What is a Medicaid Waiver? - POAC-NoVA

Achieve with Us
Home and Community Based
Medicaid Waivers and Our Pooled
Today’s Presentation
An Overview of:
 Virginia Medicaid Waivers
 The Arc of Northern Virginia Pooled Trust
 Planning for the Future of a Child with Disabilities
What is a Medicaid Waiver?
Medicaid: Medicaid is what pays for
the services you can receive from a
Medicaid Waiver.
Waiving the choice of institutional
placement and choosing to accept
services in the community.
Seven Medicaid Waivers in Virginia
 Elderly or Disabled with Consumer Direction
Waiver (EDCD)
Technology Waiver (Tech)
Individual and Families with Developmental
Disabilities Waiver (DD Waiver)
Intellectual Disability (Mental Retardation)
Waiver (ID/MR Waiver)
Day Support Waiver
Alzheimer’s Assisted Living Waiver (AAL Waiver)
Three Criteria to
Determine Eligibility
1) Financial Eligibility Criteria
2) Diagnostic Criteria
3) Functional Criteria
Diagnostic Eligibility and Services
Each Waiver has its own:
 Eligibility criteria
 Screening process
 List of services
Eligibility for Regular, State
Categorical Criteria
• Disabled or age 65 or older
• Families with children
• Pregnant women
• Recipients of cash assistance
• Low income Medicare beneficiaries
Financial Thresholds
• Low income and asset guidelines
• Thresholds vary by category group
• Consideration of exceptionally high medical bills
• Parental income/resources DO count for
minor children
Financial Eligibility for
Medicaid Long Term Care
(Waivers and Institutions)
Categorical Criteria
Must meet Long-term Care criteria defined for Waiver
Assessment of need required
Financial Thresholds
$2022 per month (gross income)
$2000 resource limit
Parent income/resources do NOT count
Common Questions and Concerns
 If I have applied for the
Waiver, have I applied
for Medicaid?
 If I applied for Medicaid,
 If our household income
is too high, does that
mean my child cannot
have a waiver?
did I apply for a waiver,
Diagnostic Eligibility
EDCD- Waiver
 Individuals who have significant medical needs. The criteria used to determine
eligibility is the nursing home criteria.
Day Support Waiver
 Individuals diagnosed with ID who have been determined to meet two of the
Level of Functioning Criteria.
Technology Waiver
 Individuals who require ongoing skilled nursing care.
 Individuals 21 and older who are dependent at least part of each day on a
mechanical ventilator or meet complex tracheotomy criteria.
 Individuals under the age of 21 who meet certain criteria based on various
methods of respiratory or nutritional support
Diagnostic Eligibility
ID/MR Waiver
 Diagnosis of ID or under age of 6 and at developmental risk
 Children on the ID Waiver who do not have a diagnosis of ID at the age of 6,
possible transfer to DD Waiver
 IQ Score & psychological testing is required
DD Waiver
 5 years and 9 months of age and have a developmental disability or “related
condition” to apply
 Cannot have a diagnosis of ID
 IQ Score & psychological testing is required
Functional Criteria
ID, DD and Day Support Waivers:
Individuals must meet Intermediate Care Facility (ICF-MR) level of care
Established by meeting dependency level in two or more categories on Level
of Functioning Survey
• Categories: Health Status, Communication, Task Learning Skills,
Personal/Self Care, Mobility, Behavior, and Community Living Skills
EDCD, AIDS, Alzheimer’s, and Technology Waivers:
Individuals must meet nursing facility eligibility criteria determined by
Universal Assessment Instrument (UAI)
• Assesses social, physical health and functional abilities
Waiver Services Vary by Waiver
Personal / Attendant Care
Respite Care
Companion Care
Day Support
In Home Residential Supports
Assistive Technology
Environmental Modifications
Personal Emergency Response System/Medication
Money Follows the Person
Employment (enclave/individual)
Prevocational services
Therapeutic Consultations
ID Waiver:
• Based on need & region population
• Approximately 8,427 people receiving services
• 5,762 on ID Waiver waitlist
• Of those:
3163 are on urgent waiting list
2599 are on non-urgent care waiting list
Numbers as of 8/08/10
Waiting List
DD Waiver:
• First come, first served
• 1045 people have DD Waivers
• App. 1000 people on the waiting list
Numbers as of August 2011
While on the waiting list,
what else can someone do?
Depending on level of need & eligibility criteria you can
apply for other waivers:
You CANNOT be on both the ID Waiver List and the
DD Waiver List.
 You CAN be on either the ID Waiver list or the DD
Waiver list AND receive EDCD or Technology Waiver
 You CAN be on the ID Waiver list AND receive the Day
Support Waiver.
Call your local county for case management and
other locally funded services or resources that
may be available to you.
How Families can ensure that their Child’s Needs
are Met and Covered
 Medicaid Waivers and government benefits are not
sufficient to provide for an accustomed level of care
and quality of life.
 Families must plan for the future of their child with
Financial, housing, recreational, employment, spiritual plans
should be made & documented
How will a family provide for their child’s future when the
parents are no longer here? By establishing a (Pooled) Special
Needs Trust.
Special Needs Trusts
 Concept simple and based on well thought out public
 The general rule is that trusts are available and
income is counted BUT
 Special Needs Trusts are an exception to
the general rule.
What Is A Special Needs Trust (SNT)?
 An SNT is a legal document designed to:
 provide
benefit to & protect the assets of a
person with a disability
 while allowing the individual to be qualified for
and receive government benefits,
 such as Medicaid, Medicaid Waivers and
Supplemental Security Income.
What’s the Purpose of a
Special Needs Trust?
 Provides a manager to meet the needs of the
Beneficiary which may arise and cannot otherwise
be met by the Beneficiary's personal resources or
 Promotes the dignity, comfort and happiness by
providing supplemental care, treatment not
otherwise covered.
Types of Special Needs Trusts
First Party or Self-Funded Trusts
Funded with disabled individual’s own assets
Third Party or Family-Funded Trusts
Funded with assets that do not belong to individual with
 May be inter vivos or testamentary
 Not subject to payback requirement
Self-Funded Trusts –
d 4 (a) Private
1. Established by the parent,
2. Funded by the individual
3. For the sole benefit of the
4. Created by a private attorney or
Self-Funded Trusts –
d 4 (c) Pooled
Established by the parent, guardian, court
or the individual
Funded by the individual
For the sole benefit of the individual
Established with a Pooled Trust Program
by using a Master Trust Document and
Joinder Agreement
Self-Funded Trusts
 Most Self-funded accounts established due to:
personal injury settlement
 An inheritance
 Any other money that threatens benefits
Upon the beneficiary’s death remaining funds in a
Self-Funded account AND ONLY A SF ACCT are
subject to a Medicaid Payback Provision unless the
Trust was established with an authorized non-profit.
In this case, the nonprofit may receive the remainder.
Family Funded Trusts –
Unfunded or Funded
 May be setup by parents, grandparents, siblings, aunts and uncles or
friends (not the individual).
 Used frequently by parents to plan for the Future:
Set up as part of estate planning process with an attorney or an authorized
non-profit to protect assets and services that your loved one is receiving
Avoid probate to have funds available immediately
Ensure your loved one has a way to obtain the items, services or the extra’s
you want to make sure they have (supplemental needs)
These can be funded during your lifetime or left unfunded until your passing
Pooled Trusts
 Pooled
Established by authorized non-profit
Maintain separate accounts for each
Established for benefit of individual with
May be created by individual, parent,
grandparent, guardian, or the Court
Third party funds used to create account or
Individual’s funds used to create account
An Example of a Pooled Trust
 The Arc of Northern Virginia manages the Trust
providing a professional staff, greater sensitivity
and individualized services.
 SunTrust, the Trustee, offers professional
investment management and has developed six
investment options from which to choose.
 There are no minimum or maximum funding
 They are more affordable for families or
What Are The Trustee’s Roles?
 Asset Management
 Account Administration
 Account Reporting
 Tax Reporting
 Check Disbursements
The Arc of Northern Virginia
& SunTrust Partnership Program Design
 Two levels of management
 Funded through living wills, life insurance policies
to the trust, gifts, the sale of stocks, property, etc
Ability to work directly with SunTrust Private
Wealth Management Team
Efficiency in transactions
Reduced fees
You don’t have to be rich to fund one
Accessing the Funds in the Trust
 Complete a simple disbursement request
form stating the purpose of the request,
amount of the request and to whom to send
the check.
 Supporting documentation is needed, such as
a receipt or bill.
 The request form is sent to The Arc of
Northern Virginia. We review it and forward
it to SunTrust.
An Example of Fees:
 One-time enrollment fee: $1050.00
 Annual fee for unfunded account: $65.00
 For funded accounts:
The Foundation of The Arc of Northern Virginia bills 75 basis
points annually of the individuals account. (. 75%) (subject to
SunTrust Bank bills 90 basis points annually. (. 90%) (subject to
 Low, competitive fees due to the overall pooled investment.
Where to Go for More Information on Waivers?
All Waivers:
Virginia Medicaid Waiver Technical Assistance Center
866-323-1088 (toll free) 1-804-786-1465
ID Waiver:
Helpful Tool to better understand the questions asked for the EDCD Waiver:
UAI Manual (Universal Assessment Inventory):
Local Community Services Board
ages 0-2
ages 3-22
ages over 22
The Arc of Northern Virginia
For more Information on
Medicaid Waivers:
Lucy Beadnell:
 [email protected]
 703-532-3214 Ext 116
 The Arc of Northern Virginia
98 N Washington St
Falls Church, VA 22046
 www.thearcofnova.org
Thank you!
For more Information on the
Pooled Trust:
Tia Marsili:
 [email protected]
 703-532-3214 Ext 115
 The Arc of Northern Virginia
98 N Washington St
Falls Church, VA 22046
Thank you!

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