Long Term Care Division

1. Long Term Care Division Alabama Medicaid Agency Long Term Care Division Outreach and Education Unit February 2004

2. P R E S E N T SAn Overview OfHome and Community Based Waiver Services

3. What Is A Waiver? • Under 1915(c) Waiver authority, states can provide services not usually covered by the Medicaid program, as long as these services are required to keep a person from being institutionalized.

4. Home and Community Based Service (HCBS) Waivers • In 1981, Congress authorized the waiver of certain federal requirements to enable a state to provide home and community based services (other than room and board) to individuals who would otherwise require SNF, ICF, or ICF/MR services reimbursable by Medicaid.

5. HCBS Waivers • The waiver programs are called 1915(c) waivers, named after the section of the Social Security Act that authorized them. • Under 1915(c) waiver authority, states can provide services not usually covered by the Medicaid program, as long as these services are required to keep a person from being institutionalized.

6. HCBS Waivers • Under HCBS Waiver programs, both the comparability and state wideness requirements may be waived to enable states to target distinct groups of recipients. • HCBS Waiver Services can be provided only as a vehicle to provide an alternative to institutional care.

7. HCBS Waivers • Initial waivers are approved for three (3) years and renewed every five (5) years thereafter.

8. What are waiver “slots”? • Each waiver program is allotted a certain number of “slots” to be filled by clients approved to receive waiver services within a waiver year.

9. Distribution of Slots • Waiver slot distribution will be determined by the Alabama Medicaid Agency.

10. Types of waiver slots • An active waiver slot is one in which a person is actively receiving waiver services and is not in a nursing facility. • A pending waiver slot is one that is pending approval for a person to receive waiver services.

11. Types of waiver slots • A filled waiver slot is one which has a person currently receiving waiver services or who has been receiving waiver services, but had subsequent placement in a nursing facility has moved or has requested termination from the waiver during the waiver year.

12. More about waiver slots • A filled slot cannot be refilled by another individual within the same waiver year that the vacancy occurred, however, the same individual who previously left the slot may fill the slot.

13. When can a waiver slot be refilled? • Although a waiver slot cannot be refilled within the same waiver year, available slots may be refilled in subsequent waiver years.

14. Transfer of Waiver Slots • If a client transfers from one waiver to another within the same waiver year, the slot is considered filled and therefore may not be refilled by a different individual.

15. Elderly and Disabled (E&D) Waiver Mental Retardation/ Developmentally Disability (MRDD) Waiver Living at Home Waiver State of Alabama Independent Living (SAIL) Waiver Specialty Care Assisted Living Facility (SCALF) Waiver Technology Assisted (TA) Waiver for Adults HIV/AIDS Waiver Medicaid Approved Home and Community Based Waivers

16. Administering State Agency • The Alabama Medicaid Agency has administrative authority over the Home and Community Based Waivers.

17. Responsibilities of the Alabama Medicaid Agency • The Operating Agency adheres to all federal guidelines described in the approved waiver document; • The health and welfare of the client is protected; • The client has free choice of providers and waiver service workers; • All direct service providers meet the qualifications as outlined in the approved waiver document; and • The client is aware of their right to express concerns regarding service provision and/or direct service provider.

18. Operating State Agencies • State agencies are charged with the responsibility of operating the home and community based waiver programs and vary by each particular waiver.

19. Responsibilities of the Operating Agencies • Manage the program by focusing on improving care for the client; • Protect the health and welfare of the client; • Give the client free choice of providers and waiver service workers; • Make sure all direct service providers meet the qualifications as outlined in the approved waiver document.

20. Elderly and Disabled(E&D) Waiver

21. E & D Waiver • Assists elderly and/or disabled individuals to live in the community who would otherwise require nursing facility care

22. E & D Waiver • Operating Agencies: ▪ Alabama Department of Public Health ▪ Alabama Department of Senior Services • No age requirement • 7500 waiver slots

23. Financial Eligibility Criteria • Individuals receiving SSI and/or State Supplementation; • Widows and Widowers under age 60; • Widows and Widowers age 60 – 64;

24. Financial Eligibility Criteria…continued • Adult children who lose supplemental security income benefits upon entitlement to the child’s insurance benefits based on disability; • Individuals who would be eligible for Medicaid in an institution because income from either parents or a spouse is not deemed available to them (referred to as institutional deeming).

25. Medical Criteria • Must meet current level of care admissions criteria for nursing facility care

26. Covered Services • Case Management • Homemaker Services • Personal Care Services • Adult Day Health Services • Respite Care (Skilled and Unskilled) • Adult Companion Services • Home Delivered Meals

27. Mental RetardationDevelopmentally Disability (MRDD) Waiver

28. MRDD Waiver • Provides Home and Community Based Services to Medicaid eligible individuals who would otherwise require the level of care available in an Intermediate Care Facility for the Mentally Retarded (ICF/MR)

29. MRDD Waiver • Operating Agency • Alabama Department of Mental Health and Mental Retardation • No age requirement • 5200 waiver slots

30. Financial Eligibility Criteria • Social Security Income (SSI) – protected groups deemed to be recipients of SSI • TANF - (Temporary Assistance to Needy Families) low income families with children • Special home and community based optional categorically needy groups whose income is not greater than 300% of the SSI federal benefit rate

31. Medical Eligibility • Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded)

32. Characteristics of Persons Requiring ICF/MR Care • Intermediate care services for the mentally retarded are those services which are needed because of the severe, chronic nature of the mental impairment that results in substantial functional limitations in three or more of the following areas of life activities:

33. Characteristics of Persons Requiring ICF/MR Care…continued • Self Care • Receptive and expressive language • Learning • Mobility • Self Direction • Capacity for independent living

34. Residential Habilitation Training Residential Habilitation – Other Living Arrangement Day Habilitation Prevocational Services Supported Employment Occupational Therapy Services Speech and Language Therapy Physical Therapy Behavior Management Companion Services Respite Care Personal Care Environmental Accessibility Adaptations Medical Supplies Skilled Nursing Assistive Technology Covered Services

35. Living At Home Waiver

36. Living At Home Waiver • Provides Home and Community Based Services to Medicaid eligible individuals who would otherwise require the level of care available in an Intermediate Care Facility for the Mentally Retarded

37. Living At Home Waiver • Operating Agency ▪ Alabama Department of Mental Health and Mental Retardation • 3 years of age and older • Waiver Slots • Year 1 – 204 • Year 2 – 326 • Year 3 - 449

38. Financial Eligibility Criteria • Social Security Income (SSI) - protected groups deemed to be recipients of SSI

39. Medical Criteria • Must meet current level of care admissions criteria for an ICF/MR (Intermediate Care Facility for the Mentally Retarded)

40. Residential Habilitation Training Day Habilitation Prevocational Services Supported Employment Occupational Therapy Speech and Language Therapy Physical Therapy Behavior Therapy Respite Care Personal Care Services Personal Care Transportation Environmental Accessibility Adaptations Specialized Medical Equipment and Supplies Skilled Nursing Community Specialist Crisis Intervention Covered Services

41. State of Alabama Independent Living (SAIL) Waiver (formerly Homebound Waiver)

42. SAIL Waiver • Serves disabled adults with specific medical diagnoses who are at risk of being institutionalized in a nursing home

43. SAIL Waiver • Operating Agency ▪ Alabama Department of Rehabilitation Services • 18 years of age or older • 550 waiver slots

44. Financial Eligibility Criteria • Social Security Income (SSI) -– protected groups deemed to be recipients of SSI • TANF-(Temporary Assistance to Needy Families) low income families with children • Special home and community based optional categorically needy groups whose income is not greater than 300% of the SSI federal benefit rate

45. Medical Criteria • Must meet current level of care admissions criteria for nursing facility care

46. Services are provided to, but not limited to, persons with a diagnosis of: • Quadriplegia • Traumatic Brain Injury • Amyotrophic Lateral Sclerosis • Multiple Sclerosis • Spinal Muscular Atrophy • Severe Cerebral Palsy • Stroke • Other substantial neurological impairments, severely debilitating diseases, or rare genetic diseases

47. Covered Services • Case Management Services • Personal Care Services • Personal Attendant Services • Environmental Accessibility Adaptations • Personal Emergency Response System • Medical Supplies • Assistive Technology • Evaluation for Assistive Technology • Assistive Technology Repairs

48. Specialty Care Assisted Living Facility (SCALF) Waiver SCALF Waiver

49. The SCALF Waiver has been approved, but not yet implemented

50. SCALF Waiver • The SCALF Waiver is designed to address the needs of individuals with a diagnosis of Alzheimer’s and/or Dementia who meet the nursing facility level of care criteria.