Understanding Waivers in Medicaid Services

What in the world are waivers? March 8, 2023

What have we talked about so far? We talked about how Medicaid fits into all of the different ways you can pay for Title VI services. We talked about who is eligible for Medicaid We talked about the components of a claim. 2

Were are we going now? Today we are going to talk about the 19159c waivers. What makes these different then regular Medicaid. How do you get into the waiver? 3

Waiver? Why is it called a waiver? The term waiver is because the program targets a specific population or health need and waives a particular part of eligibility for the specific population it serves 4

What are the 1915c waivers? These 1915c waivers are the home and community based services waivers. Waivers provide services that align with Title VI services. The elder has to be enrolled in Medicaid and a waiver to get reimbursed for commonly paid for Title VI services. 5

1915c vs. regular Medicaid It s like a sandwich If you have Medicaid, you have meat and cheese. If you have the 1915c waiver, you have delicious home made bread with fresh veggies and condiments to make a sandwich. Every state has different sandwiches on the menu, but they are not paid for with Title VI Funds! 6

How Does it All Work Together? CHCBS Waivers (Elderly Blind and Disabled, Developmental Disability, Children s and more) 1.Personal Care 2.Homemaker 3.Transportation 4.Meals 5.Participant Directed Supports 6.Medication Management 7.Home Modification 8.Chore 9.And MANY OTHERS Early Periodic Screening, Diagnostic and Treatment (EPSDT) (Medicaid benefits for members under the age of 20) 1.All Medicaid coverable, medically necessary, services must be provided even if the service is not available under the State plan to other Medicaid eligibles. Medical necessity is determined on a case-by-case basis. No arbitrary limitations on services are allowed. Medicaid State Plan Services (Traditional Medicaid for everyone) Care Coordination 1.Primary Care 2.Emergency Services 3.Pharmacy 4.PT/OT/Speech 5.Behavioral Health 6.Dental Services (optional) 7.Non-Emergency Medical Transportation 8.Home Health PDN/CNA 1. Case Management 2. Functional Assessment 7

Why is it Complicated? Every state has different waivers, and every waiver has different eligibility and service options Every service provider for every waiver service must have an agreement or contract with some enrollment process 8

What Makes it Easier? Every state waiver has a waiver agreement with the Centers for Medicare and Medicaid This agreement is a tool for you to understand what is happening in your state. These agreements are up for review and approval on a regular basis 9

Did You Know? States are required to consult with the tribes in their state when they change or renew a waiver agreement with CMS! 10

Where to Begin ALMOST every state has a waiver designated for older adults with functional limitations Time to dissect your waiver options and figure out where your services overlap You can start small! Pick a service and figure out the system with a service you are comfortable with! 11

What Are The Keys? Case Management!!! The Case Managers for the waiver you want to work with hold MANY KEYS! Case Managers may be a local government, a private or non profit entity, or a managed care organization. 12

Case Management A Case Manager conducts an assessment and evaluates the ability to complete Activities of Daily Living (ADL) The assessment tool for your state s case management is most likely set 13

Case Management The ADLs are: bathing or showering Dressing getting in and out of bed or a chair Walking using the toilet eating 14

Case Management Having a trusted person understand the assessment process and be able to advocate for the elder is IMPORTANT! It is important to have people who are culturally competent and trusted by the elder assist in the process. 15

Service Definitions Medicaid has very set service definitions. You may call a service the same name as Medicaid, but the actions may be very different. Medicaid is PROBABLY not going to change their definitions which means you may have to that s OK! 16

Good News Because waiver services are select and defined, the billing is generally limited to a few codes. 17

Good News Because waiver services are select and defined, the billing is generally limited to a few codes. 18

More Good News You have a team to assist in achieving this goal! 19

Questions???? 20