Waiver Programs: Helping
Your Clients Stay at Home
PLAN 2012 Statewide Conference
September 11, 2012
Pamela Walz
Community Legal Services
Home and Community Based
Services
 Medical
and non-medical services to allow
elderly and people with disabilities to live
independently in their homes and
communities.
 Most but not all programs are Medicaid
funded through waiver programs
Waiver Programs
Section 1915(c) of the Social Security Act:
 permits certain Medicaid provisions to be
waived to allow states to offer enhanced
services to particular populations at risk of
institutionalization
 permits use of spousal impoverishment
rules to determine financial eligibility
Waiver Programs (cont’d)
 Must
meet eligibility requirements of a
specific waiver
 In PA, the Office of Long Term Living
administers most waiver programs (Office
of Developmental Programs administers
the rest).
HCBS Waivers in PA
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PDA (Aging) Waiver
Attendant Care Waiver
AIDS Waiver
Autism Waiver (for adults 21and over with
autism)
COMMCARE Waiver (for individuals with
traumatic brain injury)
Independence Waiver (for individuals 18-59 with
physical disability but not intellectual disability or
mental illness as primary diagnosis)
HCBS Waivers in PA (cont’d)

Living Independently for the Elderly (LIFE)
 OBRA Waiver (individuals 18-59 with severe
developmental physical disability)
 Consolidated Waiver (age 3 or older with
Intellectual Disability and recommended for
ICF/MR level of care)
 Person Family Directed Support Waiver (age 3
or older with Intellectual Disability and
recommended for ICF/MR level of care but do
not need residential services)
PDA Waiver
To qualify, must be
 Resident of PA and US citizen or qualified
non-citizen
 Age 60 or over
 Nursing Facility Clinically Eligible (NFCE)
 Financially eligible for MA
 Aggregate cost of serving all participants
in a waiver must not exceed 80% of cost
to serve same group in nursing facility.
Nursing Facility Clinically Eligible
(NFCE)
 Individual
has diagnosed illness, injury,
disability or medical condition;
 As result, requires care and services
above level of room and board;
 Physician certified individual is NFCE; and
 Care and services are either:


Skilled or
Intermediate level care.
Financial eligibility for Waiver –
Income
 Income
limit for 2012 is $2,094 (300% of
the federal SSI rate)
 Spouses’ income is not counted in
determining income eligibility
 Can spend down to SSI level ($698), but
not to $2,094.
Financial eligibility for Waiver –
Resources
 Resource
limit for single individual is
$8,000 ($2,000 + $6,000 disregard)
 Married couples: spousal impoverishment
rules on resource assessment and
spousal share apply
 Estate recovery applies for Waiver
recipients age 55 or older
Aging Waiver services
 Home
health
 Personal care
 Attendant care
 Respite
 Adult Day Care
 Transportation
 Home modifications

Specialized medical
equipment, supplies
 Home delivered
meals
 Personal emergency
response
 Companion
Aging Waiver services (cont’d)
 Prior
to 7/1/12, only AAAs provided care
management. Other providers can now
bid to provide this service, now called
“service coordination”.
 Waiver recipients get full MA coverage!

Must meet SLMB or QMB income limits to get
Medicare Part B paid
Living Independently for Elders
(LIFE)
 Program
of All-Inclusive Care for the Elderly
(PACE) model
 Model of care focused around Adult Day
Care attendance
 ALL services are coordinated and provided
by LIFE

LIFE is paid a capitated rate by Medicare, Medicaid,
and/or the Participant (depending on the Participant’s
eligibility for Medicare and Medicaid)
LIFE Eligibility



Must be 55 or older for enrollment in Full-PACE LIFE
Center or 60 or older for enrollment in Pre-PACE LIFE Ctr
NFCE level of care
Available to people with any one of these combinations of
funding:




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Medicaid Only
Medicare and Private Pay
Medicare and Medicaid
Private Pay Only
For those seeking Medicaid coverage of LIFE, Waiver
income and resource limits apply and Estate Recovery
applies
Must live in area served by a LIFE program (38 counties)
LIFE Services
 Adult
day center
 Home support, home health, personal care
 Respite
 Transportation
 Meals
 Medical and nursing care
 Rehabilitation and restorative therapies
LIFE services (cont’d)
 Home
modifications
 Social activities and recreation
 Social services
 Hospital and nursing facility care when
needed
Attendant Care Waiver
Eligibility requirements:
 Resident of PA
 Between 18 and 59 years old
 NFCE
 Financially eligible for MA
 Diagnosis of physical impairment expected to
last at least 1 year
 Capable of hiring, firing, supervising attendant
care workers and managing financial/legal
affairs
Options
 State-funded
(not MA)
 Services for consumer age 60+
 Can be NFCE but not financially eligible
for Waiver OR Nursing Facility Ineligible
(NFI).
Options (cont’d)
 Services
are same as Waiver but are
capped at $714.60/month (exception is
available)
 Sliding scale cost sharing for consumers
with income greater than 125% of FPL
($1,135/mo. single, $1,532/ mo. couple in
2011)
 Waiting lists
Act 150 Program
 State-funded
attendant care program (not
MA funded)
 Same eligibility requirements as Attendant
Care Waiver except need not be
financially eligible for MA
 Minimal copayment if income >125% FPL
 No estate recovery
Domiciliary Care
 Provides
home-like living arrangement in
community for individuals who need help
with ADLs and unable to live
independently
 In
dom care provider’s own home
Dom Care Eligibility
 18
or older with difficulties with ADLs
which prevents independent living
 Cannot be NFCE
 Mobile or –semi-mobile
 Generally low-income (dom care
supplement available)
Dom Care Services
 AAA
develops care plan
 Assistance with ADLs
 3 meals/day
 Medication Administration
Family Caregiver Support Program
 Purpose
is to support individuals providing
care in the home
 Governed by state and federal law
 Act 112 of 2011 made revisions: caregiver
no longer needs to be related to person
receiving care
FCSP Eligibility

Must be primary caregiver
 Care receiver must be functionally dependent
older adult or other adult with chronic dementia
 Services available to caregivers whose care
receiver’s households are



under 200% of FPL or
to those between 200-380% with sliding scale
contribution.
No benefits if care receiver household income
>380% FPL.
FCSP Services
 Counseling,
education and training
 Assessment
 Home
chore services
 Modest financial assistance with expenses
including respite care and incontinence
supplies
 Grants for home modifications (not to
exceed $2,000)
FCSP services (cont’d)
 Maximum
monthly grant is $200, but Act
112 increases it to $500 in cases of
documented need.
 However, if local AAA average grant is
>$300/month across entire FCSP
caseload, maximum is $200.
Process to Obtain Aging Waiver
Services
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Level of care assessment by AAA
Prescription from physician indicating NFCE
Individual Service Plan (ISP) development –
must be approved by OLTL
Supports coordinator contacts agencies,
arranges and manages services
If waiver services inadequate or denied,
applicant may appeal and have fair hearing
before ALJ
Recipient participation in process
Participant Direction
 Knowing
the difference between
Participant Centered system and
Participant Direction
 Aging Waiver offers choices


the process of choosing amongst the choices
is the Participant “Centeredness” of the
system
the opportunity for the participant to exercise
control over his/her services is Participant
Direction
Participant Direction
 Traditional
ways of getting services
through HCBS Waiver = Agency Model
 Participant Direction includes


the Employer Model (wherein the waiver
consumer is the employer and hires and fires
staff with the help of a fiscal management
agency, service coordinator, etc.) and
Services My Way – which is the Employer
Model plus budget authority (wherein the
waiver consumer gets decision making ability
over how to spend budgeted amount)
Common Problems for Waiver
clients
 Inability
to spend down to Waiver
 Loss of eligibility due to failure to comply
with redetermination requirements
 Denial of particular service (e.g. adult day
care) or number of hours
 Waiting lists (CommCare, OBRA, Act 150)
Common problems for Waiver Clients
(cont’d)
 Delays

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in enrollment:
Maximus (Independent Enrollment Broker for
under-60 Waivers): lengthy waits for
assessments and determinations. Recent
Mosley settlement requires timely actions.
Individualized Service Plan approval delays
Elimination of Community Choice
 Christian
Financial debacle
Problems, cont’d
 Act
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22 HCBS regulations:
Set provider rates which may create access
problems and reduce consumer direction
Narrowed scope of Aging waiver care
management function (now called service
coordination)
Reduced nursing oversight in Aging waiver
Eliminated several services from Aging waiver
 What
happened to rebalancing???
New HCBS Opportunities Under PPACA

Section 10202. State Balancing Incentive
Payments Program
 Section 2401. Community First Choice Option—
Medicaid State Plan Option for Attendant
Services and Supports:
 Section 2402. Medicaid Home and Community
Based Services State Plan Option
 Others
Questions?
 Pam
Walz
Aging and Disabilities Unit
Community Legal Services, Inc.
pwalz@clsphila.org
(215) 227-4798