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What is a Waiver?
A waiver is a way that Medicaid can pay for services to keep you in your home so you do not have to move to a long-term care facility or nursing home. Your home is where you choose to live.
Medicaid home- and community-based waivers allow states to provide Medicaid funding to pay for services for children with disabilities without considering family income for eligibility. Waivers were developed to direct funds that previously would have been spent to support an individual with a disability in an institution to supporting that individual in the community.
The county board of DD administers Ohio’s Medicaid waiver programs for individuals with disabilities. Funding for waiver programs is provided with state and federal Medicaid dollars, and the local board of DD must provide a local match to use those funds. Services across counties may differ based on the amount of county match dollars available.
Access to waiver funds is also restricted by the number of “slots” made available annually to each county by the state. Therefore, funding available both at the state and the county level will affect the number of individuals who can access the waiver. As a result, not all individuals who are eligible receive waiver funding. County boards of DD must maintain waiting lists to distribute the waiver slots available in their county on a first-come, first-serve basis. Obtaining a waiver for in-home support does not necessarily mean that there will be 24-hour supervision. The goal of the waiver program is to teach individuals skills that will allow them to live more independently. (There are exceptions for emergency situations, such as the illness or death of a caregiver.)
There are two basic waiver programs for which an individual with autism may qualify. This information is basic. For more details, request brochures from the Ohio Board of DD at (877) 464-6733 about the waiver program. Also, talk to other families who have received waivers to learn more. You can also check out: W is for Waiver from DODD.
You cannot begin the process of obtaining a waiver without a service coordinator through your county board of DD. (However, you can be placed on the waiting list at intake without a service coordinator.) The process is rather complicated, and it is not the intent to cover this in detail here. Your service coordinator’s will take you through all the steps for obtaining a waiver, beginning with determining eligibility. Not everyone who applies for a waiver will receive one. Be sure to appeal the decision if you are denied a waiver.
Depending on the type of waiver the individual with autism is eligible for, you may receive approval to hire care providers for respite services or a provider to act as an aide for daily living. You may hire care providers through an agency or use someone who is an independent provider. You may also be approved to receive psychological services, therapies, and some kinds of safety equipment. If approved for a waiver, an individual with autism will receive a Medicaid card that can be used to supplement existing medical insurance or cover expenses for an individual who has no insurance.
The IO waiver can cover a broad range of in-home and community support services for individuals with intensive needs. The individual must meet the level-of-care-requirements for an intermediate care facility for developmentally disabled (ICF/DD). For more information, check out the IO Waiver Handbook
DODD has recently received federal approval for the SELF waiver. Enrollment will begin July 1, 2012. The SELF waiver is a much-awaited service that allows individuals with developmental disabilities to direct where and how they receive services under the waiver. DODD estimates up to 500 individuals to enroll in the the waiver the first year it is in effect, and up to 2000 individuals using the waiver by the third year it is in effect. The SELF waiver has an overall annual cost cap of $25,000 for children and $40,000 for adults. For a fact sheet on the new SELF waiver, click here. For a more detailed explanation of the SELF waiver, click here.
The Level 1 Waiver provides for a more limited range of services and has a $5,000 per year limit for services such as respite care and homemaker/personal care. There is a $6,000 limit to cover environmental modifications, specialized equipment and supplies, and a personal emergency response system. There is an $8,000 limit over three years for emergency assistance, if required. Your service coordinator at the county board of DD can guide you through the application process for waiver eligibility.
In Ohio, two state agencies, the Ohio Department of Developmental Disabilities (DODD) and the Ohio Department of Jobs and Family Services (ODJFS), govern waivers for adults and children with disabilities. DODD governs the Individual Options Waiver and Level 1 Waiver. In both cases, the county boards of DD oversee their use and administration.
Originally, ODJFS governed the Transition Waiver, however, with the passage of the 2011-2012 budget bill, the management this waiver is moving to DODD. ODJFS currently uses the Carestar agency to administer the waiver and provide service coordination to families, however this may change when the waiver moves to DODD.
Originally, the Transition Waiver was called the Ohio Home Care Waiver, and it was designed to support families with very ill and/or medically fragile children who would otherwise need to be hospitalized or live in a nursing home. It was determined that for these children, medical needs, not a developmental disability, should determine the funding source for the waiver funds.
Some children with ASD were awarded these waivers, even though they did not have serious medical needs. This was because these children had very urgent needs (safety issues, serious sleep disorders, and behavioral problems that required specific therapy) but not medical needs (feeding tubes, catheters, and breathing machines). Because of the waiting list for IO waivers, these children were not going to receive support for years.
During a routine federal review of Medicaid expenditures, the state of Ohio was told that the Ohio Home Care Waiver was not being administered according to federal guidelines. As a result, ODJFS could no longer accept children who did not meet the original medical guidelines for the waiver.
Children who were already receiving services under the ODJFS waiver, but who met the guidelines for the IO waiver under the DODD, were transferred to a new type of waiver under the ODJFS called the Transition Waiver. The families receive all the benefits that they had been receiving when they were accepted under the Ohio Home Care Waiver.
With the Transitions waiver moving to DODD, individuals on this waiver will be transitioned to other waivers and it is likely that this waiver will be phased out. This waiver is no longer accepting enrollment.
For more info, visit the ODJFS page on the by clicking Transitions Waiver
The Ohio Home Care Program offers services through the Ohio Home Care Waiver and Transitions Waiver. The waivers are designed to meet the home care needs of people who have certain medical conditions and/or functional abilities that would qualify them for Medicaid coverage in a nursing home or hospital. This program is administered by ODJFS.
The following links provide more information on eligibility requirements, services provided, and how to apply. You can also contact your county department of Job and Family Services for information.
Medicaid is the nation’s primary health insurance program for low-income and high-need Americans. Medicaid covers 60 million low-income Americans. The program provides health coverage for low-income families who lack access to other affordable coverage options and for individuals with disabilities for whom private coverage is often not available or not adequate. Today, Medicaid does not cover all individuals with low incomes. Millions of low-income adults (particularly adults without dependent children) are uninsured because they are not eligible for Medicaid and do not have access to other coverage. Given the wide array of health needs and limited incomes of enrollees, Medicaid provides a broad range of services, with limited cost-sharing.
Medicaid is the largest source of funding for safety-net providers and the dominant payer for long-term care. Medicaid also helps to make Medicare work for low-income elderly and disabled beneficiaries. Medicaid is the largest source of funding for safety-net providers (such as community health centers and public hospitals) that serve the poor and uninsured. Many of these providers are located in low-income communities or rural areas with provider shortages. Medicaid is also the nation's largest payer for long-term care services. It helps to make Medicare work for nearly 9 million low-income elderly and disabled beneficiaries who rely on Medicaid to help pay for Medicare premiums, gaps in Medicare benefits, and long-term care needs.
States and the federal government jointly administer and finance the Medicaid program. State participation in Medicaid is optional. States that elect to participate, as all have done for the past 30 years, must meet minimum federal standards related to coverage and benefits to receive federal matching funds. States have flexibility to cover populations and services beyond federal minimums and receive federal matching funds for these costs. States generally have a great deal of flexibility to determine who is covered, what services to cover, how to deliver care and how much to pay providers. Flexibility to set eligibility levels has been limited over time by increases in federal minimum levels for children and pregnant women and more recently by eligibility protections put in place under the American Recovery and Reinvestment Act (ARRA) and the Patient Protection and Affordable Care Act (ACA). However, as a result of general flexibility there is large variation from one state Medicaid program to the next. Financing for Medicaid is shared between the states and the federal government, with the federal government paying 57 percent of Medicaid costs on average across states (although this rate has been temporarily increased under ARRA). For states, Medicaid represents a major budget item and the largest source of federal revenues.
Medicaid increases access to care and limits out-of-pocket burdens for low-income people. Children and adults enrolled in Medicaid have much better access to care than those without insurance. And compared with people who do have private health insurance, Medicaid enrollees fare just as well on most measures of access to preventive and primary care, despite often cited concerns about provider participation. While there have been concerns about access to some provider types like dentists and some specialists, these issues reflect more general provider shortages as well problems with the geographic distribution of physicians that are not limited to Medicaid. Because the population covered is low-income, Medicaid does not require premiums and imposes little cost sharing, so enrollees face far fewer financial barriers to care compared to the uninsured and many with private insurance. Medicaid’s extensive use of managed care arrangements has helped to improve access to care for many of its enrollees.
Most Medicaid enrollees access care through managed care plans that use private provider networks to deliver services. Nearly three-quarters (72 percent) of Medicaid enrollees are enrolled in some type of managed care (fully capitated plans or primary care case management). These plans use networks of private providers to deliver covered services to their enrollees. Medicaid managed care enrollees are largely children and families, although many states are considering enrolling elderly and disabled beneficiaries in managed care plans as well.
Federally Mandated Services
- Ambulatory Surgery Centers
- Certified family nurse practitioner services
- Certified pediatric nurse practitioner services
- Family planning services & supplies
- Healthchek (EPSDT) program services (screening & treatment services to children younger than age 21)
- Home health services
- lnpatient hospital
- Lab & x-ray
- Medical & surgical vision services
- Medicare premium Assistance
- Non-Emergency Transportation
- Nurse midwife services
- Nursing Facility care
- Outpatient services, including those provided by Rural Health Clinics & Federally Qualified Health Centers
- Physician services
Ohio’s Optional Services
- Ambulance / ambulette
- Chiropractic services for children
- Community alcohol & drug addiction treatment
- Community mental health services
- Dental services
- Durable medical equipment & supplies
- Home and Community Waivers Based Services
- Hospice care
- lndependent psychological services for children
- lntermediate Care Facility services for people with Developmental Disabilities (ICF-DD)
- Occupational therapy
- Physical therapy
- Prescription drugs
- Private Duty Nursing
- Speech therapy
- Vision care, including eyeglasses
Ohio Medicaid offers a span of programs for older adults and people with disabilities to assist with medical expenses. These programs provide health care coverage consisting of primary and acute-care benefit packages along with long-term care. Working Ohioans with disabilities may be interested in the Medicaid Buy-In for Workers with Disabilities program.
Medicaid for the Aged, Blind & People with Disabilities (ABD)
To qualify for ABD Medicaid, applicants must be:
- age 65 or older, or
- considered legally blind, or
- an individual with a disability (as classified by the Social Security Administration), and
- must meet basic requirements.
When applying for this type of Medicaid, proof of income, resources, age or disability, citizenship (if not a U.S. citizen) and other health insurance is required. A face-to-face interview with the local county department of job and family services is also necessary. Applicants can ask an authorized representative to apply on their behalf.
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