MEDICAID WAIVER TECHNICAL
ASSISTANCE CENTER
MEDICAID
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• To provide for
health and
medical care for
certain groups of
people who have
low income
HISTORY
Medicaid was
established with
amendments to the
Social Security Act
in 1965
Medicaid Buy-In
PURPOSE

FLEXIBILITY
• States design
their own
programs within
federal standards
MEDICAID IS A JOINT PROGRAM
BETWEEN FEDERAL & STATE
GOVERNMENTS

CENTERS FOR
MEDICARE &
MEDICAID SERVICES
•
•
•
•
Federal agency
CMS
Previously HCFA
cms.hhs.gov

DEPARTMENT FOR
MEDICAL ASSISTANCE
SERVICES
• State agency
• DMAS
• www.dmas.virginia.gov
VIRGINIA MEDICAID

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
VIRGINIA’S MEDICAID

Virginia Medicaid budget for fiscal year 2005
$ 4,473,588,930
50% from state funds
50% from federal funds
MANDATORY
MEDICAID SERVICES
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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
 EPSDT
 Family Planning
 Nurse-Midwife Services
 Certified Nurse
Practitioner Services
 Transportation
 Medicare Premiums
(Part A) - Hospital; (Part B) Supplemental Insurance for
Categorically Needy
OPTIONAL
Medicaid Services Provided In Virginia
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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
 Prosthetics
 Hospice Services
 Mental Health Services
 ICF-MR
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
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
Institutional Placements

Hospitals

Nursing homes
ICFs/MR - Intermediate Care Facility for people with
mental retardation or other related conditions
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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

ELIGIBILITY
Apply at local Department of Social Services
LONG-TERM CARE
(Waivers & Institutions)
STATE PLAN MEDICAID

(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)
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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
HIPP

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
COPAYMENTS
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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 CommunityBased 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.
PATIENT-PAY
RESPONSIBILITIES
$ 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)
Patient-Pay
EDCD 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
WHAT ARE HOME & COMMUNITYBASED MEDICAID WAIVERS?
Waivers give States the flexibility to develop and
implement alternatives to institutionalization.
WHY WERE HOME &
COMMUNITY-BASED
WAIVERS ESTABLISHED?

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
HOW IS A WAIVER DEVELOPED?

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
COST EFFECTIVE
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
Waiver Must be Cost Effective

It can be individually cost effective or cost effective in
the aggregate
• Aggregate Cost Effectiveness
The 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
Medicaid Waivers
Virginia has 6 Home and Community Based
Care (1915 (c) ) Waivers
State Regulations for the Waivers can be found at:
http://leg1.state.va.us/000/reg/TOC12030.HTM#C0120
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)
 12 VAC-30-120-70
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DIFFERENT INSTITUTION - DIFFERENT WAIVER
NURSING HOMES
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HOSPITAL
AIDS
Elderly or Disabled with
Consumer Direction
Technology Assisted

AIDS

Technology Assisted
ICF/MR
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Mental Retardation

Developmental Disabilities
MR Day Support

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
SCREENING PROCESS
Pre-Admission Screening Teams of the Department of
Health & Department of Social Services
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
Elderly or Disabled with Consumer Direction Waiver
AIDS Waiver
Department of Medical Assistance Services

Technology Assisted Waiver
Community Services Board
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MR Waiver
MR Day Support Waiver
Department of Health Local Clinics

Developmental Disabilities Waiver
LEVEL OF FUNCTIONING (LOF)
SURVEY

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
UNIFORM ASSESSMENT
INSTRUMENT (UAI)

Used for nursing home placement and the AIDS,
EDCD, and Tech Waivers
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Completed as part of screening and assessment
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Assesses social, physical health and functional
abilities
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Used to gather info for planning and monitoring
needs and eligibility
SUPPLEMENT TO SCREENING

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
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Preadmission screening team sends
supplement screening request to CSB
PURPOSE OF
SUPPLEMENT SCREENING

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
LEVEL II SUPPLEMENT
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Specialized Services
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Services Identified By CSB
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Responsibility & Entitlement
CASE MANAGEMENT,
MR and DD SERVICE
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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
DD WAIVER
CASE
MANAGEMENT
MR WAIVER
CASE
MANAGEMENT
 Individual chooses their
Case Management
organization
 Various organizations

Community Services
Boards provide case
management services
provide Case Management
services
 Case Management
organizations cannot
provide other DD Waiver
services (except Consumer
Directed Services
Facilitation)
CONSUMER-DIRECTED SERVICES

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 consumerdirection and self-determination, implementation depends on
the individual and their case manager
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 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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CONSUMER-DIRECTED STAFF
QUALIFICATIONS
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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
CONSUMER-DIRECTED
STAFF
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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
CONSUMER INVOLVEMENT
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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
CONSUMER SERVICES PLAN
DD and MR WAIVERS
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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
PREPARING FOR CSP

Who will participate in your meeting

Develop a list of needed supports &
services (be honest & frank)
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Collect documentation
•
•
•
•
vocational evaluations
IEPs
school evaluations
medical documentation
HEALTH, SAFETY & WELFARE
 Adequate services must be provided
 Additional or different services should be
added if needed to protect health, safety and
welfare
Individual and Family Developmental
Disabilities Support “DD” Waiver
Eligibility Criteria
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“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
www.dmas.virginia.gov
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
DD Waiver Services
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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)
DD Waiver Statistics
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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
MR Waiver Eligibility Criteria
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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
MR Waiver Services
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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)
MR WAIVER WAITING LISTS
Urgent and Non-urgent
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CSBs and DMHMRSAS
maintain Urgent and NonUrgent 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 on the
Urgent list receives the next
available slot
Only after all Urgent needs are
met statewide will Non-urgent
needs be served
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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
URGENT CRITERIA FOR THE MR WAIVER
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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
MR Waiver Statistics

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
MENTAL RETARDATION
DAY SUPPORT WAIVER
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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
Elderly or Disabled with Consumer Direction
Waiver (EDCD)
Eligibility 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
Elderly or Disabled with Consumer
Direction Waiver Services

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
Elderly or Disabled with Consumer
Direction Waiver Services

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
Technology Assisted Waiver Criteria


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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
Tech Waiver Considerations
ADULTS

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
CHILDREN

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 devicebased respiratory or nutritional
support
 Cost effectiveness is
compared to hospital costs
Tech Waiver Services

Services that are available statewide:
•
•
•
•
Private duty nursing
Respite care
Durable medical equipment
Personal care for individuals over 21 years
of age
• Environmental Modifications
Tech Waiver Services Limits
• 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
Tech Waiver Statistics

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
AIDS Waiver Criteria

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)
AIDS Waiver Services

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
AIDS Waiver Statistics

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
BRAIN INJURY WAIVER
not 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
SERVICE PROVIDERS
DMAS is responsible for 
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
ACCESSING PROVIDERS
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
MEDICAID APPEALS

Fair Hearing

Right to challenge decisions and
actions regarding Medicaid

Decision should be issued by the
Hearing Officer within 90 days
RIGHT TO APPEAL WHEN 
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
WAITING LISTS
 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?