HOME AND COMMUNITY B S (HCBS) W P

1 Copyright May 2009 Pennsylvania Health Law Project home AND COMMUNITY BASED SERVICES ( hcbs ) WAIVER PROGRAMS: A Manual for Consumers and Advocates in Southwestern PA 2009 Pennsylvania Health Law Project Page 2 Helpline: 1-800-274-3258 and 1-866-236-6310 (TTY) This manual was written by Erin E. Guay, MA, Pennsylvania Health Law Project Pittsburgh Office. Natalie Cerino, law student intern, assisted in the develop-ment of content and formatting of the manual. *PHLP gratefully acknowledges FISA Foundation for their support, including the funding of this manual. 2009 Pennsylvania Health Law Project Page 3 Table of Contents TOPIC PAGE NUMBER Introduction 4 Background 5 Eligibility 9 Applying for Waivers 11 COMMUNITY Choice 12 Accessing Waiver Services 13 Can Family Members Be Paid Caregivers?

2 15 Specific Waiver Programs Available In Southwestern PA Aging Waiver Long-Term Care Capitation Program (LIFE) Attendant Care COMMUNITY Services Program for People with Disabilities (OBRA, COMMCARE, and Independence Waivers) Autism Waiver AIDS Waiver Michael Dallas Waiver Person/Family Directed Support (PFDS) Waiver Consolidated Waiver 16 16 19 21 23 30 33 34 35 36 Appeals 37 State-Funded hcbs Programs 39 Long-Term Care Initiatives 41 2009 Pennsylvania Health Law Project Page 4 Introduction home and COMMUNITY -Based Services ( hcbs ) Waiver Programs are available in Pennsylvania to provide supportive services to qualified indi-viduals who wish to remain in their home and/or COMMUNITY rather than enter an institution (such as a nursing home or intermediate care facil-ity).

3 There are currently 13 programs available in Pennsylvania; 12 of these are available to people living in Southwestern PA. The hcbs Waiver programs differ in terms of the population they serve, the number of people they can serve, the application process, the crite-ria that must be met in order to qualify, and the services provided. Be-cause of all these differences, figuring out which program you qualify for, and which program may best meet your needs, can be overwhelm-ing. PHLP receives numerous calls to our Helpline each year from individuals who are unaware of the Waiver programs but who may benefit from the services provided by a Waiver.

4 Furthermore, individuals call us when they have questions about the Waivers or for assistance resolving a problem related to a Waiver program. This manual focuses on the Waiver programs currently available in Southwestern PA to adults with physical, sensory, and/or develop-mental disabilities; however, basic information about all the Waivers available in Southwestern PA is included. The intent of this manual is to help consumers, family members, providers, and advocates under-stand the various options available and help them navigate the system (from applying to the programs to actually accessing services under a Waiver). 2009 Pennsylvania Health Law Project Page 5 WHAT ARE hcbs WAIVER PROGRAMS?

5 These are programs that provide individuals at risk for institutionalization with an alternative to receiving services in an institutional setting by provid-ing both medical and non-medical services to the individual living in the COMMUNITY . Waiver programs provide certain services to individuals in their home or in another COMMUNITY -based setting in order to help them remain living independently in the com-munity (which is the preference of most individuals). The services provided under the various programs are not typi-cally covered under Medicare and/or Medical Assistance, especially on a long-term basis. This includes services such as skilled nursing coverage, personal care assistance services, and home modifications.

6 The services available differ depending on the Waiver program the person quali-fies for and the service plan that is developed to address the individual s needs. Individuals who qualify for a hcbs Waiver Program also receive full benefits through Medical Assistance. Background Medical Assistance (MA) is public health care coverage for low-income families, older adults, and people with disabilities. In or-der to qualify, individuals must fit into a covered group ( , persons with a permanent disability or persons over 65 years old) and then meet the income and resource requirements of that group. Once they qualify, individuals get a certain package of medical benefits.

7 MA covers certain medical services for chil-dren under 21 years old that are NOT covered for adults such as eyeglasses, hearing aids, shift nursing. MA can be someone s only health insurance or their secondary insurance (if he/she has other coverage like Medicare). Generally, individuals cannot receive services if they live in a Personal Care home . There are certain exceptions which will be noted in the discussion of the individual Waiver programs starting on page 16. 2009 Pennsylvania Health Law Project Page 6 WHY ARE THESE PROGRAMS CALLED WAIVERS ? The state Medical Assistance (MA) program must follow certain federal requirements.

8 Waivers allow states to ask the Federal Government to waive (not apply) certain re-quirements that otherwise apply to the MA program. Under Federal rules, MA Pro-grams must: - Make Medical Assistance coverage available throughout the state; - Follow the same eligibility rules and criteria statewide; and - Offer certain benefit packages based on category of eligibility (benefit pack-ages are the same across the state). When states apply for Waiver programs, they ask the Federal Government to waive these requirements so that they can: B Target a Waiver program to a particular area of the state where the need is greatest or to a certain group of people.

9 While most of the Waivers currently available in PA are statewide, there is one Waiver program that is only available to people living in Delaware County (the Elwyn Waiver). Also, the Long-Term Care Capitation Program (called the LIFE pro-gram in PA) is only available in Allegheny, Beaver, and Westmoreland counties in Southwestern PA. Waiver pro-grams also target certain groups of people (such as people who are technology dependent or people who have a cer-tain disease such as HIV/AIDS). B Offer individuals services through the Waiver programs that are not available to the general MA population. Waiver programs provide services such as personal assistance services (help with bathing, dressing, etc), skilled nurs-ing services for adults, and home /environmental modifications.

10 These services are not available to Medical Assistance recipients who do not qualify for a Waiver. B Offer certain services that are targeted to the population being served by that particular waiver program. The different waiver programs offer a distinct set of services designed to meet the needs of the population being served. For ex-ample, skilled nursing services are covered by some Waivers but not others. Background (continued) A Waiver Program must show that it can serve the waiver target population in the COMMUNITY for a lower cost than the same population can be served in an institutional setting. 2009 Pennsylvania Health Law Project Page 7 The following Waiver programs are available in Southwestern PA for adults with physical, sensory, and developmental disabilities.