Understanding the Medicaid Waiver

A Practical Guide for Families and Individuals

with Developmental Disabilities

Published by The Governor’s Council on Developmental Disabilities – Winter 2009

What Is A Medicaid Waiver?

A Medicaid Waiver is money that can pay for services for people with developmental disabilities. These services can take place in the person’s home or in the community. Both children and adults can be supported by Medicaid Waiver services.

Medicaid usually pays for doctor appointments, hospital expenses, medicine, therapy, and some adaptive equipment. The Medicaid Waiver allows for Medicaid to be used to pay for additional services. The state writes a plan that tells what kind of services will be provided under their Medicaid Waiver program. The federal government has to approve the Medicaid Waiver plan. The Medicaid Waiver dollars are part state and part federal money.

The Medicaid Waiver services stay with the person even if they move around within Georgia. If a person moves out of state, they lose the waiver services. Each state has their own waiver so the Georgia Waiver does not transfer.

The New Medicaid Waivers

The Office of Developmental Disabilities has written two new waivers. These new waivers are designed to give people more control over how their service dollars are spent.

The NOW waiver will provide supports to people who don’t need 24 hour care. The Comprehensive waiver will provide supports to people who need 24 hour care.

Families who have heard about the new waivers are excited because they will have more options for support and more will have more control in making the decision about how the money is spent.

NOW- New Options Waiver
COMP- Comprehensive Waiver
The NOW/COMP Waivers provide a wide variety of home and community-based services to individuals with developmental disabilities, allowing them to stay out of institutional settings.
It is the largest waiver program in Georgia.
Available to all ages.
Largest waiting list for services (so the sooner you get started, the better)

Myths and Facts about Medicaid Waivers

The waiting list is ten years long. This is false. The advocates through the Unlock the Waiting List Campaign have been working with the legislature to promote a multi-year funding plan to address the waiting list. However, more planning may be needed for any growth in demand and there has been a slow down in funding due to the slumping economy. Continued advocacy efforts are needed.

Providers will go out of business with the new waivers. This is false. Providers who offer services that people want will experience growth and not go out of business under the new waivers. There should be an increase in the number of providers in Georgia over the next few years.

There are limited dollars in the waiver program and the amounts that can be spent will be capped. This is true. The new waivers will be activated using the money that is currently in the waiver program. There are no new dollars unless the legislature allocates them for this purpose.

The Supports Intensity Scale is the best tool currently available to evaluate people’s needs. This is true. The Supports Intensity Scale has the best record of being accurate in evaluating peoples’ needs. More work is being done to make it work well for children under sixteen. There will be a health risk screening tool that will make sure that medical issues are properly assessed.

There will be additional money available in case of a crisis or other extenuating circumstances. This is true. There will be flexibility and the ability to move money around if a person does not need it during the year. This will allow for additional money to be assigned to people who need more during the year.

Features of the New Waivers

Individual Budgets – With the new waivers, every person will have an individual budget based on their needs. The family will be aware of how much money is available to purchase the supports needed. In the past the dollars went to the providers to reimburse them for providing the service.

Supports Intensity Scale – The support coordinators have been trained to use the Supports Intensity Scale in an effort to find out what the individual needs. It is an interview that is done with people who know the individual well. The score on the Supports Intensity Scale (SIS) along with other information will be used to decide how many waiver dollars will be set aside for your family member’s supports and services.

Choice of Services – If a family is happy with the services they are currently receiving, they can choose want to think of other ways to support their family member, they can look at new and innovative ways of providing the community supports. Families can even choose to become responsible for hiring the people o work with their family member.

Financial Support Services – If a family wants to be in control of choosing who provides the services for their family member, then they can use the financial support service agency to pay the bills for them. The family would sign off on the time sheets and submit them for payment. The agency pays the taxes and social security, pays for the background check, and provides W-2 forms and monthly budget reports.

Options for Self Directing Services – There will be three ways that services can be directed. There is the traditional way where the provider handles all the details. There is a co-employer arrangement where the person and their family choose who will support them, but the provider manages the other aspects of the services. Or there is self direction where the person/family becomes the employer.

What Services Are Available Using Waiver Dollars?

Behavioral Support Consultation – If your family member has challenging behaviors, waiver dollars can help purchase the services of an expert to address the behaviors and support the person. ($2,450.24 maximum yearly)

Community Access – This service can be provided individually or with a group of people. It can take place during the day, in the evening, or even on weekends. Community activities that would be enjoyable to the person would be identified, and participation and support arranged.

Community Guide – Waiver dollars can pay a person to link your family member to local community resources. The community guide can research what is available based on the person’s interests and needs. ($2000.32 maximum yearly)

Community Living Support – This service helps the person live at home. The support can help with bathing, dressing, grooming, toileting, eating, shopping, banking, exercising, decision making, supervision of the person taking their medication, or other community living activities.

Community Residential Alternative – This waiver service is for people who are living in a residential home operated by a provider agency. The person can receive support in daily living activities, community activities, and household chores. The agency staff provides the training and supervision in the home. Only in the COMP waiver.

Environmental Accessibility Adaptation – Medicaid Waiver funds can be used to modify a home to make it more accessible, like adding ramps or grab bars. ($10,400 lifetime maximum)

Supported Employment or Prevocational Services – funding can support people to obtain and maintain jobs in the community or be used to teach people prevocational skills. Supported employment can be individual or group. (Yearly maximums – S.E. Individual 1440 units, S.E. Group 3840 units, Prevocational 5760 units)

Transportation – Waiver dollars can be used to purchase transportation to get people where they need to go in the community. ($2797.34 maximum yearly)

Financial Support Services – This is a service that assists families in paying for the services when the family chooses to hire the people they want to work with their family member. The financial support service manages payroll, taxes, background checks, etc. (1 unit per month)

Natural Support Training and Individual Directed Goods and Services – These two services are available only under the NOW waiver and are designed to help promote the individual’s participation in the community. Funds can be used to train people or to purchase things the person needs in the community. ($1787.08 maximum yearly for training…$1500 max/yr for goods or services)

Adult OT/ Adult PT / Adult Speech & Language – The Medicaid Waiver can pay for physical therapy, occupational therapy, or speech therapy for people over the age of 21. ($1800 maximum yearly)

Respite – The Medicaid Waiver will pay for respite care to give the family a break from their demanding schedules involved in caring for their family member who has developmental disabilities. This can be hourly or overnight. Only in the NOW Waiver ($3744 max/year)

Specialized Medical Equipment and Supplies – The Waiver can pay for medical supplies or adaptive equipment that might be needed. This could include things like disposable diapers, chux pads, latex gloves, and wipes. ($13,474 equipment lifetime cap – with annual maximum of $5,200…..$1,734.48 maximum yearly for supplies for NOW and $1,868.16 for COMP)

Support Coordination – The support coordinator will be responsible for completing all the waiver paperwork and will monitor to make sure the services are being delivered. They also check on the individual’s health and safety. The cost of support coordination is not part of the individual budget. The person can choose which support coordination agency to use.

Vehicle Adaptation – If a vehicle needs to be adapted, waiver funds can be used to pay for such things as a van lift, a portable ramp, wheelchair tie downs or brackets, or a specialized seatbelt. ($6,240 maximum lifetime cap)

An Example of a Person New to the Waiver

Mary graduated from high school and stayed at home 14 months before receiving news that she had been awarded a Medicaid waiver. Mary lives with her parents, but wants to have her own apartment in the future. Mary wants a job. She loves working with children. She helps with the child care at church during choir practice.

The support coordinator explained the new waiver to Mary and her family. They want to purchase supported employment services to help Mary become employed. They also wanted respite care for a three day weekend so her parents could celebrate their 25^thwedding anniversary. They decided to purchase transportation for Mary to get to church on choir practice night because her mother is taking a class and can’t take her. Mary also wants to join a gym and take a water aerobics class. She needs someone to go with her to help her change into her swimsuit.

Mary’s mother found a child development student at the Vo-Tech School who was willing to work with Mary in the church nursery. She also agreed to check with the Pre-K program at the elementary school where she was doing an internship. She helped arrange for Mary to work in the Pre-K program two mornings a week. They also were able to arrange for Mary to ride the school bus home at noon when the bus was transporting the children home.

A paraprofessional in the Pre-K program got to know Mary and became qualified to provide the respite care that the family needed. She already had the first aid and CPR training and had a criminal background check done before becoming employed by the school system. Mary never attended a day program, but had her services and supports designed around her interests. A service does not have to be a program or a place.

An Example of a Person Already on the Waiver

Jimmy is forty-four years old and lives with his mother who is a widow. Jimmy goes to the day program five days a week from 9:00 until 3:30. His mom works for an insurance company.

When the support coordinator explained the new waivers to Jimmy and his mother, they decided that they wanted him to continue to go to the day program four days a week. His mother is off on Wednesdays so she didn’t need him to be at the center that day. Jimmy has become very interested in NASCAR racing and loves anything that has to do with cars. This is an interest that his mother knows nothing about.

With Jimmy’s waiver funds, they purchased the services of a community guide. She explored possible activities that Jimmy might enjoy that had to do with cars. She found the following:

A car dealership who wanted to hire someone to wash cars
An auto parts store that needed help unloading trucks on Wednesday afternoons
A club for NASCAR fans that meets to watch the races on Sunday afternoons
An opportunity to vacuum out state patrol cars between shifts at 3:00 p.m.

Jimmy’s mother took him to the auto parts store on Wednesday. The assistant manager received waiver funds to teach Jimmy how to unload the truck and stock the shelves. The manager paid Jimmy minimum wage for his work from 2:00 – 6:00 p.m. on Wednesdays.

One of the NASCAR club members knew Jimmy from church. He volunteered to take Jimmy out to lunch on Sundays after church and then take him to watch the race on television with the other club members. This was a natural support that was developed based on a shared interest. It did not require any Medicaid waiver dollars.

Questions You Might Ask

What if I want to try a different way of doing services but change my mind and want to go back to the original service provider? It is fine to change your mind and you will be allowed to switch back to the service provider you prefer.

Can we spend the waiver dollars on anything that my family member wants? Waiver money cannot be spent on anything the person wants. There are rules and guidelines that have to be followed. The services that will be paid for have to be spelled out in the individual service plan and must address a need or goal area that has been agreed upon by the team who helps create the individual service plan.

Can family members be paid to provide any of the services? If there is an extenuating circumstance, a family member may be allowed to provide some of the services. The federal law says that neither the parent of a minor child nor a spouse can be paid. These requests are to be reviewed and considered on a case by case basis.

Will there be enough providers available to serve all the people on the waiver? The Office of Developmental Disabilities thinks that the number of providers in Georgia will grow under the new waivers. In other states where they have gone to more individualized services, the number of providers has grown by more than 100%.

Steps To Take To Apply For A Waiver

Contact the Intake and Evaluation Team at the Regional Office to apply for services. The Intake and Evaluation Team will screen you to determine if you are eligible for services. The Intake and Evaluation Team will place your name on either the long term or the short term waiting list. Attaching a psychological along with your application helps speed the process. You also must show proof of citizenship (birth certificate, passport, or permanent resident card)

If you are on the short term waiting list, then a planning list administrator will be assigned. This person will check in with you and your family periodically to see if there are any changes in your situation. They will also help you look for other supports.

When funding becomes available, the regional office staff will send a letter stating that you have been approved for a Medicaid Waiver. You will be given 30 days to choose which support coordination agency you want to work with. If you don’t make a selection then one will be assigned.

The Intake and Evaluation Team will come out to the house to complete the paperwork for the waiver. This includes doing a social history, a psychological update, a nursing assessment, and completing other Medicaid required documents. As a family member, be sure that the assessments thoroughly describe the needs of your son / daughter.

The Planning List Administrator will assist you and your family in completing the Individual Service Plan. Goals will be developed from needs identified in the intake assessments. The planning list administrator will also complete the Supports Intensity Scale and the Health Risk Assessment Tool which will be used to determining the level of funding that will be received.

The individual and their family will be given information about providers who work in that region. The family will choose the provider they want with help from the planning list administrator or decide if they would prefer to self direct the services. A support coordinator will be assigned when services begin.

Key People Available To Help You and Your Family

The Regional Offices have Planning List Administrators who can work with people who are trying to obtain developmental disability services.

The Intake and Evaluation Team has professional staff who can assist the family by identifying needs and recommending goals for the services and completing the eligibility evaluations.

The Support Coordinator’s role is to help make sure that the individual gets the services and supports that they need. The support coordinator makes sure all the paperwork is completed and monitors to make sure services are being delivered. They also keep a watchful eye to make sure the person receiving services is safe and in good health. This is a Medicaid Waiver service.

There will be community guides as resources to individuals and their families. These community guides will help link the person to individuals and associations in their local community that match their interests. This service is purchased using Medicaid Waiver dollars.

There are individuals with disabilities who have gone through a training program to certify them as peer supporters. They can be contacted through the Independent Living Centers around the state. Peer supporters share information that they have learned from personal experience.

There are a variety of providers who want to deliver Medicaid Waiver services. The Regional Office can provide families with a list of providers approved to deliver services within their region.

The Financial Support Services Agency is available to pay for services or goods if a family wants to hire the people they want to work with their family member. Acumen is currently the only agency in Georgia providing this service. They will pay the social security and employer taxes as well as do criminal background checks and provide a W-2 form for all people hired by the family.

RESOURCES

Georgia Advocacy Office

150 E. Ponce de Leon Ave

Decatur, GA 30030

(404) 885-1234

www.thegao.org

Parent to Parent of Georgia

www.parenttoparentofga

Statewide Independent Living Council

www.silcga.org

Governor’s Council on Developmental Disabilities

2 Peachtree St NW 26^th floor