Everything You Need to Know About Your Medicaid Waiver

The Delaware County Board of Developmental Disabilities

May 2014

Waiver Growth in Delaware County

Year # Served # Waivers % Served

2000 750 50 6.7

2013 2251 627 27.8

Waiver Dollars

2000 $ 2,118,424*

2013 $16,432,877*

*DCBDD only pays 40% of these costs

What is a Waiver?

A waiver is a Medicaid funding source that can help pay for services to keep people with disabilities in their own homes and prevent moving to a long-term care facility or nursing home. The county board is required to pay approximately 40% of the cost of waiver services. The federal government pays 60% of the cost of services

DODD Administered Waivers

Delaware County Board of DD currently administers three waivers:

• Level One Waiver Allows for minimal paid support and relies heavily on natural supports

• SELF Waiver Allows for a moderate amount of support and is Ohio’s first self-directed waiver

• Individual Options Waiver For individuals with limited or no natural support and who have a high level of need

Waiting Lists

In order for an individual to receive a waiver, he/she must make application to be placed on the waiting list

The waiting list rule OAC 5123:2-1-08 dictates enrollment based on priority categories

Refer to the Priority Score Sheet for categories

Waiting Lists in Delaware County

In Delaware County, each priority group has a weighted point value which is used to determine the individual’s priority score

All waiting lists are ordered first by priority score, then date and time of application

Currently, only individuals meeting emergency status will be considered for an IO waiver

Preparing for the Transition to Waiver Services

Begin search for providers

Providers must be certified by DODD to provide waiver services

It can take several weeks for a provider to complete the certification process

Waiver providers will not bill DCBDD for waiver services. Billing is completed through an on-line application and payment is made by the State of Ohio

Medicaid Card Service Providers (State Plan Services)

ServicesHomemaker Personal Care(IO and Level One Waiver Only)

• Basic personal care and grooming, including bathing, care of the hair, and assistance with clothing;

• Assistance with bladder and/or bowel requirements or problems, including helping the individual to and from the bathroom

• Assisting the individual with self-medication or provision of medication administration for prescribed medications and assisting the individual with, or performing, health care activities;

• Performing household services essential to the individual's health and comfort in the home

ServicesHomemaker Personal Care, Cont.

• Assessing, monitoring, and supervising the individual to ensure the individual's safety, health, and welfare;

• Light cleaning tasks in areas of the home used by the individual;• Preparation of a shopping list appropriate to the individual's dietary

needs and financial circumstances, performance of grocery shopping activities as necessary, and preparation of meals;

• Personal laundry• Incidental neighborhood errands as necessary, including

accompanying the individual to medical and other appropriate appointments and accompanying individual for walks outside the home.

ServicesTransportation

(IO, Level One and SELF Waivers)

A service that enables individuals enrolled in waivers to access waiver and other community services, activities, and resources

ServicesEnvironmental Accessibility Adaptations

Participant Goods and Services(IO, Level One and SELF Waivers)

Changes to a home that enable a person to function with greater independence.Examples include:• Installing ramps or grab-bars;• Widening doorways;• Modifying bathrooms to be wheelchair-accessible; and,• Installing specialized electrical or plumbing systems to

accommodate medical equipment;

ServicesAdaptive and Assistive Equipment (IO)

Specialized Medical Equipment and Supplies (Level One) Participant Goods and Services (SELF)

•Devices, controls or appliances that allow people to do daily living activities or to help them communicate;

•Items necessary for life support and the supplies and equipment necessary for upkeep; and,

•Durable and non-durable equipment that is not paid for by the Medicaid State Plan.

Services

Informal Respite (Level One Only)

Services provided in a person’s home, the home of a friend or family member of the individual or at sites of community

activities to give relief to the person typically providing care.

ServicesCommunity Inclusion

(SELF only)

Includes supports that promote the individual's participation in his/her community. The service includes opportunities and experiences that focus on socialization and/or therapeutic recreational activities, as well as personal growth in the home and/or community. Community Inclusion also can include peer support activities and organization of self-advocacy events. It is not meant to cover employment-related services.

Individual Options Waiver Services available with the IOW include:

• Homemaker Personal Care• Transportation• Environmental accessibility modifications• Adaptive & Assistive equipment• Adult Day Waiver Services• Remote Monitoring• Community Respite (Specialized Camps)• Residential Respite (Facility-Based Respite)• Adult Family Living*• Adult Foster Care*• Social work*• Interpreter• Home delivered meals• Nutritional services*

*exclusive to the individual options waiver

Self Empowered Life Funding Waiver Services available with the SELF waiver include:

• Support Brokerage* • Functional Behavioral Assessment*• Community Inclusion*• Participant Directed Goods and Services*• Participant/Family Assistance*• Integrated Employment*• Residential Respite• Community Respite• Remote Monitoring

*exclusive to the SELF waiver

Level One Waiver Services available with LV1 waiver include:

Homemaker/Personal Care Community Respite (Camp) Informal Respite* Transportation Personal Emergency Response Systems Specialized Medical Equipment and Supplies Environmental Accessibility Adaptations Home Delivered Meals Remote Monitoring Emergency Assistance* Adult Day Waiver Services

*exclusive to the level one waiver

$5000 annual cap combined

$7500 cap over a 3 year period

$8000 cap over a 3 year period and must meet emergency status

Waiver Service PlanningComplete Individual Support Plan (ISP) with your team

Complete Payment Authorization for Waiver Services (PAWS) A provider may not provide services or bill without this authorization

Waiver Budget Utilization – Tracking– Reallocation– Over-utilization

Your ISP is an “All Services Plan” and is to include all waiver,locally funded, and Medicaid State Plan services

Medicaid

A Medicaid Card is included with the Waiver service package and may cover therapies, hospital services, nursing services, home health aides, doctor & dental appointments and medical equipment

Many of these services are available through Medicaid State Plan Services

State Plan Services

Home Health Services

Home Health Services include:

Home Health Nursing Home Health Aide Skilled therapies (OT,PT,SLP)

Services must be medically necessary as ordered by the treating physician and documented by signature.

State Plan Services

Home Health Services

Services anyone can access with a Medicaid card, a doctor’s order and proof of medical necessity

Available Statewide

No waiting list

Home Health Services

Four hours or less per visit (intermittent service)

No more than 8 hours a day combined nursing, aide and therapies

No more than 14 hours per week of nursing and aide services combined

Home Health Services

To meet the requirement of ‘intermittent’, similar services cannot be ‘stacked’

A two-hour break is required between similar services. An example of similar services is Home Health Aide services and Waiver Homemaker/Personal Care services

Home Health ServicesCannot be billed back to back (stacked) with a similar

service type

For example:

6am-8am (no break) 8am-12pm (no break)12pm-2pm HH Aide Waiver HPC Provider HH Aide

Not Permitted

Home Health ServicesMUST have a MINIMUM 2 hour break in services

For example:

6am-10am (break) 1pm-5pm (break) 8pm-10pm HH Aide Waiver HPC Provider HH Aide

Permitted

Home Health ServicesCan be billed back to back with a DIFFERENT service type

For example:

6am-8am (no break) 8am-12pm (no break) 12pm-2pmHome Health Aide Home Health Nursing Home Health Aide

Permitted

Home Health ServicesCan be billed back to back with a DIFFERENT service type

For example:

6am-8am (no break) 8am-12pm (no break) 12pm-2pm HH Aide Waiver Informal HH Aide

Respite Provider

Permitted

Home Health Services

Home Health Services cannot be provided for the purposes of respite.

“Respite care” is the care provided to an individual unable to care for himself or herself because of the absence or need for relief of those normally providing care.

Home Health Services

Must be provided in the person’s place of residence, in a licensed day care center or in an Early Intervention program

Home Health Services

Home Health Aide Services

Services include:

Personal Care Routine catheter/colostomy care Assistance with routine maintenance exercises and passive ROM

activities in support of skilled therapy goals. Routine care of prosthetic and orthotic devices

Home Health ServicesHome Health Aide Services

Incidental Services can include: light chores, laundry, light house cleaning, meal prep and taking out trash

Main purpose of a Home Health Aide visit cannot be solely to provide incidental services

Incidental services are to be performed only for the eligible individual

May NOT provide medication administration

Increased Home Health ServicesIncreased services are available if requires more than 14 hours in a

week of aid and/or nursing services combined or more than 8 hours per day of aide, therapy and/or nursing services combined

Eligibility:

Up to age 21

Must have a comparable institutional level of care (ILOC, ICF/DD LOC, or SLOC) as determined by enrollment on a waiver or CareStar will complete assessment for those with regular Medicaid

Must need at least 1 skilled service a week (nursing or therapy)

Have part-time intermittent needs (Visits are 4 hours or less with a 2 hour min break in between like services)

Home Health Services The SSA will authorize the HHS for those on an DD

waiver

List all agencies providing home health services (aide, therapy and nursing)

Attach care plan from home health agency

Agency must have Dr.’s prescription, care plan, HHS worksheet and documentation of medical necessity on file

Private Duty Nursing Services Private Duty Nursing (PDN) is a continuous nursing

service that is more than 4 hours per visit PDN is required when more than 14 hours of nursing is

needed per week The service must be provided in the person’s home

unless it is medically necessary for a nurse to accompany the person into the community

Private Duty Nursing can be provided for the purposes of respite care

Private Duty Nursing Services

Once the request is received from the CB, a nurse with the Ohio Department of Medicaid (ODM) will complete a face to face assessment to confirm that the person has a medical condition that requires medically necessary PDN services

ODM will authorize the amount, scope and duration of the PDN service

Authorizations require renewal at least annually

State Plan Services

Prescriptions Durable Medical Equipment:

http://codes.ohio.gov/oac/5101%3A3-10-03 Appendix A Doctor and Dental Visits PT/OT – 30* visits per rolling 12 months SLP – 30* visits per rolling 12 months

*May be increased with prior authorization

Is a Waiver the Best Option?

• Comparison of Waiver Services and Medicaid Card Services (State Plan Services)

• Medicaid Card (therapies, equipment, doctor appointments, nursing, etc.)

• Can dis-enroll from the waiver at any time if it is not meeting the need

Contacts and InformationMelinda Draper, DCBDD Waiver Coordinator

Melinda.Draper@dcbdd.org or 740-201-5808

www.DCBDD.org

http://DODD.Ohio.gov

http://Medicaid.Ohio.gov