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HOME AND COMMUNITY BASED WAIVERS FOR CHILDREN WITH AN FASD

Connie Jorgensen

November 19, 2015

Minnesota has entered into Waiver agreements with the federal government to provide Minnesota citizens with more choices in services.

There are six types of waivers in Minnesota

• Alternative care –home and community based services for persons over 65 at risk of nursing • home care and have low levels of income

• Brain Injury – persons with a TBI in need of a nursing facility specializing in behavioral services • for persons with a TBI

• Community Alternative Care- persons who are chronically ill or medically fragile

• Community Alternative for Disabled Individuals – persons with disabilities that require nursing • home level of care

• Developmental Disabilities – persons with developmental disabilities that required ICF/DD level • of care

• Elderly Waiver – persons over the age of 65 who need nursing home level of care • This reference guide will focus on CADI and DD waivers, as these are most commonly used by families of

children with an FASD

Counties and Waiver Slots Available

MN Department of Human Services allocates waiver slots to each county, the number of slots allocated is based on perceived need in each individual county. It is common for some counties to have a waiting list for waiver slots, the waiting list can be fluid with priority cases moving to the top of the list at the discretion of the county social services agency The state has recently given an increase in waiver spots to many counties. Stearns County went from eight waiver slots last year to 90 for the current fiscal year. There is no waiting list currently in Stearns County.

General Information on Waivers

The Minnesota Department of Human Services sets guidelines for eligibility and use of waiver funds. Each county is able to determine their own policy and make their own decisions within the guidelines. Each county will conduct their programs differently. That is to say, there are 87 Counties and 87 different ways of processing the waivers. Waiver slots can move with a client from county to county during relocation. However the new county may handle the waiver differently than the previous county.

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General Eligibility for Waivers

The child/applicant must be eligible for Medical Assistance/includes TEFRA MA The child/applicant must be Certified Disabled, either through Social Security or through review by the State Medical Review Team (SMRT) SMRT application can be done through the local county. Include documentation to verify the child/applicant’s diagnosis/disability. This may include medical records, psychological or neuropsychological assessments, and functional skills assessment. An Individual Education Plan may not include information needed to qualify, The child/applicant must meet “nursing home level of care”. An assessment tool is used to determine eligibility which includes need for supervision/assistance 24 hours a day/seven days a week. Eligibility standards are updated/changed periodically

MN Choices Assessment

In the past a county worker completed a paper assessment specific to each program or waiver. This was subject to assessor interpretation and bias MN Choices assessment is standardized; it is one screening tool for all waiver programs, PCA and nursing services. it eliminates personal interpretation and bias by using a computerized scoring system. MN Choices assessment is in depth and comprehensive, can take 2-4 hours to complete. The MN Choices assessment is mandated by state and all counties will be using it. There is no hard deadline for the transition, some counties already using MN Choices assessment, some counties are in transition

Developmental Disability (DD) Waiver Eligibility Criteria

The child/applicant needs to eligible for Medical Assistance/MA TEFRA. The child/applicant needs to meet criteria for Developmental Disability services The child/applicant must be in need of assistance and supervision 24 hours a day/ seven days a week. the child/applicant must be determined to likely require the level of care provided to individuals in an Intermediate Care Facility for Persons with Developmental Disabilities (ICF/DD). The child/applicant must be in need of rehabilitation services The child/applicant must have an assessed need for supports and services over and above what they can receive on through the Medical Assistance plan.

Developmental Disability (DD) Services Eligibility Criteria

The client/applicant needs to have an IQ lower than 70 - or a related condition Related Conditions - functional skills assessment completed with the child/applicant having scores of TWO standard deviations or more below the mean in four areas of standardized testing. In other words, the child/applicant needs to have a standardized test, with score well below average in 4 out of 12 areas. The child/applicant needs have the above diagnosis/scores before age 21. You will need to provide documentation to verify the child/applicant meets criteria for Developmental Disability Services. Medical records, psychological or neuropsychological assessments, and standardized functional skills tests are reliable information to use. Providing the Individual Education Plan may be helpful, but being on an IEP is not an automatic qualifier for Developmental Disability Services or the DD waiver. The IEP may not include testing required to determine eligibility.

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Community Alternatives for Disabled Individuals (CADI) Waiver Eligibility Criteria

This is a catch-all program for persons under age 65 with disabilities. This would include persons with a developmental disability that does not meet criteria for DD services, persons with physical disabilities, and persons with a mental health diagnosis. Currently there is an increase in waivered services for persons with mental health diagnosis. As a result, the state is being asked to consider starting an MI waiver.

CADI Waiver Eligibility Criteria

The child/applicant needs to be on or eligible for Medical assistance/TEFRA MA The Child/applicant must be certified disabled through social security or the state Medical Review Team The child/applicant must be under the age of 65 when the waiver is opened. The child/applicant must meet “nursing home level of care”. This includes being in need of supervision/assistance 24 hours a day/seven days a week. The child/applicant must have an assessed need for supports and services over and above what is available through other funding sources. The child/applicant must have utilized Children’s Therapy and Support Services (CTSS) offered through MA and be found in need of additional services CTSS – children’s therapy services and supports. Flexible package of mental health service by qualified providers, including services such as PCA, crisis intervention, mental health behavior aid and behavioral supports, behavior analyst services, in-home therapy, possibly family support grant if child does not have a PCA. The additional services provided through the waiver are necessary for the child/applicant’s health, welfare and safety.

Children’s Therapy Services and Supports (CTSS)

Flexible package of mental health service by qualified providers, including services such as PCA, crisis intervention, mental health behavior aid and behavioral supports, behavior analyst services, in-home therapy, possibly family support grant if child does not have a PCA.

Services available through the waivers

24 hour emergency assistance Assistive technology Caregiver training and education Behavior support services Consumer Directed Community Supports Accessibility adaptations Personal Care Assistant Family Training/Counseling Independent Living Skills (ILS) training Foster Care prevocational Services Residential care Respite/crisis respite Specialist services Specialized supplies and equipment Transitional services Transportation paid parent caregiver Examples: behavior services not covered by MA, swings and sensory equipment, respite care– either out of home or in-home, home/van modifications for persons with physical limitations, supplies not covered by MA such as wipes/ chucks/swim diapers/special-prescription diets/essential oils, increased staffing and supervision of child/applicant in the home

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Paid Parent Caregiver – component of the CADI Waiver.

The child must be eligible for CADI waiver and maintain that eligibility. Paid Parent Caregiver funds could be discontinued if the child has no other needs under the CADI waiver – but this can differ from county to county. Parent gets a budget based on a daily dollar amount to care for the child. The daily dollar amount is determined based on the child’s level of need . A parent can get up to 40 hours a week, hourly rate of around $14 per hour. Some counties will allow for PCA/other services to come in beyond the parent as a caregiver hours. Some counties tell families they need to budget all of this together, so no extra PCA hours. Parent as Caregivers use a fiscal agency/support planners for payroll, taxes, and coordination of services.

TIPS AND REMINDERS The application process takes time. Expect and allow for this to take several weeks/months Child needs to be on or eligibility for MA/TEFRA (can take 1 -2 months to process MA application) Child Needs to be Certified disabled - through Social Security of State Medical Review Team (can take several month for a social security application and 1-2 months for SMRT) Waiver Request are made through the county of residence Decisions and programs will vary from county to county

.

• MN DHS Website for information on Waivers: http://mn.gov/dhs/people-we-serve/people-with-disabilities/services/home-community/programs-and-services/hcbs-waivers.jsp

If you disagree with a decision made by county social services, you can file an appeal through the MN Department of Human Services. You must follow their appeal guidelines

MINNESOTA PARENTAL FEES

What you need to know…

Jennifer Moore

Moore Family Law, PA

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History

TEFRA – 1982

Tax Equity and Fiscal Responsibility Act

• Allowed states to provide Medicaid benefits to certain disabled children without considering the parent’s income.

• Originally, TEFRA only extended benefits for institutional care.

• Extended in 1991 to allow states to issue additional home and community based services through “waivers”, allowing families to care for children in their homes.

Minnesota’s TEFRA Waiver Program • Early Adopter

• Problem: The federal government would pay for Medical Assistance levels of care through Medicaid program. However, the State would be required to fund any additional services it provided through waivers.

• Proposed Solutions: • Premiums—Works like traditional health care programs. If you

fail to pay your premium, services would stop.

• Parental Fees—Works more like a tax. If you don’t pay the premium, services will continue. However, you will be subject to revenue collections.

Parental Fee Basics

• Owed if your child receives waivered services

• Calculated on a sliding income scale based on AGI

• Parental Fee Worksheet/Estimator

• DHS establishes parental fees based on tax return data from prior years

• Parental fees are refunded RETROACTIVELY if fees exceed the services delivered

• If parental fees are not paid, the account is sent to the Department of Revenue for collection, and the DoR can use all collection mechanisms authorized by law to collect.

Collection of Past Due Amounts

• Treated like tax debts • Garnishment

• Judgment

• Suspension of Occupational Licenses

• General harassment

• Payment plans • Must meet certain criteria established by the Department of

Revenue

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What can you do?

• Plan, plan and plan

• Review the Parental Fee Worksheet • Report any changes in income +/- 10% within 30 days.

• Report any changes in family structure/placement within 30 days

• Provide any requested information

• Review the Order Determining Parental Fees • Was the parental fee calculated properly?

• Do you have any special circumstances justifying an adjustment of parental fees?

• Appeal

Appeals Process

• Deadline—30 days after receipt of Determination Order

• How to start?—Send a letter that clearly states that you wish to appeal, and the basis for your appeal.

• Process—Several stages • DHS Administrative Hearing

• Request for Reconsideration

• District Court Appeal

• Appeal to Minnesota Court of Appeals

• Appeal to Minnesota Supreme Court and beyond

• Can take years

What will happen if you appeal?

• Collections will be suspended, but if you do not win, you will still owe the fees

• Your fee may be adjusted or eliminated depending on the merits of your appeal

• You will need to prepare for a hearing

• Your child will not lose benefits

Tips for Preparing for the Hearing • Ask for service history from your financial

worker

• Get your tax returns ready

• Gather proof supporting claims that the parental fee was calculated improperly or that you qualify for an adjustment or hardship variance

• Outline the basis for your argument

• Ask for discovery

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What a Hearing is Like

• Usually conducted by phone and it is recorded

• Players • Administrative law judge • Representative from DHS parental fee unit • You (with or without an attorney)

• You will have the opportunity to tell your story, provide proof of your claim and ask the DHS representative any questions you might have

• If the hearing raises any questions, you should ask for a continuance and opportunity to review information presented

• Once the record is closed, you’ll be asked to sum up your case

• An Order will issue in about 30 days

Legal Authority

Typically: Minnesota Statutes Section 252.27; Minnesota Rules 9550.6220 – 9550.6240

Less Typically: DHS policies, violations of federal or state law, violations of federal/state constitution

Procedure: Minnesota Procedure Act, Minnesota Statutes Chapter 14

Miscellaneous Tips

• Tax planning • Wages you are paid under waivers are probably not income.

• Parental fees you paid are probably deductible as long term care costs.

• Can you time income to minimize AGI?

• BUT, see your tax professional!

• Service planning • Are you eligible for services under a policy of insurance?

• Can you self-fund services?

• Can you make do with fewer services?

Legislative Efforts

• Bills eliminating and/or reducing parental fees have resulted in both an increase in the income that you can earn before being assessed a fee AND a significant reduction in parental fees.

• Engage with MOFAS, Pacer and other organizations.

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Achieve with us

Ryan Anderson Pascual

Senior Advocate

MNsure Navigator

Jen Johnson

Senior Advocate

MNsure Navigator

About The Arc

The Arc is a nonprofit, grassroots

advocacy organization founded in 1946 by

parents of children with disabilities.

Mission Statement:

The Arc promotes and protects the rights of

people with Intellectual and Developmental

disabilities, actively supporting them and their

families in a lifetime of full inclusion and

participation in their communities.

Individuals with Intellectual & Developmental

Disabilities & their families

across the lifespan

Down syndrome

Autism Spectrum Disorders

Cerebral palsy

Fetal Alcohol Spectrum Disorders

IQ of 70 or lower

We serve the seven-county metro area

Our advocacy services are free

Who We Serve

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The Arc’s Services

Information & Assistance – by phone or on the web

Advocacy – free one-to-one intensive personal support

Abuse Prevention & Awareness – training & resources

for self-advocates, professionals & first responders

Networking Groups - meeting monthly across the metro area,

language and disability-specific groups

The Arc’s Services

Health Care Access – MNsure Navigation Services

Special Education

Social Security

Housing

Public Policy

Employment

County & state disability services

How Can You Get Involved?

• Help us spread the word! Could you or

someone you know utilize our services?

• Shop, donate & volunteer at Arc’s Value

Village stores (Richfield, New Hope, St. Paul &

Brooklyn Center, Bloomington)

• Join us • Membership

• Financial support

• In-kind gifts

• Volunteer

• Find us on social media!

Healthcare Programs for People

with Disabilities

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Objectives for Today’s Presentation

The Affordable Care Act MNsure

Medical Assistance (MA)

What is it? How to access Services and supports Specific MA programs

Adoption Help applying Resources and information

The ACA & Disabilities

Because of the ACA, NO more:

• preexisting condition

exclusions

• discriminatory premium

setting

• annual/lifetime limits Essential health benefits

Free preventive care

Habilitative therapies

Long term care services

Affordability

Choice and options

The ACA in Minnesota

The way to apply for:

Medical Assistance and MinnesotaCare

Cost sharing reductions and tax credits

Shop for and compare Qualified Health Plans (QHPs)

Apply online or by paper application

Eligibility based on income, household size & tax

filing status

Public Assistance Healthcare Programs

Medical Assistance (MA) MN’s Medicaid program//Fee for service or

Managed Care//For people with low income, age

65 & up, children, pregnant women and people

who are blind or disabled//County of residence is

“servicing agency”

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Services & Supports through MA

Case management

Dental services

Diagnostic, screening & preventive services

Eye exams & eyeglasses

Home health care services

Individual Education Plan (IEP) services

Outpatient mental health services

Personal Care Attendant (PCA) services

Physical, occupational & speech therapies

Physician and clinic visits

Prescription drugs

Routine physicals

Transportation to appointments

Medical Assistance (MA)

MA-TEFRA MA-EPD

Fee for Service Managed Care

Programs & Types of MA for people with disabilities

MA-TEFRA (Tax Equity Fiscal Responsibility Act)

For children up to age 19

Physical, developmental disability or

mental health condition

Child ineligible for MA due to

parental income

Monthly parental fee (275% FPL)

Certified disability through the State

Medical Review Team or Social

Security Administration

MA- TEFRA

Private insurance not a barrier to eligibility

Apply through MNsure Online application is fastest route

Disability questions

Eligibility determination

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MA – EPD (Employed Persons with Disabilities)

Allows people with disabilities between age

16 and 65 to work and qualify for MA

Earn at least $65/month

$20,000 asset limit for a household of one

Monthly premium & unearned income

obligation (if required)

Private insurance not a barrier to eligibility

Certified disability through the State Medical

Review Team or the Social Security

Administration

MA-EPD

Apply directly to county of residence using the

“Application for Certain Populations”

Is MNsure for people with disabilities?

It depends!

Social security benefits Employment

Disability services & supports

Adoption

Adoption & Health Care Access

Public Agency Adoption:

Adoption Assistance Agreement

Children receiving Title IV-E or state funded

adoption assistance are automatically eligible for

MA

Adoption Agreements can be extended beyond age

18 to 21

nacac.org

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Help is here!

MNsure’s website – “Get Help” – “Find an Assister”

Recap

The Affordable Care Act has created

consumer protections that benefit

people with disabilities

Medical Assistance can provide options for

people with disabilities of different ages and in

different situations

Navigators are here to help!

Achieve with us

Questions?

Thank you!

(952) 920-0855

Ask to speak with a Navigator

M-F, 8:30 am – 5 pm