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FAQ 2: Medicaid Home and Community Based Waiver Programs

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Waivers, Segments 1-9:

FAQ 2: Waivers - Introduction


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The Partnership: The Pennsylvania Training Partnership for People with Disabilities and Families.
Frequently Asked Questions, FAQ #2: Waivers - Medicaid Home and Community Based Waiver Programs.
Revised Summer 2011.


What is a Waiver?


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Waiver is a short way of saying "Medicaid Home and Community Based Waiver Program." Waivers pay for supports and services that eligible people need to live in the community instead of an institution.

Waiver programs are funded by federal and state monies. The federal (Medicaid) portion of funding is matched by the state. In Pennsylvania, the ratio is approximately 56% federal to 44% state monies (July 2011).


Why do we have Waivers?


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Katie Beckett was a young girl with significant health care needs. She lived for three years in a pediatric intensive care unit in a hospital. Her parents wanted to move her home. At the time, she was not eligible for Medicaid funding to pay for her care at home because her parents' income and resources were above the financial eligibility limit. If she lived in the hospital or nursing home, their income was not considered. Her parents advocated to have the federal rules changed, and in 1981, Congress created the Home and Community Based Waiver Program. This allowed services and supports to be provided in the community and to be paid for with Medicaid funds.

In a nutshell, we have Waivers so that people who receive Medicaid (also called Medical Assistance in Pennsylvania) funding can choose community based services in place of institutional or medical facility based care.

Waivers are designed to provide support for people to live and work in their communities. Waiver services can go hand-in-hand with the supports that family, friends, schools and community organizations provide. Waiver services can be used to support people who live in their own homes, families' homes, or in licensed and unlicensed residential settings, such as group homes, Community Living Arrangements, and supported living. People can receive a few or many services through the Waivers depending on what their needs are. For example, someone who gets all the support she needs in her home from her family and friends might need support to keep her job. The Waiver pays for a job coach to work with her a couple of hours a week. Someone who needs quite a bit of paid support might be a man who lives with his elderly mother. His mother is unable to provide all of his support, so a Waiver pays for his support to participate in social activities several days a week, to participate in some volunteer activities, and for someone to assist him on a daily basis with shopping, preparing food, personal care, laundry and cleaning his home.


How does Pennsylvania get Waivers?


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For Waivers that support people with intellectual disabilities/mental retardation, the Department of Public Welfare, Office of Developmental Programs (ODP) applies to the federal Centers for Medicare and Medicaid Services (CMS) to have Waivers approved. The State must outline eligibility criteria, types of services provided, and assurances about how the services will be delivered to recipients, including how the state will ensure the health and welfare of Waiver participants. Once a state's Waiver application is approved, CMS will monitor the Waiver program to ensure compliance with federal rules. ODP must submit a renewal request 3 years after the initial approval and then every 5 years to continue receiving Waiver funding.


What Waivers are Available Through the Office of Developmental Programs?


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The Office of Developmental Programs (ODP) in Pennsylvania offers two Waiver programs for people with intellectual disabilities/mental retardation. One is the Person/Family Directed Support (P/FDS) Waiver and the other is the Consolidated Waiver. You must meet the eligibility criteria for the Waiver and be at least 3 years old to apply.

The Office of Developmental Programs also offers an Adult Autism Waiver. For more information on the Autism Waiver contact the Bureau of Autism Services at 1-866-539-7689.


The Person/Family Directed Support (P/FDS) Waiver:

The P/FDS Waiver is known as the "small" Waiver because it has a cap of $26,000 (2011) per person each fiscal year. This funding can be used to get the support you need to participate in a wide range of activities in your community. With your Supports Coordinator, you will write an Individual Support Plan (ISP) that describes you, your life, your goals, and defines the supports and services you need to be successful. Your budget will be based on the needs identified through the planning process and in your approved Individual Support Plan (ISP). The ISP is authorized by your Administrative Entity (AE)/County. The P/FDS Waiver cannot pay for residential care in a licensed setting but it can help provide the support you need to live in your own home or your family's home. The cost of Supports Coordination does not count against the annual cap of $26,000.

The Consolidated Waiver:

The Consolidated Waiver is sometimes referred to as the "big" Waiver, residential Waiver, or the 2176 Waiver. There is no set dollar cap on your individual budget to purchase needed supports that you could receive on this Waiver. The amount of support you receive and your budget will be based on your assessed needs, as determined through the planning process and outlined in your Individual ISP. The ISP is authorized by your AE/County. This Waiver can provide the same supports and services available in the P/FDS Waiver, but also can include out-of-home residential care in the community. With both Waivers, your plan and your supports should be updated at least once per year or any time your needs change significantly.


What supports and services are available through the Waiver?


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Supports and services will vary from person to person. The waiver supports you receive are based on your assessed needs and your Individual Support Plan (ISP). This plan should be written by you and your family with your Supports Coordinator and any other people in your life that care about you and support you. It could include your friends, your neighbors, your employer, your service providers and your teacher. As a team, you will develop a plan to help you meet your needs and reach your own individual dreams and desired outcomes.

As part of this planning process, you will participate in a standardized needs assessment. The Office of Developmental Programs has chosen the Supports Intensity Scale (SIS)™ and the PA Plus as the standardized needs assessment. In the planning process you will also write outcomes that will lay out what you want to happen in your life, action steps and the support and services you will need to reach your desired outcomes. Only supports and services outlined in Pennsylvania's Intellectual Disabilities/Mental Retardation (ID/MR) Waivers can be funded under these Waivers. You should review the Service Definitions to better understand what is available to you through the Waivers. You can obtain a copy of the Service Definitions by calling The Partnership's toll free number 1-866-865-6170 and requesting a copy, or through The Partnership website at www.TheTrainingPartnership.org.

There may be things you need that are not covered under the Waiver. Your team can help you find other ways to meet these needs. These other ways can include natural supports, such as a neighbor or friend doing something free of charge. They can also include community supports and services available to all people in your community, like parks and recreation or local community organizations. All Waiver services outlined and approved in your ISP must be provided to you through the resources of the Waiver. If you are in the Person/Family Directed Support (P/FDS) Waiver, you are eligible to be funded up to the cap for services approved in your ISP. If you receive the Consolidated Waiver, there is no individual cap. Medicaid rules require that all services approved in your ISP to address your identified needs must be provided to you.

If needed services are denied, reduced, terminated, or suspended, you have the right to appeal. You should be given written notification whenever this happens. There is a formal Fair Hearings and Appeals process in place for you.

Supports and services available in the P/FDS and Consolidated Waivers include:

  • Supports Coordination
  • Companion Services
  • Homemaker/Chore Services
  • Assistive Technology
  • Specialized Supplies
  • Unlicensed Home and Community Habilitation
  • Unlicensed Residential Habilitation
  • Licensed Day Habilitation
  • Supported Employment—Job Finding and Job Support
  • Transitional Work Services
  • Prevocational Work Services
  • Home Adaptations
  • Vehicle Adaptations
  • Transportation
  • Supports Broker Services
  • Physical Therapy
  • Occupational Therapy
  • Speech/Language Therapy
  • Nursing Services
  • Behavior Therapy
  • Behavioral Support
  • Visual/Mobility Therapy
  • Respite Services for the Care Giver
  • Home Finding
  • Educational Support Services

What services are available in the Consolidated Waiver but not the P/FDS Waiver?


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Only one service is available in the Consolidated Waiver but not the P/FDS Waiver. Licensed Residential Habilitation is only available in the Consolidated Waiver. Licensed Residential Habilitation covers services provided in Community Living Arrangements (sometimes called group homes) and in licensed Lifesharing homes.

Service Definitions for each support or service are written in the Waivers and in the Service Definition Bulletin. Please note that some services have limitations on when and where you receive services, and how much of the service you can receive. A summary of the services and their definitions is available in Understanding the Office of Developmental Programs in Pennsylvania: Mental Retardation and Autism Services, often referred to as the "Gold Book." (Please see resource listing at the end of this booklet for more information.) Copies of the complete Waivers, the "Gold Book" and the Service Definition Bulletin are also available on The Partnership website, www.TheTrainingPartnership.org.


Can I choose who provides services?


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Yes, you have a right to choose who provides your Waiver services and supports. Federal rules require that a person receiving supports has the opportunity to choose any willing and qualified Medicaid Waiver provider whose costs are within reasonable limits.

The Office of Developmental Program's policy dictates that all individuals have choice, control, community, relationships, authority, responsibility and the other values set forth in the Everyday Lives doctrine. The principles of Everyday Lives are statewide policy as outlined in ODP Bulletin 00-03-05.

Your Administrative Entity (AE)/County can provide you with a list of qualified Medicaid Providers. You can also get one on the Internet through the Provider Profiles page. Please see the back of this booklet for the link to that website.

If you choose, you should have the opportunity to direct your own supports. Ask your Supports Coordinator for information about Participant-Directed Services. One way to have more control over your services is to use Financial Management Services (FMS). An FMS is an organization which will help you with some of the employer responsibilities. This will give you the freedom to choose your support personnel and design your services to meet your specific needs. Every AE/County is required to have FMS available for you. Once your budget is created and approved by you and your AE/County, you can use an FMS to exercise the authority to manage your support professionals to best meet your needs.


How do I apply for a waiver?


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You can apply for Waivers at your County Mental Health/Mental Retardation (MH/MR) Office. Waiver application is separate and apart from registration for Intellectual Disabilities/Mental Retardation (ID/MR) services. You must be registered and eligible for ID/MR services to even apply for an ID/MR Waiver. If you are eligible for ID/MR services and you receive Medical Assistance (MA), your Supports Coordinator will assist you in completing the application for the Waiver. You will do this by filling out the Waiver Application and Service Delivery Preference form (DP 457). Using the DP 457, you will select whether you want your services provided in an Intermediate Care Facility for People with Mental Retardation (ICF/MR) or in a home- and community-based setting. If you choose to receive your services in home- and community-based settings, you will also formally apply for the Waiver using this form.

To be eligible for an Intellectual Disabilities/Mental Retardation Waiver you must meet the following criteria:

  1. You need to meet the requirements for ID/MR services in Pennsylvania (have a diagnosis of ID/MR).
  2. You must need the same level of care provided in an Intermediate Care Facility for People with Mental Retardation (ICF/MR). This is determined by a Qualified Mental Retardation Professional (QMRP) and a medical evaluation.
  3. You must need active treatment (means you need at least one on-going waiver service).
  4. Your income can not exceed 300% of SSI ($2022 per month— 2011 figures) and there are limits on the value of your assets. However, you can own a home, a car and a burial plot. Questions about financial eligibility can be answered by the local County Assistance Office (CAO).

After you apply, you will be notified in writing within 30 days if you are eligible for an ID/MR Waiver. The decision will say that you are "likely" to be eligible for the waiver. This is a preliminary decision. When funding is available for you to be enrolled in a Waiver, the AE/County program will verify that you meet all of the conditions to be on an ID/MR Waiver. If you are not eligible for any reason, you may appeal that decision.


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