VA Medicaid Waivers

At the bottom of the page is a glossary of words for the various services offered. Below this is a few documents that you may find to be helpful in your quest for Virginia's Medicaid Waivers.

A quick note to parents of children with special needs. VA's Medicaid Waivers DO NOT count the parents income. Only the child's income is counted. Even if a child receives SSI, they are well below the income limit, which is 300% of SSI.

On a separate note, if you are on the MR Waiver, please contact "The UP Center" in your area. They are THE MOST VALUABLE resource for this waiver.

Guide for Long-term Care Services in VA

VA's Medicaid Waivers for Persons with Disabilities, Their Parents & Their Caregivers

A Guide for Long-term Care Services in VA

ALZHEIMER's ASSISTED LIVING (AAL) WAIVER

OVERVIEW OF AAL WAIVER

The 2004 General Assembly mandated that DMAS develop a home- and community-based care waiver for individuals with Alzheimer’s disease or a related dementia. This waiver became a reality in 2005 and will initially serve 200 individuals. Participants must reside in an assisted living facility (ALF) licensed by the Virginia Department of Social Services, be in a safe and secure environment, meet Virginia’s criteria for nursing facility placement and be receiving an Auxiliary Grant (AG). In order to participate in the program, the ALF must meet certain criteria. The individual must not have a diagnosis of mental retardation or serious mental illness. It is estimated that the waiver would be approximately $50 a day per participant.

INDIVIDUALS ELIGIBILITY:

Individuals eligible to be placed on this waiver are currently either:

Remaining at home where an adult child is typically serving as primary caregiver;
Residing in an ALF without the benefit of specialized services, which are not provided in the base $50 per day rate;
Residing in a more expensive institutionalized nursing facility setting. Through the Alzheimer’s Assisted Living Waiver, recipients would be able to receive an appropriate level of care within special care units of ALFs

To initiate services, call the local department of social services to schedule an appointment to be screened for long-term care services. If hospitalized, request a screening from the hospital social worker or discharge planner. There is no cost to be screened to determine eligibility for the waiver. Individuals receiving AAL Wavier services must also be receiving an Auxiliary Grant (AG) and have no patient pay for waiver services. DSS determines eligibility for the AG program.

Enrollment is limited to 200 individuals and once 200 individuals have enrolled, DMAS will begin a waiting list.

AAL AVAILABLE SERVICES

Assisted Living: Assistance with activities of daily living, housekeeping, and supervision;
Medication Administration: Medication administered by a licensed professional;
Nursing evaluations: Evaluation by a registered nurse;
Therapeutic and Recreational Programming: Weekly activity program based on needs and interests;
Individuals receiving AAL Waiver services also receive services through the Medicaid program. Examples include medications (for those individuals not covered under Medicare), physician visits, acute care hospitalizations, and certain therapies

ELDERLY OR DISABLED WITH CONSUMER DIRECTION (EDCD) WAIVER

OVERVIEW OF EDCD WAIVER

Nursing facility pre-admission screening teams conduct a pre-admission screening. A pre-authorization contractor performs prior authorizations of services. Providers are an institution, facility, agency, partnership, corporation, or association that meets the standards and requirements set forth by DMAS and has a current, signed contract with DMAS to be a provider of waiver services.

INDIVIDUALS ELIGIBILITY:

The EDCD Waiver got its start in Virginia in 2005, merging two existing waivers. Eligible individuals must meet the nursing facility eligibility criteria;
EDCD service may be used while on a wait list for other waivers ( one must meet criteria for both waivers)

AAL AVAILABLE SERVICES:

Adult Day Health Care;
Medication Monitoring;
Personal Care Aide Services;
Respite Care;
Personal Emergency Response System (PERS);
Transition Coordiantion;
Transition Services

HIV/AIDS WAIVER

OVERVIEW OF HIV/AIDS WAIVER

The HIV/AIDS Waiver was developed in 1991. This waiver provides services to individuals who are diagnosed with the human immunodeficiency virus (HIV), who are experiencing the symptoms associated with acquired immune deficiency syndrome (AIDS), and who would otherwise require care provided in a nursing facility or a hospital.

INDIVIDUALS ELIGIBILITY:

Individuals must have a diagnosis of HIV or AIDS and be experiencing medical and functional symptoms associated with the disease that require hospital or nursing facility care to receive services under the waiver;
Individuals must meet Medicaid eligibility criteria as determined by the local department of social services. Individuals who are found to be eligible for the HIV/AIDS Waiver and choose to receive services may apply for Medicaid using special rules which allow the individual to receive a higher income and still qualify for Medicaid

HIV/AIDS AVAILABLE SERVICES:

Nutritional Supplements;
Personal Emergency Response System (PERS);
Transition Services;
Private Duty Nursing;
Personal Care (agency or consumer-directed options);
Respite Care (agency or consumer-directed options);

HOW TO INITIATE SERVICES:

Call the local department of social services in your area to schedule an appointment to be screened for long-term care services or if hospitalized, request a screening from the hospital social worker or discharge planner;
There is no cost to be screened to determine the eligibility for the waiver;
The DSS worker who processes the Medicaid application will use special rules that apply to individuals found eligible for the HIV/AIDS waiver

IFDDS - INDIVIDUAL AND FAMILY DEVELOPMENTAL DISABILITIES SUPPORT WAIVER

OVERVIEW OF IFDDS WAIVER

The IFDDS Waiver provides services to individuals who are 6 years of age and older who have a related condition and do not have a diagnosis of mental retardation who (1) meet the Intermediate Care Facility for the Mentally Retarded or Persons with related conditions (ICF/MR) level of care criteria (i.e., they meet two out of seven levels of functioning in order to qualify); (2) are determined to be at imminent risk of ICF/MR placement, and (3) are determined that community-based care services under the waiver are the critical services that enable the individual to remain at home rather than begin placed in an ICF/MR.

A related condition is a severe chronic disability, closely related to mental retardation/intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior, one which manifested before the person reaches age 22, likely to continue indefinitely and results in functional limitation in 2 or more following categories: health status, communication, task learning skills, personal/self care, mobility, behavior, and community living skills. Examples of related conditions may include but not limited to cerebral palsy, muscular dystrophy, asperger’s disorder, shaken baby syndrome, autism, spina bifida and epilepsy.

INDIVIDUALS ELIGIBILITY:

An individual is eligible for services based on three factors:
Diagnostic Eligibility
Functional Eligibility
Financial Eligibility
An individual who is at least 5 years/ 9 months may request or seek services through the local Child Development Clinic where you live.

Other Autism Medicaid resources:
Children under the age of six with autism may be eligible for services on the MR/ID waiver. You may contact the local Community Service Board (CSB) in your area to obtain details;
Children less than 21 years of age may receive services through The Early and Periodic Screening, Diagnosis and Treatment Services (EPSDT) services click for details Maternal and Child Health
EDCD waiver may provide some supportive services while waiting for services from another waiver (see below) Contact your local Department of Social Services in your area to obtain details

IFDDS AVAILABLE SERVICES:

Assistive Technology;
Attendant Services;
Companion Services (Agency or Consumer Directed);
Crisis Stabilization;
Crisis Supervision;
Day Support;
Family and Caregiver Training;
Environmental Modifications
In-home Residential Support;
Personal Care Services;
Personal Emergency Reponse System (PERS);
Prevocational Services;
Respite Care (Agency or Consumer Directed);
Skilled Nursing Services;
Supported Employment;
Therapeutic Consultation;
Transition Services

TECHNOLOGY ASSISTED (Tech) WAIVER

OVERVIEW OF TECHNOLOGY ASSISTED WAIVER
The Technology Assisted Waiver is designed to afford individuals who meet the age appropriate waiver and financial eligibility criteria a choice of home and community based care services rather than reside in an acute care hospital, long stay hospital or specialized care nursing facility. Eligible individual’s are both children and adults who are chronically ill or severely impaired, needing both a medical device to compensate for the loss of a vital body function and require substantial and ongoing skilled nursing care to avert further disability or to sustain their lives.
WAIVER ENROLLMENT
Regardless of age, the request for consideration for enrollment into the waiver may originate from acute care hospitals, skilled nursing facilities, through the local department of social services or the health department in which the individual lives or from the community. All individuals must have a Virginia Universal Assessment (UAI) Instrument completed by the local preadmission screening team in the community, nursing facility or hospital discharge planner. The Department of Medical Assistance Services completes the final waiver eligibility determination and enrollment as well as the authorization for skilled private duty nursing services.
CRITERIA
Waiver applicants must meet the following age appropriate medical and functional specialized care nursing facility criteria:
Children under the age of 21 must require daily dependence on device-based respiratory or nutritional support, including mechanical ventilators, tracheostomy care, oxygen, tube feedings, prolonged intravenous medication administration or peritoneal dialysis and need substantial and ongoing nursing care as indicated by a score of 50 or greater on the Pediatric Scoring Tool;
Adults 21 or older must require ongoing and substantial nursing care and be dependent on mechanical ventilation or meet all of the complex tracheostomy criteria as indicated on the Adult Scoring Tool;
Individuals under the age of 21 who meet certain criteria based on various methods of respiratory or nutritional support;
Individuals who meet Medicaid eligibility criteria as determined by the local department of social services. Parents’ income and resources are not considered by DSS when making a financial eligibility determination for a child under the age of 18 who is enrolling in the Tech Waiver;
Individuals enrolled in the waiver must have a backup plan which includes a primary caregiver who assumes responsibility for and provides skilled nursing care at least eight hours a day and when the skilled agency nurse is not available. All caregivers must be trained in the waiver individual’s care.
Applicants who are eligible for third-party payments for private duty nursing services are not eligible for enrollment into the waiver. When third-party coverage is voluntarily dropped, enrollment can not be considered until 365 days have passed since the discontinuance occurred.
AVAILABLE SERVICES:
Assistive Technology;
Environmental Modifications;
Personal care (Adults Only);
Personal Emergency Response System (PERS);
Skilled Private Duty Nursing;
Skilled Private Duty Nursing - Respite;
Transition Services;
WHO CAN INITIATE SERVICES?
There is no cost to be screened to determine eligibility for the waiver. There may be a patient pay for services based on the individual’s earned and unearned income. The local department of social services eligibility worker will determine if an individual has a patient pay.
WHO COORDINATES CARE ONCE THE SCREENING PROCESS HAS BEEN COMPLETE?
The screening team will forward the screening to the Department of Medical Assistance Services (DMAS) where a care coordinator is assigned and the final determination for enrollment based on state and federal criteria, policy and regulations is made. The care coordinator will assist with a smooth transition to waiver services communicating with your physician and the agency provider you have chosen and authorize skilled private duty nursing hours based on assessed needs.

Day Support (DS) Waiver

SERVICES

Effective August 28, 2006 daily management of the waiver was shifted from DMAS to the Department of Behavioral Health and Developmental Services, Office of Mental Retardation (OMR).

For information, please refer to the DBHDS website at:

http://www.dbhds.virginia.gov/ODS-default.htm

Intellectual Disabilities/Mental Retardation (ID/MR) Waiver

SERVICES

Effective August 28, 2006, daily administration of the waiver will be managed by the Department of Behavioral Health and Developmental Services, Office of Mental Retardation (OMR), in collaboration with DMAS.

For information, please refer to the DBHDS website at:

http://www.dbhds.virginia.gov/ODS-default.htm

Glossary

Assistive technology: specialized medical equipment, supplies, devices, controls and appliances, which enable the individual to better perform activities of daily living, to perceive, control or communicate with his/her environment, or are necessary to his/her proper functioning at home and in the community.

Companion services: provide socialization and other non-medical support to adults 18 and older at home or at various locations in the community. The focus is on “instrumental activities of daily living” (e.g., assistance with housekeeping activities, preparation of meals, shopping). This service may be agency-directed or consumer-directed.

Consumer-directed services: offer the individual/family the option of hiring workers directly, rather than using traditional agency staff.

Crisis stabilization: expert intervention (and may include one-to-one supervision) for someone with mental retardation who is experiencing serious psychiatric or behavioral problems which jeopardize his/her current community living situation. The goal is to avoid emergency psychiatric hospitalization or institutional admission or other out-of-home placement, as well as to stabilize the individual and strengthen the current living situation so the individual can be supported during and beyond the crisis period.

Day support: training, and support away from home to help the individual to learn new skills for using the community. These services may be located in a “center” or provided in regular locations in the community.

Department of Medical Assistance Services (DMAS): the state agency responsible for Medicaid-funded services in Virginia.

Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS): the state agency that conducts many of the day-to-day functions of MR Waiver operations and oversight.

Department of Social Services (DSS): the state agency that determines eligibility for Medicaid benefits and “patient pay” amounts (i.e., what an individual owes toward the cost of his/her own MR Waiver services).

Environmental modifications: physical adaptations to an individual’s home or vehicle needed by the individual to ensure his/her health, welfare and safety or enable him/her to experience greater independence in the home and around the community.

Intermediate Care Facility for Persons with Mental Retardation (ICF-MR): A segregated Medicaid-funded setting in which nearly all of an individual’s habilitation, medical, nutritional and therapeutic needs are met in one place. This is the institutional placement that is "waived" when an individual chooses the MR Waiver.

Level of Functioning Survey: the tool used in the MR Waiver to determine if an individual meets the level of care required in an ICF-MR, thereby meeting one of the criteria for eligibility for the MR Waiver. It is completed by the case manager every year.

Patient Pay: a cash amount, determined by the local Dept. of Social Services, that some individuals owe each month toward the cost of their own MR Waiver services. Patient Pay is usually the amount in excess of the standard monthly personal allowance, which is based upon the maximum amount of the Supplement Security Income (SSI) payment. People who work are afforded a higher allowance. It is not the same as a co-pay for medications in that it is based on the individual’s monthly income and the full amount is paid only once per month.

Personal assistance: direct support with activities of daily living (e.g., bathing, toileting, personal hygiene skills, dressing, transferring, etc.), instrumental activities of daily living (e.g., assistance with housekeeping activities, preparation of meals, shopping, etc.), accessing the community, taking medication or other medical needs, and monitoring the individual’s health status and physical condition. These services may be agency-directed or consumer-directed.

Personal emergency response systems (PERS): an electronic device that enables the individual who is alone to access a centralized, staffed emergency center in the event of an emergency.

Prevocational services: training and assistance to prepare an individual for paid or unpaid employment. These services are not job task-oriented. These are for individuals who need to learn skills fundamental to employment such as accepting supervision, getting along with co-workers, using a time clock, finishing assignments.

Residential Support Services: Help to learn new skills to live safely and productively at home and in the community for people who live in a variety of settings (apartment, family home, group home, sponsor home).

Respite services: temporary, substitute care for that which is normally provided by the family or other unpaid, primary caregiver of an individual. These short-term services may be provided because of the primary caregiver’s absence in an emergency or the on-going need for relief. These services may be agency-directed or consumer-directed.

Skilled nursing services: nursing services ordered by a physician for individuals with serious medical conditions and complex health care needs. This service is available only for individuals for whom these services cannot be accessed through another means. These services may be provided in an individual’s home, community setting, or both.

Supported employment: supports to enable individuals with disabilities to work in settings in which persons without disabilities are typically employed. They may be provided to one person in one job (e.g., a person working to bus tables in a restaurant) or to several people at a time when those individuals are working together as a team to complete a job (e.g., such as a grounds maintenance crew).

Therapeutic consultation: expert training and technical assistance in any of the following specialty areas to enable family members, caregivers, and other service providers to better support the individual. The specialty areas are: Psychology, Behavior, Speech and Language Pathology, Occupational Therapy, Physical Therapy, Therapeutic Recreation and Rehabilitation Engineering.