Facts About the Four Home and Community Based Waiver Programs
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 (HCBS) 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 waivers.
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 HCBS waivers. If so, you have a right to be placed on a waiver enrollment database if there is no waiver opening available.
What are the CAP Waivers?
For individuals with a developmental disability who are clients 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 (HCBS).
The HCBS 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 and are at risk of out-of-home placement.
Services Covered:
- Hours per month available for Personal Care and based on assessed need.
- $6,737 per year is available for Supported Employment, Community Access, Pre-vocational or Person to Person services, based upon a Pathway to Employment.
- $1,454 per year available for any combo of Behavior Management and Consultation, Community Guide, Environmental Accessibility, Adaptations, Specialized Medical Equipment/Supplies, Occupational Therapy, Specialized Psychiatric Services, Physical Therapy, Speech, Hearing and Language Services, Staff/Family Consultation and Training, and Transportation.
- $6,000 per year available for Emergency Assistance.
The Basic Plus Waiver
The Basic Plus Waiver is intended for people who live with their families or in an adult family home or in another setting with assistance or an Assisted Residential Care (ARC) and at high risk of out of home placement.
Services Covered:
- Hours per year available for Personal Care based on assessed need.
- $9,846 per year is available for Supported Employment, Community Access, Pre-vocational or Person to Person services, based upon a Pathway to Employment.
- $6,192 per year is available for any combo of skilled nursing and all of the special services in the Basic Waiver (see above).
- Based on individual need, up to 44 hours of respite per month is available.
- $6,000 per year available for Emergency Assistance.
Core Waiver
The Core Waiver is intended for people who need up to 24-hour residential services, has had 18 or more days of inpatient psychiatric care in the last 12 months, or requires daily to weekly one-on-one support, physical or health needs.
Services Covered:
- Residential Services, Supported Employment, Community Access, Prevocational or Person to Person services, Behavior Management and Consultation, Personal Care, as well as other Respite Services defined as not covered under the Medicaid program or readily available in a particular location.
Community Protection 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, Pre-vocational, Behavior Management and Consultation, as well as other Services defined as not covered under the Medicaid program or readily available in a particular location.
Waivers Provide an ALTERNATIVE to institutional services.
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 (parental income is not considered for children).
The DSHS Division of Developmental Disabilities (DDD) has a set number of openings available under each of the waivers.
Ask your case manager if you are eligible to be on one of the HCBS waivers.
Once you are determined eligible for waiver services and funding is available, 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.
How Do the Waivers Work?
An assessment is conducted and an individual written Plan of Care is developed that includes:
- All your health and welfare service needs (waiver & non-waiver);
- Amount and duration of service(s) to be provided (regardless of funding source); and
- Your choice of service provider(s)
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 HCBS 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 (POC):
- All your health & welfare service need(s)
- Amount & duration of service(s)
- Your choice of provider(s)
Freedom of Choice
The law requires that each individual eligible for the waivers will be given freedom of choice in selecting qualified providers of each service written in the plan.
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.
You may appeal if:
- You are not given the choice of home and community-based services, as an alternative to institutional care,
- You are denied the most cost effective Medicaid waiver services of your choice: or,
- You are denied the service provider of your choice.
Frequently Asked Questions
Is the state responsible for paying for all Medicaid waiver services identified in the Plan of Care?
Yes; those services available on a particular Home and Community-Based Services waiver would be funded by Medicaid.
The Plan of Care should describe all of the waiver and non-waiver services you need to meet your health and welfare needs to live successfully 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.
What does “amount” and “duration” mean?
This refers to levels of care,such as hours of service required to meet your needs over a specific period of time. The Plan of Care form contains this requirement.
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?
Those services available through the HCBS waivers should be fully funded at the approved utilization levels (amount and duration of service) stated in your Plan of Care.
As my needs change and a reassessment shows that I need more service hours, can DDD deny those hours due to inadequate funding?
If a reassessment indicates that your needs have changed and more waiver services are required to successfully live in the community, DDD is obligated to ensure that you receive the additional services or are offered an institutional setting.
Moving to an institutional setting would only be done in situations where an individual requested this option, a qualified provider could not be found, the person’s health and safety would be seriously compromised if he/she continued to live in the community, or their needs cannot be met on the current waiver.
How can I appeal if I am denied services or eligibility?
You should request a fair hearing if you have been denied:
- The opportunity to participate in the HCBS 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 360-753-2531