Achieve with Us.
Virginia Medicaid Waivers:
Access and Services
Debra Holloway
Director of Training and Technical
Assistance
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)
Waivers 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.
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 Service
Nutritional Supplements
Personal Care Services
Personal Emergency Response System
Transition Services
Prevocational Services
Residential Support
Respite
Skilled Nursing
Supported Employment
Therapeutic Consultation
Transition Coordination
There are Seven Waivers
Administered by the
Commonwealth of Virginia
• Elderly or Disabled with Consumer Direction
(EDCD)
• Individual and Family Developmental Disabilities
Supports (IFDDS)
• HIV/AIDS
• Technology Assisted (Tech)
• Intellectual Disabilities Waiver (ID)
• Day Support
• Alzheimer’s Assisted Living (AAL) Waiver managed
by the Facility and Home-Based Care Unit
• Mental Health Waiver (Demonstration Waiver)
Reviewing Today:
• Elderly or Disabled with Consumer Direction
Waiver (EDCD)
• Technology Assisted Waiver (Tech)
• Individual and Families with Developmental
Disabilities Waiver (DD)
• Intellectual Disabilities Waiver (ID)
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 Personal Care, Respite
– Developmental Disabilities Waiver - Personal Care,
Respite, Companion
– Intellectual Disability Waiver - Personal Assistance,
Respite, Companion
– AIDS Waiver– Personal Care, Respite
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
• 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
• This waiver is constructed to allow persons
to remain in the community that meet
nursing facility level of care.
• 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)
Eligibility
• 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.
Criteria
• 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
Examples
• 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
• Request for screening, contact your local Health
Department/Department of Social Services
• Schedule visit with pre-admission screening
teams of the Department of Health &
Department of Social Services.
• Completed Medicaid application (child’s
information only!)
Services
• Adult Day Health Care
• Personal Care* (agency or consumer
directed)
• Respite* (agency or consumer directed)
• Personal Emergency Response System
(PERS)
• Transition Services ($5000 max)
• Transition Coordination
Technology Assisted Waiver (Tech)
• No age limit to eligibility
• No waiting list
Eligibility
• 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
Criteria
• Doctor must certify need for care; and need
substantial and ongoing skilled nursing care
• Care must be cost effective
• Primary caregiver must be trained and accept
responsibility for 8 hours or more per day
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.
Services
• 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 hours)
• Environmental Modifications ($5000)
• Assistive Technology ($5000)
• Durable Medical Equipment
• Transition Services ($5000)
Individual and Family Developmental
Disabilities Support Waiver (DD)
• Wait list is maintained by the Department
of Medical Assistance Services (DMAS)
• Can be placed on the waiting list at age 5
years 8 months
• 150 new slots July 1, 2011
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 an
Intellectual Disability.
• Meet the level of care for admission to an
ICF/MR. The individual must meet 2 out of 7
levels of functioning.
Screening
• 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
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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
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Self-care
Understanding and use of language
Learning
Mobility
Self-direction
Capacity for independent living
Transitioning from ID to DD Waiver
• Annually each child receiving ID 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.
Services
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Adult Companion (CD & Agency)
Assistive Technology ($5000)
Crisis stabilization
Environmental Modifications ($5000)
In-home residential
Prevocational and Day Support
Skilled Nursing
Supported Employment
Therapeutic consultation
PERS - Personal emergency response system
Family/caregiver training (80 hours a year)
Respite care (CD & Agency)
Personal care services
MFP Transition Services ($5000)
Individual with Intellectual Disability
Waiver (ID)
• Day-to-day ID waiver operations are
managed by the Department of Behavioral
Health and Developmental Services
(DBHDS)
• Locally, ID Waiver services for individuals
are coordinated by case managers
employed by Community Services Boards
• 275 New waiver slots, July 1, 2011
Eligibility
• Individuals must have an evaluation that reflects
their current level of intellectual and adaptive
functioning.
• Six and over – a psychological evaluation with a
diagnosis as having an intellectual disability.
• Six and under – either a psychological or
standardized developmental evaluation that
states the child has a diagnosis of intellectual
disability or is at developmental risk.
Criteria
• All individuals receiving ID 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
• Urgent
• Non-Urgent
ID WAIVER WAITING LISTS
Urgent and Non-urgent
• CSB’s and DBHDS 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 ID Waiver, including
needing services within 30
days, but don’t meet Urgent
criteria
• Planning list = need services in
the future
Urgent Criteria for the ID 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
Services
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Adult Companion Care (CD & Agency)
Assistive Technology ($5000)
Crisis Stabilization
Day Support and prevocational services
Environmental Modifications ($5000)
Residential support (Individual’s home or group
home)
PERS – personal emergency response system
Personal Care (Agency or Consumer Directed)
Skilled Nursing
Respite Care (CD & Agency)
Therapeutic Consultation
Supported Employment
MFP Transition Services ($5000)
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
EPSDT
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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
Medical Necessity
• The medical justification for a service must
accompany the request for EPSDT treatment
services
-Services not covered
Respite
Environmental Modifications
Vocational
Educational
Health Insurance Premium Payment
Program (HIPP)/ HIPP for Kids
• 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
HIPP
• 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
• A person may appeal if their benefits are:
-Terminated
-Denied
-Suspended
-Reduced
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
Steps
• Request an appeal or review
(804)-371-8488
• 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 ID will
qualify for ID Waiver. MYTH
• I can be on a wait list for the DD Waiver
or the ID Waiver while I am receiving
services from another Waiver. FACT
Waiting Lists
ID Waiver has 2 waiting lists
Urgent and Non-urgent:
CSB determines who is the most urgent to receive available ID 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?
Debra Holloway
Director of Training and Technical
Assistance
888-604-2677 ext. 103
dholloway@thearcofva.org
www.thearcofva.org