right to challenge decisions and actions regarding Medicaid

  • Decision should be issued by the Hearing Officer within 90 days

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  • Application of benefits is denied

  • The agency takes action or proposes to take action which will adversely affect, reduce, or terminate receipt of benefits

  • Request for a specific benefit is denied; in whole or in part

  • The agency does not act with reasonable promptness

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  • DD and MR Waivers are the only Waivers with waiting lists

  • MR Waiver has 2 waiting lists: Urgent and Non-urgent and a planning list

  • DD Waiver has 2 waiting lists: Level I (CSP less than $25,000) and Level II (CSP more than $25,000)

  • No waiting list for the AIDS, EDCD and Tech Waivers

  • Waiting lists are permissible, but waiting lists must move at a reasonable pace

    What is a reasonable pace?