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The
Facts About the Community
Alternatives Waivers
Revised January
2004
(Graphics
have been removed from this internet version)
Table of Contents
About This Booklet...
THE INFORMATION PROVIDED
in this booklet comes from the
Centers for Medicare and Medicaid Services (CMS), in
response to questions asked about Medicaid Title XIX
Home and Community-Based Services Waivers, also known
as the Community Alternatives Program (CAP) Waivers.
In Washington State, nearly one
third of individuals eligible to receive
services from the Department of Social and Health
Services (DSHS) Division of Developmental
Disabilities (DDD) are on the CAP waivers.
CAP
waiver services are funded in part by federal
Medicaid dollars, and the federal government has
specific rules that states must follow in order to
receive federal funding. CMS is the federal
funding agency that enforces compliance with
Medicaid rules.
Ask your case manager if you are eligible to
receive services through the CAP waivers. If
so, you have a right to receive appropriate and
timely services that meet your needs (or the needs
of your son or daughter with a developmental
disability).
What are the CAP Waivers?
For
individuals with a developmental disability who
are a client of the DSHS Divison of Developmental
Disabilities and require the level of support provided in an
Intermediate Care Facility for the Mentally Retarded
(ICF/MR), the state offers the option of home and
community-based services.
Funding for these services comes through a
federal program under Title XIX Medicaid called the
Home and Community-Based Waivers, known in this state
as the Community Alternatives Program (CAP) Waivers.
The CAP waivers
allows the state to use Medicaid
funding while "waiving"
Medicaid rules that require services to be provided
in an institutional setting.
The purpose of the
waivers are to provide integrated, community-based
services to individuals with developmental
disabilities.
Home and
Community-Based Services (HCBS) Waivers
The Basic Waiver
The Basic Waver is intended for people who
live with their families or in their own
homes. |
Services Covered:
-
Hours per year
available for Person Care and based on assessed
need.
-
$6,500 per year is
available for any combo of Supported Employment,
Community Access, Pres-vocational or Person to
Person services.
-
$1,425 per year
available for any combo of Behavior Management
and Consultation, as well as other Medical
Services defined as not covered under the
Medicaid program or readily available in a
particular location.
-
$6,000 per year
available for Emergency Assistance.
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The Basic Waiver Plus
The Basic Plus Waiver is intended for people
who live with their families or in another
setting with assistance and at high risk of
out of home placement. |
Services Covered:
Hours per year
available for Person Care and based on assessed
need.
$9,500 per year is
available for any combo of Supported Employment,
Community Access, Pres-vocational or Person to
Person services.
$6,070 per year is
available for any combo of skilled nursing and
all of the special services in the Basic Waiver.
$6,000 per year
available for Emergency Assistance.
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Core Waiver
The Core Waiver is intended for people who
need up to 24-hour residential services or
who live at home but are at immediate risk
of out of home placement due to
extraordinary behavioral challenges, has had
18 or more days of inpatient psychiatric
care in last 12 months or requires daily to
weekly one-on-one support, physical or
health needs. |
Services Covered:
Residential
Services, Supported Employment, Community
Access, Person to Person services, Behavior
Management and Consultation, Personal Care, as
well as other Medical Services defined as not
covered under the Medicaid program or readily
available in a particular location.
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Public Safety Waiver
The Public Safety Waiver is intended for
people who need 24-hour on site awake staff
supervision and therapies to maintain their
own and community safety. |
Services Covered:
Residential
Services, Supported Employment, Behavior
Management and Consultation, as well as other
Medical Services defined as not covered under
the Medicaid program or readily available in a
particular location.
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Who
is Eligible?
Eligibility for waiver services
includes people
with
developmental disabilities who are:
- A client of DSHS Division of Developmental
Disabilities;
- Eligible for Medicaid services in an institution;
- Determined to need home and community-based services in order to live in the
community; and
- The individual's gross income does not
exceed 300 percent of the SSI benefit amount and
the individual's resources do not exceed $2,000.
The DSHS Division of Developmental Disabilities (DDD) has a
set number of openings available under each of the CAP
Waivers.
Ask your case manager if you are
eligible to be on the CAP waivers.
Once you are determined eligible for
waiver services, you must be informed of any
feasible alternative and given the choice of
either institutional or home and
community-based services. If you have been
determined ineligible, you have the right to appeal the
decision.
The CAP is
not a limit nor a lid...it's an
ALTERNATIVE to
institutional services.
How Do
the Waivers Work?
An assessment is conducted and an
individual written plan of care is developed that
includes:
The federal government will not reimburse for waiver services that are not
included in this plan of care.
Be sure that all of your service needs are written
in the plan before you sign it.
The state is
required, under the Medicaid CAP waivers, to fund all
Medicaid waiver services written in the plan of care
and to update your plan annually.
Write in your
plan of care:
Freedom of Choice
The state assures that each individual eligible for
the waivers will be given freedom of choice in
selecting qualified providers of each service
written in the plan.
You may appeal if:
If you are
denied freedom
of choice
in provider(s) and
services(s )…
be
sure to get the denial in writing.
You can
appeal the denial.
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- You are not given the choice of home and
community-based services, as an alternative to institutional care.
- You are denied the Medicaid waiver services of your
choice: or,
- You are denied the service provider of your choice.
Frequently Asked Questions
Q.
Is the state responsible for paying for all Medicaid waiver services identified in the plan of care?
A. Yes. Those services available through the Home
and Community-Based Services waivers would be funded by Medicaid.
The plan of care should describe
all of the waiver and non-waiver services you need to successfully live in the community.
The descriptions should include the amount and duration of the services to be provided as well as identify the providers of the services.
Services not available through the waiver could be funded through another source. Non-waiver services are often funded through the Medicaid State Plan or state supported programs.
Q.
What does "amount" and "duration" mean?
A.
This refers to levels of care, such as hours
of
service required to meet your needs over a
specific period of time. If the form being used does
not include these items, ask your case manager to write it
in.
Q. Is it allowable for DDD to deny a Medicaid eligible service with a disclaimer that the delivery of services depends on the availability of services and/or funding?
A.
Those services available through the CAP waivers should be fully funded at the approved utilization levels (amount and duration of
service) stated in your plan of care.
Q.
As my needs change and a reassessment shows that I need more service hours, can DDD deny those hours due to inadequate funding?
A.
If a reassessment indicates that your needs have changed and more waiver services are required to successfully live in the community, DDD would be obligated to ensure that you received the additional services or move to an institutional setting.
Moving to an institutional setting would only be done in situations where a qualified provider could not be found or the person's health and safety would be seriously compromised if he/she continued to live in the community
or your needs cannot be met on the current waiver.
Q.
How can I appeal if I am denied services or
eligibility?
A.
You should request a fair hearing if you have been denied:
- The opportunity to participate in the CAP
waivers;
- The choice of home and community-based
services as an alternative to institutional
care;
- A needed waiver service;
- The provider of your choice.
Your application for a hearing must be written and filed with the DSHS office of appeals within
90 days of the denial.
You may also request a fair hearing if there has been:
- A reduction or termination of service; or
- An unreasonable delay in acting on an
application for eligibility for a service or for
an alternative service.
To request a fair hearing, write to:
OFFICE OF ADMINISTRATIVE HEARINGS
PO Box 42489
Olympia, WA 98504-2489
Phone:
800-583-8271 or
360-586-3027
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