Heidi has a BS in Civil Engineering from Purdue. After the birth of her son Jacob, she elected to stay home to ensure his needs were met. Heidi is very involved in many organizations;last year she was appointed by the Governorâs office to be on 3 Medicaid Reform committees, looking at overhauling the entire Medicaid system.Heidi currently has an advocacy distribution list of over 2,500 members to promote awareness of the advocacy issues that affect children and adults w/ disabilities & empower parents. Dearest Advocates:
Based on a number e-mails I received in the last few days…….
Below is the text presentation that I gave at the FOCUS (Families of Children Under Stress) educational conference held on Feb. 4th regarding the Katie Beckett Waiver program. I thought everyone could benefit from the below information that I presented. PLEASE note this presentation did not include the recent changes to the eligibility criteria based on our advocacy effort that I released today! Also:
Happy
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What is the Katie Beckett Waiver ?
• Category for Medicaid eligibility based on the Tax Equity & Fiscal Responsibility Act (TEFRA) 1982.
• State’s are allowed to make Medicaid available to a disabled child if:
– 18yrs old or younger, AND
– Meet federal criteria for childhood disability, AND
– Meet institutional Level of Care, AND
– Can safely be served at home, AND
– Cost does not exceed the applicable institutional cost.
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What is the KB Waiver criteria based on?
• Federal Regulations established general requirements in 42CFR 435.225.
– Requires institutional level of care: nursing home, hospital, or intermediate care facility- mental retardation.
1. Intermediate Care Facility – Mental Retardation – 442CFR440.150 & 42CFR483.440
• Requires 24 hour supervision AND active treatment.
2. Hospital Level of Care – 42CFR440.10
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3. Nursing Home LOC – 42CFR440.155
• DHR Rules 290-5-8 & OCGA 31-7-1(1)(b).
• Requires 24 hour nursing care.
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How is the Level of Care determined for the KB Waiver?
• Initial application made to DFCS.
– Clinical detail is sent to and reviewed by Georgia Medical Care Foundation.
– If Level of Care is satisfied, DFCS does cost neutrality assessment.
• Georgia Medical Care Foundation does clinical review.
– A certified Prospective Review Organization.
– Co-Medical Directors and nurse reviewers.
What is the Appeal process for KB Waiver?
• An initial administrative appeal can be requested from GMCF. You have 30 calendar days to supply additional information.
• A 2nd appeal can be made by requesting a hearing directly from the DCH. (Fair hearing in front of a judge)
Background on Katie Beckett Waiver for
• KB Waiver was created to waive income limits of parents to establish eligibility for Medicaid in 1982.
• This is an optional Medicaid Program for
• In 2001, the only national study ever conducted concluded that 20 states enrolled approximately 25,000 children in Medicaid through the KB waiver option.
• Increase in KB Waiver denials since May 2005. No specific disability has been targeted.
• Over 6,200 families had the KB waiver before the new guidelines were implemented on 11/15/04.
• Over 1,600 children have been denied with a projection of 48% by FY 2007.
• Over 71% of all KB Waiver families have primary healthcare insurance. Therefore, Medicaid is secondary insurance.
• KB waiver is already a cost reduction program versus the States alternative to institutional care.
• KB Waiver accounted for $33 million of the 2003 Medicaid expense. This represents less than 1% of the total Medicaid budget.
• Based on data given by DCH at the Public Hearing for KB waiver held on 1/19/06:
• GA program has had significant growth: 250% growth in 5 yrs; 2,694 FY2000, 6,299 FY2004.
• Since 6/1/05:
• 2,761 have applied to renew: 37% approved.
• 461 have applied for 1st time: 33% approved.
• 1274 have request 1st appeal: 10% approved.
• 246 have requested hearings: 67 resolved
Tips and Traps
• Review the new eligibility criteria by going to www.communityhealth.state.ga.us.
• All applications after 11/15/04 have new forms which include the following:
– Pediatric DMA6(A).
– Care Plan (DMA 706).
– Cost-Effectiveness Form (DMA 704 which replaced the Deeming waiver Physicians Referral Form).
• Fill out all forms out as a “Provider” NOT as a “Parent”.
• Always send everything to GA Healthcare Partners / DCH by certified mail.
• DCH is currently reviewing applications submitted in September 2005.
• #1 Reason for denials is an administrative denial (lack of paperwork and incomplete package).
• Submit ALL the forms and supporting documentation in one application.
• Put together a Table and Contents and tab each document.
Networking & Building Alliances
• If you are denied, contact Governor’s Council on Developmental Disabilities (GCDD) via e-mail at pnobbie@dhr.state.ga.us. They are keeping track of denials in the state.
• Contact your State Senator and Representative’s by going to www.vote-smart.org and inputting your zip code. They need to hear from you about your situation and how it impacts your family.
• Contact Governor Perdue: Georgia.Governor@gov.state.ga.us.
• Stress when talking to your legislators that the majority of the KB waiver families are hardworking, middle class, tax paying, voting citizens that have never asked from anything from the State until they had a child with a disability.
• Atlanta Alliance on Developmental Disabilities is also involved and looking for suggestions. http://aaddpolitical.blogspot.com/
• Work with the media to get the message out and to help educate the general population of our concerns.
• AJC is currently asking for feedback during this legislative session. http://my.ajc.com/WBRH037AF62C6991AEF773D35A3F10
• Get Involved! Advocating is the key to success in getting the services we need for our children. Send on e-mail to : heidijmoore@comcast.net if you would like to be placed on my advocacy distribution list.
• My goal: Make the issues easy to understand and explain to advocates what they can do to influence change in this State.
• Tips for Appealing:
• In the original denial letter, the parents have 30 Calendar days to appeal.
• Resubmit any Medicaid documents that you feel you may have not filled out properly based on the new eligibility criteria.
• Prepare a 24 hour Care Plan going into detail about your child’s day. Explain everything you do as a parent that goes beyond a “typical” child’s duties as a parent.
• Have all your doctors, therapists and any other professional that works with you child submit a letter explaining why your child needs the waiver.
• Contact your local State Senator and Representative and send copies of e-mails to the Governor.
• Financial Responsibility:
• The first Denial letter allows parents 30 days to provide additional information to support the level of care approval request. Whether the parents submits additional information or not, the benefits should continue until a Final Denial letter is issued.
• The Final Denial letter allows parents 30 days to request an appeal. Benefits are terminated at the end of the month, once the Final Denial letter is served. However, upon request, benefits are reopened retroactively if an appeal is requested. The benefits continue through the hearing process.
• When the appeal decision has been rendered and properly served, the benefits can be terminated at the end of the month that the hearing decision was rendered and served.
• Families could be held liable for coverage provided during the appeal process. If the family is a new applicant, they would receive no coverage during the appeal process.
Appeal Process
• Detailed information on the procedural aspects of a fair hearing and instructional video on representing yourself in a hearing without an attorney can be found at: www.osah.ga.gov/
• If any parent feels that they have been discriminated against during the fair hearing they can report it to Chief Justice Louis Oakley or Deputy Chief Judge Michael Malihi. Contact information can be found on the above website.
• List of helpful websites:
• Medicaid’s Main ICF-MR page: http://www.cms.hhs.gov/medicaid/icfmr/default.asp
• ICF-MR level care and “persons with related conditions”: http://www.healthlaw.org/library.cfm?fa=download&resourceID=61843&appView=folder&print
• Great site to find current lawsuits in other states re: disabilities: http://www.healthlaw.org/
• When you see a code w/ "CFR" go here to look it up. Most healthcare is in title 42. Medicaid's definitions are listed here. http://www.gpoaccess.gov/cfr/retrieve.html
• An appeals decision re: 24 active care vs. 24 supervision. This is the court's breakdown of the fed regs and how they interpreted them. http://www.state.in.us/judiciary/opinions/previous/archive/02280101.nhv.html
• Autism Handbook http://www.usd.edu/cd/autism/Autism%20Handbook.pdf
Current Concerns and Solutions to KB Waiver Situation
• Consistency of review. We need to make sure that “reviewers” are not just looking at the Individual Education Plans (IEP’s) that report the child’s progress, not the delays, as well as, the child’s disability, appeal info. etc.
• Federal Regulations versus the States interpretation. It is my understanding that the State is currently exceeding the regulations for hospital, nursing home and intermediate care facility levels of care determination for eligibility. “Active treatment” definition also needs to be defined.
• Qualifications of the medical review team. Making sure all those on the review team have pediatric and clinical experience in disability related issues.
• Problems with the overall communication process and training of staff. DFACS case workers are not able to help families as they go through the process due to lack of knowledge of the system. Also having a “live” person available to help answer questions families may have during the documentation and appeal process.
• Reauthorization Process needs to be modified. The status of many children does not significantly change from year to year yet our families, doctors, nurses, therapists, etc have to fill out a stack of paperwork every year that may not be necessary. This adds time and money to the process without adding value.
• Possible Solutions for those that do not qualify for KB waiver but need support. Create an Insurance Risk Pool, Buy-in insurance program or a State fund pool to help families with costs not met by their insurance. May also want to look at a new waiver for those children that do not qualify for KB Waiver but have significant behavioral, health related and developmental delay needs. The State may also need to look at increasing the private insurance’s responsibility for standards of care for children.
• Overall: Families are asking for a clear and fair review process for their child’s KB waiver
Other Things to know:
• Attend Disability Day at the Capitol to be held on February 23, 2006. More info: www.gcdd.org.
• Medicaid Modernization. The Governor’s office is looking to reform the entire Medicaid population. This recently was announced to be delayed until 2007.
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• Get involved and monitor your child’s Medicaid card.
– www.ghp.georgia.gov and request a password from GA Health Partnership to be able to track Medicaid charges to your child’s account.
– This is very important in order to verify and report problems. You can report a complaint via the website as well.
– Only through education, accountability and communication are we going to be able to make a difference in the process.
Heidi J. Moore
(Proud Mother to Jacob - 6 years old with Down syndrome & Jared - 4 years old)
"Help The Children Now, So They Can Help Themselves Later!"
The material contained in this e-mail is for general information only. It is not intended in any way to provide or offer legal advice. To obtain legal advice, please consult with your attorney or a qualified legal representative.