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What is a Waiver?

Everything You Need to Know About Your Medicaid Waiver Delaware County Board of Developmental Disabilities November 2009. What is a Waiver?.

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What is a Waiver?

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  1. Everything You Need to Know About Your Medicaid WaiverDelaware County Board of Developmental DisabilitiesNovember 2009

  2. What is a Waiver? • A waiver is another way that Medicaid can pay for services to keep people with disabilities in their homes so they do not have to move to a long-term care facility or nursing home. The local county board is required to pay 40% of the cost of waiver services and Medicaid pays the remainder (also known as HCBS waiver) • In order for an individual to receive a waiver, they must make application to be placed on the waiting list

  3. Waiting List • The waiting list rule OAC 5123:2-1-08 dictates enrollment based on priority categories. • Refer to the Priority Score Sheet for categories.

  4. Waiting Lists in Delaware County In Delaware County, each priority group has a weighted point value which is used to determine the individuals priority score All waiting lists are ordered first by priority score and then date and time of application One must have a minimum score of 2 in order to meet priority for the Level One Waiver. This increases to a minimum score of 11 in order to meet priority for the Individual Options Waiver

  5. Why do I want a waiver? • Comparison Charts for local funding • Medicaid Card (therapies, equipment, doctor appointments, nursing) • Can disenroll from the waiver at any time if it is not meeting the need

  6. Applying for a Waiver • A person must be Medicaid eligible to be eligible for a waiver • Adults on the waiting lists should apply for Medicaid if his/her name is on the waiting list (JFS 7200) • Medicaid eligibility is determined by the local Job & Family Services office and takes into consideration: • Income • Assets • Disability and age • Children will need to wait until a slot is available and assigned before applying for Medicaid due to household income inclusions

  7. Applying for a Waiver continued… • Delaware County Board of DD will send the Medicaid and Waiver applications to the family (7200 and 2300) • The family will complete the applications and send them to DCJFS. DCJFS will set an appointment and send notification to the family • A person must remain eligible for Medicaid to receive waiver services

  8. Preparing for the Transition toWaiver Services • Begin search for providers • Providers must be certified by DODD to provide waiver services • It can take several weeks for a provider to complete the certification process • IO and LV1 providers will not bill DCBDD for waiver services. Billing is completed through the MBS on-line application and payment is made by DODD • Medicaid Card Service (State Plan/CORE) providers are listed at http://www.ohiohcp.org/

  9. Waiver EnrollmentAges 5 and Under • Reports from EI Specialists, school staff or therapists that document delays in at least three of six areas (reports must be less than 6 months old). Delay areas include (OAC 5101:3-3-07(D)(2)): • Adaptive behavior • Physical development or maturation, fine and gross motor skills, growth • Cognition • Communication • Social or emotional development • Sensory Development Protective Level of Care Ohio Developmental Disability Profile* *exclusive to the individual options waiver

  10. Waiver EnrollmentAges 6 and Over • Functional Assessment • Ages 6-8 Attachment C • Ages 9-11 Attachment D • Ages 12-15 Attachment E • Ages 16+ Attachment F Protective Level Of Care Medical Evaluation • Not time sensitive • Must contain relevant information and confirm diagnosis Psychological report • Not time sensitive • Must contain relevant information and confirm diagnosis Ohio Developmental Disability Profile* *exclusive to the individual options waiver

  11. Individual Options Services available with the IOW include: Homemaker Personal Care Transportation Environmental accessibility modifications Adaptive & Assistive equipment Social work* Interpreter* Home delivered meals* Nutritional services* Adult Day Waiver Services *exclusive to the individual options waiver

  12. Level One Services available with LV1 waiver include: Homemaker/Personal Care Informal Respite* Institutional Respite Transportation Personal Emergency Response Systems Specialized Medical Equipment and Supplies Environmental Accessibility Adaptations Emergency Assistance* Adult Day Waiver Services *exclusive to the level one waiver $5000 annual cap combined $6000 cap over a 3 yr. period $8000 cap over a 3 yr period – must meet emergency status to access this service.

  13. Waiver Service Planning • Complete Individual Support Plan (ISP) with your team • Complete Payment Authorization for Waiver Services (PAWS) • Read and understand your PAWS (refer to sample PAWS) • Waiver Utilization • Tracking • Reallocation • Over-utilization • Your ISP is an “All Services Plan” and is to include all waiver, • locally funded, and Medicaid card services

  14. Medicaid A Medicaid Card is included with the Waiver service package and may cover therapies, hospital services, nursing services, home health aides, doctor & dental appointments and medical equipment Many of these services are available through Medicaid State Plan Services

  15. State Plan Services Home Health Services (OAC 5101:3-12-01) Services anyone with a Medicaid card and a Doctor’s order can access Available Statewide No waiting list

  16. Home Health Services Home Health Services include: Home Health Nursing Home Health Aide Skilled therapies (OT,PT,SLP) Services must be medically necessary as ordered by the treating physician.

  17. Home Health Services Four hours or less per visit (intermittent service) No more than 8 hours a day combined nursing/aide and therapies No more than 14 hours per week of nursing/aide

  18. Home Health Services To meet the requirement of ‘intermittent’, similar services cannot be ‘stacked’ For example—2 consecutive hours of service cannot be authorized as 1 hour of Home Health Services aide and 1 hour as Waiver HPC provider. A 2 hour break is required.

  19. Home Health Services Cannot be billed back to back (stacked) with a similar service type For example: 6am-8am(no break) 8am-12pm(no break)12pm-2pm HH Aide Waiver HPC Provider HH Aide Not Permitted

  20. Home Health Services MUST have a MINIMUM 2 hour break in services For Example: 6am-10am(break) 1pm-5pm(break) 8pm-10pm HH Aide Waiver HPC Provider HH Aide Permitted

  21. Home Health Services Can be billed back to back with a DIFFERENT service type For example: 6am-8am (no break)8am-12pm (no break)12pm-2pm Home Health Aide Waiver Nursing Home Health Aide Permitted

  22. Home Health Services • Can be billed back to back with a DIFFERENT service type • For example: • 6am-8am (no break) 8am-12pm (no break) 12pm-2pm • HH AideWaiver Informal HH Aide • Respite Provider • Permitted

  23. Home Health Services Home Health Services cannot be provided for the purposes of respite or habilitative care

  24. Home Health Services Per OAC 5101:3-12-01 (D) (4) (c) “Respite care” is the care provided to a consumer unable to care for himself or herself because of the absence or need for relief of those normally providing care.

  25. Home Health Services Must be provided in the consumer’s place of residence or in a licensed day care, or in an Early Intervention program .

  26. Home Health Services • Home Health Aide Services • Per OAC 5101-3-12-01(F)(2)(e) • Services include: • Personal Care • Routine catheter/colostomy care • Assistance with routine maintenance exercises and passive ROM activities in support of skilled therapy goals. • Routine care of prosthetic and orthotic devices

  27. Home Health Services Home Health Aide Services Per OAC 5101-3-12-01(F)(2)(f) Incidental Services can include: light chores, laundry, light house cleaning, meal prep and taking out trash Main purpose of a Home Health Aide visit cannot be solely to provide incidental services Incidental services are to be performed only for the consumer May NOT provide medication administration

  28. Home Health Services Worksheet The SSA will complete the HHS worksheet for those on an MRDD waiver (DCBDD form) List all agencies providing home health services (aide, therapy and nursing less than 14 hours per week) Attach care plan from home health agency Agency must have Dr’s script, care plan and HHS worksheet on file

  29. Increased Home Health Eligibility: Up to age 21 Must have a comparable institutional level of care (ILOC, ICF MR/DD LOC, or SLOC) Must need at least 1 skilled service a week (nursing or therapy) Have part-time intermittent needs (Visits must continue to be 4 hours or less with 2 hour min break in between like services)

  30. Home Health Services Must be reflected on service plan for children enrolled on a DODD-administered waiver. (Use worksheet) For children on ODJFS-administered waivers, the case manager authorizes these services via the service planning process. Provider Type---Medicare Certified Home Health Agency providers are listed at http://www.ohiohcp.org/

  31. Home Health Services Crosswalk Services at a Glance Types of services Separated into age groups Eligibility Providers • State Plan Therapies • SLP, OT, PT • Fee for Service • HHA • Hospital • Physician • IPs (not available for all services)

  32. Private Duty Nursing Services OAC 5101:3-12-02 Private Duty Nursing is continuous nursing that is more than 4 hours per visit. PDN is required when more than 14 hours of nursing is needed per week. Must be provided in the consumer’s place of residence unless it is medically necessary for a nurse to accompany the consumer into the community. The Private Duty Nursing Service can be provided for the purposes of respite care.

  33. Private Duty Nursing ODJFS shall complete a face-to-face assessment to confirm that the consumer has a medical condition that requires medically necessary PDN services once they receive the request form from the CB. ODJFS will authorize the amount scope and duration of PDN services. Authorized for no more than 1 year for consumers enrolled on an DODD-administered waiver

  34. Durable Medical Equipment Rule: 5101:3-10-03 "Medicaid Supply List“ List of supplies: http://www.registerofohio.state.oh.us/pdfs/5101/3/10/5101$3-10-03_PH_FF_A_APP1_20090320_1057.pdf

  35. Any Questions? Ohio Department of Developmental Disabilities http://dodd.ohio.gov/ Delaware County Board of DD www.dcbdd.org Ohio Department of Job & Family Services http://jfs.ohio.gov/

  36. Melinda Draper Waiver Coordinator mdraper@dcbdd.org 740-368-5802 ext 506 Roxanne Richardson Support Administrator rrichardson@dcbdd.org 740-368-5801 ext 308 Questions?

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