Overview of Texas Medicaid WaiversLong Term Services and SupportsLauren ChenowethJune 2018

Objectives• Provide information about the program authority

and administration• Provide an overview of Texas waivers to include

• Eligibility• Service array• Services available through the consumer

directed services (CDS) option• Overview of state plan services

What is Medicaid?• Medicaid is a jointly funded state-federal program that

provides medical coverage to eligible needy persons. • Federal laws and regulations:

• Require coverage of certain populations and services• Provide flexibility for states to cover additional

populations and services• Medicaid is an entitlement program, meaning:

• Guaranteed coverage for eligible services to eligible persons

• Open-ended funding based on the actual costs to provide eligible services to eligible persons

Joint State & Federal Program• Both federal and state governments have a role in

overseeing and funding the Medicaid program.• At the federal level, Medicaid is administered by

the Centers for Medicare and Medicaid Services (CMS) within the U.S. Department of Health and Human Services.

Joint State & Federal Program (cont.)

• Authority for the Medicaid program comes from:• Social Security Act (SSA)

• Provides general welfare benefits for certain populations.

• State Plan• Contract between CMS and the State of Texas.

• Waivers • “Waives off” State Plan requirements or SSA

requirements.

What is a Waiver?• A waiver enables states to receive federal Medicaid

matching funds without complying with certain requirements set forth in §1902 of the Social Security Act (SSA). • Limiting a waiver service to specific geographic areas

§1902(a)(1) (Statewideness)• Comparability of services, such as offering an array

of community-based services to those who would otherwise require institutionalization

• Income and resources -- States can apply institutional income and resource (eligibility) rules for medically needy who would other wise qualify for waiver services at 300% federal poverty level (FPL)

What is a Waiver? (cont.)

• A waiver enables states to receive federal Medicaid matching funds without complying with certain requirements set forth in §1902 of the Social Security Act (SSA). • Freedom of choice

Texas Medicaid Waivers

Texas Medicaid Waivers• 1915(b) waiver

• Non-Emergency Medical Transportation (NEMT)• 1915(c) waiver

• Community Living Assistance and Support Services (CLASS)

• Deaf Blind with Multiple Disabilities (DBMD)• Home and Community-based Services (HCS)• Medically Dependent Children Program (MDCP)• Texas Home Living (TxHmL)• Youth Empowerment Services (YES)

Texas Medicaid Waivers (cont.)

• 1115 Demonstration Waivers• Texas Healthcare Transformation and Quality

Improvement Program (THTQIP)• STAR• STAR+PLUS• Dental• STAR Kids

Services Delivery Options• Individuals may select how they would like some

services delivered• Agency Option - Standard service delivery

through an agency• Service Responsibility Option - Individual

manages day-to-day activities and the provider agency manages business activities

• Consumer Directed Services (CDS) -Individual manages both day-to-day and business activities

• CDS individuals receive financial management services and may receive support consultation.

1915(c) Waivers• Texas operates six 1915(c) waivers

• These waiver programs are:• CLASS• DBMD• HCS• TxHmL• MDCP• YES

• Renewed every five years.

CLASSCommunity Living Assistance and Support Services (CLASS) 1915(c) waiver• Provides home and community-based services to

individual’s who have a diagnosis of a related condition qualifying them for placement in an Intermediate Care Facility for Persons with an Intellectual Disability or Related Condition (ICF/IID)

• Provides case management and direct services through two separate agencies

CLASS (cont.)

Community Living Assistance and Support Services (CLASS) 1915(c) waiver• Services are available statewide and must be

within the program annual cost limit• Individuals may live in their own home or their

family home

CLASS Population• Must meet financial eligibility for Medicaid• Must have a related condition as the primary diagnosis• Must have substantial functional limitations in at least

three of the following areas: • Self care• Language• Learning• Mobility• Self direction• Capacity for independent living

• Must not be enrolled in another waiver

CLASS Service Array• Adaptive aids• Auditory Integration

Training/Auditory Enhancement Training

• Behavioral support services

• Case management• Cognitive rehabilitation

therapy

• Continued family services

• Dental• Dietary• Financial Management

Services• Habilitation services• Minor home

modifications

CLASS Service Array (cont.)

• Nursing services• Occupational, speech,

and physical therapies• Prescribed Drugs• Prevocational services• Respite services• Specialized therapies

• Support Consultation• Support family services• Supported employment• Employment assistance • Transition assistance

services (TAS)

CLASS Service ArrayCDS services available in CLASS• Cognitive rehabilitation therapy • Habilitation services • Nursing services• Occupational, speech, and physical therapies• Respite services• Supported employment• Employment assistance • Financial Management Services• Support Consultation

DBMDDeaf Blind with Multiple Disabilities 1915(c) waiver• Provides home and community-based services as an

alternative to residing in a ICF/IID to individuals of all ages who are deafblind, or have a condition that will result in deafblindness, and who have an additional disability.

• Provides case management and direct services through a single agency.

• Services are available statewide and must be within the program annual cost limit.

• Individuals may live in their own home, their family home, or in a residence with one to five other individuals with similar needs.

DBMD Population• Must meet financial eligibility for Medicaid• Must be deafblind or function as deafblind• Must have one other disability that results in

impairment to independent functioning• Must not be enrolled in another waiver

DBMD Service Array• Adaptive aids• Assisted Living• Audiology services• Behavioral support

services• Case management• Chore services• Day habilitation

• Dental• Dietary services• Financial Management

Services• Intervener • Minor home

modifications• Nursing

DBMD Service Array (cont.)

• Occupational therapy• Orientation and mobility• Physical therapy• Prescribed Drugs• Residential habilitation• Respite

• Speech, language, and hearing therapy

• Support Consultation• Supported employment• Employment assistance• Transition assistance

services (TAS)

DBMD Service ArrayCDS Services in DBMD• Intervener • Residential habilitation• Respite• Supported employment• Employment assistance• Support Consultation• Financial Management Services

HCSHome and Community-based Services 1915(c) waiver• Provides individualized services to people of all ages who

qualify for ICF/IID level of care• HCS waiver services are provided by a comprehensive

program provider, and service coordination is provided by the local intellectual and developmental disability authority (LIDDA).

• Services are available statewide and must be within the program annual cost limit.

• Individuals may live in their own home, their family home, or a small residential setting in the community.

HCS Population• Must meet financial eligibility requirements• Must have a primary diagnosis of an intellectual

disability with an IQ of 69 or below, or an IQ of 75 or below and a related condition

• Must be eligible for Level of Care I or VIII (only if diverting from a nursing facility

• Must not be enrolled in another waiver

HCS Service Array• Adaptive aids• Audiology services• Behavioral support

services• Cognitive rehabilitation

therapy• Day habilitation• Dental

• Dietary services• Employment assistance• Financial Management

Services• Minor home modifications• Nursing services• Occupational therapy

HCS Service Array (cont.)

• Physical therapy• Pre-enrollment minor

home modifications• Residential assistance• Respite • Social work services

• Speech/language pathology

• Support Consultation• Supported employment• Supported home living • Transition Assistance

Services

HCS Service Array CDS services available in HCS• Cognitive rehabilitation therapy

• Employment assistance

• Financial Management Services

• Nursing services

• Respite

• Support Consultation

• Supported employment

• Supported home living

TxHmLTexas Home Living 1915 (c) waiver• TxHmL provides select services and supports up to

$17,000 per year for individuals who qualify for ICF/IID level of care.

• TxHmL waiver services are provided by a TxHmL program provider, and service coordination is provided by the LIDDA.

• Services are available statewide and must be within the program annual cost limit.

• Individuals may live in their own home or their family home.

TxHmL Population• Must meet financial eligibility requirements• Must have a primary diagnosis of an intellectual

disability with an IQ of 69 or below, or an IQ of 75 or below and a related condition

• Must live in their own home or their family home (no residential component)

• Must not be enrolled in another waiver

TxHmL Service Array• Community support

(transportation) • Day habilitation• Respite• Supported employment• Employment assistance• Adaptive aids

• Audiology• Behavioral support• Dental• Dietary services• Minor home

modifications

*All services in TxHmL can be provided by the CDS option.

TxHmL Service Array (cont.)

• Nursing services• Occupational therapy• Physical therapy• Social work services• Speech/language

pathology

• Financial Management Services

• CFC-Support Consultation

• CFC-Financial Management Services

• CFC-PAS/Habilitation

*All services in TxHmL can be provided by the CDS option.

MDCPThe MDCP 1915(c) waiver: • Provides a variety of services and supports for

families caring for children who are medically dependent as an alternative to residing in a nursing facility

• Available statewide • Services in MDCP are provided through managed

care organizations through the STAR Kids and STAR Health programs

MDCP Population• Must be under 21 years of age• Financial eligibility• Must meet the medical necessity requirements for

nursing facility admission• Have an individual plan of care (IPC) that does not

exceed 50 percent of the reimbursement rate that would have been paid for that same person to receive services in a nursing facility, as of Aug. 31, 2010

MDCP Services• Adaptive aids • Flexible family support services • Minor home modifications • Respite • Transition assistance services• Supported employment• Employment assistance

MDCP ServicesCDS services in MDCP• Flexible family support services • Respite • Supported employment• Employment assistance• Financial management services

Texas Medicaid –State Plan Services

Title XIX LTSS Services• Community Attendance Services (CAS)

• Provides non-skilled in-home attendant service to adults with an approved medical need for assistance with personal care tasks

• Individuals must be within 3 times SSI income and resource limits

• Primary Home Care (PHC)• Provides non-skilled in-home attendant service

to adults with an approved medical need for assistance with personal care tasks

• Individuals must be SSI eligible

Title XX LTSS Services (cont.)

• Family Care (FC)• Provides non-skilled in-home attendant service to

adults who are functionally limited in performing non-personal care tasks

• Individuals must be within 3 times SSI income

• Resource limits are $5,000 for an individual and $6,000 for a couple

Title XX LTSS Services (cont.)

• Consumer Managed Personal Attendant Services (CMPAS) • Provides non-skilled in-home attendant service to

adults with an approved medical need for assistance with personal care tasks to be supervised by the individual receiving services.

• The CMPAS Program includes a co-payment provision based on income to allow an individual to participate in the program regardless of income.• Individuals must be within 3 times SSI income to

receive services without a co-pay. • There is no resource limit.

CDS Services AvailableFor all programs (CAS, PHC, FC and CMPAS) provide the following services through the agency or CDS option:• Escort: Accompanying the individual on trips to

obtain a medical diagnosis or treatment or both.• Home Management: Assistance with

housekeeping activities which support the individual’s health and safety.

• Personal Care: Assistance with activities of daily living related to the individual’s health.

CASE Management & Service DeliveryCase management and direct services are provided by two separate agencies:• FC:

• HHSC case managers provide case management.

• CMPAS:• Case management (service coordination) is

provided by the HCSSA.• Provision of agency services for FC and CMPAS

are provided by a licensed HCSSA.

Resources

• Waiver comparison charthttps://hhs.texas.gov/sites/default/files//documents/doing-business-with-hhs/providers/resources/ltss-waivers.pdf

• Texas Medicaid State Plan Services & Support comparison charthttps://hhs.texas.gov/sites/default/files//documents/doing-business-with-hhs/providers/resources/texas-medicaid-state-plan-services-and-supports.pdf

ResourcesCLASS and DBMD Information Letters• Removal of services codes for Habilitation in both

CDS & DSA options from IPC – IL 2017-15 https://www.dads.state.tx.us/providers/communications/2017/letters/IL2017-15.pdf

• DFPS investigation changes – IL 2015-81 https://www.dads.state.tx.us/providers/communications/2015/letters/IL2015-81.pdf

• Transportation as a result of CFC – IL 2015-53 https://www.dads.state.tx.us/providers/communications/2015/letters/IL2015-53.pdf

ResourcesPolicy Webpages• HCS - https://hhs.texas.gov/doing-business-

hhs/provider-portals/long-term-care-providers/home-community-based-services-hcs

• TxHmL - https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/texas-home-living-txhml

• CLASS - https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/community-living-assistance-support-services-class

ResourcesPolicy Webpages• DBMD - https://hhs.texas.gov/doing-business-

hhs/provider-portals/long-term-care-providers/deaf-blind-multiple-disabilities-dbmd

• MDCP - https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/medically-dependent-children-program-mdcp

ResourcesPolicy Webpages

• CMPAS - https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-managed-personal-attendant-services-cmpas

• FC - https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/family-care-fc

ResourcesPolicy Webpages• CAS – https://hhs.texas.gov/doing-business-

hhs/provider-portals/long-term-care-providers/community-attendant-services-cas

• PHC - https://hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/primary-home-care-phc

ResourcesPolicy Mailboxes• HCS hcspolicy@hhsc.state.tx.us• TxHmL txhmlpolicy@hhsc.state.tx.us• CLASS classpolicy@hhsc.state.tx.us• DBMD dbmdpolicy@hhsc.state.tx.us• MDCP mdcppolicy@hhsc.state.tx.us• CMPAS cmpas@dads.state.tx.us• CAS/FC/PHC CCADPolicy@hhsc.state.tx.us_______________________________________________

• CDS CDS@hhsc.state.tx.us

Questions?

Thank youMary Valente, MPAff, LBSWmary.valente@hhsc.state.tx.us