Update on MRDD Waivers September 19, 2001

1
Welcome to DMAS
Fall Case Managers Meeting November 12, 2009
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• WebEx CourtesyPamela Lewis
• Long-term Care Waiver ServicesMelissa Fritzman
• DMAS UpdatesKathleen Dickerson

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Just a little WebEx Courtesy

• Upon entry into the WebEx session
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• We may hear background music.
• Thank you

4
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6
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8
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11
Remember

• Mute your phone when
  joining the session.
• Do not place your phone
  on HOLD - we may
• hear background music.

12

Long-term Care and Waiver Services

• Melissa Fritzman, Supervisor
• Facility and Home Based Services Unit
• Virginia Department of Medical Assistance Services

13
Medicaid Program History

• Authorized as part of the SSA Amendments of 1965,
  signed into law July 30, 1965.
• By 1998, the Medicaid program nationally provided
  services to approximately 40.6 million low income
  individuals at a cost of 169 billion.

14
Medicaid Program History

• The Virginia Medicaid program was established in
  1969.
• Originally administered by the Virginia
  Department of Health DMAS was created and
  designated as the single state agency charged
  with administering the program in March 1985.

15
Mandatory Services Provided Through Medicaid

• Lab and X-Ray Services
• Physician Services
• Home Health Services
• EPSDT
• Family Planning
• Nurse-Midwife Services
• Transportation
• Medicare Premiums (Part A) - Hospital (Part B) -
  Supplemental Ins. For Categorically Needy

• Inpatient Hospital Services
• Emergency Hospital Services
• Outpatient Hospital Services
• Nursing Facility Care
• Rural Health Clinic Services
• Federally Qualified Health Center Clinic Services

16
Optional Services Provided Through Medicaid

• Other Clinic Services
• Skilled Nursing Facility Services for Individuals
  under 21 years of age
• Podiatrist Services
• Optometrist Services
• Clinical Psychologist Services
• Certified Pediatric Nurse and Family Nurse
  Practitioner Services
• Home Health PT, OT, and Speech Therapy

• Dental Services for Persons under 21
• Physical Therapy Related Services
• Prescribed Drugs
• Case Management Services
• Prosthetics
• Mental Health Services
• Mental Health Clinic Services
• Hospice Services
• Medicare Part B Premiums for the Medically Needy

17
Who is Eligible for Medicaid?

• Categorical Eligibility
• Aged, blind, and
• disabled
• Families with
• children
• Recipients of
• cash assistance
• Pregnant women
• and children
• Low income
• Medicare
• beneficiaries

Financial Eligibility After meet a category must
meet income and asset guidelines, as well as
non-financial criteria.
18
Medicaid Funded

• Long Term Care

19
Long-Term Care Services Defined

• Institutional Services
• Nursing Facility
• Intermediate Care Facilities for the Mentally
  Retarded (ICF/MR)
• Community Based Services
• Waivers
• Program of All-Inclusive Care For the Elderly
  (PACE)

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Eligibility for Long-Term Care Services

• To be eligible for Medicaid-funded long-term care
  services individuals must
• Qualify for Medicaid and
• Meet specified long-term care criteria according
  to a standardized long-term care assessment
  instrument
• Uniform Assessment Instrument (UAI) for nursing
  facility level of care
• Level of Functioning (LOF) Survey for ICF/MR
  level of care

21
Qualify for Medicaid

• Individuals who are Medicaid eligible at the time
  of application for LTC services are not
  automatically eligible for LTC services if they
  meet the functional assessment.
• The local DSS must assess the individuals
  eligibility for Medicaid (LTC) and calculate a
  patient pay. Everyone must have a calculation,
  not everyone has a patient pay.

22
Screening Process
DSS completes a Medicaid application if necessary
to determine Medicaid eligibility. If Medicaid
eligible, DSS completes bottom half of DMAS-225
and send to provider. DSS also sends a Notice of
Obligation of patient pay to the recipient.
If there is a provider, the provider could
initiate the DMAS-225 process by completing the
top half of the DMAS-225 and sending it to DSS.
If expect to be eligible for Medicaid within 180
days
23
Qualify for MedicaidDMAS -225

• The DMAS-225 is the service providers
  authorization to bill Medicaid for LTC services.
• DMAS-225 is to be sent by the EW no later than 45
  days from date of application, and 30 days from
  the date of a reported change.
• If the individual does not receive LTC services
  for 30 days, he must be referred to the
  Eligibility Worker for a determination of
  continued Medicaid eligibility.

24
Alternate Institutional Placement

• There must be an alternate institutional
  placement for which Medicaid pays.
• Must determine the most appropriate institutional
  placement for an individual, and must name that
  placement in the waiver application.
• This does not mean that the individual must
  actually be placed in the institution or make
  application to an institution.

To Receive Approval to Implement a Waiver
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Alternate Institutional Placement
Criteria for Admission to the Waiver
Criteria for Admission to Institution

• The individual who is applying for a waiver must
  meet the same criteria that is used for admission
  to the institution. 42 C.F.R. 441.302 (c)(1) 42
  C.F.R. 441.303 (c)(2)

To Receive Approval to Implement a Waiver
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Why Do We Do What We Do?

• Why Is Pre-Admission Screening Important?

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Why we do Pre-Admission Screenings

• In order to be eligible for long-term care
  services, individuals must be screened to
  determine if they meet the admission criteria.
• Virginia has one of the most stringent criteria
  in the country.
• For Nursing Facilities and Home and Community
  Based Waivers The authorized assessors are the
  local health departments in conjunction with the
  local departments of social services and acute
  care hospitals.

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Preadmission Screening
Some waivers have a wait list. LOF Level of
Functioning Tool
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Criteria for Eligibility Determination based on
Individuals Abilities/Needs

• For Nursing Facility, PACE and Home and Community
  Based Care Waivers
• For waiver placement individual must be at risk
  for nursing facility placement within 30 days of
  assessment without the provision of waiver
  services.

30
Activities of Daily Living There are three
different ways to meet the criteria for ADL
dependencies

• Dependent in 2-4 ADLs, plus semi-dependent or
  dependent in behavior and orientation, plus
  semi-dependent in joint motion or semi-dependent
  in medication administration, OR
• Dependent in 5-7 ADLs plus dependent in Mobility,
  OR
• Semi-Dependent in 2-7 ADLs, plus dependent in
  mobility, plus dependent in behavior and
  orientation.

AND Have Medical Nursing Needs
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Required Activities of Daily Living (for
purposes of Medicaid eligibility)

• Although Mobility is not considered an activity
  of daily living, it is an area where screeners
  have questions. The definition of mobility is
  the extent of the individuals movement outside
  his/her usual living quarters.

• Bathing
• Dressing
• Transferring
• Toileting
• Bowel Function
• Bladder Function
• Eating/Feeding

32
Behavior and Orientation

• Behavior and Orientation are considered one item
  for the purposes of criteria determination.
• Semi-dependency and dependency are based on the
  combination of both behavior and orientation.
• Remember In order to meet this criteria, the
  individual must be dependent in both areas.

33
Medical Nursing Needs

• In addition to meeting functional criteria, in
  order to receive Medicaid reimbursement, the
  individual must have medical or nursing
  supervision or care needs that are not primarily
  for the care and treatment of mental disease
  (Alzheimers and dementia are not considered
  mental diseases.)

34
Medical Nursing Needs There are three different
ways to have one

• The individuals medical condition requires
  observation and assessment to assure evaluation
  of the persons needs due to the inability for
  self observation or evaluation OR
• The individual has complex medical conditions
  which may be unstable or have the potential for
  instability OR
• The individual requires at least one ongoing
  medical or nursing service.

35
Examples of Medical Nursing Needs (May or may
not necessarily indicate on ongoing medical
nursing needs. Except as specified, the risk of
the identified conditions are not a medical
nursing need if not a current problem.)

• Care of small uncomplicated pressure ulcers and
  local skin rashes
• Management of those with sensory, metabolic, or
  circulatory impairment with demonstrated clinical
  evidence of medical instability
• Infusion therapy
• Oxygen

• Routine care of colostomy or ileostomy or
  management of neurogenic bowel and bladder
• Use of physical or chemical restraints
• Routine skin care to prevent pressure ulcers for
  individuals who are immobile

36
Examples of Medical Nursing Needs (May or may not
necessarily indicate on ongoing medical nursing
needs. Except as specified, the risk of the
identified conditions are not a medical nursing
need if not a current problem.)

• Application of aseptic dressings
• Routine catheter care
• Respiratory therapy
• Therapeutic exercise and positioning
• Chemotherapy
• Radiation
• Dialysis
• Suctioning

• Supervision for adequate nutrition and hydration
  for individuals who show clinical evidence of
  malnourishment or dehydration or have a recent
  history of weight loss or inadequate hydration
  which, if not supervised, would be expected to
  result in malnourishment or dehydration.

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What Do Services Look Like?

• Overview of What Makes PACE and Waivers Special

38
Medicaid Services Long Term Care

• Program for the All-Inclusive Care of the Elderly
  (PACE)
• Community based waivers
• Aids Waiver
• Alzheimers Waiver
• Developmentally Disabled
• Day Support Waiver
• Elderly or Disabled Consumer Direction Waiver
• Mental Retardation Waiver
• Tech Waiver

An increasing emphasis
39
Medicaid ServicesLong Term Care

• Facility based programs
• Assisted Living
• Home Health
• Hospice
• Nursing Facilities
• Specialized Care
• ICF/MR
• Rehabilitation Programs
• In / Out patient
• School

A decreasing emphasis
40
Medicaid Services PACE

• PACE is a Program of All Inclusive Care for the
  Elderly
• Serves persons 55 and older that meet nursing
  facility criteria in the community.
• Provides all health and long-term care services
  centered around an adult day health care model.
• Combines Medicaid and Medicare funding.

41
Medicaid Services PACE
Map Key
Frederick
Sentara PACE Mountain PACE
Centra PACE Riverside PACE Hampton
Riverside PACE Richmond Appalachian PACE

Winchester
Manassas Park
Loudoun
Falls Church
Clarke
Warren
Arlington
Fauquier
Shenandoah
Alexandria
Fairfax City
Fairfax
Rappahannock
PrinceWilliam
Manassas
Page
Rockingham
Harrisonburg
Culpeper
Stafford
Madison
Highland
KingGeorge
Augusta
Fredericksburg
Greene
Orange
Staunton
Westmoreland
Spotsylvania
Albemarle
Bath
Essex
Waynesboro
Northumberland
Caroline
Louisa
Charlottesville
Lexington
Clifton Forge
Richmond
Fluvanna
King Queen
Buena Vista
Accomack
Covington
Hanover
Goochland
Nelson
Lancaster
Rockbridge
Alleghany
King William
Middlesex
Henrico
Amherst
Buckingham
Powhatan
Botetourt
Richmond
NewKent
Matthews
Cumberland
Craig
Lynchburg
Northampton
Gloucester
Chesterfield
JamesCity
Appomattox
CharlesCity
Roanoke
Amelia
Bedford
Col.Heights
Giles
Salem
Prince Edward
Roanoke City
York
Buchanan
Prince George
Poquoson
Williamsburg
Petersburg
Campbell
Bedford
Montgomery
Surry
Nottoway
Hopewell
Hampton
Dickenson
Bland
Dinwiddie
Newport News
Tazewell
Isle ofWight
Charlotte
Radford
Wise
Norfolk
Lunenburg
Franklin
Pulaski
Sussex
Portsmouth
Russell
Floyd
Norton
Wythe
Virginia Beach
Brunswick
Smyth
Pittsylvania
Franklin
Henry
Suffolk
Lee
Carroll
Emporia
Washington
Chesapeake
Southampton
Danville
Scott
Mecklenburg
Galax
Patrick
Halifax
Grayson
Martinsville
Greensville
Bristol
42
Waivers

• Social Security Act allows states to waive the
  freedom of choice of provider, statewideness, and
  amount, duration, and scope of services
  requirements in order to
• Have managed care programs (Section 1915(b)
• Try new approaches through research and
  demonstration (Section 1115) and
• Allow services to be provided in the community
  rather than in institutions (Section 1915(c) Home
  and Community Based Care Waivers) . About 30 of
  long term care spending is provided through HCBS
  waivers.

43
Waivers Recipient Choice

• The applicant must be offered
• the choice in all of the following
• Waiver
• Alternate institution
• Providers
• Services

44
Waivers Cost Effective

• It can be individually cost effective or cost
  effective in the aggregate.
• Aggregate Cost Effectiveness The average cost
  to Medicaid for individuals enrolled in a waiver
  cannot cost more than the average cost to
  Medicaid for individuals in the comparable
  institution.
• Individual Cost Effectiveness Cost to Medicaid
  for the individual in the community cant exceed
  the cost in the comparable institution.
• DMAS has chosen to use aggregate cost
  effectiveness.

45
Waivers Community Based

• Medicaid waiver funds cannot
• pay for room and
  board.
• Services must be
  based in the community
• Waiver Payments are for Services Rendered

46
7 Medicaid Waivers
47
Waivers Eligibility - All Waivers

• Cannot be served in more than one waiver at a
  time (federal requirement).
• Can be on one waiver
• while on a waiting list
• for another waiver if
• meet the criteria for
• admission to both
• waivers.

DD Waiver
EDCD Waiver
John Doe
John Doe
48
Waivers Consumer-Directed Services
a growing trend
49
Waivers Consumer-Directed Services
Consumer-Directed
Agency Directed

• Services provided by a enrolled Medicaid Agency
  who hires and monitors staff that provide
  services to a variety of individuals.

• The individual consumer or their representative
  employs and monitors staff providing services
  exclusive to them.

50
Waivers Consumer-Directed Personal Care Services

• Available in four of Virginias waivers
• HIV/AIDS (personal care and respite)
• EDCD (personal care and respite)
• DD Waiver (personal care and respite)
• MR Waiver (personal care, respite, and companion)

51
Alzheimers Assisted Living (AAL) Waiver

• Assisted Living Assistance with activities of
  daily living, housekeeping, and supervision.
• Medication Administration Medication
  administered by a licensed professional.
• Nursing evaluations Evaluation by a registered
  nurse.
• Therapeutic and Recreational Programming Weekly
  activity program based on needs and interests.
• Individuals receiving AAL Waiver services also
  receive services through the Medicaid program.
  Examples include medications (for those
  individuals not covered under Medicare),
  physician visits, acute care hospitalizations,
  and certain therapies.

52
Day Support (DS) Waiver

• Day Support
• Prevocational Services
• Supported Employment

• Daily administration is managed by the Department
  of Behavioral Health and Developmental Services,
  Office of Developmental Services (ODS), in
  collaboration with DMAS.
• For information, please refer to the DBHDS
  website at
• www.dbhds.virginia.gov/ODS-default.htm.

53
Elderly or Disabled with Consumer Direction
(EDCD) Waiver

• Adult Day Health Care
• Medication Monitoring
• Personal Care Aide Services
• Respite Care
• Personal Emergency Response System (PERS)
• Transition Coordination
• Transition Services

54
HIV/AIDS Waiver

• Nutritional supplements
• Personal Emergency Response System (PERS) 
• Transition Services 
• Private duty nursing
• Personal care (agency or consumer-directed
  options)
• Respite care (agency or consumer-directed
  options)

55
Individual and Family Developmental Disabilities
Support (IFDDS) Waiver

• Assistive Technology
•  Attendant Services
•  Companion Services (Agency or Consumer Directed)
  
•  Crisis Stabilization
•  Crisis Supervision
•  Day Support
•  Family and Caregiver Training
•  Environmental Modifications
•  In-home Residential Support
•  Personal Care Services
•  Personal Emergency Response System (PERS)
•  Prevocational Services
•  Respite Care (Agency or Consumer Directed)
•  Skilled Nursing Services
•  Supported Employment
•  Therapeutic Consultation
•  Transition Services

56
Intellectual Disabilities/Mental Retardation
(ID/MR) Waiver

• Residential Support Services
• Day Support
• Supported Employment
• Personal Emergency Response Systems (PERS)
• Prevocational Services
• Personal Assistance
• Respite
• Companion
• Assistive Technology
• Environmental Modifications
• Skilled Nursing Services
• Therapeutic Consultation
• Crisis Stabilization

• Daily administration is managed by the Department
  of Behavioral Health and Developmental Services,
  Office of Developmental Services (ODS), in
  collaboration with DMAS.
• For information, please refer to the DBHDS
  website at www.dbhds.virginia.gov/ODS-default.htm.
  

57
Technology Assisted (Tech) Waiver

•  Personal Emergency Response System (PERS)
•  Transition Services
•  Personal care (Adults Only)
•  Private duty nursing
•  Respite care
•  Environmental Modifications
•  Assistive Technology

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Questions and AnswersLong-Term Care Issues

• Pre-Admission Screeners list serve at
• http//www.dmas.virginia.gov/ltc-Pre_admin_screen
  ers.htm
• For questions, please contact the Division of
  Long-Term Care at 804-225-4222, or by fax at
  804-612-0040.
• Please visit the DMAS website at
• www.dmas.virginia.gov

59
Updates
60
Disease Management (DM) in Virginia

• Virginia Healthy ReturnsSM disease management
  (DM) program has been operated by Health
  Management Corporation since January 2006.
• However, due to the downturn in the economy and
  the severe state budget shortfalls, funding
  decisions had to be made to reduce spending in
  FY10. One of the difficult decisions was to
  discontinue the Healthy Returns program.
  Therefore, the Healthy Returns disease management
  program is no longer be available, after October
  31, 2009.
• DMAS communicated program changes to enrolled
  disease management members prior to October 31,
  2009. DMAS has communicated program changes to
  providers. HMC will accept informational calls
  through November 30th. If you have questions,
  contact Meredith Lee at meredith.lee_at_dmas.virginia
  .gov

61
H1N1 Vaccine

• The Virginia Department of Medical Assistance
  Services (DMAS) and its Managed Care
  Organizations will cover and pay for the H1N1
  vaccine the same as any other vaccine that is
  covered and paid for today.
• DMAS will follow the Centers for Disease Control
  guidelines for determining medical necessity when
  authorizing and paying for screenings associated
  with the H1N1 infection. The process used by
  providers for reimbursement will not change.

62
http//www.virginiamanagedcare.com
63
Withdrawal of Virginia Premier from Culpeper
Effective October 1, 2009 Virginia Premier Health
Plan will no longer be available as a health plan
option in Culpeper. This means only one health
plan will operate in the locality. In following
with guidelines from the Centers for Medicare and
Medicaid Services (CMS), Culpeper is designated
as rural and only one health plan is required.
As of October 1, 2009 coverage will be provided
through AMERIGROUP Community Care.
64
Withdrawal of Virginia Premier from Caroline,
Madison, Orange, Rappahannock, and Warren Counties
Effective October 1, 2009 Virginia Premier Health
Plan is no longer available in the following
counties Caroline, Madison, Orange,
Rappahannock, and Warren.
This change will not affect Medicaid eligibility.
Members will be pre-assigned to one of the
other Medicaid health plans participating in
their locality. During the pre-assignment
process members will be given the option to make
a choice between the health plans available in
their area. Coverage with their new health plan
will begin on December 1, 2009.
65
FAMIS MOMS Expands to 200 FPL

• On July 1, 2009, DMAS implemented the expansion
  of the FAMIS MOMS program from 185 TO 200
  Federal Poverty Level (FPL).

The expansion is expected to increase access to
prenatal care for an additional 135 pregnant
women each year while also improving birth
outcomes and reducing uncompensated care at
hospitals. FAMIS materials can be ordered free
of charge from the FAMIS website at
www.famis.org. For more information, contact
Shelagh Greenwood at shelagh.greenwood_at_dmas.virgin
ia.gov
66
Early Intervention Changes

• Provider Certifications  More than 929
  individuals have completed all 4 training modules
  necessary for certification.  DBHDS has certified
  670 individuals. 
• DMAS Provider Enrollment  DMAS has enrolled over
  72 providers.  Not all of the local lead agencies
  (LLA) have enrolled.
• Recipient Match and Data Entry Of the 6000 plus
  children enrolled in the early intervention
  program, DMAS was able to find 2,434 who were an
  exact match to children in the MMIS.  Even though
  DMAS' involvement is only a small part of the
  total Part C Program, there are 2400 plus
  children who will now have their services paid
  for with funds outside of the Part C allotted
  funds thereby freeing up funds for those children
  who do not have insurance. 

Early Intervention Birth to Three
67
Smiles for Children Update Medicaid/FAMIS Dental
68
Smiles for Children Rocks!

• Smiles for Children
• Began July 1, 2005
• In FY 2009, 40 of all eligible children actually
  received dental services
• Over 22 of Virginia dentists are participating
• Over 80 of participating providers are billing
  for services

69
Focus of Current Efforts

• Maintain close partnerships with the Virginia
  Dental Association, the dental community, and key
  stakeholders
• Continue provider recruitment/retention efforts
• Continue member outreach and education activities

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1-888-912-3456
http//www.dmas.virginia.gov/dental-home.htm
http//www.doralusa.com
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QUESTIONS