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Exploring Medicaid Waivers. Debra Holloway The Arc of Virginia Family Involvement Project. Different Institution - Different Waiver.

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exploring medicaid waivers

Exploring Medicaid Waivers

Debra Holloway

The Arc of Virginia

Family Involvement Project

different institution different waiver
Different Institution - Different Waiver
  • Waivers provide funding for a wide variety of services for people of all ages who have disabilities or are elderly so that they may remain in their homes and communities rather than an institutional placement such as a hospital, nursing home

or ICFs/MR (intermediate care facility)

  • Means “Low income” – Wrong!
  • Waiver eligibility is not dependent on


waiver must be cost effective
Waiver Must be Cost Effective
  • Virginia’s waiver programs for the elderly and disabled are expensive but still less costly than compatible institution care.
  • The elderly and disabled represent

30% of Medicaid program recipients.

what are the services different waivers have different services
What are the services?Different Waivers have different services.
  • Adult Day Health Care
  • Assistive Technology
  • Case Management
  • Companion Services
  • Crisis Intervention/Stabilization
  • Day Support
  • Environmental Modifications
  • Family Caregiver Training
  • Nursing Services
  • Nutritional Supplements
  • Personal Care Services
  • Personal Emergency Response System
  • Prevocational Services
  • Residential Support
  • Respite
  • Skilled Nursing
  • Supported Employment
  • Therapeutic Consultation
  • Transition Coordination
  • Transition Services
there are seven waivers administered by the commonwealth of virginia
There are seven waivers administered by the Commonwealth of Virginia
  • Elderly or Disabled with Consumer Direction (EDCD)
  • Individual and Family Developmental Disabilities Supports (IFDDS)
  • Technology Assisted (Tech)
  • Mental Retardation (MR)
  • Day Support
  • Alzheimer’s Assisted Living (AAL) Waiver managed by the Facility and Home-Based Care Unit
  • Mental Health Waiver (Demonstration Waiver)
Elderly or Disabled with Consumer Direction Waiver (EDCD)
  • Technology Waiver (Tech)
  • Individual and families with Developmental Disabilities Waiver (DD)
  • Mental Retardation Waiver

(MR Waiver, ID or intellectually disabled)

consumer directed services
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
consumer directed services9
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 staff, how to handle difficult situations, how to complete employment paperwork, etc.
  • SF provides list of people who have said they want to work as consumer-directed staff 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 (using a contractor, PPL) pays the attendants, companion aides and respite workers on behalf of the individual
consumer directed employees attendants companions respite workers
Consumer-Directed EmployeesAttendants, Companions, Respite Workers
  • Consumer-Directed employees may not be -
    • Parents of minor children or spouses of the individual receiving consumer-directed services
  • If the Consumer-Directed employee lives with the person receiving services -
    • Service Facilitator must have objective written documentation as to why there are no other providers available to provide care
elderly or disabled with consumer direction waiver
Elderly or Disabled with Consumer Direction Waiver
  • This waiver is constructed to allow persons to remain in the community that meet nursing facility level of care.
  • Current enrollment 14,034
  • No waiting list
  • Screening is conducted by the Preadmission Screening team made up of a representative from The Department of Health and the Department of Social Services using the Uniform Assessment Instrument (UAI)
  • This waiver serves the elderly and persons of all ages with disabilities. The individual may receive this service through a service provider or though consumer direction.
  • An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver.
  • Qualify for Medicaid (individual)
  • Meet long term care criteria according to Uniform Assessment Instrument (UAI)

Pre-Admission Screening Criteria:

    • Functional capacity (the degree of assistance an individual requires to complete activities of daily living); and
    • Medical or nursing needs
    • Risk of nursing facility placement
  • Functional Dependencies:

bathing, dressing, toileting, transferring, eating/feeding

  • Medical and nursing needs:

catheter care, supervision for adequate nutrition and hydration, therapeutic exercise and positioning, management of those with sensory, metabolic, or circulatory impairment.

getting started
Getting Started
  • Request for screening, contact your local Health Department
  • Schedule visit with pre-admission screening teams of the Department of Health & Department of Social Services.
  • Completed Medicaid application (child’s information only!)
  • Adult Day Health Care
  • Personal Care (agency or consumer directed)
  • Respite 720 hrs. (agency or consumer directed)
  • Personal Emergency Response System (PERS)
  • Assistive Technology ($5000 max calendar year)
  • Environmental Modifications ($5000 max calendar year)
  • Transition Services ($5000 max)
  • Transition Coordination
technology assisted waiver tech
Technology Assisted Waiver (Tech)
  • No age limit to eligibility
  • No waiting list
  • Currently serving 319 individuals.
  • Serves individuals who need a medical devise to compensate for the loss of a vital body function and requires substantial and ongoing skilled nursing care to remain safely in their homes.
  • Screening: UAI is used for adults and Tech Waiver scoring tool is used for children
  • The Department of Medical Assistance Services (DMAS) reviews individual’s private insurance policy for private duty nursing benefits
  • Case management provided by DMAS nurses
  • Different rules for children and adults
  • Doctor must certify need for care; and need substantial and ongoing skilled nursing care; and
  • Care must be cost effective; and
  • Primary caregiver must be trained and accept responsibility for 8 hours or more per day
screening process
Screening Process
  • DMAS receives a referral from community resources, family, other parties
  • DMAS completes a Scoring Tool to determine if the individual meets the specialized care criteria for the waiver
  • If the criteria is met DMAS conducts a home assessment.
  • DMAS works with the primary caregiver, referral source to secure appropriate nursing care for the individual in the home
  • DMAS authorizes needed services for the provider agency upon the start of care
  • Private Duty Nursing (16 hours maximum a day, except children may have 24 hours a day for the first 30 days after hospital discharge)
  • Personal Care (adults only)
  • Respite Care (360)
  • Environmental Modifications ($5000)
  • Assistive Technology ($5000)
  • Durable Medical Equipment
  • Transition Services ($5000)
individual and family developmental disabilities support waiver dd
Individual and Family Developmental Disabilities Support Waiver (DD)
  • Wait list is maintained by the Department of Medical Assistance Services (DMAS)
  • Recipients served FY07 594, and 640 are waiting.
  • Can be placed on the waiting list at age 5 years 8 months
eligibility criteria
Eligibility Criteria
  • “Related Conditions” Waiver
  • Must be 6 years of age and over and meet the related conditions criteria, including autism; and
  • Individual must not have a diagnosis of Mental Retardation.
  • Meet the level of care for admission to an ICF/MR. The individual must meet 2 out of 7 levels of functioning.
  • The Virginia Department of Health Child Development Clinics will screen individuals with the Level of Functioning (LOF) Survey which is the assessment instrument used to determine eligibility to for an ICF/MR
  • You can download a copy of the “Request for Screening” from www.dmas.virginia.gov. Compete the form and fax or mail it to the CDC. The psychological assessment is a requirement of the screening determination.
related conditions also referred to as developmental disability
RELATED CONDITIONSalso 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
transitioning from mr to dd waiver
Transitioning from MR to DD Waiver
  • Annually each child receiving MR Waiver services who will be 6 years of age the following year can be up for consideration for transfer to the DD Waiver.
  • If the child meets DD Waiver eligibility the child can transition to the DD Waiver.
  • Adult Companion (CD & Agency/up to 8 hours a day)
  • Assistive Technology ($5000)
  • Crisis stabilization
  • Crisis supervision
  • Environmental Modifications ($5000)
  • In-home residential
  • Prevocational
  • Companion Care
  • Day support
  • Skilled nursing
  • Supported employment
  • Therapeutic consultation
  • PERS
  • Family/caregiver training (80 hours a year)
  • Respite care (720)
  • Personal attendant services
  • Transition Services ($5000)
mental retardation waiver mr
Mental Retardation Waiver (MR)
  • Day-to-day MR waiver operations are managed by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS)
  • Locally, MR Waiver services for individuals are coordinated by case managers employed by Community Services Boards
  • Wait list - Waiting list as of 12/08 4,375
  • 7,942 waivers approved

400 new MR Waiver slots funded, 200 available

July 1, 2009, 200 available January 1, 2010

  • Individuals must have an evaluation that reflects their current level of intellectual and adaptive functioning.
  • Six and over – a psychological evaluation with a diagnosis of mental retardation.
  • Six and under – either a psychological or standardized developmental evaluation that states the child has a diagnosis of mental retardation or is at developmental risk.
  • All individuals receiving MR Waiver services must meet the ICF-MR level of care.
  • Case Manager completes a “Level of Functioning Survey.” The individual needs to have significant needs in two or more of the survey’s seven categories.
waiting list
Waiting List
  • Urgent
  • Non-Urgent
urgent criteria for the mr waiver
Urgent Criteria for the MR Waiver
  • Primary caregivers are both 55 yrs or older (or if 1, is 55 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
mr waiver waiting lists urgent and non urgent
CSBs and DMHMRSAS maintain Urgent and Non-Urgent lists

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 is the most urgent

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
  • Adult Companion Care
  • Assistive Technology ($5000)
  • Congregate Residential
  • Crisis Stabilization/Supervision
  • Day Support
  • Environmental Modifications ($5000)
  • Family/caregiver Training
  • In-home Residential
  • Medication Monitoring
  • PERS
  • Personal Care (Agency or Consumer Directed)
  • Prevocational Services
  • Private Duty Nursing/Skilled Nursing
  • Respite Care (720) (Agency or Consumer Directed)
  • Therapeutic Consultation
  • Supported Employment
  • Transition Services ($5000)
early periodic screening diagnosis and treatment epsdt
Early 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

  • 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
medical necessity
Medical Necessity
  • The medical justification for a service must accompany the request for EPSDT treatment services

-Services not covered


Environmental Modifications



health insurance premium payment program hipp
Health Insurance Premium Payment Program (HIPP)
  • If an individual receiving waiver services has private health insurance, Medicaid will be the individuals secondary insurance
  • DMAS may reimburse the individual for all or a portion of their monthly private health insurance premium
  • Application must be completed separately from the Medicaid application.
  • 1-800-432-5924
  • Visit www.dmas.virginia.gov scroll to “Client Services” click on “More Services” then click on “HIPP Information”
recipient appeal
Recipient Appeal
  • A person may appeal if their benefits are:





medicaid appeals
Medicaid Appeals
  • Fair Hearing
  • Right to challenge decisions and actions regarding Medicaid
  • Appeal must be requested within 30 days of the decision or action that you disagree with
  • Decision should be issued by the Hearing Officer within 90 days
  • Request an appeal or review


  • Notify appeals division in writing
  • Be specific about what you want

-Results in a hearing

-Decision made

myth or fact
  • All persons with a disability of MR/ID will qualify for MR Waiver. MYTH
  • I can be on a wait list for the DD Waiver or the MR Waiver while I am receiving services from another Waiver. FACT
waiting lists
Waiting Lists

MR Waiver has 2 waiting lists

Urgent and Non-urgent:

CSB determines who is the most urgent to receive available MR Waiver funding

DD Waiver waiting list

First come, first served with wait list numbers assigned

10% of available money allocated for emergency situations

DMAS staff determine who receives available emergency slots

No waiting list for AIDS, Alzheimer’s, EDCD and Tech

Waiting lists are permissible, but waiting lists must move at a reasonable pace. What is a reasonable pace?

the arc of virginia family involvement project
Debra Holloway

Family Involvement Project Manager


ext. 103


The Arc of Virginia



The Arc of VirginiaFamily Involvement Project