Medicaid Waiver

What Is A Waiver and How does Delicate Home Health Care help you?

In the state of Virginia, Medicaid waivers are a way for Medicaid resources to be used to support people to receive services in their homes and communities instead of going into institutions (homes) where it costs the State of Virginia more money to care for the individual There are seven Medicaid waivers in the state of Virginia. Delicate Home Health Care focuses on the three Waivers listed below for your loved one to stay at their home and get care.

How Delicate Home Health Care Partners With You

In the State of Virginia Waiver Programs, there are 2 types of service models – The Consumer Directed and the Agency Directed.

Consumer Directed

Consumer Directed services, sometimes called “self-directed” or “participant-directed” services, further empower individuals with disabilities and older adults to have greater control over the services they receive. They can assess their own needs, determine how and by whom these needs should be met, and monitor the quality of services they receive.

The underlying principle of Consumer Directed services is that individuals with disabilities and older adults have the primary authority to make choices that work best for them, regardless of the nature or extent of their disability or the source of payment for services.

Consumer Directed have 4 main actors: Employer On Record (EOR), Attendant (the Caregiver), Service Facilitator (SF) and the Fiscal/Employer Agen(FEA)

Employer On Record

To receive Consumer Directed Services in the State of Virginia, the individual (the patient) or a designated representative (Husband, Daughter Son, Family member etc.) must act as what they call Employer of Record (EOR). An EOR is the person who performs the functions of the employer – in other word, the person (EOR) must be able to hire an Attendant (the care giver), sign the time sheet, make sure the Plan Of Care is followed. Must have a backup incase attendant does not come to work

Attendant

An attendant is the person hired by the EOR to provide services directly to the individual. An Attendant is sometimes referred to as an “aide” or “assistant,” An Attendant personal care, respite care, and companion care

Fiscal/Employer Agent (F/EA)

Fiscal/Employer Agent (F/EA) is a company or group that provides services for individuals choosing consumer-directed services. The company would conduct activities include conducting criminal background checks on potential attendants; processing hiring paperwork for attendants; receiving, verifying and processing attendant time sheets; maintaining attendant payroll records; and processing all tax forms and payments for the employer and the attendant that are required by the Internal Revenue Service

Service Facilitator

A Services Facilitator is a Medicaid-enrolled provider who supports the Consumer Directed Services recipient and their families. Delicate Home Health Care is a Service Facilitator. We hold your hand and work with you all the way. We make it happen

Delicate Home Health Care provides

• Will train you (EOR) and provide you a reference manual and explain the duties and responsibilities of the EOR. We will explain to you the individual rights and responsibilities
• We manage the Fiscal Agent Services Request for you. We main and document all records and assure no delay in your services
• We provide initial compressive visit – we work with the care coordinator to determine if a comprehensive or reassessment is appropriate
• We develop Plans(s) for the CD Services

Consumer Directed expects you to me responsible for you care or care of your loved once. Delicate Home Health Care is there as your Facilitator to assure your incompliance with DMAS and to aid you succeeded.

Agency Directed

Unlike Consumer Directed (CD), the Agency Directed (AD) services hires, train, schedules, manages, monitor and dismisses employees. The CD models places the responsibilities on the Employer on Record for direct hiring, training, scheduling, managing and dismissing employees.

Delicate Home Health Care is an Agency Directed provider. We support you from the start; we work with you fill-out the Waiver qualification form and navigate the Medicaid Bureaucracy with you. We use our experience and the know-how to point you to the right department and the right people.

On our website is a tool that helps you determine your Weaver qualification.

Delicate Home Health Care Provides the following services as Agency Directed

• Our Registered Nurse (RN) perform the assessment and completes and the DMAS forms to obtain the Authorization.
• We file and maintain all the necessary document for approval of your Plan Of Care (POC)
• We will provide you with the best Care Giver that fits your needs. In Delicate Home Health Care, you have the right to access and approve you care giver. You have the right to request a different care giver if necessary
• We schedule, manage and monitor the services provided.
• Our RN visits according to your agreed upon schedule for reassessment and evaluations
• We update your family doctor on conditions and status of care.
• Our Care givers provide assistance with activities of daily living (ADLs), such as dressing, bathing, eating, housekeeping, shopping, and assistance with self-administration of medication.

Delicate Home Health Care participates in the following 3 main Waivers

State of Virginia offer the following Waiver services defined below that is offered to individuals as an alternative to avoid admission to an institution when the individual is in imminent risk of institutional placement. “Imminent risk of institutional placement” is defined as “needs to enter a facility within one month if he or she does not receive waiver services.”

CC Plus Waiver

CCC Plus - Commonwealth Coordinated Care Plus Waiver. The CC Plus Waiver combines the Elderly and Disabled Consumer Directed (EDCD) and Tech Assisted waivers CCC Plus Waiver is the Waiver provided to you so that your love once does not get admitted into the Nursing Facility, The Local Department of Social Services (LDSS) and the local Department of Health screen for eligibility for admission to a Nursing Facility

• Qualification - The criteria to qualify for CCC Plus include the Medical Needs, Nursing Needs and Functional Capacity. There is no age requirement. One most important thing is that you must be a risk for Nursing Home Placement to qualify
• Services – The services provided in this Waiver includes Personal Care Assistance, Respite Care, Personal Emergency Response Systems (PERS) and Adult Day Healthcare

Delicate Home Health Care will help you determine your qualification. Our Medicaid and Waiver experts work with you every step of the way and provide the Plan of Care and the Care you need. We help you figure it out. Most people know that they can apply for Medicaid, but do not know that the Waiver is there for them

DD Waivers - The Developmental Disabilities Waiver (DD Waiver) provides services that assist eligible individuals with Intellectual and Developmental Disabilities (IDD) to participate as active members of their communities.

DD Waivers include 3 Waivers – The Community Living (CL) Waiver, Family and Individual Supports (FIS) Waiver and the Building Independence (BI). The Facility for DD Waiver is an Intermediate Care Facility for Individual Intellectual Disabilities (ICF/IID).

What you need to know about DD Waiver

• Waitlist – DD Waiver has long Waiting list – the earlier you apply the better
• Where to get help – Local Community Service Board & Behavioral Health Authorities
• Qualification - Must have diagnosis of Developmental Disability. A physiological evaluation showing IQ and diagnosis is required. Must have a functional need using VIDES Survey
• Services – The services provided under DD Waiver includes the Personal Care Assistance, Respite Care, Residential Support, Support Employment, Companion Care Services, Skilled Nursing, Assistive Technology etc.

CCC Plus Waiver Process

The CCC Plus Waiver is a Medicaid program for elderly and individuals with disabilities that makes it possible for individuals to receive services in their homes and in their communities. You must apply to qualify. Delicate Home Health Care provides education and knowledge in quidding one navigate the process, understand the process and provide care for the individual

The Application Process

• You must first apply for Medicaid Assistance if you do not have one. Delicate Home Health Care can guide you through the process. Anyone can apply. Click here CommonHelp for online application and create account.
  
  Online Application - Delicate Home Health Care will guide you create online account and start the process and apply for assistance (Medical Assistance for the Individual and Appendix D). For questions and answer, you can click here for most of your questions. Online application are faster
  
  Summiting Paper Work Yourself - You can also submit paper applications – first print and apply with this Medical Assistance Application Form (Medical Assistance Application Form In Spanish), then complete Form Appendix D for Medicaid to cover nursing facility or community-based long-term care services, you can complete Appendix D – Adults over age 19 with a disability and other Adults Age 65 and Over, Including People Who Need Long term care services. Please bring with you a completed financial application for Adult Medicaid and the Appendix D form to your local Department of Social Services (DSS) and request a screening for Long Term Care. Please write CCC Plus/Long Term Care Screening on the top of the form
  
  Please review some of the following link for clarification to some of your questions
  
  If you need someone on the phone to help you with completing the form, you can call (855) 242-8282. This is available in English and Spanish

• Local Department of Social Services (DSS). You can locate your local DSS by clicking here

Waiver Screening Process

A social worker from DSS or a nurse from the local Department of Health (DOH) will schedule an assessment with you. Contact DSS as needed – keep in mind, financial application must be done with DSS even if screening is done with DOH.

This is the process

A. This DSS screening should take place in your home.
B. The individual that is being screened needs to be there during the visit
C. The DSS Screening Personnel will be looking for the following (see Pre-Admission Screening Manual Appendix B for details):

1. A Disability

2. Functional Dependencies (see Functional Dependency Categories for details and specific Criteria)

   1. Criteria for Joint Motion:

      1. Ability to move his or her fingers, arms and legs.
      2. Active ROM (ability to move own extremities)
      3. Passive ROM (assisted movement by others)

   2. Criteria for Medication Administration:

      1. Medication Administration refers to the person(s) who administers medications such as the child and caregiver as a unit, the child as age appropriate, or if the child is being referred elsewhere, the person(s) who will administer medications following referral.
   3. Criteria for Behavior Pattern and Orientation:
   4. Behavior Pattern is the manner of conducting oneself within one’s environment.
   5. Orientation is the awareness of an individual within his or her environment in relation to time, place, and person.
   6. Screening considerations for children, as age appropriate, include: assistance to engage in safe actions and interactions; refrain from unsafe actions and interactions; exhibits disruptive or dangerous behavior such as: verbal and physical abuse to self or others; wandering; removing or destroying property; acting in a sexually aggressive manner; reported neurological impairment; hyper/hypo sensitivity to external stimulus; constant vocalizations/perseveration; impaired safety skills; engages in smearing behavior; sleep deprivation; reported cognitive impairment; lack of awareness; unable to respond to cues; unable to communicate basic needs and wants; disorientation/disassociation; unable to follow directions; unable to process information or social cues; and unable to recall personal information. If the child exhibits any of these, as age appropriate, score accordingly.
3. Medical/Nursing Needs
4. Risk of Placement with Specialized Care (It is often helpful to have a letter from your physician supporting this need.

Assessment Criteria

Functional Capacity

Individuals may be considered to meet the functional capacity requirements for nursing facility care when one of the following describes their functional capacity:

1. Individual is rated dependent in two to four of the Activity of Daily Livings (ADLs), or is rated semi-dependent or dependent in Behavior Pattern and Orientation, and also semi-dependent in Joint Motion or semi-dependent in Medication Administration;
2. Individual is rated dependent in five to seven of the ADLs and rated dependent in Mobility or
3. Individual is rated semi-dependent in two to seven of the ADLs and rated dependent in Mobility and Behavior Pattern and Orientation

Rating Abbreviations

After Approval

Select Model of Service Delivery and Choose Provider

1. Agency Directed:
   1. You chose an Agency – Delicate Home Health Care.
   2. Delicate Home Health Care will perform and Assessment, document form 97A/B and Form 90.
   3. Delicate Home Health Care obtain Authorization for you,
   4. Provide Care givers that matches your needs and your personality
2. Consumer Directed:
   1. You choose Service Facilitator – Delicate Home Health Care
   2. We Establish the Employee on Record.
   3. The EOR hire and schedule your own attendants.
   4. Delicate Home Health Care (Service Facilitator) helps you with training and hold your hand to navigate the process.

If You Choose Consumer-Directed Care

• Service Facilitator – (Delicate Home Health Care) Conducts what is called Initial Visit:
  1. Trains Employer of Record (EOR) on hiring procedures.
  2. Initiates process by contacting Medicaid’s Fiscal Agent (PPL).
  3. Conducts initial assessment.
  4. Creates Plan of Care (POC).
  5. Estimates how many hours the Individual will qualify for.
• Post Initial Meeting:
  1. Service Facilitator – (Delicate Home Health Care) Requests prior-authorization for hours through a prior authorization 3rd party.
  2. EOR is set up to be employer.
  3. EOR recruits, hires, and schedules attendants.

DD Waiver (CL/FIS)

Development Disability Waiver provides services to individuals with Intellectual and Development Disability (IDD). DD Waivers in the state of Virginia includes the Community Living (CL) Waiver and the Family and Individual Support (FIS) Waiver.

Family and Individual Support (FIS) are for individuals living with their families, friends, or in their own homes.

Community Living Waiver is 24/7 services and support for individuals with complex medical and/or behavioral support needs through licensed services.

DD Waiver Application
To apply for DD Waiver, you would contact your local Community Service Board (CSB)

Qualification Criteria
Qualification for a DD Waiver is based on three criteria areas

1. The individual must be diagnosed for development disability (autism, cerebral paisy etc)
2. Financial – Please refer to CCC Plus on how to apply for Medical Assistance
3. Function – this is determined during the VIDES screen with the local CSB

After Approval
The FIS/CL Comprehensive Waivers have a very long wait list based on priority, so you will start on the combined waiting list for BI, CL & FIS waivers.

1. Select a Case Manager to develop your Plan Of Care (POC):
   1. If you are on Medicaid via Straight Medicaid or FAMIS or the CCC Plus Waiver, you may receive targeted case management on an as-needed basis.
   2. If you do not have Medicaid, the initial POC will be developed and no further services will be available until your slot is funded on the FIS Waiver, however, you could be served through the IFSP program or private pay for CM.
2. Why would I want to do this if the wait list is so long?
   1. It is important for Virginia and the Federal Government to know how many people are in need of services and NOT getting them!
   2. If you have Medicaid via the CCC Plus Waiver, FAMIS, etc, you can receive targeted case management.
   3. You are eligible for the Individual and Family Support Program, which provides up to $1,000/fiscal year to the individual or family member of the individual on the wait lists in varying amounts, as requested and approved by DBHDS.
3. When your “slot” is funded:
   1. Case Manager assists you to coordinate all services available.
   2. Select model of service delivery for Personal Care / Respite / Companion Services and choose a provider.
4. Choosing a Provider:
   1. Agency-Directed:
      1. You chose an agency.
      2. They place their hired staff with you.
   2. Consumer-Directed
      1. You are the boss.
      2. You choose a provider such as At Home Your Way to be your “Service Facilitator.”
      3. You hire and schedule your own attendants.
      4. A Service Facilitator helps you continually.

If You Choose Consumer-Direction for Your Personal Care Services Service Facilitator Conducts Initial Visit:

1. Trains Employer of Record (EOR) on hiring procedures.
2. Initiates process by contacting Medicaid’s Fiscal Agent (PPL).
3. Conducts initial assessment.
4. Creates Plan Of Care (POC).
5. Estimates how many hours the individual will qualify for.

Post Initial Meeting:

1. Service Facilitator – Requests prior authorization for hours.
2. EOR is set up to be employer.
3. EOR recruits, hires, and schedules attendants.

Begin Services.

To Review the DMAS FIS Waiver Manual
Visit DMAS’s Website: