Medicaid Waiver Overview
Debra Holloway, The Arc of VA Director of Training and Technical
Assistance
Lynne Blythe, Infant & Toddler Connection of Rappahannock Rapidan,
Local System Manager & Program Manager
Who We Are
• The Arc of Virginia is a state chapter of The Arc of the United
States, the nation’s largest and oldest human rights
organization for individuals with intellectual and
developmental disabilities.
• The Arc’s membership is composed of people with
disabilities, family members, community advocates and
concerned citizens.
• We are a statewide, non-profit organization composed of 25
local chapters around the Commonwealth. We work to
promote and protect the human rights of people with
intellectual and developmental disabilities and actively
support their full inclusion and participation in the
community throughout their lifetime.
Who We Are
• Infant & Toddler Connection of Virginia provides Part C
services to children from birth to 36 months. There are 40
Part C programs across Virginia.
• Infant & Toddler Connection of Rappahannock Rapidan
provides Part C services in the counties of Culpeper,
Fauquier, Madison, Orange, & Rappahannock counties.
• Medicaid Wavier Mentors are a group of approximately 30
people across Virginia that are available to provide
information & support to individuals searching for
information about Virginia’s Medicaid Waivers.
Today’s Outcomes
The people that work with young children & their
families will learn information about how to:
– Direct families to accurate information about
Virginia’s Medicaid Waivers.
– Help families learn the steps to apply for the
EDCD, ID, or DD Waiver
– Provide families with information about HIPP &
EPSDT benefits.
4
Different Institution
Different Waiver
• Waivers provide funding for a wide
variety of services for people of all ages
who have disabilities, or are elderly, in
order for them to remain in their homes
and communities instead of an
institutional placement (i.e. 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
comparable institutional care.
• Average cost per year – Intellectual Disability
Waiver -$74,674 per person/year. Institutional cost
is over $150,000 per person/year for the ID Waiver.
• Virginia spends over $262 million/year on state
operated institutions for people with intellectual
disabilities. Average institutional cost is $250,000
per person, per year.
Department of Justice
Settlement
• Individuals with Intellectual and developmental disabilities
are unnecessarily institutionalized.
• Total of 4,200 home and community based waivers.
• 800 – transition out of institutions
• 3,000 on the urgent list
• 450 DD
• Family supports
• Crisis System – START
• Case management
• Housing
• Oversight
www.thearcofva.org
http://www.dbhds.virginia.gov/Settlement.htm
Virginia
Home & Community Based Care Waivers
State Regulations for the Waivers
http://leg1.state.va.us/000/reg/TOC12030.HTM#C0120
Alzheimer’s and Related Dementias
Assisted Living Waiver (Alzheimer’s Waiver)
12 VAC-30-120-1500 Day Support Waiver for Individuals with
Intellectual Disabilities (Day Support Waiver)
12 VAC-30-120-900 Elderly or Disabled with Consumer
Direction Waiver (EDCD Waiver)
12 VAC-30-120-700 Individual and Family Developmental
Disabilities Support Waiver (DD Waiver)
12 VAC-30-120-211 Intellectual Disability Waiver (ID Waiver)
12 VAC-30-120-70 Technology Assisted Waiver (Tech Waiver)
 12 VAC-30-120-1600





8
Reviewing Today:
• Elderly or Disabled with Consumer
Direction Waiver (EDCD)
• Individual and Families with Developmental
Disabilities Waiver (DD)
• Intellectual Disability 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 the following
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
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 respite and/or personal care
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. But one person can’t be on
waiting lists for ID & DD Waivers.
Criteria
• Financial criteria= child’s income is considered, not the
parents’ income. Child’s resources (i.e. savings account)
are considered at age 18.
• 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 Capacity:
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.
also: speech, occupational, and physical
therapy provided through an IFSP or IEP
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!)
Individual and Family Developmental
Disabilities Support Waiver (IFDDS)
• Wait list is maintained by the
Department of Medical Assistance
Services (DMAS)
-chronological
• Can be placed on the waiting list at age
5 years 8 months
• 1,000+ individuals on the waiting list
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 having
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.
• Qualify for Medicaid (individual). Child’s
income only is considered for financial
eligibility.
Screening
• The Virginia Department of Health Child
Development Clinics (6 regional 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
•
•
•
•
•
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 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.
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
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.
• Financial- only child’s income is considered,
not the parents’ income.
ID WAIVER WAITING LISTS
• CSB’s and DBHDS maintain
Urgent and Non-Urgent lists
• CSB provides individual with
written notice if placed on a
waiting list and if there is a
change in status to another
list
• Only after all Urgent needs
are met statewide will Nonurgent needs be served
• Slot moves with you to a
different town in VA, not out
of the state.
• Non-urgent = meet criteria for
the ID Waiver, including
needing services within 30
days, but don’t meet Urgent
criteria.
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
Different Waivers Have
Different Services
Adult Day Health Care *
Personal Care Services*
Personal Emergency Response System
Respite*
Assistive Technology
Supported Employment
Therapeutic Consultation
Environmental Modifications
Case Management
Companion Services
Crisis Intervention/Stabilization
Day Support
Therapeutic Consultation
Family Caregiver Training
Prevocational Services
Residential Support
Transition Coordination
Transition Services
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
•
•
•
•
•
•
•
•
•
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 click on “Client
Services” to the left 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
-If appeal is lost, can continue through an
Administrative Review in Circuit Court
Debra Holloway, Director of Training and Technical
Assistance, 804-649-8481 ext. 103, dholloway@thearcofva.org
www.thearcofva.org
Lynne Blythe, Infant & Toddler Connection of Rappahannock
Rapidan, Local System Manager & Program Manager, 540-9297480 ext. 101, lblythe@rrcsb.org