INTELLECTUAL DISABILITIES WAIVER SERVICES IN PENNSYLVANIA. In Pennsylvania, a variety of home and community-based services and

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1 Disability Rights Network of Pennsylvania 1414 N. Cameron Street Second Floor Harrisburg, PA (800) (Voice) (877) (TDD) INTELLECTUAL DISABILITIES WAIVER SERVICES IN PENNSYLVANIA In Pennsylvania, a variety of home and community-based services and supports are available to individuals with intellectual disabilities. Most of the services and supports are funded through Medical Assistance home and community-based waivers. The purpose of this booklet is to help people with intellectual disabilities, their family members, and interested others in understanding the intellectual disabilities waivers in Pennsylvania. What are Medical Assistance waivers? People with intellectual disabilities can be eligible for Medical Assistance, also known as Medicaid or MA. Medical Assistance is a program that pays for a range of health care services (such as physician visits, dental care, home health services, and targeted case management). Other health care

2 services (such as physical therapy, occupational therapy, speech/language therapy, and nursing services) may also be available to people with intellectual disabilities through Medical Assistance but are subject to limits. The limits may not meet the needs of a person with an intellectual disability. When the Medical Assistance law was first written, the main long-term care services for people with intellectual disabilities were Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/ID). ICF/ID programs are often provided in congregate, institutional settings. In 1981, the United States Congress decided that states should be encouraged to shift Medical Assistance services for long-term care away from institutional settings (like ICF/ID programs or nursing facilities). To encourage states to develop more integrated services, states were given the option to ask for a waiver of certain federal Medical Assistance requirements. Waiving these federal requirements allowed states to provide long-term care services in home and community-based settings rather than in institutional settings. The new programs provided under 2

3 these waivers of federal requirements were known as home and community-based waivers 1 (usually referred to as waivers ). Home and community-based waivers are developed by states and approved by the federal government. These waivers allow states to: Identify the target group covered by the waiver (such as people with intellectual disabilities or people age 60 and over). Provide services beyond those health care services that are traditionally covered by Medical Assistance. Identify the maximum number of people that may receive services under the waiver. Specify the services available through the waiver, as well as any limits on those services. Specify the criteria that providers must meet in order to be considered qualified to provide waiver services. To receive approval for a home and community-based waiver, a state must show that it is able to meet federal waiver requirements. For example, states must develop ways to ensure the health and welfare of people 1 These waivers are also called HCBS (home and community-based services) waivers and 1915(c) waivers. 3

4 receiving services through the waiver, including ways to identify and prevent abuse, neglect, and exploitation. Are there waivers for people with disabilities in Pennsylvania? Pennsylvania has received federal approval to run several home and community-based waivers for Pennsylvanians with disabilities. There are waivers in Pennsylvania for people with physical disabilities, people with developmental disabilities other than intellectual disabilities, people with autism spectrum disorder, people with traumatic brain injury, people with Acquired Immunodeficiency Syndrome (AIDS), people age 60 or over, children in need of early intervention services, and people with intellectual disabilities. What are the waivers for people with intellectual disabilities in Pennsylvania? There are two waivers in Pennsylvania for people with intellectual disabilities: The Consolidated Waiver and the Person/Family Directed Support (P/FDS) Waiver. Both waivers are overseen by Pennsylvania s Department of Public Welfare (DPW), Office of Developmental Programs (ODP). 4

5 What are the differences between the Consolidated and P/FDS Waivers? Although the Consolidated and P/FDS waivers both serve people with intellectual disabilities, there are some differences between the waivers. Overall, the Consolidated Waiver is the larger of the two intellectual disabilities waivers in terms of the number of people served, the scope of services available, and the amount of funding available. Some of the specific differences include: Non-financial eligibility criteria: Consolidated Waiver The person must be three years of age or older, have a diagnosis of an intellectual disability, require an ICF/ID level of care, require active treatment, and may not reside in a licensed Personal Care Home. P/FDS Waiver The person must be three years of age or older, have a diagnosis of an intellectual disability, require an ICF/ID level of care, and require active treatment. The person may not reside in a licensed or unlicensed Community Home for People with Intellectual Disabilities, Family Living Home, Child Residential Facility, or Community Residential Rehabilitation Services Home. The person may not reside in a licensed Personal Care Home with 11 or more residents (if the 5

6 person s move-in date is July 1, 2008 or after). In addition, a person may only be enrolled if his or her needs can be met through waiver services that do not cost more than $30,000 per Fiscal Year. Maximum number of people served: A maximum number of people to be served is identified in the waivers for each Fiscal Year. The number may be adjusted with approval of the federal government. Consolidated Waiver This Waiver can serve a maximum of 17,637 unduplicated people in Fiscal Year 2012/2013. P/FDS Waiver This waiver can serve a maximum of 11,200 unduplicated people in Fiscal Year 2012/2013. Overall cost of waiver services: Consolidated Waiver A person is entitled to receive the waiver services he or she needs regardless of the total cost of those services. P/FDS Waiver A person is entitled to receive the waiver services he or she needs, up to an annual cost of $30,000 per Fiscal Year. This $30,000 does not include the cost of Supports Coordination services. 6

7 Available services. The following services are available in both the Consolidated and P/FDS Waivers: Unlicensed Home and Community Habilitation Companion Services Prevocational Services Licensed Day Habilitation Services Transitional Work Services Supported Employment Job Finding and Job Support Respite Supports Coordination Supports Broker Services Transportation Behavioral Support Therapy Services (Physical Therapy, Occupational Therapy, Behavior Therapy, Speech/Language Therapy, and Visual/Mobility Therapy) Nursing Homemaker/Chore Services Home Accessibility Adaptations Vehicle Accessibility Adaptations Assistive Technology 7

8 Education Support Services Specialized Supplies The following services are only available in the Consolidated Waiver: Licensed Residential Services (Community Homes for People with Intellectual Disabilities, Family Living Homes, Child Residential Treatment Facilities, and Community Residential Rehabilitation Services Homes) Unlicensed Residential Services (exempt from licensing as Community Homes for People with Intellectual Disabilities or Family Living Homes) Is the Consolidated or the P/FDS Waiver the right one for me? If the services required to meet a person s needs are expected to cost $30,000 or less per Fiscal Year, he or she can qualify for either the P/FDS Waiver or the Consolidated Waiver, but would usually be enrolled in the P/FDS Waiver. If the costs of services necessary to meet a person s needs are expected to be more than $30,000 per Fiscal Year, the person can only qualify for the Consolidated Waiver. The person must meet all eligibility criteria to be enrolled in the Consolidated or P/FDS Waiver. A person may only be enrolled in one waiver at a time. A person can move from the 8

9 P/FDS Waiver to the Consolidated Waiver, if needed when there are available openings. A person can move from the Consolidated Waiver to the P/FDS Waiver, but gives up rights to the Consolidated Waiver and is limited to the P/FDS financial limitation of $30,000 per Fiscal Year. There have been instances when it has been suggested that a person move from the Consolidated Waiver to the P/FDS Waiver, but this is almost always a bad idea. Even if a person s needs can currently be met in the P/FDS Waiver, it is likely that in the future the person may need services in the Consolidated Waiver. In addition, there is no guarantee that the person will be able to get reenrolled into the Consolidated Waiver when needs change, even if the P/FDS Waiver can no longer meet his or her needs. Are all people with intellectual disabilities entitled to enrollment in either the Consolidated or P/FDS Waiver? Not everyone who needs waiver services can get into a waiver. As explained on page 6 above, both the Consolidated and P/FDS Waiver have a maximum number of people that can be served during each Fiscal Year. Any person not enrolled in either the Consolidated or P/FDS Waiver but in need of waiver services should be on the waiting list for services. The 9

10 waiting list is established through the Prioritization of Urgency of Need for Services (PUNS) process, which is explained below. How do I apply for the Consolidated P/FDS Waiver? ODP uses Administrative Entities throughout the state to do certain tasks, including application and enrollment for both waivers. Administrative Entities are currently the County Intellectual Disabilities programs. For example, the Administrative Entity in Dauphin County is the Dauphin County Mental Health/Intellectual Disabilities Program. Staff in each County Program should be familiar with the Consolidated and P/FDS Waivers. County Program staff must help people with intellectual disabilities in applying to either of the waivers. County Programs must offer Form DP-457 to anyone with intellectual disabilities who is enrolled in Medical Assistance and is likely to need the level of services provided in ICF/ID. Form DP-457 asks the person with intellectual disabilities his or her preference to receive services in home and community-based or institutional settings. If the person chooses home and community-based services, Form DP-457 also serves as the application for enrollment in one of the waivers. 10

11 A person with intellectual disabilities may also apply for the waivers on his or her own by completing Form DP-457 and giving it to his or her County Program. Form DP-457 can be found as Attachment 1 to this booklet. A list of County Programs can be found online at: How is eligibility for the Consolidated and P/FDS Waivers decided? After Form DP-457 is completed, the County Program must determine whether there are any openings in the waivers. If there are no openings, the person is placed on the waiting list for services. Refer to the section titled How do people get enrolled from the waiting list? to learn more about how people are moved off of the waiting list. While the person is waiting, he or she may be able to get some non-waiver funding through the County Program. This funding is known as base funding. If an opening is available to enroll the person into a waiver, the County Program must decide whether the person is eligible. The County Program first notifies the person in writing of an opening. This written notice includes instructions for enrollment requirements. The notice may ask the person to submit information to help determine eligibility, including psychological, social, developmental, and medical information. 11

12 The eligibility process also involves an assessment by a Qualified Intellectual Disabilities Professional (QIDP, which was previously known as a Qualified Mental Retardation Professional, or QMRP). The assessment documents the person s limitations in activities of daily living. The QIDP may need to have a face-to-face interview with the person if a review of available written information is not enough to make an eligibility decision. A medical evaluation that shows that the person is in need of ICF/ID services is also required. This medical evaluation may be completed on Form MA- 51, or some other form used by the person s physician, as long as the form shows a need for Intermediate Care Facility services. Form MA-51 can be found as Attachment 2 to this booklet. It is important for the person to submit all requested information if it is available. Missing information could result in the loss of the enrollment opportunity. If the County Program decides that the person is eligible for an Intermediate Care Facility level of care, the application is sent to the local County Assistance Office for a decision on financial eligibility. Financial eligibility requirements include maximum limits for a person s income and resources. The County Assistance Office has 30 calendar days to determine financial eligibility. 12

13 People who already get Medical Assistance for health care will be determined financially eligible for the waivers. Otherwise, a person s income can be at or below 300% of the Supplemental Security Income (SSI) Federal Benefit Rate, 2 and generally he or she can have up to $8,000 in resources. Examples of resources are money in a savings account or checking account. Money set aside to pay for a burial plot is not counted toward this $8,000 limit in resources. Once overall eligibility is decided, the County Assistance Office sends a notice of eligibility to the person and the County Program. This eligibility notice includes Form PA-162, which will state the effective date for waiver enrollment. Waiver services may only begin on or after this enrollment date. Once an eligibility decision is made, the County Program notifies the person in writing within 20 calendar days of the decision. The written notice must include Form DP-250, which states whether the person has been determined eligible. The notice must also state the waiver into which 2 In 2012, the monthly Supplemental Security Income (SSI) Federal Benefit Rate is $698. Therefore, in 2012, 300% of the monthly Supplemental Security Income (SSI) Federal Benefit Rate is $2,

14 the person will be enrolled. Form DP-250 is included as Attachment 3 to this booklet. If the County Program decides that the person is not eligible, the person may appeal this decision by completing Form DP-458. The County Program must help the person to complete Form DP-458 if needed. Form DP-458 is included as Attachment 4 to this booklet. How do people get enrolled from the waiting list? As previously noted, both the Consolidated and P/FDS Waivers have a maximum number of people that can be served in the waiver each year. ODP may only enroll people up to this number. The number of people in Pennsylvania with intellectual disabilities in need of services is more than this number, which has resulted in the ODP having a waiting list for the waivers. This waiting list uses the Prioritization of Urgency of Need for Services process, known as PUNS, to rank people s need for enrollment in the waivers. The PUNS assessment uses a standard form to get information on the needs of people with intellectual disabilities who have asked for services. The PUNS form is completed by the person s supports coordinator in 14

15 consultation with the person. Completion of the PUNS form results in the person s needs being assigned one of the three categories: 1. Emergency The person needs services within the next 6 months. 2. Critical The person needs services in more than 6 months, but less than 2 years. 3. Planning The person needs services in the next 2 to 5 years. The waivers currently require that people in the emergency category are enrolled into a waiver before those in the critical or planning categories. Therefore County Programs must first enroll people with an emergency PUNS when there are openings in either of the waivers. The PUNS form must be reviewed at least annually and updated if needed to show the person s current needs. This annual review and update must be completed by the person s supports coordinator. If a person does not have a PUNS and is currently in need of services, or expects a need in the future, he or she should contact the County Program to arrange for an assessment. 15

16 More information on the PUNS process can be found in ODP Bulletin , titled Prioritization of Urgency of Need for Services (PUNS) Manual, which can be found at: What happens after waiver enrollment? An Individual Support Plan, known as an ISP, must be developed before waiver services are provided to the person. Sometimes a person already has an ISP for non-waiver or base services, and this ISP must be updated to include needed waiver services. If a person does not yet have an ISP, one must be created that shows the person s assessed needs, and the services and supports that will be used to meet those needs. The ISP is developed by the person, his or her supports coordinator, and the person s team. The ISP is developed using a person-centered process. This process requires that the person s individual preferences be included in the ISP. The ISP must also include the services that are required to meet the person s assessed needs. The person has the right to freely choose the provider or providers that will provide needed services. The person s supports coordinator should 16

17 provide the person with a list of providers that are able to provide the needed services to the person. The provider or providers that the person chooses are included in the ISP along with the amount of service that the provider will deliver. The person s supports coordinator must submit the draft ISP to the County Program for approval. Once the County Program authorizes the services, those services should be provided to the person. Services should be provided as they are listed in the ISP. The person may report concerns with his or her services at any time to the supports coordinator, County Program, or ODP. In addition, the person has the right to change providers, including supports coordination providers, at any time. The person s choice of provider may only be limited if: The provider is not qualified to provide the needed service. Medical Assistance and the waivers include criteria that providers must meet prior to delivering any service. A provider is qualified by the County Program using these criteria and may only be selected to provide a service once the provider is considered qualified. 17

18 The provider is not willing to provide services to the person. Federal law requires that a provider be willing to provide services to a person. What are the appeal rights under the waivers? People receiving waiver services have the right to appeal most negative decisions regarding their waiver services. People may request an appeal when: It is decided that the person does not meet an ICF/ID level of care and is denied waiver enrollment. The person is told that he or she may not apply for waiver services. The person is not offered the choice between waiver services and institutional care. The person is denied the choice of willing and qualified providers to provide his or her waiver services. The person is denied the waiver service or services of his or her choice, including the amount, duration, and scope of service. A decision or action is taken to refuse, suspend, reduce, or terminate a waiver-funded service. Services are not provided with reasonable promptness. This includes a failure to provide services that are authorized in the ISP and failure to 18

19 enroll the person in the waiver with reasonable promptness due to the lack of openings in the waiver or an incorrect PUNS category. A person may file an appeal even if he or she has agreed to and is receiving the services that have been authorized in the ISP. For example, a person may appeal the amount of services authorized in the ISP or the failure to allow a choice among willing and qualified providers. County Programs must provide written notice of adverse, or negative, decisions. The notice should include the reason for the decision and the person s right to appeal by requesting a Fair Hearing with the Department of Public Welfare, including how to file an appeal and the deadline for filing an appeal. Appeals must be filed within 30 calendar days of the date on the written notice of the negative decision. The appeal should state that you request a Fair Hearing and the reasons why you disagree with the decision. For more help, refer to the Disability Rights Network of Pennsylvania s publication Medical Assistance and Medicaid Waivers: Appeals, Grievances, and Complaints at 19

20 If the negative decision involves a reduction, suspension, or termination of an existing, authorized waiver service, written notice must be provided at least 10 calendar days before the effective date of the decision. For these types of decisions, the person may continue to receive the service pending the appeal if the appeal request is submitted within 10 calendar days of the date on the written notice, before the effective date of the decision. Even if this 10-day deadline is missed, however, the person can still file an appeal within 30 days of the date on the written notice. The appeal request (Form DP-458) is included as Attachment 4 to this booklet. It is important to note that the right to a Fair Hearing does not apply to: Changes in services that are caused solely by a change in federal or state law, regulation, or policy that changes the services available under the waiver. Changes in services that are caused by a waiver amendment approved by the federal government. Services that are funded outside of the waiver and other Medical Assistance funding. 20

21 Services provided during a period of time when the person is ineligible for waiver services. A provider s unwillingness to provide waiver services to the person. CONTACT INFORMATION If you need more information or need help, please contact the intake unit of the Disability Rights Network of Pennsylvania (DRN) at (voice) or (TDD). The address is: intake@drnpa.org. The mission of the Disability Rights Network is to advance, protect, and advocate for the human, civil, and legal rights of Pennsylvanians with disabilities. Due to our limited resources, the Disability Rights Network cannot provide individual services to every person with advocacy and legal issues. The Disability Rights Network prioritizes cases that have the potential to result in widespread, systemic changes to benefit persons with disabilities. While we cannot provide assistance to everyone, we do seek to provide every individual with information and referral options. IMPORTANT: This publication is for general informational purposes only. This publication is not intended, nor should be construed, to 21

22 create an attorney-client relationship between the Disability Rights Network and any person. Nothing in this publication should be considered to be legal advice. PLEASE NOTE: For information in alternative formats or a language other than English, contact the Disability Rights Network at Ext. 400, TDD: , or drnpa-hbg@drnpa.org. The creation of this publication was funded by a grant to the Disability Rights Network under the Developmental Disabilities Assistance and Bill of Rights Act ($1.5 Million, 100%). JULY DISABILITY RIGHTS NETWORK OF PENNSYLVANIA. 22

23 This application is from the Department of Public Welfare, Office of Developmental Programs. If you need language assistance, free of charge, please call HOME AND COMMUNITY-BASED OR ICF/MR APPLICATION AND SERVICE DELIVERY PREFERENCE FORM I. CONFIRMATION OF UNDERSTANDING I,, have been informed of the following: (NAME OF INDIVIDUAL) a. That I am likely to require the level of care provided in an Intermediate Care Facility for people with Mental Retardation (ICF/MR). I understand that this is based on a preliminary determination of eligibility for ICF/MR level of care, and that the determination will be subject to formal review. b. About feasible home and community-based service alternatives to services provided in an ICF/MR c. About my right to indicate a preference for home and community-based services funded under the Waiver as an alternative to services provided in an ICF/MR and about my rights to a fair hearing before the Department of Public Welfare, Bureau of Hearings and Appeals. In declaring my preference for home and community-based services funded under the Waiver or ICF/MR, I,, understand the following: (NAME OF INDIVIDUAL) a. That I must meet Department of Public Welfare eligibility standards to receive services funded by the Waiver or ICF/MR. b. That a fair hearing and appeal will not be granted if I am appealing changes caused solely by state or federal law or regulation requiring a change in the type of services available. c. That completion of Service Delivery Preference does not guarantee services. Availability of State and Federal funds control the allocated resources for individuals to be served in the Waiver. II. DESIGNATION OF SERVICE PREFERENCE My service preference is: (initials or mark of individual, surrogate, or QMRP beside one option) Home and community-based services funded under the Waiver Services in an ICF/MR None at this time (If this option is chosen, Section III. does not apply.) III. APPLICATION Please indicate agreement and understanding of the following: (initials or mark of individual, surrogate, or QMRP beside each option) I,, hereby make application to be considered for the (NAME OF INDIVIDUAL) above indicated services for individuals with mental retardation. I,, understand that by submission of this application, (NAME OF INDIVIDUAL) I can expect a formal assessment of my need for services by the County/Administrative Entity. DP /08

24 IV. PARTICIPANT INFORMATION AND SIGNATURES A. Individual. (This section must be completed for the individual who is requesting services). INDIVIDUAL NAME: ACCESS NUMBER: CURRENT STREET ADDRESS: CITY: STATE: ZIP: TELEPHONE NUMBER: ( ) SIGNATURE: DATE: B. Surrogate. (This section must be completed when the individual s surrogate signifies the preference for Waiver or ICF/MR services on the individual s behalf.) NAME: STREET ADDRESS: CITY: STATE: ZIP: TELEPHONE NUMBER: ( ) SIGNATURE: DATE: C. Independent Qualified Mental Retardation Professional. (This section must be completed by the independent qualified mental retardation professional who is responsible to document the individual s preference for Waiver or ICF/MR services). NAME: AGENCY: STREET ADDRESS: CITY: STATE: ZIP: TELEPHONE NUMBER: ( ) SIGNATURE: DATE: D. County MH/MR Program/Administrative Entity Designee. (This section must be completed by the County MH/MR Program/Administrative Entity that offers the individual or surrogate the preference for Waiver or ICF/MR services). COUNTY DESIGNEE NAME: TITLE: AGENCY STREET ADDRESS: CITY: STATE: ZIP: TELEPHONE NUMBER: ( ) SIGNATURE: DATE: DP /08

25 INSTRUCTIONS FOR COMPLETING MA-51 MEDICAL EVALUATION NOTE: THE MA-51 IS VALID AS LONG AS IT REFLECTS THE CURRENT CONDITIONS FOR THE APPLICANT At the top of the page, mark if this is a new or updated MA-51. Questions 1-7 are self-explanatory. 8. Physician License Number. Enter the physician license number, not the Medical Assistance number. 9. Evaluation At. Enter 1-5 to describe where evaluation took place. If 5 is used, specify where evaluation was completed. 10. Signature. Applicant should sign if able. If unable, legal guardian or responsible party may sign. 11. Essential Vital Signs. Self-explanatory. 12. Medical Summary. Include any medical information you feel is important for determination of level of care. Please list patient s known allergies in this section. 13. Vacating of building. How much assistance does the patient require to vacate the building? 14. Medication Administration. Is the patient capable of being trained to self-administer medications? 15. Diagnostic Codes and Diagnoses. ICD-9-CM diagnostic codes should be put in the blocks, then written by name in the space next to the block. List diagnoses starting with primary, then secondary, and finally tertiary. There is room for any other pertinent diagnoses. 16. Professional and Technical Care Needs. Indicate care needed. Examples of other include mental health and case management. 17. Physician Orders. Orders should meet needs indicated in box 16. Medications should have diagnoses to support their use. 18. Prognosis. Indicate patient s prognosis based on current medical condition. 19. Rehabilitation Potential. Indicate based on current condition. Should be consistent with box A. Physician s Recommendation. Physician must recommend patient s level of care. If the box for other is checked, write in level of care. In order to provide assistance to a physician in the level of care recommendation, the following definitional guidelines should be considered: Nursing Facility Clinically Eligible (NFCE) Personal Care Home ICF/MR Care ICF/ORC Care Inpatient Psychiatric Care Requires health-related care and services because the physical condition necessitates care and services that can be provided in the community with Home and Community Based Services or in a Nursing Facility. Provides Personal Care services such as meals, housekeeping, & ADL assistance as needed to residents who live on their own in a residential facility. Provides health-related care to MR individuals. More care than custodial care but less than in a NF. Provides health-related care to ORC individuals. More care than custodial care but less than in a NF. Provides inpatient psychiatric services for the diagnoses and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. 20B. Complete only if Consumer is NFCE and will be served in a Nursing Facility. Check whether the patient will be eventually be discharged from facility based on current prognosis. If yes, check expected length of stay. 20C. The physician must sign and date the MA-51. A licensed physician must sign the MA-51. It may not be signed by a physician in training (a Medical Doctor in Training [MT] or an Osteopathic Doctor in Training [OT]. Questions 21 and 22 completed by the OPTIONS Unit in the Area Agency on Aging. MA 51-1/04

26 MEDICAL EVALUATION NEW UPDATED 1. MA RECIPIENT NUMBER 2. NAME OF APPLICANT (Last, first, middle initial) 3. SOCIAL SECURITY NO. 4. BIRTHDATE 5. AGE 6. SEX 7. ATTENDING PHYSICIAN 8. PHYSICIAN LICENSE NUMBER 9. EVALUATION AT (Description and code) 10. For the purpose of determining my need for TITLE XIX INPATIENT CARE, Home and Community Based Services, and if applicable, my need for a shelter deduction, I authorize the release of any 01 Hospital medical information by the physician to the County Assistance Office, State Department of Public 02 NF Welfare or its agents. 03 Personal Care/Dom Care 04 Own House/Apartment 05 Other (Specify) SIGNATURE - APPLICANT OR PERSON ACTING FOR APPLICANT DATE 11. HEIGHT WEIGHT BLOOD PRESSURE TEMPERATURE PULSE RATE CARDIAC RHYTHM 12. MEDICAL SUMMARY 13. IN EVENT OF AN EMERGENCY THE PATIENT CAN VACATE THE BUILDING 1. Independently 2. With Minimal Assistance 3. With Total Assistance 15. ICD-9-CM DIAGNOSTIC CODES 14. PATIENT IS CAPABLE OF ADMINISTERING HIS/HER OWN MEDICATIONS 1. Self 2. Under Supervision 3. No 16. PROFESSIONAL AND TECHNICAL CARE NEEDED - CHECK EACH CATEGORY THAT IS APPLICABLE Physical Therapy Special Skin Care 17. PHYSICIAN ORDERS Medications PRIMARY (Principal) SECONDARY TERTIARY Speech Therapy Parenteral Fluids Occupational Therapy Suctioning Inhalation Therapy Special Dressings Irrigations Other (Specify) 18. PROGNOSIS - CHECK ONLY ONE 19. REHABILITATION POTENTIAL - CHECK ONLY ONE 1. Stable 2. Improving 3. Deteriorating 1. Good 2. Limited 3. Poor 20A Treatment Rehabilitative and Restorative Services Therapies Diet Activities Social Services Special Procedures for Health and Safety or to Meet Objectives PHYSICIAN S RECOMMENDATION Nursing Facility Clinically Eligible Services to be provided at home or in a nursing facility To the best of my knowledge, the patient s medical condition and related needs are essentially as indicated above. I recommend that the services and care to meet these needs can be provided at the level of care indicated - check only one 20B. COMPLETE ONLY IF CONSUMER IS NURSING FACILITY CLINICALLY ELIGIBLE AND WILL BE SERVED IN A NURSING FACILITY. ON THE BASIS OF PRESENT MEDICAL FINDINGS THE PATIENT MAY EVENTUALLY RETURN HOME OR BE DISCHARGED. YES NO If Yes, Check Only One 1. Within 180 days 2. Over 180 days 20C. PHYSICIAN S SIGNATURE Personal Care Home Services provided in a Personal Care Home ICF/MR Care Services to be provided at home or in an Intermediate care facility for the mentally retarded ICF/ORC Care Services to be provided at home or in an Intermediate care facility for consumers with ORCs Inpatient Psychiatric Care Other (Please Specify) PHYSICIAN (PRINTED NAME) TELEPHONE PHYSICIAN SIGNATURE DATE FOR DEPARTMENT USE 21A. MEDICALLY ELIGIBLE Medical and other professional personnel of the Medicaid agency or its designee MUST evaluate each applicant s or recipient s need for admission by reviewing and assessing the evaluations required by regulations. Yes No Medically Appropriate 21B. Length of Stay Within 180 days Over 180 days for Waiver Services 22 Comments. Attach a separate sheet if additional comments are necessary. REVIEWER S SIGNATURE AND TITLE DATE ORIGINAL TO CAO - RETAIN PHOTOCOPY FOR YOUR FILE MA 51-1/04

27 TITLE: CERTIFICATION OF NEED FOR ICF/MR LEVEL OF CARE This application is from the Department of Public Welfare, Office of Developmental Programs. If you need language assistance, free of charge, please call FUNDING SOURCE: P/FDS WAIVER CONSOLIDATED WAIVER ICF/MR I. PURPOSE. THE PURPOSE OF THIS FORM IS TO CERTIFY WHETHER THE FOLLOWING NAMED INDIVIDUAL REQUIRES AN ICF/MR LEVEL OF CARE FOR DETERMINING ELIGIBILITY FOR HOME AND COMMUNITY SERVICES FUNDED UNDER THE CONSOLIDATED OR PERSON/FAMILY DIRECTED SUPPORT WAIVERS OR FOR ADMISSION TO AN ICF/MR. INDIVIDUAL S NAME: CURRENT ADDRESS: CITY: STATE: ZIP: DATE OF BIRTH: (MM/DD/YYYY) SOCIAL SECURITY NUMBER: TELEPHONE NUMBER: ( ) II. QUALIFIED MENTAL RETARDATION PROFESSIONAL CERTIFICATION. (COMPLETE SECTION A IF THE INDIVIDUAL MEETS ICF/MR LEVEL OF CARE CRITERIA OR SECTION B IF THE INDIVIDUAL DOES NOT.) A. I HEREBY CERTIFY THAT THIS INDIVIDUAL: 1. HAS COMPLETED ALL STANDARDIZED ASSESSMENTS AND PSYCHOLOGICAL, SOCIAL, AND MEDICAL EVALUATIONS NECESSARY TO DETERMINE NEED FOR AN ICF/MR LEVEL OF CARE IN ACCORDANCE WITH CRITERIA ESTABLISHED BY THE DEPARTMENT OF PUBLIC WELFARE, OFFICE OF DEVELOPMENTAL PROGRAMS. and 2. WILL BENEFIT FROM A PROFESSIONALLY DEVELOPED AND SUPERVISED PROGRAM OF ACTIVITIES, EXPERIENCES, OR THERAPIES THAT ARE NECESSARY FOR ASSISTING THE INDIVIDUAL TO FUNCTION AT HIS OR HER GREATEST PHYSICAL, INTELLECTUAL, SOCIAL, OR VOCATIONAL POTENTIAL OR TO PREVENT REGRESSION OR LOSS OF CURRENT OPTIMAL FUNCTIONAL STATUS. SIGNATURE DATE ( ) ADDRESS TELEPHONE NUMBER B. I HEREBY CERTIFY THAT THIS INDIVIDUAL DOES NOT REQUIRE AN ICF/MR LEVEL OF CARE BASED ON THE CRITERIA ESTABLISHED BY THE DEPARTMENT OF PUBLIC WELFARE, OFFICE OF DEVELOPMENTAL PROGRAMS. SIGNATURE ADDRESS ( ) DATE TELEPHONE NUMBER III. DETERMINATION BY THE DEPARTMENT OF PUBLIC WELFARE DESIGNEE, THE COUNTY MH/MR PROGRAM OR ADMINISTRATIVE ENTITY. THIS INDIVIDUAL IS DETERMINED TO REQUIRE AN ICF/MR LEVEL OF CARE. COUNTY MH/MR PROGRAM OR ADMINISTRATIVE ENTITY SIGNATURE DATE THIS INDIVIDUAL IS DETERMINED TO NOT REQUIRE AN ICF/MR LEVEL OF CARE. COUNTY MH/MR PROGRAM OR ADMINISTRATIVE ENTITY SIGNATURE ADDRESS DATE ( ) TELEPHONE NUMBER DP 250 2/08

28 FAIR HEARING REQUEST FORM HOME AND COMMUNITY-BASED WAIVER SERVICES FOR INDIVIDUALS WITH MENTAL RETARDATION This application is from the Department of Public Welfare, Office of Developmental Programs. If you need language assistance, free of charge, please call TO: DEPARTMENT OF PUBLIC WELFARE BUREAU OF HEARINGS AND APPEALS (THE COUNTY MH/MR PROGRAM OR ADMINISTRATIVE ENTITY WILL FORWARD THIS APPEAL TO THE APPROPRIATE BUREAU OF HEARINGS AND APPEALS OFFICE LISTED ON PAGE 3) DATE: FROM: NAME OF APPELLANT: DAY TELEPHONE NUMBER: ( ) MAILING ADDRESS: SIGNATURES: APPELLANT: WITNESS: (If APPELLANT Makes Mark) WITNESS: (If APPELLANT Makes Mark) I hereby request a Fair Hearing before the Department of Public Welfare, Bureau of Hearings and Appeals. I am requesting this appeal on behalf of the following individual who is applying for or receiving home and community-based services funded under a Medicaid Waiver for individuals with mental retardation. NAME OF INDIVIDUAL APPLYING FOR OR RECEIVING SERVICES: MEDICAID ACCESS NUMBER OF INDIVIDUAL APPLYING FOR OR RECEIVING SERVICES: I REQUEST THIS APPEAL BASED ON THE FOLLOWING ACTIONS: I REQUEST THE FOLLOWING REMEDIES TO RESOLVE THIS APPEAL (EXPLAIN): NAME OF INDIVIDUAL S SURROGATE (If Applicable): MAILING ADDRESS: DAY TELEPHONE NUMBER: ( ) RELATIONSHIP TO INDIVIDUAL: SIGNATURE OF INDIVIDUAL S SURROGATE (If Applicable): PLEASE INDICATE WHICH TYPE OF HEARING YOU ARE REQUESTING: (See Instructions For More Information) TELEPHONE HEARING (Appellant and Administrative Entity or County Program will be at Different Telephone Numbers) Appellant Number ( ) TELEPHONE HEARING (Appellant and the Administrative Entity or County Program will be at the same telephone number) FACE-TO-FACE HEARING (All parties involved in the hearing are at one location.) FACE-TO-FACE HEARING (Appellant and local office of Bureau of Hearings and Appeals will be at one location for the hearing. The Administrative Entity or County Program will participate in the hearing via telephone. This type of telephone hearing is expected to be an available option for individuals or surrogates in April 2008 or soon thereafter.) Please indicate below if information is needed in a language other than English and specify the language. Indicate any communication assistance (interpreter, device, sign language) or other accommodation that you require at the hearing: DP 458 3/08

29 INSTRUCTIONS AND NOTICE OF RIGHT TO FAIR HEARING HOME AND COMMUNITY-BASED WAIVER SERVICES OR ICF/MR SERVICES FOR INDIVIDUALS WITH MENTAL RETARDATION If you are applying for Waiver services or services in an Intermediate Care Facility for the Mentally Retarded (ICF/MR), or if you object to an action taken affecting your claim for Waiver services, you have the right to a county or local pre-hearing conference with the County Program or Administrative Entity and a Fair Hearing before the Department of Public Welfare, Bureau of Hearings and Appeals, if: The individual with mental retardation who is determined likely to meet an ICF/MR level of care and is enrolled in Medical Assistance or surrogate 1 is not given the opportunity to express a service delivery preference for either Waiverfunded or ICF/MR services. The individual or surrogate is denied the individual s preference of Waiverfunded or ICF/MR services. Based on a referral from the Administrative Entity (AE) or County Program, a Qualified Mental Retardation Professional (QMRP) determines that the individual does not require an ICF/MR level of care as a result of the level of care determination or re-determination process and eligibility for services is denied or terminated. The individual or surrogate is denied Waiver-funded service(s) of the individual s choice, including the amount, duration, and scope of service(s). The individual or surrogate is denied the individual s choice of willing and qualified Waiver provider(s). A decision or an action is taken to refuse, suspend, reduce, or terminate a Waiver-funded service authorized on the individual s ISP. 1 Not everyone can make legally binding decisions for themselves. This would include minor children and some adults who have substantial mental impairment. In these instances, a substitute decision-maker may be identified under State law. Substitute decision-makers have various legal titles, but for the purposes of this bulletin, they will be referred to as surrogates. Surrogates include the following: Parents of children under 18 years of age under the common law and 35 P.S Legal custodian of a minor as provided in 42 Pa.C.S Health care agents and representatives for adults as provided in 20 Pa.C.S. Ch. 54. Guardians of various kinds as provided in 20 Pa.C.S. Ch. 55 (as limited by 20 Pa.C.S. 5521(f)). Holders of powers of attorney of various kinds as provided in 20 Pa.C.S. Ch. 56. Guardians of persons by operation of law in 50 P.S. 4417(c). Any of these would be considered legal representatives as the Center for Medicaid and Medicare Services uses that phrase. Please see Application for a 1915(c) Home and Community-Based Waiver: Instructions, Technical Guide and Review Criteria ( DP 458 3/08

30 County or Local Pre-hearing Conference: If you choose to have a county or local pre-hearing conference with your County MH/MR Program or Administrative Entity Designee, you may do so without forfeiting your appeal rights if you contact the County MH/MR Program or Administrative Entity Designee within 13 DAYS of your notification of the decision or action that is to be taken that you want to appeal. A county or local pre-hearing conference is optional for you. Appeal to Bureau of Hearings and Appeals: You have the right to file an appeal directly with the Department of Public Welfare, Bureau of Hearings and Appeals. You have a right to appeal any action or failure to act and to have a hearing if you are dissatisfied with any decision to refuse, suspend, reduce, or terminate Medicaid Home and Community-Based Waiver services. Form DP 458 (attached) must be used to file your appeal with the Bureau of Hearings and Appeals. Appeal Timeframe for the Continuation of Waiver Services: If you are appealing a change [that is, reduction, termination, or suspension] in Waiver-funded services that were approved and authorized in your individual support plan, are already being provided to you and you want those Waiver services to continue without change during the appeal process, you must file the appeal within 13 DAYS of the Administrative Entity s notification of the decision to change your Waiver services. Form DP 458 must be completed and sent to your Administrative Entity within the 13 day period. They will forward your appeal to the Bureau of Hearings and Appeals. Please note that services will NOT continue if the action to reduce, terminate, or suspend services is based solely on a change in Federal or State law or regulations that requires an automatic change in the amount and type of services available under the Waiver. Appeal Timeframe where the Continuation of Waiver Services is not Involved: Form DP 458 must be completed within 30 days of your notification of the decision or action that is to be taken that you want to appeal. The completed Form DP 458 must be sent to your County MH/MR Program or Administrative Entity. They will forward your appeal to the Bureau of Hearings and Appeals. Type of Hearing Requested: The Bureau of Hearings and Appeals will conduct a hearing for you over the telephone or face-to-face. Please check the appropriate box to indicate the type of hearing you want to occur. Telephone Hearings: If you do not have a telephone that can be used to conduct this hearing, you may use a telephone at the County MH/MR Program or Administrative Entity office, or the telephone of a friend, relative, or neighbor. Please indicate the telephone number where all parties may be reached to conduct the hearing. Face-to-face Hearings: This type of hearing is held in one of the following locations: Erie, Harrisburg, Philadelphia, Pittsburgh, Plymouth, or Reading. More information on the exact location of the hearing site will be sent to you and the AE or County Program if you request a face-to-face hearing. In the near future, a second option will be given to the appellant for face-to-face hearings in which the appellant and the Administrative Law Judge will be at the Bureau of Hearings and Appeals and the AE or County Program will participate via telephone. Accommodations Needed by You at the Hearing: If you need accommodations to attend or participate in the hearing, please indicate the specific accommodations required (language interpreter, communication device, etc.) on Form DP 458 when you file your appeal. You may supply your own interpreter or bring your own communication device, etc., to the hearing. However, if you cannot supply your own accommodation, all requests for assistance in obtaining an accommodation must be made in advance of the hearing. Please contact your County MH/MR Program or Administrative Entity Designee or the Bureau of Hearings and Appeals to request assistance. Contact Information: If you want a county or local pre-hearing conference to discuss your concerns, or if you need assistance to file an appeal, please contact the County MH/MR Program or Administrative Entity Designee listed below: NAME: ADDRESS: ADDRESS: TELEPHONE NUMBER: ( ) DP 458 3/08

31 Your County MH/MR Program or Administrative Entity Designee will photocopy Form DP 458 and send a copy to you and the appropriate Regional Office and Central Office of Developmental Programs. The Office of Developmental Programs Regional and Central Office addresses are as follows: SOUTHEAST REGIONAL OFFICE OF DEVELOPMENTAL PROGRAMS 1400 SPRING GARDEN STREET PHILADELPHIA, PA NORTHEAST REGIONAL OFFICE OF DEVELOPMENTAL PROGRAMS 100 LACKAWANNA AVENUE SCRANTON, PA CENTRAL REGIONAL OFFICE OF DEVELOPMENTAL PROGRAMS ROOM 430, WILLOW OAK BLDG. HARRISBURG STATE HOSPITAL HARRISBURG, PA WESTERN REGIONAL OFFICE OF DEVELOPMENTAL PROGRAMS 300 LIBERTY AVENUE PITTSBURGH, PA OFFICE OF DEVELOPMENTAL PROGRAMS ROOM 512, HEALTH AND WELFARE BUILDING P. O. BOX 2675 HARRISBURG, PA The Department of Public Welfare, Bureau of Hearings and Appeals contact information is provided below: BUREAU OF HEARINGS AND APPEALS HEADQUARTERS and BUREAU OF HEARINGS AND APPEALS CENTRAL REGION Bureau of Hearings and Appeals 2330 Vartan Way, Second Floor Harrisburg, Pa Phone: (717) BUREAU OF HEARINGS AND APPEALS NORTHEAST REGION Federal Hearings and Appeals 117 West Main Street Plymouth, Pa Phone: 1(800) BUREAU OF HEARINGS AND APPEALS SOUTHEAST REGION Bureau of Hearings and Appeals 1400 Spring Garden Street, Room 1608 Philadelphia, Pa Phone: (215) BUREAU OF HEARINGS AND APPEALS WESTERN REGION Bureau of Hearings and Appeals Two Gateway Center, Suite Stanwix Street Pittsburgh, Pa Phone: (412) Representation at the Hearing: You have the right to represent yourself at the hearing. You or your surrogate may present the reasons why you disagree with the action or decision to the Bureau of Hearings and Appeals Administrative Law Judge presiding over the hearing. You or your surrogate may present evidence and witnesses to support your case. You have the right to have someone else represent you. If you need Legal Counsel, a list of Legal Aid Offices is attached. If you request additional help, the County MH/MR Program or Administrative Entity Designee will refer you to advocacy organizations in your community. DP 458 3/08