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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. - PowerPoint PPT Presentation
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Waiver Programs: Helping Waiver Programs: Helping Your Clients Stay at HomeYour Clients Stay at Home
PLAN 2012 Statewide ConferencePLAN 2012 Statewide ConferenceSeptember 11, 2012September 11, 2012
Pamela WalzPamela WalzCommunity Legal ServicesCommunity 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
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 WaiverPDA Waiver
To qualify, must beTo qualify, must be Resident of PA and US citizen or qualified Resident of PA and US citizen or qualified
non-citizen non-citizen Age 60 or over Age 60 or over Nursing Facility Clinically Eligible (NFCE)Nursing Facility Clinically Eligible (NFCE) Financially eligible for MAFinancially eligible for MA AggregateAggregate cost of serving all participants cost of serving all participants
in a waiver must not exceed 80% of cost in a waiver must not exceed 80% of cost to serve same group in nursing facility.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 –Financial eligibility for Waiver –ResourcesResources
Resource limit for single individual is Resource limit for single individual is $8,000 ($2,000 + $6,000 disregard)$8,000 ($2,000 + $6,000 disregard)
Married couples: spousal impoverishment Married couples: spousal impoverishment rules on resource assessment and rules on resource assessment and spousal share applyspousal share apply
Estate recovery applies for Waiver Estate recovery applies for Waiver recipients age 55 or olderrecipients age 55 or older
Aging Waiver servicesAging Waiver services
Home healthHome health Personal carePersonal care Attendant careAttendant care RespiteRespite Adult Day CareAdult Day Care TransportationTransportation Home modificationsHome modifications
Specialized medical Specialized medical equipment, suppliesequipment, supplies
Home delivered Home delivered mealsmeals
Personal emergency Personal emergency responseresponse
CompanionCompanion
Aging Waiver services (cont’d)Aging Waiver services (cont’d)
Prior to 7/1/12, only AAAs provided care Prior to 7/1/12, only AAAs provided care management. Other providers can now management. Other providers can now bid to provide this service, now called bid to provide this service, now called “service coordination”.“service coordination”.
Waiver recipients get full MA coverage!Waiver recipients get full MA coverage! Must meet SLMB or QMB income limits to get Must meet SLMB or QMB income limits to get
Medicare Part B paidMedicare Part B paid
Living Independently for Elders Living Independently for Elders (LIFE)(LIFE)
Program of All-Inclusive Care for the Elderly Program of All-Inclusive Care for the Elderly (PACE) model(PACE) model
Model of care focused around Adult Day Model of care focused around Adult Day Care attendanceCare attendance
ALL services are coordinated and provided ALL services are coordinated and provided by LIFEby LIFE LIFE is paid a capitated rate by Medicare, Medicaid, LIFE is paid a capitated rate by Medicare, Medicaid,
and/or the Participant (depending on the Participant’s and/or the Participant (depending on the Participant’s eligibility for Medicare and Medicaid)eligibility for Medicare and Medicaid)
LIFE EligibilityLIFE Eligibility Must be 55 or older for enrollment in Full-PACE LIFE Must be 55 or older for enrollment in Full-PACE LIFE
Center or 60 or older for enrollment in Pre-PACE LIFE CtrCenter or 60 or older for enrollment in Pre-PACE LIFE Ctr NFCE level of careNFCE level of care Available to people with any one of these combinations of Available to people with any one of these combinations of
funding:funding: Medicaid OnlyMedicaid Only Medicare and Private PayMedicare and Private Pay Medicare and Medicaid Medicare and Medicaid Private Pay OnlyPrivate Pay Only
For those seeking Medicaid coverage of LIFE, Waiver For those seeking Medicaid coverage of LIFE, Waiver income and resource limits apply and Estate Recovery income and resource limits apply and Estate Recovery appliesapplies
Must live in area served by a LIFE program (38 counties)Must live in area served by a LIFE program (38 counties)
LIFE ServicesLIFE Services
Adult day centerAdult day center Home support, home health, personal careHome support, home health, personal care RespiteRespite TransportationTransportation MealsMeals Medical and nursing careMedical and nursing care Rehabilitation and restorative therapiesRehabilitation and restorative therapies
LIFE services (cont’d)LIFE services (cont’d)
Home modificationsHome modifications Social activities and recreationSocial activities and recreation Social servicesSocial services Hospital and nursing facility care when Hospital and nursing facility care when
neededneeded
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
OptionsOptions
State-funded (not MA)State-funded (not MA) Services for consumer age 60+Services for consumer age 60+ Can be NFCE but not financially eligible Can be NFCE but not financially eligible
for Waiver OR Nursing Facility Ineligible for Waiver OR Nursing Facility Ineligible (NFI).(NFI).
Options (cont’d)Options (cont’d)
Services are same as Waiver but are Services are same as Waiver but are capped at $714.60/month (exception is capped at $714.60/month (exception is available)available)
Sliding scale cost sharing for consumers Sliding scale cost sharing for consumers with income greater than 125% of FPL with income greater than 125% of FPL ($1,135/mo. single, $1,532/ mo. couple in ($1,135/mo. single, $1,532/ mo. couple in 2011)2011)
Waiting listsWaiting 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
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 DirectionParticipant Direction Knowing the difference between Knowing the difference between
Participant Centered system and Participant Centered system and Participant DirectionParticipant Direction
Aging Waiver offers choices Aging Waiver offers choices the process of choosing amongst the choices the process of choosing amongst the choices
is the Participant “Centeredness” of the is the Participant “Centeredness” of the systemsystem
the opportunity for the participant to exercise the opportunity for the participant to exercise control over his/her services is Participant control over his/her services is Participant DirectionDirection
Participant DirectionParticipant Direction Traditional ways of getting services Traditional ways of getting services
through HCBS Waiver = Agency Modelthrough HCBS Waiver = Agency Model Participant Direction includes Participant Direction includes
the Employer Model (wherein the waiver the Employer Model (wherein the waiver consumer is the employer and hires and fires consumer is the employer and hires and fires staff with the help of a fiscal management staff with the help of a fiscal management agency, service coordinator, etc.) andagency, service coordinator, etc.) and
Services My Way – which is the Employer Services My Way – which is the Employer Model plus budget authority (wherein the Model plus budget authority (wherein the waiver consumer gets decision making ability waiver consumer gets decision making ability over how to spend budgeted amount)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 Common problems for Waiver Clients (cont’d)(cont’d)
Delays in enrollment: Delays in enrollment: Maximus (Independent Enrollment Broker for Maximus (Independent Enrollment Broker for
under-60 Waivers): lengthy waits for under-60 Waivers): lengthy waits for assessments and determinations. Recent assessments and determinations. Recent MosleyMosley settlement requires timely actions. settlement requires timely actions.
Individualized Service Plan approval delays Individualized Service Plan approval delays Elimination of Community ChoiceElimination of Community Choice
Christian Financial debacleChristian Financial debacle
Problems, cont’d
Act 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 PPACANew HCBS Opportunities Under PPACA
Section 10202. State Balancing Incentive Section 10202. State Balancing Incentive Payments ProgramPayments Program
Section 2401. Community First Choice Option—Section 2401. Community First Choice Option—Medicaid State Plan Option for Attendant Medicaid State Plan Option for Attendant Services and Supports:Services and Supports:
Section 2402. Medicaid Home and Community Section 2402. Medicaid Home and Community Based Services State Plan OptionBased Services State Plan Option
OthersOthers
Questions?
Pam Walz
Aging and Disabilities Unit
Community Legal Services, Inc.
(215) 227-4798