STATE AGENCY WAIVER PROGRAMS: COMMUNITY LONG TERM CARE. Jocelin Dawson, SCDHHS Lori Manos, SCDDSN Susan Bolt, SCDHHS

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1 STATE AGENCY WAIVER PROGRAMS: COMMUNITY LONG TERM CARE Jocelin Dawson, SCDHHS Lori Manos, SCDDSN Susan Bolt, SCDHHS Presentation is current as of November 26, 2013

2 UPDATES ON MEDICAID LONG TERM CARE PROGRAMS Susan Bolt

3 Susan Bolt Department of Health and Human Services Division of Community Long Term Care

4 OBJECTIVES OF PRESENTATION Provide an overview of Medicaid Home and Community Based waivers Provide on update on the CLTC program and services

5 MEDICAID HCBS WAIVERS Home & community based waivers are alternatives to institutional care Require special permission from the federal government & must be renewed every 5 years Must be cost effective All have the goal of reducing institutional care and do so by having waiver participants work with a case manager to customize services to meet individual needs.

6 TO QUALIFY: Must be Medicaid eligible, which includes resource, income and categorical restrictions Be determined to be medically in need of institutional care (LOC)

7 WAIVER SERVICES Case Manager will work with participant and family/caretakers to develop a plan of care and choose services that will best meet their needs. Services are provided by enrolled Medicaid providers. Consumers have freedom of choice in the selection of providers.

8 COMMUNITY LONG TERM CARE MISSION STATEMENT Our mission is to provide a cost effective alternative to institutional placement for eligible clients with long term care needs, allowing them to remain in a community environment if they choose.

9 COMMUNITY LONG TERM CARE Central office and 13 regional offices Provides day to day operations for 3 waivers- Community Choices, HIV and Ventilators waivers Certifies LOC and PASRR (preadmission screening and resident review) for Medicaidsponsored nursing facility placement Administers one State Plan program-children s Personal Care Aide (CPCA) Determines nursing facility LOC for applicants for HASCI waiver, Home Again and TEFRA.

10 COMMUNITY CHOICES WAIVER Must be 18 years or older Must meet the nursing facility LOC Must be Medicaid eligible CLTC is currently serving 12,712 persons statewide under this waiver. Currently there are over 2330 persons on a statewide waiting list for this program.

11 SERVICES- COMMUNITY CHOICES Case Management Personal Care I and II Attendant Companion Adult Day Health Care Respite in a NF or CRCF Meals Environmental Modification/Enhanced EM Nutritional Supplements Nursing Home Transition service Personal Emergency Response System (PERS) Telemonitoring Adult Care Home

12 HIV WAIVER Serves all ages Must meet the hospital LOC Must be HIV+ or diagnosed with AIDS Must have at least two HIV related conditions Must be certified At Risk for hospitalization by an MD, NP or PA. Must have (or have a history of) a CD4 count below 500. Must be Medicaid eligible Currently serves 850 persons Currently there is a waiting list of 45.

13 SERVICES- HIV Case Management Personal Care I and II Attendant Meals Private Duty Nursing Two Extra Prescription Drugs Nutritional Supplements Environmental Modification & Enhanced EM Companion

14 VENTILATOR WAIVER Must be 21 years of age or older Must meet the nursing facility LOC and be dependent on a life sustaining ventilator a minimum of 6 hours per day Must be Medicaid eligible Currently serving 42 persons Currently there is no waiting list

15 SERVICES- VENTILATOR Personal Care I and II Attendant Respite in an institution In-home Respite Environmental Modification & Enhanced EM Private Duty Nursing Two Extra Prescription Drugs Specialized Medical Equipment and Supplies Nutritional Supplements Personal Emergency Response System

16 STATE PLAN PROGRAMS Currently serving 848 in the CPCA program Children s Personal Care Aide (CPCA) Must be under age 21 Must be currently eligible for Medicaid Must meet medical necessity criteria Required functional deficit and MD must state there is a service need

17 PROCESS FOR CLTC Referral is made to CLTC Centralized Intake Phone: Fax: Electronic Referral: https://phoenix.cltc.state.sc.us/initial_electronic_referrals/new If person meets intake criteria, the case will be assigned to a nurse For persons applying for the Community Choices or HIV waiver, a telephone assessment will be conducted by an intake nurse. The results of this assessment will determine the placement on the waiting list If person does not already have Medicaid or require resource verification, he/she will be directed to make a financial determination application with Eligibility

18 PROCESS (CONT.) A nurse will conduct a home visit to complete an assessment and determine the LOC or medical necessity. For CPCA, the applicant may be enrolled in the program once medical necessity and Medicaid eligibility is established For waivers, once the applicant has been determined to meet the LOC and financial eligibility has been met, he/she is ready to be enrolled when a slot is available. Once enrolled into the program, a case manager will be assigned. He/she develops a plan of care and authorizes services.

19 QUESTIONS?

20 SOUTH CAROLINA DEPARTMENT OF DISABILITIES AND SPECIAL NEEDS WAIVER PROGRAMS Lori Manos, Director Service Coordination and Planning

21 WHAT IS A HOME AND COMMUNITY-BASED WAIVER? Home & community based waivers are alternatives to institutional care Require special permission from the federal government & must be renewed every 5 years Must be cost effective

22 TO QUALIFY: Must be Medicaid eligible, which includes resource, income and categorical restrictions Be determined to be in need of institutional care (Level of Care)

23 WHAT WAIVERS ARE OFFERED BY DDSN? Intellectual Disabilities/Related Disabilities Waiver (formerly known as the MR/RD Waiver) Head and Spinal Cord Injury Waiver Pervasive Developmental Disorder Waiver Community Supports Waiver

24 WHO IS ELIGIBLE FOR THE ID/RD WAIVER? People who: are diagnosed with an intellectual disability or a related disability choose to receive services in his/her home and/or community rather than in an ICF/ID require the degree of care that would be provided in an ICF/ID (meet ICF/ID Level of Care) have assessed needs that can be met by provision of services funded by the waiver are eligible for Medicaid are awarded an ID/RD Waiver slot

25 ID/RD SLOT AWARD/WAITING LIST Applicants who meet the Critical Criteria will be placed on the Critical ID/RD Wavier waiting list and will be enrolled in the ID/RD Waiver based on the earliest referral date contingent upon funding. Critical Criteria: An applicant will be assigned to the Critical ID/RD Waiver wailing list when he/she requires a service available thru the ID/RD Waiver which, if not provided, will likely result in serious and imminent harm; OR Has an immediate need for direct care or supervision, which directly relates to the person s disability; OR

26 ID/RD SLOT AWARD/WAITING LIST (CONT) Has recently lost a primary caregiver or is at imminent risk of losing primary caregiver; OR Is ready for or has recently been discharged from a hospital and needs services immediately to prevent readmission. o Applicants who do not meet the critical Criteria will be placed on the Regular ID/RD Waiver waiting list and will be enrolled in the ID/RD Waiver based on earliest referral date. o Applicants on the Regular ID/RD Waiver waiting list will be processed for waiver enrollment when there are no current applicants on the Critical ID/RD Waiver waiting list contingent upon available funding.

27 ID/RD WAIVER SERVICES Residential Habilitation (CTHs and SLPs) Day Services (Day Activity, Community Services, Employment Services, Support Center, and Career Preparation) Adult Day Health Care, Adult Day Health Care Nursing, and Adult Day Health Care Transportation PERS (Personal Emergency Response System)

28 ID/RD WAIVER SERVICES (CONT.) Adult Companion Services Personal Care Services Respite Adult Attendant Care Services Specialized Supplies, Medical Equipment, and Assistive Technology Psychological Services Behavior Support Services Nursing Services

29 ID/RD WAIVER SERVICES (CONT.) Adult Dental Services Adult Vision Services Prescribed Drugs Audiology Services Environmental Modifications Private Vehicle Modifications Incontinence Supplies

30 WHO IS ELIGIBLE FOR THE HEAD AND SPINAL CORD INJURY WAIVER? People who: Are Medicaid eligible; Meet Level of Care for ICF/ID or Nursing Facility (NF); Are less than 65 years old at the time of enrollment Meet diagnostic criteria of traumatic brain injury, spinal cord injury or both or a similar disability not associated with the process of a progressive degenerative illness, disease, dementia or a neurological disorder related to aging, regardless of the age of onset. Where the individual: Has urgent circumstances affecting his/her health or functional status; and

31 WHO IS ELIGIBLE FOR THE HEAD AND SPINAL CORD INJURY WAIVER? (CONT) Is dependent on others to provide or assist with critical health needs, basic activities of daily living or requires daily monitoring or supervision in order to avoid institutionalization; and, Needs services not otherwise available within existing community resources, including family, private means and other agencies/programs, or for whom current resources are inadequate to meet the basic needs of the individual, which would allow them to remain in the community.

32 HASCI SLOT AWARD/WAITING LIST An individual who meets criteria for Urgent Priority will be allocated the first available Waiver slot. If more than on individual is in Urgent Priority status, individuals will be allocated Waiver slots based on date and referral. Individuals who do not meet criteria for Urgent Priority will be placed in Regular status and will be allocated Waiver slots based on earliest date of referral if there are no current applicants with Urgent Priority.

33 HASCI WAIVER SERVICES Prescribed Drugs Residential Habilitation Day Activity Career Preparation Employment Services Psychological Services Personal Emergency Response Systems (PERS) Speech and Hearing Services Respite Care Supplies, Equipment and Assistive Technology Attendant Care/Personal Assistance

34 HASCI WAIVER SERVICES (CONT.) Physical Therapy Occupational Therapy Medicaid Waiver Nursing Services Private Vehicle Modifications Environmental Modifications Behavioral Support Health Education for Consumer-Directed Care Peer Guidance for Consumer-Directed Care Incontinence Supplies

35 WHO IS ELIGIBLE FOR THE PERVASIVE DEVELOPMENTAL DISORDER (PDD)WAIVER? Children who: are ages 3 through 10 years. are diagnosed with a ASD (Autism Spectrum Disorder) by age eight years. meet Medicaid financial criteria or provide documentation of financial ineligibility for Medicaid. require the degree of care that would be provided in an ICF/ID (meet ICF/ID Level of Care choose to receive services in his/her home and/or community rather than in an ICF/ID are awarded a PDD Waiver slot

36 PDD SLOT AWARD/WAITING LIST Applicants are awarded slots based on earliest application/referral date.

37 PDD WAIVER SERVICES Case Management Early Intensive Behavioral Intervention 1. Assessment 2. Plan Implementation 3. Program Development & Training 4. Lead Therapy 5. Line Therapy

38 WHO IS ELIGIBLE FOR THE COMMUNITY SUPPORTS WAIVER? People who: are diagnosed with an intellectual disability or a related disability choose to receive services in his/her home and/or community rather than in an ICF/ID require the degree of care that would be provided in an ICF/ID (meet ICF/ID level of care) have needs that can be met by provision of services funded by the waiver and whose safety/well being can be assured when services are limited to $10,986 per fiscal year are eligible for Medicaid are awarded for CS Waiver slot

39 CS WAIVER SLOT AWARD/WAITING LIST Applicants are awarded slots based on earliest referral/application date.

40 COMMUNITY SUPPORTS WAIVER SERVICES Adult Day Health Care/Nursing/Transportation Personal Care Services Respite Behavior Support Services Day Activity Career Preparation Community Services Employment Services Support Center Services

41 COMMUNITY SUPPORTS WAIVER SERVICES (CONT.) In-Home Supports Environmental Modifications Private Vehicle Modifications Assistive Technology and Appliances Incontinence Supplies

42 HOW TO APPLY FOR DDSN WAIVERS Request the waiver through Your service coordinator/early interventionist Your SC/EI provider Your local Disabilities and Special Needs Board, or Call DDSN s toll free number You may apply for more than one waiver Once your name is placed on a waiting list, you will be notified in writing by DDSN.

43 QUESTIONS?

44 MEDICALLY COMPLEX CHILDREN S WAIVER Jocelin T. Dawson

45 MEDICALLY COMPLEX CHILDREN S (MCC) WAIVER The Medically Complex Children s (MCC) Waiver replaced the Medically Fragile Children s Program (MFCP) effective 1/1/09. The MCC waiver is available statewide to serve children from birth to age 18. The MCC waiver provides care coordination by Registered Nurse s (RN) with 3 years of pediatric services.

46 MEDICALLY COMPLEX CHILDREN S WAIVER, CONTINUED The MCC waiver will serve children who meet: Nursing Facility (NF) or Intermediate Care Facility- Intellectual Disability (ICF-ID) level of care Have a chronic physical/health condition that is expected to last longer than 12 months Medical eligibility criteria which identifies the child as being dependent upon: Medications, Hospitalizations, Skilled Nursing Services, Ancillary Services and Specialists.

47 MEDICALLY COMPLEX CHILDREN S (MCC) WAIVER SERVICES OFFERED The services offered in the MCC waiver include : 1) Care Coordination 2) Pediatric Medical Day Care 3) Respite

48 INCONTINENCE SUPPLIES As of January 1, 2013, Incontinence Supplies is no longer an MCC waiver services. It is now a State Plan service. Referrals are now taken through Centralized Intake if not in a waiver. Centralized Intake # The Medical Criteria: The following criteria must be met for beneficiaries to receive incontinence supplies under the South Carolina Medicaid Plan Home Health benefit: 1. Must be a Medicaid beneficiary age 4 or above. 2. Inability to control bowel or bladder function. This must be confirmed by a physician in writing.

49 INCONTINENCE SUPPLIES 3. An order must be obtained from the PCP that the beneficiary is incontinent. The Physician Certification of Incontinence DHHS Form 168IS must be completed by the primary physician initially and every 12 months at a minimum for waiver beneficiaries. Certifications for non-waiver beneficiaries are effective for timeframes of three months, six months, nine months or 12 months and are based on the selection chosen by the physician. 4. The assessment conducted by the SCDHHS nurse will determine the frequency of incontinence and this determination will establish the amount of supplies authorized

50 MEDICALLY COMPLEX CHILDREN S (MCC) WAIVER, CONTINUED Referrals for the MCC waiver can be initiated by a Parent, Physician, BabyNet, Early Intervention (EI), Hospital discharge planner or others. Priority is given to applicant (s) who are either: In foster care, or In need of skilled private duty nursing services, or in the hospital awaiting discharge.

51 MEDICAL ELIGIBILITY ASSESSMENT (MEA) CRITERIA Medications Number of medication(s) Frequency of medication Route of medication Hospitalizations Number of Hospital Stay Number of ER visits Nursing care Respiratory Monitoring Neurological Monitoring Functional Monitoring Skin care needs Other Nursing needs Specialists Number of specialists Number of visits Therapies Number of therapies Frequency of therapies NOTE: The MEA Tool is used on a quarterly basis to track a child s progress.

52 CARE COORDINATION SERVICE Coordination of chronic and preventive medical management. Conduct health related assessments ( Health Risk developmental or disease) Ensure best practice guidelines are followed for acute illness, prevention and chronic care management.

53 CARE COORDINATION SERVICE, CONTINUED Coordinate specialty care services with other providers. Review and interpret subspecialty recommendations. Provide continuity of care for inpatient and outpatient problems 24 hours a day. Create and maintain an Emergency Medical Plan to be used by EMS personnel and caregivers at home.

54 CARE COORDINATION SERVICES, CONTINUED Coordinate medical services, allied health (OT, PT, Speech Therapy) and other Early Periodic, Screening, and Developmental Test (EPSDT) services. Facilitate participation of health related team members in care planning. Provide family training regarding medical care in the home.

55 CARE COORDINATION SERVICES, CONTINUED Conduct family training to address disease management and when appropriate the child s management of their medical condition. Monthly physician evaluations to reassess the plan of care and ensure new needs are addressed through the care coordination process.

56

57 MEDICALLY COMPLEX CHILDREN S WAIVER Department of Health & Human Services Division of Community Options Medically Complex Children s Waiver 1801 Main Street, Suite 909 Columbia, South Carolina phone fax Referrals can be made via fax, or phone Jocelin T. Dawson Waiver Administrator

58 QUESTIONS?

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