Medi-Cal Home and Community Based Services (HCBS) Waivers

Elissa Gershon, Senior AttorneyDisability Rights CaliforniaJune 5, 2013

HCBS Waivers in California being discussed today:

•Medi-Cal Home and Community Based Services Developmental Disabilities Waiver (DD Waiver)

•Medi-Cal Nursing Facility/Acute Hospital Home and Community Based Services Waiver (NF/AH Waiver)

What is “Institutional Deeming”?• Medi-Cal is allowed to determine your

eligibility using “institutional deeming.” This means Medi-Cal will evaluate you for eligibility as if you lived in an institution, and not with your parents or spouse.

• Why? Because without the Waiver, people whose incomes are otherwise too high to qualify for Medi-Cal would be eligible to receive Medi-Cal funded care in an institution (ICF/DD, nursing facility, subacute facility, etc.)

What is the DD Waiver?

•Medi-Cal program that pays for many home and community based services provided by regional centers. Often considered a funding stream, not a separate program.

•DD Waiver services will be listed in the consumer’s Individual Program Plan (IPP) or IFSP (Individual Family Service Plan)

Who is eligible for the DD Waiver?You are eligible for DD Waiver services if you: • Meet California’s definition of developmental disability,

• Are a regional center consumer,

• Get Medi-Cal or would be eligible for Medi-Cal if your spouse’s or parents’ (if you are under age 18) income or resources were not counted, and

• Qualify for care in a Medi-Cal funded intermediate care facility (ICF)

▫ You do not have to be in an ICF to be eligible for the DD Waiver — you just have to need the care and have needs that qualify you for services in an ICF.

Do all regional center consumers qualify for DD Waiver services?

No. Some regional center consumers do not qualify for DD Waiver services because:

•Their needs do not match those required to qualify for ICF services– such as having significant medical needs

Remember: Even if you are not eligible for DD Waiver services, you can still receive the services listed in your IPP or IFSP

How Do I Apply for the DD Waiver?

• You may not need to apply. The regional center usually identifies people who are eligible.

• But, if your regional center does not identify you for DD Waiver services, you have the right to apply on your own. Make certain there is a service covered under the DD waiver in your IPP or IFSP.

• Send a letter to your regional center asking to be identified as eligible for the DD Waiver for the services you need. And, make sure that the DD Waiver services you need are included in your IPP or IFSP.

• The regional center will send you a letter to let you know if you are eligible for DD Waiver services.

Why is it a good idea to get DD Waiver services if I am eligible?• The DD Waiver services you receive cannot be limited by where

you live in the state.

• Regional centers cannot use Purchase of Service (POS) guidelines to limit the amount or kind of services you receive under the DD waiver.

• Consumers who receive DD Waiver services get their IPP or IFSP reviewed every year (instead of every three years).

• Children who get Medi-Cal under the DD Waiver have extra protections.

▫ Redetermination before ending the child’s Medi-Cal eligibility.

▫ Continuing Eligibility for Children provisions (no-cost Medi-Cal coverage for up to 12 months after the child is found to be no longer eligible for any coverage under Medi-Cal).

• Consumers who are eligible for DD Waiver services have an extra vehicle exemption.

What are DD Waiver Services?• Homemaker• Home Health Aide Services• Respite Care• Habilitation: Residential habilitation for children services, Day

habilitation, Prevocational services, Supported employment services• Environmental Accessibility Adaptations• Skilled Nursing• Transportation• Specialized Medical Equipment / Supplies• Chore Services• Personal Emergency Response System (PERS)• Family Training• Adult Residential Care: Adult Foster Care, Assisted Living, Supported

Living Services• Vehicle Adaptations• Communication Aides• Crisis Intervention: Crisis Intervention Facility Services, Mobile Crisis

Intervention• Nutritional Consultation• Behavior Intervention Services• Specialized Therapeutic Services• Transition / Set-Up Expenses• Habilitation

For more information:

•Look for the DD Waiver at the Department of Health Services web site: http://www.dhcs.ca.gov/services/medi-cal/Pages/HCBSDDMediCalWaiver.aspx

•Read more about the DD Waiver in DRC’s Rights Under the Lanterman Act at: http://www.disabilityrightsca.org/pubs/506301Ch13.pdf

What is the NF/AH Waiver?

•Medi-Cal program that pays for home and community based services for people who would otherwise qualify for care in a nursing facility.

•Pays for services beyond what is available in the Medi-Cal State Plan (regular Medi-Cal).

Who is eligible for the NF/AH Waiver?

Eligibility Requirements:

• Must have full scope Medi-Cal Eligibility

• Physically Disabled (no age limit)

• Must meet one of the following levels of care:

▫ acute hospital,

▫ adult or pediatric subacute nursing facility,

▫ distinct-part nursing facility,

▫ adult or pediatric Level B (skilled) nursing facility, or

▫ Level A (intermediate) nursing facility (NF)

• Must meet other criteria and requirements listed in the waiver

How Do I Apply for the NF/AH Waiver?Complete the HCBS Waiver Application and send to

DHCS In-Home Operations. The application is at:

http://www.dhcs.ca.gov/formsandpubs/publications/Documents/HCBS%20Waiver%20App.pdf

Note: There is a waitlist for individuals at the NF-A/B level of care unless:

• The application is turning 21 and aging out of EPSDT or

• The applicant resides in a nursing facility

What are NF/AH Waiver Services?• Private Duty Nursing, including Shared Nursing• Home Health Aide Services • Case Management• Transitional Case Management• Environmental Accessibility Adaptations• Personal Emergency Response Systems (PERS)• PERS Installation and Training• Medical Equipment Operating Expenses• Waiver Personal Care Services• Community Transition• Habilitation Services• Respite Care (home and facility)• Developmentally Disabled/Continuous Nursing Care Non-

Ventilator Dependent Services• Developmentally Disabled/Continuous Nursing Care

Ventilator Dependent Services

How to Get NF/AH Waiver Services:

•You can choose from the menu of NF/AH Waiver services up to a cost-cap for your level of care

•Your doctor must include the services you need in a Plan of Treatment

•Cost-cap includes most other Medi-Cal services: IHSS, and unless enrolled in managed care, CBAS, medical supplies and equipment Institutional Level of Care

Annual Institutional Rate

Annual Waiver Cost-Cap

Nursing Facility (NF)-A

$34,388 $29,548

Nursing Facility (NF)-B

$56,074 $48,180

NF-B Pediatric $110,280 $101,882NF-Distinct Part $124,342 $77,600NF-Subacute, Adult

$271,697 $180,219

NF-Subacute, Pediatric

$282,574 $240,211

Acute Hospital $437,757 $305,283

•

For more information:

The Nursing Facility/Acute Hospital Waiver is available at:

http://www.dhcs.ca.gov/services/medi-cal/Pages/NFAHMedi-CalWaiver.aspx

DISABILITY RIGHTS CALIFORNIA1-800-776-5746