VA Medicaid Waiver

Virginia’s Medicaid Waivers for

Persons with Disabilities,

Their Parents, and Caregivers

Introduction

Medicaid Waivers were developed to encourage people with disabilities and the elderly to access services in their homes and communities. Medicaid is a joint federal-state program. Medicaid Waivers provide funding to serve people who are eligible for long-term care in institutions such as hospitals, nursing facilities, and intermediate-care facilities. Through Medicaid Waivers, states can "waive" certain requirements including the requirement that individuals live in institutions in order to receive Medicaid funding.

This guide focuses on five of the waivers currently available in Virginia:

Mental Retardation/Intellectual Disabilities (MR/ID) Waiver
Day Support Waiver
Individual and Family Developmental Disabilities Support (IFDDS or DD) Waiver
Elderly or Disabled with Consumer Direction (EDCD) Waiver
Technology-Assisted (Tech) Waiver

In addition, there are two other home-and-community-based waivers, the HIV/AIDS Waiver and the Alzheimer’s Assisted Living Waiver. For information on these waivers, see the DMAS listing on page 9 of this guide.

This guide covers the following topics:

Good News About Virginia Waivers – page 2
Realities About Virginia Waivers – page 3
Overview of Waivers – pages 4-7
What MORE Can You Do? – page 8
Government Agencies and Resources – page 8
Other Resources and Supports – page 9

Note: Contact information for waiver-related agencies is included on pages 8 and 9.

1 2

Good News About Virginia Waivers

The financial eligibility requirements for waivers are quite different from the financial eligibility requirements for regular Medicaid coverage. Regardless of the age of the person with a disability, financial eligibility for a Medicaid Waiver is based on the individual’s income and assets only. Other sources of income and assets, such as those of the individual’s parents, are disregarded. A person with a disability may have income equal to 300% of the maximum Supplemental Security Income (SSI) payment amount, and up to $2,000 in available assets such as savings, stocks, and bonds. If a child’s parents or caregivers have an income that is too high to qualify the family for Medicaid, the child with a disability may still receive a waiver slot. Having a waiver does not affect any other government funds for which a person is eligible.

An individual receiving waiver services is also entitled to all other services that are available to persons on regular Medicaid. In particular, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is an extremely valuable health-care resource for children under the age of 21 who have disabilities or special health-care needs. EPSDT provides for monitoring of health and disability conditions, preventive services, and treatment to correct or improve conditions, including ongoing maintenance needs. EPSDT also covers necessary services not provided under Virginia’s regular Medicaid plan, such as dental care and personal care services. In addition, treatment is included for any health or mental health care need identified during EPSDT screening. Parents need to know about EPSDT and determine whether this service could benefit their children under 21. For more information, contact the Department of Medical Assistance Services (see page 9).

If a person receiving waiver services has private group health insurance, Medicaid will be the person’s secondary insurance. DMAS may reimburse the person for all or a portion of their monthly private health insurance premium through the Health insurance Premium Payment (HIPP) Program. Contact information for HIPP is on page 9 of this guide.

An individual’s waiver funding continues for as long as the person continues to meet financial, medical, and functional eligibility requirements for the waiver services. Services under the MR/ID, Day Support, and DD Waivers are authorized for a one-year period, with annual review by the case manager and automatic renewal as long as the individual is still eligible and in need of services.

A person may be able to receive services under one waiver while being on the waiting list for another waiver. This allows the individual and his or her family to access some services under an alternate waiver while waiting for additional services to become available through the other waiver. If a person eventually receives a slot for the preferred waiver, funding

from the alternate waiver is discontinued, and services will be funded through the preferred waiver. 3

Some waiver services are available either through a traditional agency or through "consumer direction." Agency-directed services are controlled by an agency that hires staff and assigns them to the individual who needs services. Consumer-directed services are controlled by the person with a disability or by someone acting on his or her behalf. The consumer recruits, hires, supervises, and fires (if need be) his or her own staff. The consumer is the employer of his or her staff and signs off on the timesheets for payment, which are then submitted to Public Partnerships LLC, the fiscal agent for payment. A person using consumer-directed services will have a facilitator, paid by DMAS, for assistance in learning about consumer-directed services and for ongoing support.

Realities About Virginia Waivers

Medicaid and Medicaid Waivers are part of the network of services for people with disabilities in Virginia. Medicaid waiver funds are government funds, and the availability of waivers is dependent on federal and state government priorities and budgeting. As reported in The State of the States in Developmental Disabilities, Virginia ranks 41st in per person spending on Home and Community Based Waiver Services in comparison with other states (Braddock et al., 2005).

Waivers are funded per "slot." A slot is an opening of waiver services available to a single individual. For both the MR/ID and the DD (IFDDS) Waivers, there are long waiting lists of persons who have already applied. During the 2007 General Assembly, 330 new MR/ID waiver slots and 100 new DD (IFDDS) waiver slots were included in the final budget. Even so, there are thousands of persons who have been assessed as eligible and are still waiting to a receive waiver slot. It is important to put an individual on the waiting list even if no slots are currently available. Waiting lists clearly support the unmet need for services, and this is something that the members of the General Assembly need to know when making decisions on funding priorities.

Receiving a waiver slot does not guarantee that a person will be able to access services included in the waiver. Services can be provided only by approved agencies in each locality. There may be a limited number of approved persons or agencies in a particular area to provide services such as respite care or home modifications. Reimbursement rates may make it challenging to attract and retain skillful providers, so, just as in the health care profession in general, there is often a high turnover rate in service providers. If you have a case manager, it is important to keep him or her informed if you are having difficulty in

accessing services, because if services are not used it is possible that waiver funds may be terminated. 4

Medicaid waivers vary from state to state. If an individual receives waiver services in Virginia and then moves to another state, he or she will lose the Virginia waiver funding. The person must reapply for waiver services in their new home state. (Exceptions to this policy are made only in the case of individuals placed out of state by the Virginia services network). It is important to consider the alternatives when making a decision to move to another state. Your case manager can give you information to assist you with this decision.

Some individuals with disabilities and their families consider Medicaid-funded hospitals, nursing homes, and intermediate-care facilities the most appropriate placement for the individual, while others see institutions as a "last resort" placement. Most individuals in institutions have a low probability of accessing waiver services and returning to their home communities.

It is important for all families to plan ahead for the long-term financial and care needs of their loved ones by carefully managing their own financial and care resources, exploring community and faith-based options, and learning about government programs such as Social Security Disability Income (SSDI) and Supplemental Security Income (SSI). (For information on these programs, see the Social Security Administration listing on page 9 of this guide).

Important note: Waiver funding is limited. It is important to balance advocating for oneself or one’s own family member with recognizing the very real needs of other people with disabilities across the state. Individuals and families must honor the system and use it responsibly. Individuals and families must exercise the same integrity as consumers that they demand from the services system.

Mental Retardation/Intellectual Disability (MR/ID) Waiver

Services available: residential support services, day support, supported employment, prevocational services, personal assistance (agency or consumer directed), respite (agency or consumer directed), companion services (agency or consumer directed), assistive technology, environmental modifications, skilled nursing services, therapeutic consultation, crisis stabilization, and personal emergency response systems (PERS). Support coordination is also provided.

Eligibility: An individual must be age 6 or older and have a diagnosis of MR OR be under age 6 and at developmental risk. The person must be eligible for placement in an intermediate-care facility for persons with mental retardation or other related conditions (ICF-MR). This is established using the "Level of Functioning" survey. (To see a "Level of Functioning" form in advance, request one from your case manager). 5

Children on the MR/ID Waiver who do not have a diagnosis of mental retardation should be screened at age 6 and may transfer to the DD (IFDDS) Waiver.

There are 3 types of lists for the MR/ID Waiver:

1. Urgent Waiting List – needing waiver services immediately

2. Non-urgent Waiting List – needing waiver services within 30 days

3. Planning List – will need waiver services at some point in the future

MR/ID waiver slots are given first to individuals who meet the criteria for the Urgent Waiting List. There are currently many people on each of these lists.

How to apply: Contact your local Community Services Board (CSB) or Behavioral Health Authority (BHA) to request a screening using the "Level of Functioning" survey. A case manager will be assigned to the individual if he or she does not already have one there.

Be an advocate! If there is a change in the individual’s status at the CSB or BHA, or if a different case manager is assigned to the individual, double-check to make sure that your family member is still on the appropriate MR/ID waiver list (waiting list or planning list). If a person is not receiving any services through the CSB or HBA, their case may be closed, and in that situation it is possible that they may be dropped from the MR/ID Waiver waiting or planning list. In order to avoid this, it is best to stay in monthly contact with your case manager. Whether you are receiving services or on a waiting or planning list, keep your case manager apprised of any concerns or questions that you have about the status of your situation.

The MR/ID Waiver is administered by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) Office of Mental Retardation in collaboration with DMAS (Department of Medical Assistance Services).

Day Support Waiver

Services available: Day support, prevocational services, and supported employment.

Eligibility: Persons on the MR/ID waiver Urgent or Non-Urgent Waiting Lists are eligible if they have a MR/ID diagnosis. Individuals are selected according to the date when services were first necessary, regardless of urgency. An individual can remain on the waiting list for the MR/ID Waiver while being served by the Day Support Waiver, and transfer to the MR/ID Waiver once a slot becomes available. 6

How to apply: Contact your local Community Services Board (CSB) or Behavioral Health Authority (BHA) to request a screening using the "Level of Functioning" survey. (To review the "Level of Functioning" form in advance, request one from your case manager).

Waiting list status: There is currently no waiting list for this waiver.

The Day Support Waiver is administered by the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) Office of Mental Retardation in collaboration with DMAS (Department of Medical Assistance Services).

Individual & Family Developmental Disabilities Support (DD or IFDDS) Waiver

Services available: day support, companion services (agency or consumer directed), supported employment, in-home residential support, therapeutic consultation, personal care services (agency or consumer directed), respite care (agency or consumer directed), supported employment, skilled nursing services, attendant services, family and caregiver training, crisis supervision, environmental modifications, assistive technology, personal emergency response system (PERS), and prevocational services. Support coordination is also provided.

Eligibility: The DD Waiver provides services to individuals 6 years of age and older who have a diagnosis of a developmental disability and do not have a diagnosis of mental retardation. Individuals also must require the level of care provided in an intermediate-

care facility for persons with mental retardation or other related conditions (ICF/MR). Children who do not have a diagnosis of mental retardation, and have received services through the MR/ID Waiver, become ineligible for the MR/ID Waiver when they reach the age of 6. At that time, they can be screened for eligibility for the DD Waiver; if found eligible they will receive a DD waiver slot without being placed on the DD waiver waiting list.

How to apply: Download a copy of the "Request for Screening" form (available at www.dmas.virginia.gov/content/ltc-dd_wvr_request_for_services.htm -- click on link at top of page). Complete the form and fax or mail it to the Child Development Center in your locality (see same webpage). If you are unable to download the form, call your local Child Development Center or DMAS (see contact information on page 9 of this guide).

Waiting list status: There is currently a waiting list for this Waiver. The DD Waiver is administered by the Department of Medical Assistance Services (DMAS). 7

Elderly or Disabled with Consumer Direction (EDCD) Waiver

Services available: personal care aide services (agency or consumer directed), adult day health care, respite care (agency or consumer directed), skilled respite care, personal emergency response system (PERS), and medication monitoring.

Eligibility: This waiver serves the elderly and persons of all ages with disabilities. An individual must meet nursing facility eligibility criteria, including both medical needs and functional capacity needs (assistance with activities of daily living). An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver and then transfer to the preferred waiver once a slot becomes available.

How to apply: Request a screening from your local department of health or social services. A Uniform Assessment Instrument (UAI) will be completed to determine eligibility. (The UAI form can be found at http://www.dmas.virginia.gov/downloads/forms/UAI.pdf. The pre-admission screening criteria used for the EDCD Waiver can be found at http://websrvr.dmas.virginia.gov/manuals/NHPAS/appendixB_nhpas.pdf).

Waiting list status: There is currently no waiting list for this waiver. The EDCD Waiver is administered by DMAS.

Technology Assisted (Tech) Waiver

Services available: personal care, private duty nursing, respite care, environmental modification, and assistive technology.

Eligibility: Children and adults must require substantial and ongoing skilled nursing care. Children under the age of 21 are eligible if they are dependent on technology to substitute for a vital body function and have exhausted available third-party insurance benefits for private-duty nursing. Tech Waiver services may be limited or denied for individuals who can receive services through a third-party payment source.

How to apply: For individuals under age 21, contact DMAS for an in-home assessment by a DMAS registered nurse. For individuals age 21 and older, contact your local social services department. For individuals age 21 and older who are hospitalized, contact the hospital social worker or discharge planner for screening; DMAS should be contacted after the screening has been done. Individuals age 21 and older are assessed using the Uniform Assessment Instrument (http://www.dmas.virginia.gov/downloads/forms/UAI.pdf).

Waiting list status: There is currently no waiting list for the Tech Waiver. This waiver is administered by DMAS. 8

What MORE Can You Do?

In order to get the necessary services for your child, caregivers need to be advocates. Waiver slots are limited in number and cannot serve all the people who could benefit from waiver-funded services. If you feel your family member truly needs a waiver slot and is eligible for one, you must take action.

If a waiver slot is denied:

Double-check the eligibility criteria, including those for any waiting lists on the waiver in question. For the MR/ID and Day Support Waivers, persons on the Urgent and Non-Urgent Waiting Lists have higher priority than those on the Planning Lists.
Talk with your case manager’s supervisor for a second opinion on the denial.
Request "reconsideration." The agency then has 10 days to reconsider the application and either approve it or present additional reasoning for upholding the denial. If the agency fails to reconsider within 10 days or if the denial is upheld, you can appeal the decision. The process to appeal is inexpensive, relatively easy, and family-friendly. If the application is denied on appeal, the only further appeal is through the court system.
Contact other parents, local disability support groups, or the resources listed on page 9 of this guide for suggestions about handling denials of waiver slots.

Government Agencies and Resources

Community Service Boards and Behavioral Health Authorities: For the CSB or BHA in your locality, call toll-free 1-800-451-5544 or go to www.dmhmrsas.virginia.gov (click on "Locate Services in Virginia" in the left-hand bar, then click on "Community Services Boards").

Social Services Departments: For the Social Services Department in your locality, call toll-free 1-800-552-3431 or go to www.dss.virginia.gov (click on "Local Offices" at left).

Health Departments: For Health Department locations in your area, check the local government section of your phone book (city or county); or go to www.vdh.virginia.gov (click on "Local Health Districts" in bar at top of page, then click on your geographic area on the state map to open the appropriate web page). 9

Child Development Centers: For the Child Development Center serving your locality, go to www.dmas.virginia.gov/content/ltc dd_wvr_request_for_services.htm; or call DMAS at 804-786-1465 (select "Waivers" and then for "DD Waiver").

DMAS (Virginia Department of Medical Assistance Services): call 804-786-1465 or go to www.dmas.virginia.gov.

DMHMRSAS (Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services): call 804-786-3921 or go to www.dmhmrsas.virginia.gov.

Health Insurance Premium Payment (HIPP) Program: call 1-800-432-5924 or go to www.dmas.virginia.gov (scroll down under "Client Services" and click on "More Services," then click on "HIPP Information").

Social Security Administration: for the Social Security office in your area, go to www.ssa.gov/phila/states/virginia.htm, or call 1-800-772-1213 (when the automated recording asks the reason for your call, say "find a local office").

Other Resources and Supports

"Home and Community-Based Services for People with Disabilities: Medicaid Waiver Services Guide," Spring 2004 edition (Medicaid Waiver Technical Assistance Center). Available online at www.endependence.org (click on "Publications").

Medicaid Waiver Technical Assistance Center: For more information or to find a Medicaid Waiver Mentor near you, call the Center at 1-866-323-1088 (toll-free) or 757-461-8007. The mentors are also listed at the end of the guide mentioned above.

"The Commonwealth of Virginia: RoadMap to Services: A resource guide for people with disabilities, long term illnesses, and the elderly". Available online at www.varoadmap.com.

"Care Connection Notebook: Financing Your Child’s Health Care," 2005 (Parent to Parent of Virginia). Available at www.ptpofva.com (click on "Programs" at top, then scroll down to "Products").

The Arc of Virginia: call 804-649-8481 or go to www.arcofva.org.

Commonwealth Autism Service: call toll-free 1-800-649-8481 or go to www.autismva.org.

July 2007

The Partnership for People with Disabilities is a university center for excellence in developmental disabilities at Virginia Commonwealth University. VCU is an equal opportunity/affirmative action institution providing access to education and employment without regard to age, race, color, national origin, gender, religion, sexual orientation, veteran’s status, political affiliation, or disability. If alternative formats of this document are needed, please contact Janet Willis at (804) 828-0073 or (800) 828-1120 (TTY Relay). The Va-LEND project is s supported in part by the Health Resources and Services Administration, Maternal and Child Health Bureau, through grant # T73 MC00040