Elderly or Disabled with Consumer Direction Waiver EDCD

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Elderly or Disabled with Consumer Direction
Waiver (EDCD)

• an Update
• November 9, 2004

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Presentation Outline
Background Information About Waivers Brief
Discussion of Current Waivers What the EDCD
Waiver Will Look Like Status of EDCD Waiver
Implementation Quality Framework
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Medicaid State Plan Services vs. Waivers

• Usually services must be available in the same
  amount, duration, and scope to all similarly
  situated Medicaid recipients. Services are to be
  available to the extent they are available to the
  general public, providers must be willing and
  able to provide services, and recipients must be
  allowed to choose their providers.
• In addition, services cannot usually be targeted
  by age or type of disability.
• Waivers allow states to waive these
  requirements and target specific ages or
  disabilities, provide services only in parts of
  the state, and have managed care programs.

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Home and Community BasedServices - 1915(c)
Waivers

• Optional programs that afford States flexibility
  to develop and implement alternatives to
  institutionalization. Approved initially for 3
  years, and then in 5 year increments.
• Can request waivers for individuals who are
• Aged or disabled, or both or
• Mentally retarded or developmentally disabled, or
  both or
• Mentally ill
• Alternate institution can be a nursing facility,
  ICF/MR, or hospital.

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Alternate Institutional Placement

• There must be an alternate institutional
  placement for which Medicaid pays. Cannot get a
  waiver with an alternate institutional placement
  of an IMD. Medicaid does not pay for
  services in an IMD for people between the ages of
  21 and 64.
• Must determine the alternate institutional
  placement, 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.

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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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Must Offer Choice

• In order to have a waiver approved by the
  Centers for Medicare and Medicaid Services (CMS),
  the applicant must be offered the choice between
  the waiver and the alternate institution.
• 42 C.F.R. 441.302(d)

To Receive Approval to Implement a Waiver
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To Receive Approval to Implement a Waiver

• The Single State Medicaid agency must
• make policy
• administer the program
• can contract services but must retain
• responsibility for policy and administration
• of the program 42 C.F.R. 431.10
• The waiver Plan of Care must be subject to
  approval by the Medicaid agency. 42 C.F.R.
  441.431(b)(1)

Applies to all Medicaid Services
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To Receive Approval to Implement a Waiver

• The Medicaid Agency must also assure CMS that
  there are safeguards to protect the health and
  welfare of recipients.
• 42 C.F.R. 441.302(a)

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Waiver Payments are for Services Rendered

• Waivers provide services that are not available
  to the general Medicaid population.
• Waivers dont have to offer the same services
  with the same service definitions as other
  waivers.
• Medicaid waiver funds
  cannot
• pay for room and
  board.

To Receive Approval to Implement a Waiver
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Waiver Must be Cost Effective

• It can be individually cost effective or cost
  effective in the aggregate.
• Aggregate Cost Effectiveness The average cost
  to Medicaid of individuals on the waiver cannot
  cost more than the average cost to Medicaid of
  individuals in the comparable institution. (Can
  have service limits.)
• Individual Cost Effectiveness Cost to Medicaid
  for the individual in the community cant exceed
  the cost in the comparable institution.
  Interpretation from CMS is the average cost.

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Presentation Outline
Background Information About Waivers Brief
Discussion of Current Waivers What the EDCD
Waiver Will Look Like? Status of EDCD Waiver
Implementation Quality Framework
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Number of Individuals Served Expenditures in
Waivers in FY 2004
Source CMS 372 reports FY 04 MR and AIDS Waiver
totals are not yet available
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• What Waivers Have in Common

• What Waivers Have in Common

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Waiver Eligibility - All Waivers
What Waivers Have in Common

• Financial eligibility is determined as if the
  person is institutionalized (institutional
  deeming rule).
• The income and resources of parents are not
  counted when determining eligibility for the
  Waiver for a child under 18.
• Spousal impoverishment policies apply.

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Waiver Eligibility - All Waivers

• Cannot be served in more than one waiver at at
  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.

ED Waiver
DD Waiver
John Doe
John Doe
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Waiver Eligibility - All Waivers
What Waivers Have in Common

• The State and CMS agree to a number of slots that
  will be available for the waiver.
• The State cannot exceed the number of slots that
  have been agreed upon.
• States must conduct yearly level of care reviews
  on all waiver recipients.

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Waiver Eligibility
What Waivers Have in Common

• Higher income level for long term care 300 of
  SSI income level which is currently 1,692 (will
  be 1,737 January 2005) - all waivers. (Federal
  law will not allow a state to use an income level
  higher than 300 of SSI.)
• For AIDS, CD-PAS, Elderly and Disabled, and
  Technology Assisted Waivers, individual could be
  on a spend-down if income is over this amount.
  There is no spend-down option for the MR and DD
  Waivers.

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Waiver Eligibility Most Waivers
What Waivers Have in Common

• Most waiver recipients must contribute toward the
  cost of care through payment of a patient pay.
  The patient pay is usually all income in excess
  of 100 of the SSI income level - currently 564
  (579 in January 2005).
• Two exceptions
• the AIDS waiver does not have a patient pay
• the CD-PAS, DD, and MR waivers allow individuals
  to keep more of their earned income.

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Due to Expenses of Employment...
What Waivers Have in Common

• Individuals in CD-PAS, DD, and MR Waivers...
• Can keep earned income up to a total of 300 of
• SSI income level if working 20 or more
  hours/week.
• Can keep earned income up to a total of 200 of
• SSI income level if working 8-20 hours/week.
• Still have a patient pay from unearned income.
• total of earned and unearned income

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Consumer Directed Personal Care Services
What Waivers Have in Common

• Available in four of Virginias waivers
• AIDS
• CD-PAS
• Waiver
• DD Waiver (personal care and respite)
• MR Waiver (personal care, respite, and companion)

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Consumer Directed Personal Care Services

• Afford recipients or family caregivers direct
  control over who, how, and when services are
  provided.
• Waiver recipient is the employer of record with
  the IRS.
• In Virginia personal assistants are classified as
  domestic workers and are not subject to workers
  compensation claims.

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Consumer Directed Personal Care Services

• At a minimum, personal assistants cannot be a
  legally responsible relative (a spouse or a
  parent of a minor child). Waivers can and do
  define differently.
• Payment is not made to other family members
  unless there is objective, written documentation
  as to why there are no other providers available
  to provide the service.
• These are federal requirements.

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Consumer Directed Personal Care Services

• The assistant is paid on behalf of the waiver
  recipient by a fiscal agent.
• The fiscal agent (currently DMAS), is recognized
  by the IRS, and allows recipients to receive
  consumer-directed services while being assured
  that all employment tax responsibilities are
  properly handled. DMAS is currently developing
  an Request for Proposal (RFP) to contract this
  function out.

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Presentation Outline
Background Information About Waivers Brief
Discussion of Current Waivers What the EDCD
Waiver Will Look Like Status of EDCD Waiver
Implementation Quality Framework
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What will the EDCD Waiver look like?

• CD-PAS
• Consumer-directed personal care (42-hour per week
  limit)
• Decreased patient pay if working

• Elderly and Disabled
• Agency Directed Personal Care
• Respite (including skilled respite)
• Adult Day Health Care
• Personal Emergency Response System

• EDCD
• Decreased patient pay if working
• Personal Care Agency and Consumer-directed
• (no 42-hour per week limit)
• Respite agency and consumer-directed
• Skilled Respite agency directed
• Adult Day Health Care
• Personal Emergency Response System (PERS)

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Benefits of Combining the Waivers

• Individuals can receive either agency or
  consumer-directed services, or both
• 720 hours of respite care per year for relief of
  unpaid caregivers, including skilled respite
• Access to PERS if it replaces supervision
• Eliminated 42-hour per week limit for
  consumer-directed personal care

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Considerations

• Waiver must remain cost-effective.
• Level of care reviews are revealing some people
  do not meet criteria these are generally people
  who have fewer hours of care. As they are
  removed from the waivers, the average number of
  hours will increase. It remains to be seen how
  this will affect cost-effectiveness.
• All waiver recipients must have a back-up plan in
  order to receive services.

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Changes to Home Health

• Skilled nursing maintenance services will be
  provided if there is no one else willing and able
  to provide the services (do not have to be
  home-bound but federal regulations require
  services to be provided in the individuals
  home). Must be ordered by a physician and prior
  authorized. This does not take the place of a
  back-up plan.
• Examples catheter changes, insulin shots, B-12
  shots. Memo is on the DMAS web site
  (www.dmas.virginia.gov)
• These are visits it is not private duty nursing
  in which the nurse stays to provide on-going
  care, such as vent care, etc.

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Presentation Outline
Background Information About Waivers Brief
Discussion of Current Waivers What the EDCD
Waiver Will Look Like Status of EDCD Waiver
Implementation Quality Framework
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In order to have a waiver, we must have both...
Approved State Regulations

Approved Waiver from CMS
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Status of EDCD Waiver

• Waiver has been approved by CMS
• Emergency regulations are being promulgated
• Expect an effective date of February 1, 2005

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Implementation Timeline

• Manual finalized and on the website by January 1,
  2005.
• Training will take place in January
• Preadmission screening teams
• All providers
• Service facilitators
• Recipients of ED and CD-PAS Waivers notified of
  the changes via letter in January (after
  training) and brochure about the EDCD Waiver.
• People in CD-PAS and ED Waivers will be changed
  to the EDCD waiver the last two weeks of January
  (this will be automatic, people will not have to
  reapply).

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Presentation Outline
Background Information About Waivers Brief
Discussion of Current Waivers What the EDCD
Waiver Will Look Like Status of EDCD Waiver
Implementation Quality Framework
35
Quality Framework

• Mandated by the Centers for Medicare and Medicaid
  Services (CMS) for Waiver Services.

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Quality Framework

• Encompasses three functions
• Discovery Collecting data and direct
  participant experiences in order to assess
  ongoing implementation of the program
• Remediation Taking action to remedy specific
  problems or concerns that arise.
• Continuous Improvement Using data and quality
  information to engage in actions that lead to
  continuous improvement in the HCBS program.
• Increased reporting to CMS about waivers,
  quarterly and yearly reports. New waiver
  template.

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Quality Framework

• DMAS has meet with an Advisory Group and
  discussed the framework. They discussed 7 areas
  for identifying data as part of the Quality
  Framework
• Consumer Survey Data
• Complaints
• Enrollment Data
• Chart Reviews
• Assessment Data
• Medical/Pharmacy Data
• Vital Statistics

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Quality Framework

• DMAS has signed agreements with Medstat and the
  Human Services Resource Institute (HSRI) to
  receive technical assistance for the next year.
  We met with them in August and November
• Goal is to work toward a quality framework that
  spans all waivers