What is Maryland's Medicaid Home and Community-Based Service (HCBS) Waiver?
It is a way for DDA to receive matching federal dollars for funds spent by DDA on community services provided to Medicaid-eligible individuals without that person having to enter an institution.
The Social Security Act gives states the option of requesting waives of certain federal requirements in order to develop community-based alternatives to placing Medicaid-eligible individuals in hospitals, nursing facilities or institutions. Maryland's HCBS waiver for individuals with developmental disabilities supports the development of home and community-based alternatives to placing individuals in institutions operated by the Developmental Disabilities Administration (DDA) or in out-of-state institutions. Additionally, it makes home and community-based services available to individuals who would otherwise qualify for Medicaid only if they were in an institutional setting.
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Whom does the waiver serve?
This waiver serves both eligible adults and children with developmental disabilities who qualify for Medical Assistance (MA).
Who is eligible?
Individuals are eligible who have been determined to have full eligibility status (rather than eligibility for support services only), have been determined by the Department of Health and Mental Hygiene's Division of Eligibility Waiver Services to be eligible for Medicaid under this waiver.
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Is Medicaid/Medical Assistance considered welfare?
Medical Assistance is not welfare. It is health insurance coverage for eligible individuals. It assists people obtaining needed medical care and services including waiver services. Waiver services are not covered by private insurance.
What if our family income is too high to qualify?
Waiver eligibility for Medicaid counts only the applicant's income regardless of his/her age.
How is Medicaid eligibility under the waiver different from regular Medicaid eligibility?
Under the waiver, Medicaid eligibility is determined based only on the applicant's income and assets, not the income and assets of family members or other individuals that may reside with them. Also, the amount of monthly income an individual is allowed to receive and still qualify for Medical Assistance card is significantly higher ($1,737 under the waiver compared to $350 under regular MA eligibility). The Social Security Administration adjusts these amounts annually. Under the waiver, the applicant's assets, unless protected in certain kinds of trust funds, must be under $2,500. This is the same asset threshold as regular Medicaid eligibility.
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What are the benefits from enrolling my relative in the waiver?
Individuals enrolling in the waiver benefit from the guarantee of a resource coordinator and access to other Medicaid services. These other services range from prescription medication to certain therapies. The Medical Assistance card can be used to cover certain health and medical expenses that are not covered by private insurance. Additionally, enrolling in the waiver ensures your right to request a Fair Hearing within ninety (90) days of the date you are notified of any change in your services.
Each enrollment in the waiver helps other people with developmental disabilities that are waiting for services. The federal dollars received for services already provided to you or your relative and paid for by DDA are used to serve additional people who are waiting for services. The more people enrolled in the waiver, the broader the base for support for additional service you or your relative may need. If you or your family member is receiving services from DDA, you are benefiting from the people who have already enrolled in the waiver.
What services are covered under Maryland's Waiver for Individuals with Developmental Disabilities?
Case management services (resource coordination/targeted case management), community residential services, community supported living arrangements, respite care services, behavioral support services, and adult day habilitation including supported employment.
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Is there a risk that the waiver could be discontinued?
While there is never a guarantee that a federal program will continue, enrolling in the waiver creates a strong base of support for community services by supporting a claim of one federal dollar for every state dollar spent on waiver services. This not only allows DDA to serve more people, it requires that Maryland give assurance to the US Government that it will continue to put up its share of the cost. A right to appeal protects against any reduction in Medicaid service. Maryland's Waiver for Individuals with Developmental Disability has operated continuously since 1984.
Is there a risk of losing Medical Assistance coverage?
A change in the amount of the person's income or assets or other eligibility factors could cause a person to lose Medical Assistance eligibility under the waiver. Given the higher income threshold, this happens less than it does for Medical Assistance recipients not enrolled in the waiver.
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After enrolling in the waiver, can a waiver-covered service be denied?
There are two situations under which waiver covered services could be denied. First, if the need for a particular service is not agreed to and documented in the individual plan of care developed by the team, requested service cannot be approved. Second, if the additional service requested is one that is considered to duplicate the service currently received, only one of the services will be approved. Any decision made regarding a waiver recipient's service(s) may be appealed and Maryland is required to give waiver participants information on how to make such appeals.
What regulations and monitoring apply to waiver services?
All waiver services are subjected to the same quality assurance requirements that apply to non-waiver service Compliance monitoring is performed through a combination of the Department of Health and Mental Hygiene's - Office of Health Care Quality (OHCQ), resource coordinators and regional office staff. Periodically, the Regional Office of the federal Centers for Medicare & Medicaid Services (CMS) will conduct a review of waiver services.
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Have COMAR regulations been written for Maryland's Waiver for Individuals with Developmental Disabilities? What Chapter?
-COMAR 10.09.26 is the Medicaid regulation governing the Medicaid Home & Community-Based Waiver for Individuals with Developmental Disabilities. Medicaid staff is currently revising these regulations to reflect the changes in the renewed waiver.
Why would a person's Medical Assistance card become invalid after he/she is enrolled in the waiver program/accepted as a Medical waiver conversion?
Being enrolled in Maryland's Waiver for Individuals with Developmental Disabilities should not make a person's Medical Assistance card invalid. The Department of Health and Mental Hygiene's Division of Eligibility Waiver services continually reevaluates (referred to as a re-determination) the individual's financial information in accordance with regulations. If a person's income and assets exceed these limits, then he or she is determined ineligible for medical assistance. If determined ineligible for medical assistance, the person would have to be discharged from the waiver.
The re-determination process involves the Division of Eligibility Waiver services sending a request for information to one of the following: the provider agency, family or Resource Coordinator. If this information is not returned by the timeframe stated in the request, the person will lose medical assistance.
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How does a person re-enroll in Medical Assistance and in the waiver? Who does this?
If a person has been discharged from Maryland's Waiver for Individuals with Developmental Disabilities, a new waiver meeting will be held to produce a new plan followed by the completion of a Medical Assistance application. The Resource Coordinator is responsible for handling this.
Do individuals, living in their own homes or with their family, lose their State Plan Personal Care Services if they enroll in the waiver?
Individuals living in their own homes or in their family's home will not lose State Plan Personal Care Services when they enroll in the waiver if they only receive a day program or a supported employment placement.
Individuals living in their own home will lose their State Plan Personal Care services when they enroll in the waiver if they receive CSLA services that duplicate the services received under the State Plan. However, DDA may want to replace the loss of State Plan Personal Care services to prevent the individual from losing any service.
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Can providers bill individuals for the cost of their transportation if the individual is enrolled in the waiver?
No, they cannot, for several reasons. first, transportation to from Day Programs remains on the DHMH Non-Chargeable Services List, meaning that the provider of the service (transportation) cannot charge the consumer for that service. Second, providers of day habilitation are reimbursed for transportation under the Fee Payment System. Third, agencies providing supported employment are expected to meet the transportation needs of the people they serve. The DDA's Home and Community-Based Services waiver for individuals with developmental disabilities has always included language prohibiting the charging of transportation cost for attending supported employment.
What Developmental Disability services and State Plan services, if any, are exclusive?
Individuals receiving residential services in (including Alternative Living Units, Group Homes or Individual Family Care and Community Supported Living Arrangements) through the waiver cannot also receive State Plan Personal Care services in their residence. Individuals receiving day habilitation services (including Day Programs and Supported Employment) through the waiver cannot also receive State Plan Medical Day Care services on the same day.
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If a family has private health insurance and their relative enrolls in the waiver, the family and the individual must use Medical Assistance (MA) coverage for all of their health and medical needs.
Not true. The MA card covers only the individual who is enrolled in the waiver. It can be used to pay for certain health and medical expenses for that individual that are not covered by private insurance. MA is always the payer of last resort.
Enrolling in the waiver means more paperwork for my provider and me and means more people coming to my house.
There are only two more pages required for waiver participants compared to what is required for consumers not enrolled in the waiver. There is a one-page form to enroll in the waiver and a one-page certification and recertification form.
Providers are not required to submit additional documents for waiver participants receiving residential or day habilitation services. For individuals receiving supported employment or personal support, providers must submit one monthly invoice (Community Based Services Invoice - DHMH248) based on that waiver participant's attendance to enable DDA to prepare and submit a claim for federal reimbursement.
The DDA requirements that apply to in-home reviews are the same whether an individual is enrolled in the waiver or not.
Annually, for individuals not receiving SSI, the The Department of Health and Mental Hygiene's Division of Eligibility Waiver services will send a request for information to one of the following: the residential provider agency, the family or the resource coordinator to gather information to make a determination about continued medical assistance eligibility. If this information is not returned by the timeframe stated in the request, the person will lose medical assistance.
Enrolling in the waiver means the provider is paid less for serving my family member.
Not true, because DDA pays the same rates for services whether the consumer is enrolled in the waiver or not.
Enrolling in the waiver results in individuals and/or their families being charged for their care.
Not true. Individuals receiving residential services who have earned or unearned monthly income are required to contribute to their cost of care whether they are in the waiver or not. The formula for calculating this contribution is the same for waiver participants as for non-waiver consumers.
Once a person is enrolled in the waiver, he/she is entitled to receive all services that theoretically could be available under the waiver.
Not true. A waiver enrollee's right to receive a service is dependent on a finding that the individual needs the service, based on appropriate assessment criteria that the State develops and applies fairly to all waiver enrollees.
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