A Guide to Medicaid A Guide to Medicaid Waiver Programs Waiver
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A Guide to Medicaid A Guide to Medicaid Waiver Programs Waiver Programs in Georgia in Georgia
Transcript of A Guide to Medicaid A Guide to Medicaid Waiver Programs Waiver
A Guide to Medicaid A Guide to Medicaid Waiver Programs Waiver Programs
in Georgiain Georgia
Table of Contents
Community Alternatives ..............................................................
What is Medicaid? .........................................................................
How to Apply for Medicaid Home andCommunity-based (waiver) Services ........................................
Medicaid Home and Community-based (waiver) Programs......
Community Care Services Program (CCSP) ...................
Independent Care Waiver Program (ICWP) .................
Mental Retardation Waiver Program (MRWP) and .....Community Habilitation and Support Services (CHSS)
SOURCE ................................................................................(Service Options Using Resources in a Community Environment)
What Other Services Does Medicaid Cover? .........................
What’s Not Covered?....................................................................
Your Rights and Responsibilities ................................................
Telephone Numbers and Web Sites .............Inside back cover
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Home and Community ServicesA Guide to Medicaid Waiver Programs in Georgia
If you have been referred for nursing home orother institutional care, but could stay in yourhome or in the community with special services,and you meet other requirements, you may beeligible for home and community-basedservices through Georgia’s Medicaid program.
These services are called waiver programs,because the Centers for Medicare andMedicaid Services (CMS) allows states to“waive” certain Medicaid requirements andpay for home and community-based servicesas an alternative to institutions, such asnursing homes or hospitals for people withmental retardation (ICF-MRs). Essentially,the law provides you a choice.
Under federal regulations, the total cost ofproviding home and community-basedservices may not be more than the cost ofproviding care in a hospital, nursing home orICF-MR.
A Guide to Medicaid Waiver Programs in Georgia
COMMUNITY ALTERNATIVES 1
Georgia has several home and community-based waivers. Some of the waiver programservices are: assistance with daily livingactivities (bathing, dressing, meals,housekeeping), help with arranging medicalor support services and relief forcaregivers. This booklet describes waiverprograms for people who are elderly,physically disabled, have mental retardationor who have a developmental disability. Forinformation about other waiver programs forchildren, such as the Deeming (KatieBeckett) or Model waivers, call the GeorgiaHealth Partnership at 770-570-3373 (MetroAtlanta) or 866-211-0950 (Statewide).
Although different waiver programs offerdifferent services, they have some things incommon. Each program is designed to helppeople who qualify for institutional careremain in the community or return to thecommunity from nursing homes, hospitalsor ICF-MRs. Each program also requiresthat people be eligible for Medicaid. Toqualify for a waiver program, you can havehigher income and resources than permittedin the regular Medicaid program.
H o m e a n d C o m m u n i t y S e r v i c e s
COMMUNITY ALTERNATIVES 2
A Guide to Medicaid Waiver Programs in Georgia
WHAT IS MEDICAID?/HOW TO APPLY FOR SERVICES 3
What is Medicaid?Medicaid is a medical assistance programthat helps many people who can’t affordmedical care pay for some or all of theirmedical bills. If you apply and are approvedfor Medicaid, you will receive a plasticMedicaid card in the mail. Medicaid will payparticipating doctors, pharmacists, hospitalsor other providers for your care.
If you or someone in your family needshealth care, you should apply for Medicaideven if you are not sure whether youqualify or if you have been turned down inthe past.
How to Apply for Medicaid Home andCommunity-Based (waiver) ServicesIf you are interested in a waiver program,contact the agency listed. If you qualify,someone will guide you through the nextsteps of the Medicaid application process.You will be notified within 90 days or lesswhether you are eligible for waiver services.If you are told that you do not qualify, youcan ask for a hearing. If you are eligible forwaiver services, you will be advised aboutwhen services will begin.
Medicaid Home and Community-Based(waiver) ProgramsWaiver programs help people who areelderly or have disabilities and need help tolive in their home or community instead ofan institution such as a nursing home or ICF-MR. Each program offers several “core”services:
service coordination (help with managingcare needs and services)personal support (assistance with dailyliving activities, i.e. bathing, dressing,meals and housekeeping)home health services (nursing, homehealth aide, and occupational, physicaland speech therapy)emergency response systemsrespite care (caregiver relief)
Additional services are available under eachprogram. Following are brief descriptions ofthe home and community waivers. Sometimeswaiver services are added or changed. Theagencies that handle the waiver programscan provide more detailed information aboutcovered services.
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MEDICAID HOME AND COMMUNITY-BASED PROGRAMS 4
Sometimes people may meet the criteria toreceive Medicaid services under a waiverprogram, but may not receive servicesimmediately. Funding for the programs islimited, and only a certain number of peoplecan receive services based on availablefunds. This means there are nearly alwayspeople on the waiting lists for the home andcommunity-based waivers.
A person may be selected from the waitinglist based on the severity of need, theavailability of informal/family support, thelength of time on the waiting list and aperson’s continued eligibility for the level ofcare provided in a nursing home or ICF-MR.
It is important to be sure that informationabout your condition and situation isaccurate. You have the right to correct orupdate information that may affect yourplacement on the waiting list.
A Guide to Medicaid Waiver Programs in Georgia
MEDICAID HOME AND COMMUNITY-BASED PROGRAMS 5
Community Care Services Program (CCSP)This program provides home and community-based services to people who are elderlyand/or functionally impaired or havedisabilities. The program helps eligiblerecipients return to the community fromnursing homes or remain in their own homes,the homes of caregivers or in othercommunity settings as long as possible.Individuals served through the CCSP mustbe eligible for Medicaid and meet thesecriteria:
Qualify for the level of care providedby a nursing home;Have limitations which make it difficultto perform normal daily living activitiesand live independently; andHave health needs that can be met inthe community with services offered bythe program and within establishedindividual cost guidelines. The individualcost is estimated based on theprojected care plan.
Some additional CCSP services are adult dayhealth care, alternative living services(personal care home) and home deliveredmeals.
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COMMUNITY CARE SERVICES PROGRAM 6
To apply for CCSP, contact the Area Agency on Agingserving your area:
A Guide to Medicaid Waiver Programs in Georgia
COMMUNITY CARE SERVICES PROGRAMS
Northwest Georgia RDC (Rome).................800-759-2963
Legacy Link, Inc. (Gainesville).....................800-845-5465
Atlanta Regional Commission (Atlanta) .....404-463-3100
Southern Crescent RDC (Franklin) ............866-854-5652
Northeast GA RDC (Athens).......................800-474-7540
Lower Chattahoochee RDC (Columbus).....800-249-7468
Middle Georgia RDC (Macon) .......................888-548-1456
Central Savannah River RDC (Augusta)...888-922-4464
Heart of Georgia Altamaha RDC (Baxley) 888-367-9913
Southwest Georgia Council on Aging (Albany) 800-282-6612
Southeast Georgia RDC (Waycross) .........888-732-4464
Coastal Georgia (Brunswick)........................800-580-6860
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Independent Care Waiver Program (ICWP)This program offers services that help alimited number of adult Medicaid recipientswith physical disabilities live in their ownhomes or in the community instead of ahospital or nursing home. ICWP services alsoare available for persons with traumaticbrain injuries (TBI).
Independent Care is for eligible Medicaidrecipients who have severe physicaldisabilities, are between the ages of 21 and 64when they apply and meet the criteria below:
Capable of directing their own services(individuals with a traumatic brain injurydo not have to meet this criteria);Have a severe physical impairmentand/or TBI that substantially limits oneor more activities of daily living andrequires the assistance of anotherindividual;Medically stable but currently in ahospital or nursing facility or at risk ofplacement because community-basedsupport services are not available; andCertified for a level of care appropriate forplacement in a hospital or nursing facility.
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INDEPENDENT CARE WAIVER PROGRAM 8
Other factors, including: risk of placementin an institution, length of time on thewaiting list, availability of a support system,ability to live independently and anestimated cost of care (based on theprojected care plan) also help determinewhether eligible applicants can receivewaiver services.
In addition to the core services, ICWPcovers specialized medical equipment andsupplies, counseling and home modification.ICWP does not pay for room and board.
You, your case manager and your familyand/or friends work together as a planningteam to establish a plan of care. The planassesses your present circumstances,strengths, needs, goals, services required, alisting of the providers selected andprojected budget. Funds must be availableto serve you for the plan to be approved bythe state Medicaid agency.
To apply for ICWP, contact the GeorgiaHealth Partnership (GHP) at 678-527-3632or 1-800-982-0411. GHP will ask youquestions over the phone, have you submit anapplication and schedule an in-personassessment. Based on the informationprovided, you may be eligible for ICWP andapproved to receive services as fundingbecomes available.
A Guide to Medicaid Waiver Programs in Georgia
INDEPENDENT CARE WAIVER PROGRAM 9
Mental Retardation Waiver Program(MRWP) and Community Habilitationand Support Services Waiver (CHSS)The Mental Retardation Waiver Program andCommunity Habilitation Support Servicesoffer home and community-based servicesfor people who have mental retardation ora developmental disability. A diagnosis ofdevelopmental disability includes mentalretardation or other closely relatedconditions such as cerebral palsy, epilepsy,autism or neurological problems that requirethe level of care provided in an intermediatecare facility for people who have mentalretardation (ICF-MR).
Seven regional boards with responsibility formental health, mental retardation andsubstance abuse services (under thesupervision of the Georgia Department ofHuman Resources) determine eligibility forthe MRWP and CHSS programs andcoordinate service delivery with approvedMedicaid providers.
In addition to core services, MRWP coversday habilitation and supported employment,residential training and supervision,specialized medical equipment and supplies,vehicle adaptations and home modifications.Under the CHSS program, you can choose asingle qualified Medicaid provider for acomprehensive package of services.
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MENTAL RETARDATION & COMMUNITY HABILITATION AND SUPPORT SERVICES WAIVER PROGRAMS 10
To apply for MRWP or CHSS, contact yourregional Board of Mental Health, MentalRetardation and Substance Abuse:
A Guide to Medicaid Waiver Programs in Georgia
MENTAL RETARDATION & COMMUNITY HABILITATION AND SUPPORT SERVICE WAIVER PROGRAMS
Region 1 NorthMHDDAD Regional Office (Cartersville) ..770-387-5411
Region 2 MetroMHDDAD Regional Office (Atlanta).........404-463-6367
Region 3 West CentralMHDDAD Regional Office ..........................770-254-7474
Region 4 CentralMHDDAD Regional Office (Dublin)............478-274-7912
Region 5 East CentralMHDDAD Regional Office (Augusta)........707-667-4833
Region 6 Southwest MHDDAD Regional Office (Albany)...........229-430-3017
Region 7 Southeast MHDDAD Regional Office (Brunswick).....912-280-6893
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SOURCEIn specified areas of the state, a programcalled SOURCE (Service Options UsingResources in a Community Environment), linksprimary medical care with many long-termhealth services in a person’s home orcommunity to prevent hospital and nursinghome care or speed the return to thecommunity from a nursing home or hospital.
SOURCE serves frail elderly and disabledGeorgianswho are eligible for SSI/Medicaid(Supplemental Security Income). People underthe age of 65 are eligible if they have a signif-icant disability and are receiving SSI/Medicaid.
An assessment helps to determine how muchcare a participant needs. An individual care planis designed based on the need for medicalmonitoring and assistance with functionaltasks. Family members and other informalcaregivers as well as staff from supportagencies participate in care plans. In additionto the core services, SOURCE offers homedelivered meals, adult day health care, personalcare home and 24-hour medical access.
The program is currently available in the Albany,Atlanta, Augusta, Baxley/Hinesville, Blue Ridge,Columbus, Gainesville, Sandersville, Savannahand Waycross areas, and participants must bea resident of one of the 117 counties servedby the program. There is no waiting list forthe SOURCE program.
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To apply for SOURCE, call the number listed below for theprogram serving your county:
A Guide to Medicaid Waiver Programs in Georgia
SOURCE
Albany-Albany ARC............................................................229-888-6852Counties: Baker, Calhoun, Clay, Colquitt, Decatur, Dougherty, Early,Grady, Lee, Miller, Mitchell, Seminole, Terrell, Thomas, WorthAtlanta- Atlanta SOURCE ...............................................404-728-4973Counties: DeKalb, FultonBlue Ridge-United Health System - Pruitt..................706-632-9263
770-925-1143Counties: Butts, Cherokee, Clayton, Cobb, Douglas, Fannin, Fayette,Gilmer, Gwinnett, Henry, Lumpkin, Murray, Paulding, Pickens,Rockdale, Towns, UnionButler-SOURCE Care Management ................................478-862-5886Counties: Bibb, Bleckley, Burke, Columbia, Crawford, Crisp, Dodge,Dooly, Glascock, Greene, Hancock, Harris, Houston, Jefferson,Johnson, Lauren, Lincoln, McDuffie, Macon, Marion, Peach, Pulaski,Quitman, Randolph, Richmond, Schley, Stewart, Sumter, Talbot,Taliaferro, Taylor, Twiggs, Upson, Warren, Washington, Webster,Wilkes, WilkinsonColumbus-Columbus Regional Healthcare System.................706-660-6345Counties: Chattahoochee, Harris, MuscogeeGainesville-Legacy Link, Inc.............................................770-538-2650Counties: Banks, Dawson, Franklin, Habersham, Hall, Hart,Stephens, WhiteSavannah-Candler Health System...................................912-234-2186Appling, Bacon, Bryan, Bulloch, Chatham, Effingham, Evans, JeffDavis, Liberty, Long, McIntosh, Tattnall, ToombsWaycross-Diversified Resources, Inc...........................912-285-3089Counties: Atkinson, Ben Hill, Berrien, Brantley, Brooks, Camden,Charlton, Clinch, Coffee, Cook, Echols, Glynn, Irwin, Lanier,Lowndes, Pierce, Tift, Turner, Ware, Wilcox
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For more information, please call 404-651-6889.
What Other Services DoesMedicaid Cover? It’s always a good idea to ask your doctor orpharmacist whether Medicaid covers thespecific service or item you need. There aresome limits to these services, and some mayrequire you or your doctor to get permissionfirst. (This is called prior approval.)
Following are basic Medicaid services.Additional services are offered by each ofthe waiver programs. Your caseworker canprovide more information about otheravailable services.
In general, Medicaid covers these services:Doctors’ and nurses’ office visits (whenyou visit a doctor or nurse for check-ups, lab tests, exams or treatment)Prescription drugsInpatient hospital services (room andboard, drugs, lab tests and otherservices when you have to stay in thehospital)Outpatient hospital services (servicesyou receive in a hospital, even though youdo not stay in the hospital overnight)Nursing facilities (nursing homes)Emergency ambulance servicesEmergency dental care for adults; comprehensive dental care forindividuals under age 21
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WHAT OTHER SERVICES DOES MEDICAID COVER? 14
Non-emergency transportation (to get toand from medical appointments if youdon’t have any other means of trans-portation)Medical equipment and supplies prescribedby a doctor for use in your home (such aswheelchairs, crutches or walkers)Home health services ordered by adoctor and received in your home (suchas part-time nursing, physical therapy orhome health aides)Hospice care services provided by aMedicaid hospice provider
Some other services covered by Medicaidinclude:
Case managementDiagnostic, screening and preventiveservicesLaboratory servicesMedicare cost sharingMental health clinic servicesOrthotics and prosthetics (artificiallimbs and replacement devices)Podiatry servicesTherapy services (physical, occupationaland speech)County Public Health DepartmentsDialysis and services for end-stagerenal (kidney) disease
A Guide to Medicaid Waiver Programs in Georgia
WHAT OTHER SERVICES DOES MEDICAID COVER? 15
What’s Not Covered?Some services are not covered by Medicaid.These include: private duty nursing, servicesgiven by a relative or member of yourhousehold, cosmetic surgery, disposables(such as adult diapers or bandages), experi-mental items and chiropractic servicesamong others. If you’re not sure whatMedicaid covers, ask your provider or callthe Georgia Health Partnership at 770-570-3373 (Metro Atlanta) or 866-211-0950(Statewide).
Your Rights and ResponsibilitiesOnce you are eligible for Medicaid, you areguaranteed certain rights, but with rightscome responsibilities.
Your RightsYou have the right to timely andadequate notice. You must receive noticein writing before Medicaid takes anyaction to end your Medicaid eligibility orchange the services you receive.You have the right to a fair hearing ifyou disagree with a decision regardingyour Medicaid eligibility or if you feel
H O M E A N D C O M M U N I T Y S E R V I C E S
WHAT’S NOT COVERED?/YOUR RIGHTS AND RESPONSIBILITIES 16
that Medicaid has not served yourmedical needs properly. To request ahearing, contact your county Departmentof Family and Children Services (DFCS)office within 10 days after you havereceived a notice about eligibility orservices.You have a right not to be discriminatedagainst because of political beliefs,religion, disability, race, color, sex,national origin or age. If you are applyingfor someone else, these rights andresponsibilities apply to that person. Toreport eligibility or provider discrimi-nation, call 1-800-533-0686.
Your ResponsibilitiesYou are responsible for providing trueand complete information about yourcircumstances, including your income, thesize of your family, your currentaddress, and other information thathelps Medicaid decide whether or notyou continue to be eligible for Medicaidservices.You are responsible for reporting changesin your circumstances. If your income,resources, living arrangements, familysize, or other circumstances change, theycould affect your eligibility. It is yourresponsibility to let your caseworker orthe Social Security Administration (SSA)know about these changes within 10 daysof the change.
A Guide to Medicaid Waiver Programs in Georgia
YOUR RIGHTS AND RESPONSIBILITIES 17
If you receive payments from any othertype of insurance or health-relatedbenefit, you must inform yourcaseworker of these payments within 10days. These payments may come fromprivate health, dental or vision insurance;Medicare; CHAMPUS; or any paymentfor an accident or injury. Be sure toreport any of these sources of insuranceto your caseworker when you apply forMedicaid. You must also report anymoney you have received or may receivein the future from an injury or accidentcaused by another person or liable party.
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YOUR RIGHTS AND RESPONSIBILITIES 18
Helpful Telephone Numbers and Web Sites
To find out more about Medicaid eligibility, contactyour county DFCS office. Look in the governmentpages of your telephone book for Department ofFamily and Children Services.
To locate a county health department, call404-657-2700 or look in the government pages.
To locate the Area Agency on Aging that serves yourcommunity, call 404-657-5258.
To locate a Social Security Administration officenear you, call 1-800-772-1213.
For questions about your Medicaid card, call 770-570-3373 or 866-211-0950.
To learn more about your nursing home rights andoptions, contact the Long Term Care Ombudsman at888-454-5826.
To learn more about Georgia Medicaid, stop by yourlocal library and log onto the Internet. The web siteaddress is www.ghp.georgia.gov.
