A few weeks ago I gave a presentation to the Down Syndrome Association of Atlanta that I thought might be helpful to you. The presentation has years worth of information in it thanks to many people that have worked with me on my advocacy efforts and trying to better understand the system in order to help my family and thousands of others.
Please remember: I am just an informed parent and not an attorney. If you need legal advice, please contact an attorney. This information should be used for general information only!
In addition, if you would like to see my previous advocacy email postings, please go to the following website:
Medicaid Waivers and Advocacy
Your Child Needs YOU!
Heidi J. Moore
Parent Advocate for Children and Adults with Disabilities
Proud Mother to Jacob– 7 yrs old with Down syndrome and Jared – 5 yrs old
The material contained in this presentation 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 qualified legal representative.
Agenda
•Medicaid - Waivers and Supports.
•Tips and Traps.
•Networking and Building Alliances.
•Advocacy
•General Information - Things you should know!
Medicaid
Medicaid is a federal entitlement program of medical assistance for people of low-income who are:
•Age 65 and older;
•Blind or have other disabilities;
•Children;
•Pregnant women;
•and families with children.
Medicaid Basics
•Funding for Medicaid comes from both state and federal dollars.
•Each state’s Medicaid program is unique. (must be in compliance with federal guidelines.)
Medicaid Eligibility
•Individual must meet both “categorical” and “financial” requirements.
•In Georgia, the following categories of people
are eligible for Medicaid:
•Parents and children,
•Pregnant women and infants,
•Children through age 18, and
•The aged, blind and disabled
•In Georgia, SSI recipients are automatically eligible for Medicaid.
What is the Katie Beckett / Deeming 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 child with a disability 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.
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
•Georgia uses Interqual.
3. Nursing Home LOC – 42CFR440.155
•DHR Rules 290-5-8 & OCGA 31-7-1(1)(b).
•Requires 24 hour nursing care.
Background on Katie Beckett-Deeming Waiver for Georgia
•KB Waiver was created to waive income limits of parents to establish eligibility for Medicaid in 1982.
•This is an optional Medicaid Program for Georgia.
•In 2001, the only national study ever conducted concluded that 20 states enrolled approximately 25,000 children in Medicaid through the KB waiver option. Georgia was the second highest ranked State for KB waivers.
•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 2,400 children have been denied since that time.
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)
•As of 1/17/07, DCH is currently conducting fair hearings for January 2006 requests! DCH has limited any patient liability to 3 months, should the hearing not turn out in the parents favor.
Appealing…..Tips & Traps
•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.
–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/
Tips and Traps
•Review the eligibility criteria by going to www.communityhealth.state.ga.us or http://dch.georgia.gov/00/channel_title/0,2094,31446711_31946814,00.html
•All applications 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).
–3rd Party Liability Health Insurance Info. Questionnaire (DMA 285).
Tips and Traps
•Fill out all forms out as a “Provider” NOT as a “Parent”.
•Always send everything to GA Healthcare Partners / DCH by certified mail / return receipt.
•#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.
•Question #7 on DMA6(A) “Does guardian think the applicant should be institutionalized? Yes or No”.
•Don’t date the DMA6(A) until submitting the entire application package. (Form only good for 30 days!)
•Include a picture of your child. Make it personal!
Home and Community Based Service Waivers
•Section 1915c of the Social Security Act allows the federal government to “waive” (ignore) certain Medicaid rules to enable states to cover home and community-based services as an alternative to institutionalization.
•These are called Home and Community Based Service Waivers.
Service Waivers
“Waive” Medicaid policies that require institutionalization of an individual before non-medical services can be provided.
•This allows states to offer programs that provide additional services
to Medicaid eligible individuals in their home and/or community.
Georgia’s Service Waiver Programs
•CCSP (Community Care Services Program)
•ICWP (Independent Care Waiver Program)
•CHSS (Community Habilitation Support Services)
•MRWP (Mental Retardation Waiver Program)
Community Care Services Program
The Community Care Services Waiver (CCSP) is for the elderly with disabling conditions and people with severe physical disabilities who need in-home support services.
To apply: CCSP Intake Unit (Atlanta Regional Commission)
(404) 463-3244 www.agewiseconnection.com
Eligibility: Must have a functional impairment. • Require nursing home level of care • Medicaid eligible • Any age
May include cost share which is determined by individual’s monthly income Resource limit. Individual may have up to $2,000 in resources.
Provides Adult Day Health • Personal Support Services • Out of Home respite care • Home delivered meals • Home delivered services, e.g. nursing, PT, OT, ST • Alternative Living Services • Emergency response services
Independent Care Waiver Program
The ICWP is for adults between ages 21 and 64, with physical disabilities or traumatic brain injury.
•Individuals must be able to direct their own care. Must be at risk of nursing home or hospital placement.
•Services include: case management, companion services, including homemaker services, personal support services, environmental modification, skilled nursing, specialized medical equipment and supplies, personal emergency response systems, counseling, occupational therapy, adult day services, respite care, physical therapy, and speech therapy.
Community Habilitation Support Services
§ This waiver program was created to serve individuals in institutional settings to facilitate their move back into the community.
§ Individuals are not being added to this program.
§ Individuals must be Medicaid eligible; have mental retardation since birth or before age 18, or another developmental disability since birth or before age 22, which requires services similar to those needed by people with mental retardation.
§ Services are residential supports, day habilitation and supported employment.
Mental Retardation Waiver Program
The MRWP provides a wide array of community based services to individuals with developmental disabilities.
To be eligible for an MRWP, an individual must:
•be Medicaid eligible;
•Have mental retardation or another developmental disability which requires services similar to those needed by people with mental retardation;
•Be at risk for going into an institution for people with mental retardation if unable to get the services you need in the community.
The MRWP is available to all ages.
MRWP Services
•Natural Support Enhancements
•Respite Care
•Specialized Services
•Medical Equipment
•Personal Support
•Day Support
•Day Habilitation
•Supported Employment
•Home Modifications
•Support Coordination
•Residential Training and Supervision
Support Coordination
•Support coordination is a separate State contract-
it does not use an individual's waiver money.
•Support Coordination is for those on the Short Term Planning List and for those enrolled in the program.
•The regional office contracts for support coordination.
MRWP
+The largest service waiver program in Georgia.
+The largest waiting list for services
(over 6,000 people statewide)
+Georgia has had this waiver since 1989.
MHDDAD Regional Offices
Region 1:
(706) 802-5272 or toll-free 1-800-646-7221.
Region 2:
(706) 792-7733 or toll-free 1-866-380-4835.
Region 3: (770) 414-3052. Clayton, Cherokee, Cobb,
DeKalb, Douglas, Fayette, Fulton,
Gwinnett, Henry and Rockdale
Region 4: (229) 225-5099.
Region 5:
(912) 303-1670 or toll-free 1-800-348-3503.
NOW Waiver will likely replace MRWP on 7/07
•Behavioral support up to $2,460 max a year
•Community access
•Community Guide services up to $ 2000 max a year
•Community living support
•Community residential
•Dental services for adults up to $ 500 a year
•Environmental accessibility adaptations up to $ 10,000 lifetime
•Financial support services
•Natural support training and individual directed goods and services
•Professional therapeutic services up to $ 1800 a year
•Respite
•Specialized medical equipment and supplies
•Support coordination
•Transportation up to $ 2800 a year
•Vehicle adaptation up to $ 6,240 max lifetime cap
Medicaid Covered Services
•GAPP (Georgia Pediatric Program)
•SOURCE (Service Options Using Resources in Community Environments)
The above are services (not waivers) covered under Medicaid.
Things to Know….
For those who already have a waiver
•Individuals who have a Medicaid waiver are entitled to
ALL the necessary services provided in that waiver program.
•Waivers can be used anywhere in the state of Georgia
but cannot be transferred out-of-state.
For those who are waiting for a waiver.
•Parents and family members need to advocate for services.
Networking & Building Alliances
•Contact Governor’s Council on Developmental Disabilities (GCDD) via e-mail (vmsuber@dhr.state.ga.us) regarding being placed on their “Moving Forward” e-mail update during the legislative session.
•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 .
Networking & Building Alliances
•Stress when talking to your legislators that the majority of the our 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 (AADD) is also involved in advocating for the disability waiting list. http://www.unlockthewaitinglists.com/
•Work with the media to get the message out and to help educate the general population of our concerns and abilities of our children (given the right resources)!
Networking
•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. (over 2,500+ members)
•My goal: Make the issues easy to understand and explain to advocates what they can do to influence change in this State.
•Additional information can be found at:
–www.kidshealthcarega.org
–http://www.lgtinc.org/authors/41/Heidi-J.-Moore
•Effective February 2007, Heidi now provides fee based consultation services for the Medicaid application process for the Katie Beckett Waiver and MRWP and other advocacy issues including education, healthcare and general information. Please contact her for additional information.
More Helpful Website Information
•GCDD guide to waivers :
http://www.openminds.com/indres/111306gawaivers.pdf
•Summary of GA Medicaid waivers :
http://www.unlockthewaitinglists.com/pdf/summaryofwaivers.pdf
•Medicaid’s Main ICF-MR page: http://www.cms.hhs.gov/medicaid/icfmr/default.asp
•Parent to Parent of GA KB Waiver Information:
http://www.parenttoparentofga.org/roadmap/insurance/insurancedeemingcover.htm
•Unlock The Waiting Lists website :
•http://www.unlockthewaitinglists.com/
•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
Update : Strengthening Families of Children with Disabilities (SFCD)- KB Waiver Foundation.
•In April 2006, the legislature approved $7.6 million to go towards families that have been denied from the KB waiver.
•A foundation was formed to manage this process. (Community Foundation of Greater Atlanta-CFGA)
•Eligibility: Families that were denied the Katie Beckett Waiver from Oct 2005 - to date.
•One time prepaid debit card will be paid in the amount of $2,600/child expires March 31, 2007.
•Funds are being set aside to address the long-term needs of medically fragile children and their families
•Currently, DHR is finalizing the Advisory Committee members.
•Contacts: Lita Ugarte- Program Officer- CGGA (404) 688-5525 and Brian Dowd with DHR bddowd@dhr.ga.gov 404-657-3592..
Advocacy Issues
Therapy Issues-
–Starting Sept. 1, 2006, Prior Authorizations are needed for more than 8 units/month for ST, PT, OT.
–Starting Nov. 1, 2006, CHOA no longer accepts outpatients for therapy.
–HB 549 – Defines “Medically Necessary Services” and being prescribed by Physician not defined by DCH. Also changes process and need for prior authorizations. Currently awaiting Governor's signature!
Other Advocacy Issues:
•Administrative Service Organization (ASO) coming in 2007 for all disability waivers.
•SB 10 Voucher program for children with IEP’s. Waiting Governor's signature.
•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.
Be Prepared, Advocate,
and Win……
YOUR Child Depends on YOU!
Assistive Technology
full story
printer version