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>> MY NAME IS ANN BACHRACH, AND I AM THE SPECIAL
PROJECTS DIRECTOR FOR THE PENNSYLVANIA HEALTH
LAW PROJECT.
JUST SO YOU ALL KNOW, I'VE BEEN WORKING ON MEDICAID
FOR THE LAST 25 YEARS.
SO I'M ABOUT TO LAUNCH INTO SOMETHING THAT COULD EITHER
BE ENORMOUSLY DETAILED AND WE WILL GET THROUGH ALL
45 SLIDES THAT I CREATED, OR WE CAN PICK AND CHOOSE
A LITTLE BIT.
SO THAT'S WHERE THE QUIZ COMES IN.
HOW MANY OF YOU ARE HERE-- BECAUSE THERE ARE REALLY
SORT OF THREE SEGMENTS TO THIS PRESENTATION.
ONE IS ABOUT MEDICAID AND HOW TO MAKE MEDICAID
WORK NOW.
THE SECOND IS ABOUT ALL OF THE VARIOUS OPTIONS
FOR CHILDREN TURNING 18, OR YOUTH TURNING 18,
AND SORT OF THE INS AND OUTS OF WAIVERS AND HOW YOU GET
SOCIAL SECURITY TO SUPPORT, ET CETERA, ET CETERA
AND THEN THE THIRD PIECE IS WHAT THE AFFORDABLE CARE
ACT, SOMETIMES AND OFTEN REFERRED TO AS OBAMA CARE,
MEANS IN TERMS OF CHANGES TO THE SYSTEMS AS THEY EXIST NOW.
SO HOW MANY PEOPLE REALLY CAME FOR THE HOW TO MAKE
MEDICAID--WHAT IS MEDICAID, AND HOW TO MAKE MEDICAID
WORK NOW? SHOW OF HANDS?
YOU DON'T HAVE TO CHOOSE JUST ONE.
YOU CAN CHOOSE MORE THAN ONE.
ALL RIGHT.
HOW MANY PEOPLE ARE REALLY INTERESTED IN THE,
SO WHAT HAPPENS AFTER SOMEBODY TURNS 18?
OK.
AND THEN THE THIRD PART OF, WHAT DOES OBAMA CARE
MEAN IN THE FUTURE?
OK.
SO WE'RE GOING TO RUN THROUGH THE FIRST FEW
SLIDES, AND WE CAN COME BACK TO THOSE WITH QUESTIONS.
I'M GOING TO TRY AND LEAVE ENOUGH TIME SO THAT WE CAN
ASK QUESTIONS, AND I MAY STOP PERIODICALLY AS WE GO
THROUGH THIS.
BUT IT IS, AS YOU CAN SEE, A FAIRLY INTENSE PROCESS.
SO LET'S DO THIS.
MEDICAID IS THE STATE AND FEDERAL PROGRAM.
SO AS WE SORT OF TALK THROUGH THIS,
THERE ARE FEDERAL RULES AND STATE RULES THAT APPLY
TO THE PROGRAM.
THERE'S NO LIMIT ON THE NUMBER OF PEOPLE WHO CAN
ENROLL, AND IT USES SORT OF AN UNLIMITED SET OF FEDERAL
AND STATE DOLLARS.
CHILDREN UNDER 21 ARE ENTITLED TO ALL MEDICALLY
NECESSARY SERVICES.
SO WE'RE GOING TO KEEP THAT IN MIND AS WE GO BECAUSE
WE'LL PLAY THOSE OTHER, AND SO WHAT ABOUT
18 TO 21-YEAR-OLDS, ET CETERA, ET CETERA
CHILDREN WITH DISABILITIES IN PENNSYLVANIA HAVE
A SPECIAL CATEGORY OF MEDICAID.
IT IS REFERRED TO OFTEN AS THE "LOOPHOLE."
THIS IS NOT A GOOD WORD TO USE.
THIS IS NOT A GOOD WORD TO USE BECAUSE IT IMPLIES
THE IDEA THAT WE'RE KIND OF WORKING AROUND THE RULES,
THAT WE'RE-- IT'S NOT QUITE RIGHT.
AND IN THIS PARTICULAR GUBERNATORIAL ADMINISTRATION,
IT SOUNDS LIKE FRAUD.
AND IT'S NOT.
SO I'M GOING TO--THAT'S WHY ALL THOSE LITTLE WORDS,
LITTLE SYMBOLS THAT WOULD MEAN I'D BE CURSING,
IF YOU CALL IT LOOPHOLE.
WE'RE GOING TO CALL IT LOOPHOLE NOW,
AND THEN WE'RE GOING TO STOP CALLING IT LOOPHOLE.
WE'RE GOING TO CALL IT PH 95.
WE CAN CALL IT THE FAMILY OF ONE.
WE CAN CALL IT CHILDREN WITH DISABILITIES CATEGORY.
BUT WE'RE NOT GOING TO CALL IT LOOPHOLE.
PROMISE?
THANK YOU.
FAMILIES CAN ALSO HAVE PRIVATE INSURANCE
AND STILL USE THIS CATEGORY OF MEDICAID.
ALL RIGHT.
CHILDREN IN THE PH 95 CATEGORY--I CALL IT PH 95,
SO WE'RE JUST GOING TO FLOW WITH THAT THIS MORNING.
IT'S FOR CHILDREN WHOSE FAMILY INCOME IS TOO HIGH
TO GET SSI CASH.
SO IF YOUR CHILD IS ELIGIBLE IN GETTING CASH--
(INAUDIBLE QUESTION FROM AUDIENCE)
SO IF YOUR CHILD OR YOUNG ADULT IS GETTING CASH ASSISTANCE
THROUGH SSI, THEY'RE NOT IN THE PH 95 CATEGORY.
THEY ARE IN A DIFFERENT CATEGORY IN MEDICAID,
AND I'M NOT GOING TO RUN THROUGH THE 485,000
DIFFERENT CATEGORIES IN MEDICAID.
WE'LL GET TO THAT AT THE END,
OF WHERE I'M GOING TO SIMPLIFY IT,
LIFE IN GENERAL.
BUT THE CHILD'S CONDITION HAS TO MEET OR EQUAL
THE SSI DISABILITY CATEGORY FOR CHILDREN,
AND THEN, AS THEY GET TO BE OVER 18,
THEY WILL HAVE TO MEET THE CATEGORY OF DISABILITY
FOR ADULTS.
SO THAT'S A PIECE TO KEEP IN MIND.
PARENTAL INCOME AND ASSETS DOESN'T COUNT
IN THE PH 95 CATEGORY.
SO WHEN WE--THIS IS WHAT MAKES THIS SUCH A GENEROUS
CATEGORY IN PENNSYLVANIA IS THAT WE DON'T COUNT,
UNLIKE MOST OTHER STATES, WE DON'T COUNT PARENTAL INCOME
OR THEIR ASSETS.
MOST OF THE CHILD'S INCOME DOESN'T COUNT,
OR MOST TYPICAL CHILD INCOME DOESN'T COUNT--
SOCIAL SECURITY BENEFITS, CHILD ORDERED--COURT ORDERED CHILD
SUPPORT, OR CHILD-ORDERED COURT SUPPORT--I DON'T KNOW
HOW THAT WORKS-- OTHER INCOME FOR THE CHILD,
IF THE CHILD HAD A TRUST FUND AS A RESULT
OF A SETTLEMENT OR A LAWSUIT.
THAT INCOME WOULD COUNT.
ALL RIGHT.
THE CATEGORY HAS-- THE CHILD'S ILLNESS
OR DISABILITY HAS GOT TO LAST 12 MONTHS OR MORE.
THIS IS ONE OF THE BIG SORT OF MISNOMERS IN THIS,
IS THAT IT REALLY HAS TO BE-- I HAD SOMEONE IN THE
DEPARTMENT OF INSURANCE TELL ME THAT CHILDREN WITH BAD
DENTAL DISEASE COULD GET THE PH 95 CATEGORY,
AND I SAID, "NO, THAT'S REALLY SO IMMINENTLY FIXABLE
IT WOULD NOT BE IN THAT CATEGORY."
SO THERE'S A LOT OF MISINFORMATION,
EVEN AMONG PEOPLE WHO ADMINISTER THESE PROGRAMS.
HAVING AN IEP IS NOT ENOUGH.
FUNCTIONAL IMPAIRMENT IS WHAT'S REALLY CRITICAL.
AND THE STANDARDS VARY SLIGHTLY BASED ON THE BODY
SYSTEM, YOU KNOW, OR WHETHER THIS IS AN INTELLECTUAL
DISABILITY.
COUNTY ASSISTANCE OFFICES CAN MAKE A PRESUMPTIVE
ELIGIBILITY PIECE OF THIS.
I DON'T THINK WE'RE GOING TO SORT OF SPEND A WHOLE LOT
OF TIME ON THIS, WHILE YOU'RE WAITING FOR THE
FULL DISABILITY.
IF MEDICAID OR THE SOCIAL SECURITY ADMINISTRATION SAYS
YOUR CHILD IS NOT DISABLED, YOU SHOULD APPEAL.
AND OUR OFFICE, WHICH YOU'LL FIND AT THE END OF THIS
PRESENTATION, CAN HELP YOU BECAUSE YOU CAN'T GET
MEDICAL ASSISTANCE IF THE DISABILITY DETERMINATION
IS DENIED.
OBVIOUSLY, THIS CAN'T JUST BE SOMETHING THAT,
YOU KNOW, YOU AND YOUR NEIGHBORS CAME UP WITH.
YOU NEED A PROFESSIONAL TO SAY, YOU KNOW,
WHAT AND WHY AND HOW LONG IT'S EXPECTED TO LAST.
PARENTS CAN CERTAINLY ASSIST THE DOCTOR WITH THE CONTENT
OF THINGS.
THERE ARE LOTS OF MODEL LETTERS ON OUR WEBSITE,
WHICH IS WWW.PHLP.ORG, TESTS, EVALUATIONS,
SCHOOL RECORDS, ALL OF THOSE. YOU KNOW, A FAX
CAME INTO OUR OFFICE YESTERDAY WITH 45 PAGES
OF DOCUMENTATION.
IT FELL ON THE FLOOR AND GOT ALL MIXED UP,
BUT, YOU KNOW, SOMETIMES MORE PAPER CAN BE HELPFUL.
ANNA, HOW AM I DOING?
AM I GOING TOO FAST FOR YOU?
A LITTLE.
SORRY.
I REALIZED I HAD HIT 60 BEFORE I EVEN CHECKED
WITH YOU.
SORRY.
AS WE SAID, THE FUNCTIONAL IMPAIRMENT IS REALLY THE KEY
IN THIS, HOW LONG IT'S GOING TO LAST AND WHAT IT REALLY
MEANS IN A CHILD OR YOUTH'S DAY-TO-DAY LIFE.
AND I'M GOING TO TRY AND FLY THROUGH SOME OF THIS BECAUSE
WE GET SOME MORE COMPLICATED STUFF AS IT GOES.
PRIVATE INSURANCE PAYS FIRST.
THIS IS PROBABLY NOT SURPRISING.
THE MEDICAL ASSISTANCE PROGRAM REALLY DOESN'T WANT
TO BE PAYING FOR EVERYTHING IF THERE'S SOMEONE ELSE WHO
CAN PAY FIRST.
SO WE NEED TO SORT OF SHOW THAT YOU'VE EITHER EXHAUSTED
YOUR PRIVATE INSURANCE BENEFITS OR PRIVATE
INSURANCE DOESN'T COVER THESE SERVICES.
SO ONE COMMON EXAMPLE OF THAT IS SERVICES FOR
CHILDREN WITH AUTISM ARE NOT ALWAYS COVERED
BY PRIVATE INSURANCE.
EVEN THOUGH WE HAVE A LAW IN THIS STATE,
LOTS OF INSURANCE IS EXEMPTED FROM THAT.
THE OTHER PIECE IS THAT IT HAS TO BE MEDICALLY
NECESSARY SERVICES.
YEARS AGO, SOMEONE GAVE ME THE EXAMPLE OF EPSDT COULD
COVER A SWIMMING POOL BUILT IN THE BACKYARD UNLESS WE
PUT SOME LIMITS.
AND I WAS LIKE, "I CANNOT IMAGINE ANYBODY SORT OF EVEN
SUBMITTING A SWIMMING POOL AS AN EXAMPLE OF WHAT THEY
WANTED PAID FOR.
BUT IT DOES HAVE TO BE MEDICALLY NECESSARY, AND IT DOES HAVE TO
BE PRESCRIBED BY A PROFESSIONAL.
THE STANDARDS FOR MEDICAL NECESSITY ARE HERE.
I'M NOT GOING TO SORT OF RUSH THROUGH THEM BECAUSE
I THINK WE HAVE OTHER THINGS THAT WE WANT TO GET TO,
AND WE CAN COME BACK TO THAT AT SOME OTHER POINT.
OBVIOUSLY, THE LETTER HAS TO COME FROM A PROFESSIONAL,
AS WE SAID, YOU KNOW, LISTING THE SPECIFICS AS
MUCH AS POSSIBLE AND, YOU KNOW,
SORT OF EXPLAINING HOW THE DEVICE OR TREATMENT WILL
ENHANCE THINGS.
HERE'S THE PIECE WHERE I THINK WE'RE GOING TO JUMP
TO WHAT THE BULK OF FOLKS HAVE COME TO.
BUT LET'S STOP AND ASK IF THERE ARE ANY QUESTIONS SO
FAR BECAUSE I'M ABOUT TO SORT OF SWITCH TO THAT
SECOND TOPIC.
WOW, OK.
WE'RE GOOD.
SO AS WE ARE TALKING ABOUT CHILDREN AND YOUTH--
AND I'M GOING TO TRY AND-- FROM MY PERSPECTIVE,
THOSE TERMS ARE INTERCHANGEABLE.
MY CHILDREN ARE IN THEIR LATE TWENTIES AND THIRTIES,
AND I STILL CALL THEM CHILDREN.
SO IT'S NOT A PEJORATIVE IF I KEEP USING THE WORD CHILD.
AT AGE 18, THE MEDICAID ELIGIBILITY RULES CHANGE.
AT AGE 18, THE SUPPLEMENTAL SECURITY INCOME,
SSI, RULES CHANGE.
AND AT AGE 21, CERTAIN SERVICES ARE NOT COVERED
BY MEDICAL ASSISTANCE.
SO THAT GUARANTEE OF ALL MEDICALLY NECESSARY SERVICES
CONTINUES FOR A CHILD IN MEDICAID UNTIL AGE 21.
EVEN THOUGH THE CATEGORY IN WHICH THEY'RE GETTING
SERVICES MAY CHANGE, THEY'RE STILL ENTITLED TO THAT EPSDT--
EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT.
THAT'S THE MEDICAL NECESSITY ALL SERVICES CATEGORY,
AND IT GOES TO AGE 21, EVEN THOUGH THE CATEGORY
OF MEDICAL ASSISTANCE THE CHILD OR YOUTH IS RECEIVING
HAS CHANGED.
GOOD?
ALL RIGHT.
SO SORT OF TWO BENCHMARKS, AGE 18 AND AGE 21.
AND AGE 21 SORT OF LINES UP, AGAIN,
WITH THE SCHOOL-BASED IEP SERVICES, AS WELL.
SO AT AGE 18, PARENT INCOME FOR SSI NO LONGER COUNTS.
SO REMEMBER, WE TALKED ABOUT HOW PARENT INCOME DOESN'T
COUNT FOR MEDICAID FOR A CHILD.
BUT FOR SOCIAL SECURITY, IT DOES UNTIL THE CHILD TURNS
18, AND THEN IT'S ONLY THE CHILD'S INCOME,
EVEN IF THE CHILD IS STILL LIVING AT HOME.
BUT THE ADULT DISABILITY STANDARD NOW APPLIES.
AND THAT IS BASED MUCH MORE ON THE ABILITY TO GO TO WORK
THAN THE CHILD'S CATEGORIES ARE.
SO AN ADOLESCENT WHO MAY HAVE MET THE SOCIAL SECURITY
DISABILITY CRITERIA AT AGE 17 MAY NOT MEET IT AT AGE 18.
THE SSI IS CRITICAL BECAUSE THAT'S REALLY HOW MEDICAID
CONTINUES FOR A LOT OF CHILDREN,
FOR A LOT OF YOUTH.
THERE ARE LOTS OF OTHER WAYS,
AND WE'RE GOING TO TALK ABOUT SOME OF THOSE.
SO PH 95, AS WE SAID, ENDS AT AGE 18.
TO STAY ON MA, YOU NEED TO FIT INTO ANOTHER CATEGORY
OF MEDICAL ASSISTANCE.
AND APPLYING FOR SSI IS THE FIRST STEP IN THAT.
AS WE SAID, EPSDT REMAINS--THAT ALL MEDICALLY
NECESSARY SERVICES PIECE REMAINS TO AGE 21
AND INCLUDES ALL THOSE THINGS THAT A CHILD OR YOUTH MAY
HAVE BEEN RECEIVING: SHIFT NURSING,
IN-HOME NURSES AID SERVICES, WRAP-AROUND SERVICES
FOR A TEENAGER, FAMILY-BASED THERAPY,
RESIDENTIAL TREATMENT FACILITY,
AND OTHER SERVICES KIND OF DEPENDS ON THE ELIGIBILITY
CATEGORY.
IF YOU'RE DENIED SSI-- BECAUSE THE SOCIAL
SECURITY ADMINISTRATION, WHICH IS WHAT SSA STANDS FOR--
I PROBABLY HAVEN'T EXPLAINED ALL OF THESE
ACRONYMS REALLY WELL-- YOU NEED TO CONSIDER APPEALING,
AGAIN, BECAUSE OF THAT CLOSE TIE TO MEDICAID SERVICES.
IF YOU'RE DENIED SSI BASED ON THE CHILD OR YOUTH'S
INCOME OR ASSETS, YOU CAN STILL APPLY FOR MEDICAL
ASSISTANCE.
SO IF YOU'RE NOT GETTING CASH FROM SSI,
YOU CAN STILL GET MEDICAL ASSISTANCE IN CERTAIN
CATEGORIES.
WE'RE GOING TO TALK A LITTLE BIT ABOUT MAWD.
I LOVE THAT TERM, MAWD.
IT MAKES ME THINK OF THAT, YOU KNOW,
WAY 1970S SERIES WITH BEA ARTHUR.
SHE WAS A FEISTY CHARACTER.
I LIKE MAWD AS AN ACRONYM.
THERE'S A HEALTHY HORIZONS CATEGORY,
WHICH HAVE HIGHER INCOME LIMITS AND NO ASSETS
FOR CHILDREN UNDER AGE 21, AND THEN THERE ARE HOME
AND COMMUNITY SERVICES, COMMUNITY-BASED SERVICES
WAIVERS.
WE'RE GOING TO GO INTO THOSE IN A FAIR AMOUNT OF DETAIL.
HOW AM I DOING SO FAR?
IT'S ONLY BEEN 15 MINUTES, AND I'VE COVERED A WHOLE TON
OF STUFF.
YOU GUYS KEEPING UP WITH ME?
>> YES.
EXCELLENT, EXCELLENT-- I LIKE THIS GROUP.
YOU CAN ALL COME BACK TO OUR OFFICE AND ANSWER QUESTIONS
ON THE HOTLINE.
ALL RIGHT.
MAWD, WHICH STANDS FOR MEDICAL ASSISTANCE
FOR WORKERS WITH DISABILITIES.
YOU HAVE TO BE WORKING AT LEAST TEN HOURS A MONTH,
AND YOU HAVE TO BE GETTING PAID.
THE WORK CAN BE ANYTHING.
YOU CAN BE WALKING SOMEONE'S DOG.
YOU CAN BE COLLECTING SOMEONE'S MAIL WHO'S,
YOU KNOW, IN FLORIDA FOR THE WINTER.
YOU CAN BE WATERING SOMEONE'S PLANTS.
YOU CAN BE BABYSITTING.
YOU CAN BE WASHING CARS.
YOU HAVE TO BE 16 OR OLDER BECAUSE TECHNICALLY YOU'RE
NOT REALLY SUPPOSED TO BE WORKING UNDER AGE 16,
SO THAT'S WHERE THAT KIND OF COMES FROM.
AND YOU HAVE TO HAVE A DISABILITY OR MEDICAL
CONDITION THAT WOULD MEET THE SOCIAL SECURITY
DISABILITY CRITERIA, EXCEPT THAT YOU'RE EMPLOYED.
YOU KNOW, YOU CAN STILL GO TO WORK.
YOU'RE DOING SOME WORK.
AND THIS CAN REALLY EXPAND BEYOND TEN HOURS A MONTH.
I MEAN, YOU CAN BE WORKING A FAIR AMOUNT,
AND THE CATEGORY IS REALLY DESIGNED TO ALLOW PEOPLE
WITH DISABILITIES TO KEEP THEIR MEDICAL ASSISTANCE
SERVICES, WHICH ARE OFTEN SO CRITICAL TO EVEN BEING ABLE
TO GET OUT OF BED FOR SOME FOLKS,
LET ALONE, YOU KNOW, SORT OF GET TO WORK.
BUT, YOU KNOW, THE INCOME USED TO JUST EXEMPT YOU
FROM THIS CATEGORY ENTIRELY.
SO YOU HAVE TO HAVE COUNTABLE INCOME,
AND YOUR ASSET LIMITS NEED TO BE BELOW THESE LIMITS
FOR THIS PARTICULAR PROGRAM.
AND ONE OF THE REASONS I PRINTED OUT ALL OF THE PAGES
OF THIS PRESENTATION IS THAT YOU'RE GOING TO SEE THAT
ASSETS AND INCOME VARY BY CATEGORY.
SO MAWD IS FAIRLY GENEROUS BECAUSE THERE IS ALSO
A DISREGARD OF SOME OF THE INCOME THAT YOU'RE EARNING.
SO, YOU KNOW, IF YOU'RE-- SAY YOU'RE MAKING $100 A MONTH.
50% OF THAT WOULD BE DISREGARDED TO BEGIN WITH.
ALL RIGHT.
SO IT REALLY IS A GREAT CATEGORY,
PARTICULARLY FOR YOUNG ADULTS WHO MAY ONLY BE
WORKING PART-TIME.
>> IS THIS A STATE OF PENNSYLVANIA PROGRAM
OR A FEDERAL PROGRAM?
>> THIS IS ACTUALLY A FEDERALLY SUPPORTED PROGRAM.
SO THERE'S--YOU KNOW, WE TALK A LOT ABOUT PROGRAMS
THAT HAVE A FEDERAL AND STATE MATCH.
THIS IS ONE OF THEM, AND IT IS AN OPTION THAT MANY OTHER
STATES TAKE UP IN DIFFERENT WAYS.
SO YOU CAN'T EARN MORE THAN $2,269
A MONTH IN WHAT IS COUNTED AS INCOME,
SO THINK ABOUT DOUBLING THAT,
AND THAT'S SORT OF THE MAXIMUM AMOUNT,
WHICH IS--IT'S CERTAINLY NOT GOING TO BUY YOU A HOUSE
AT THE BEACH, BUT IT'S NOT A BAD MONTHLY SALARY.
AND YOUR COUNTABLE ASSETS NEED TO BE BELOW $10,000,
SO A SAVINGS ACCOUNT, YOUR BOAT--I DON'T KNOW,
BOAT ALWAYS COMES UP-- AND THEN YOU NEED TO PAY
A PREMIUM FOR THIS, WHICH IS 5% OF THAT COUNTABLE INCOME.
BUT AGAIN, IT'S A FAIRLY GENEROUS BENEFITS PACKAGE,
AND IF YOU'RE UNDER 21, YOU'RE STILL GETTING THAT
EPSDT STUFF.
SO THINK ABOUT THIS ONE IF SOME OF THESE OTHER
CATEGORIES DON'T COME THROUGH.
THIS IS, I THINK, A PARTICULAR CATEGORY
FOR YOUTH AGING OUT WHO HAVE AUTISM,
ARE ON THE SPECTRUM BUT REALLY COULD GO TO WORK BUT,
AT THE SAME TIME, DON'T WANT TO LOSE THEIR SUPPORTS.
NOW, WE'RE GOING TO WALK THROUGH THE HOME
AND COMMUNITY SERVICES, HOME AND COMMUNITY-BASED
SERVICES WAIVER.
THERE ARE A LOT OF THEM, SO WE'RE ABOUT TO SORT
OF PLUNGE OFF THE TOP OF THE HILL HERE.
THE FEDERAL GOVERNMENT CAN ALLOW STATES--AND YOU HEARD
KATHY THIS MORNING TALK ABOUT WAIVERS AND COMMCARE
AND A BUNCH OF OTHER PIECES.
SO WE'RE GOING TO ADDRESS SOME OF THESE IN DETAIL.
BUT UNDER THESE WAIVERS, STATES CAN OFFER, SO IN OTHER WORDS,
THEY MAKE A PLAN.
THEY WRITE TO THE FEDERAL GOVERNMENT.
THEY SAY, "WE WANT TO CREATE THIS WAIVER,
AND IN THIS WAIVER WE'RE GOING TO CHANGE THE USUAL
STANDARDS FOR INCOME.
WE'RE GOING TO CHANGE THE USUAL SETS OF SERVICES.
WE'RE GOING TO ADD SOME.
WE'RE GOING TO SUBTRACT SOME OTHERS."
THEY NEED TO GET PERMISSION TO WAIVE THE USUAL RULES
FOR MEDICAID.
THAT'S WHY THEY'RE CALLED WAIVERS.
AND THEY CAN OFFER CERTAIN SERVICES TO CERTAIN PEOPLE,
WHICH IS REALLY ONE OF THE BIGGEST SHIFTS.
GENERALLY, MEDICAID USED TO APPLY TO EVERYBODY
IN THE SAME WAY ACROSS THE STATE.
THIS IS THE WAIVER OF THAT REQUIREMENT SO THAT YOU CAN
CREATE CERTAIN CATEGORIES OF PEOPLE WHO GET CERTAIN SETS
OF SERVICES.
SO THE SERVICES UNDER THESE WAIVERS CAN MEET BOTH
MEDICAL AND NON-MEDICAL NEEDS FOR A PARTICULAR GROUP
OF PEOPLE.
WAIVERS, YOU KNOW, THE CONCEPT IS THAT WE'RE
FUNDING SERVICES IN THE COMMUNITY THAT,
YOU KNOW, WOULD NOT OTHERWISE BE AVAILABLE.
IT ALLOWS THEM TO REMAIN IN THE COMMUNITY,
TO NOT HAVE TO GO TO AN INSTITUTIONAL SETTING,
EITHER A NURSING HOME OR A RESIDENTIAL TREATMENT
FACILITY.
THINK PENNHURST AS WHAT USED TO BE THAT INSTITUTION.
AND THEY REALLY BEGIN TO FILL THE GAPS THAT WOULD
OTHERWISE BE PRESENT AS A CHILD MOVES OUT OF EPSDT.
THEY ARE NOT LIKELY TO MEET ALL MEDICALLY NECESSARY
SERVICES, BUT THEY REALLY ARE GOING TO MEET A FAIR
AMOUNT OF THEM.
AND THE ABILITY TO GET A WAIVER,
OF COURSE, IS DEPENDENT UPON WHETHER THERE'S AN OPEN SLOT
BECAUSE A LOT OF THESE ARE LIMITED BY SIZE.
AND YOU HEARD KATHY TALK THIS MORNING ABOUT
THE WAITING LIST FOR INTELLECTUAL DISABILITY
SERVICES, AS NOTED IN THIS SLIDE.
AND THAT WAS BEFORE I HAD HEARD HER PRESENTATION,
SO I DIDN'T COPY.
THESE ARE THE LIST OF WAIVERS I'M GOING TO COVER TODAY.
THERE ARE SOME OTHERS, MOSTLY THAT APPLY
TO THE ELDERLY, SO I HAVEN'T-- I HAVEN'T WALKED
THROUGH THOSE.
IF YOU WORK WITH PEOPLE OVER 65,
YOU KNOW, GO TO OUR WEBSITE OR CALL US OR WHAT HAVE YOU.
I'M NOT AS FLUENT IN THOSE SO,
YOU KNOW, I MAY NOT ASK YOU TO CALL ME,
BUT SOMEONE ELSE.
SO WE'RE GOING TO WALK THROUGH THESE KIND OF ONE
AT A TIME, AND I WILL EXPLAIN ALL THE ACRONYMS AS WELL,
JUST SO THAT-- DON'T FREAK OUT.
IT'S JUST THAT IS MAKES THE SLIDE REALLY LONG IF I SPELL
OUT ALL THOSE WORDS.
SO, THE AUTISM WAIVER, THIS IS NOT GOING TO BE
COMPLETELY BRILLIANT.
YOU HAVE TO BE AGE 21 OR OLDER,
SO YOU HAVE TO HAVE LEFT THE EPSDT CATEGORY OF SERVICES.
YOU NEED TO BE--WELL THAT'S CLEARLY NOT RIGHT.
THIS IS WHAT HAPPENS WHEN YOU BORROW SLIDES.
YOU HAVE TO BE DIAGNOSED WITH AUTISM OR AN AUTISM
SPECTRUM DISORDER.
CLEARLY, I MESSED THAT UP.
WOW.
I AM SO SORRY.
THIS IS NOT THE RIGHT SLIDE.
I JUST CHANGED THE TITLE OF THAT.
I WONDER WHAT I DID NEXT.
THERE, OK.
SO I AT LEAST GOT SOME OF IT RIGHT.
LET ME GO BACK AND SEE IF I CAN FILL IN.
YOU DO NEED TO BE AGE 21 AND OVER.
THAT'S THE FIRST PART.
YOU NEED TO HAVE A DIAGNOSIS OF AUTISM,
AND IT DOES REQUIRE, NOT A HOSPITAL, SKILLED NURSING
OR INTERMEDIATE CARE FACILITY LEVEL OF CARE,
CERTAINLY NOT THAT.
BUT CERTAINLY, YOU NEED SUPPORT SERVICES IN ORDER TO,
YOU KNOW, FUNCTION IN THE COMMUNITY.
THESE ARE NOT THE SERVICES YOU WOULD GET.
THEY'RE KIND OF NICE, BUT THEY'RE PROBABLY NOT
APPROPRIATE IN MANY WAYS.
AND I WILL FIX THESE AND SEND THAT OUT.
BUT THEY ARE--YOU KNOW, THINK OF THE AUTISM SERVICES
THAT A YOUTH WOULD NEED, AND THOSE WOULD BE COVERED.
THEY MAY BE LIMITED IN SCOPE AND NOT,
YOU KNOW, SORT OF HIT THE FIVE DAYS A WEEK,
YOU KNOW, FOR X NUMBER OF HOURS.
THEY MAY BE MORE LIMITED, AND THEY ARE DESIGNED
TO SUPPORT, YOU KNOW, A YOUNG ADULT IN THE COMMUNITY.
THEY ARE LIMITED.
SO AS WE SAID, THIS IS HOW YOU WOULD DO THIS.
CONTACT THE BUREAU OF AUTISM SERVICES.
NEW APPLICANTS, AS WE SAID, THERE'S A WAITING LIST
FOR THESE SERVICES AT THE MOMENT.
IT IS A FIRST-COME-FIRST-SERVED,
AND I HAVE NO IDEA WHAT PUNS ACTUALLY STANDS FOR,
BUT IT REALLY IS-- RIGHT, THANK YOU.
SAY THAT AGAIN LOUDER.
>> PRIORITIZATION AND UTILIZATION OF NEEDS SURVEY.
>> RIGHT.
SO THERE IS NOT A REQUIREMENT THAT THAT YOU
MEET A CERTAIN CRITERIA ON THAT SURVEY.
AND, YOU KNOW, CLEARLY IT GOES--THE PRIORITY IS FOR FOLKS
WHO ARE NOT GETTING OTHER SERVICES.
SO THERE'S, YOU KNOW, A KIND OF HIERARCHY OF NEED.
QUESTIONS ON THE AUTISM WAIVER THAT I CLEARLY DIDN'T
ANSWER?
>> (INAUDIBLE QUESTION FROM AUDIENCE)
>> RIGHT, NOT RESIDENTIAL, EXACTLY.
I--YES, PARTLY BECAUSE WE HAVE A LARGE GROUP,
BUT ALSO BECAUSE IT'S BEING RECORDED AND THERE WILL BE
THIS GAP IN THE RECORDING.
THE QUESTION WAS: ARE THE SERVICES COVERED ONLY
IN THE IN-HOME SETTING OR COMMUNITY SETTING,
NOT IN AN INSTITUTIONAL SETTING?
THE ANSWER TO WHICH IS YES.
THESE ARE SERVICES--THESE ARE HOME AND COMMUNITY-BASED
SERVICES.
ALL OF THESE WAIVERS THAT I'M GOING TO DESCRIBE
ARE HOME AND COMMUNITY-BASED SERVICES.
>> (INAUDIBLE QUESTION FROM AUDIENCE)
>> THE SECOND QUESTION IS DO THESE SERVICES COVER JOB
COACHING AND OTHER SUPPORTS, JOB RELATED SUPPORTS,
EMPLOYMENT RELATED SUPPORTS?
AS FAR AS I KNOW, THEY DO.
THESE ARE SOMEWHAT CUSTOMIZED SERVICES,
AND SO IT DEPENDS ON THE NEED OF THE PERSON SEEKING
THE WAIVER SERVICES.
MOVING ON, ATTENDANT CARE WAIVER.
I'M GOING TO PUT THIS DOWN BECAUSE I'M CRAMPING UP IN
MY SHOULDER.
I GOT THE FUNCTIONAL CRITERIA RIGHT,
JUST SO I-- I STOPPED BORROWING SLIDES.
SO THE FUNCTIONAL CRITERIA IS YOU NEED TO BE BETWEEN
AGES 18 AND 59.
AFTER AGE--WHEN YOU GET TO BE MY AGE,
YOU ACTUALLY BEGIN TO QUALIFY FOR LONG-TERM CARE
SERVICES UNDER A DIFFERENT GROUPING.
YOUR PHYSICAL IMPAIRMENT, AGAIN,
NEEDS TO BE--NEEDS TO LAST 12 MONTHS OR MORE,
SORT OF SIMILAR TO THE PH 95 CRITERIA.
YOU NEED TO BE MENTALLY ALERT AND CAPABLE
OF SELECTING, SUPERVISING ATTENDANTS,
AND MANAGING YOUR OWN AFFAIRS.
SO THIS IS FOR SOMEONE, YOU KNOW,
CAPABLE OF SORT OF DIRECTING AT LEAST SOME OF THEIR CARE.
AND IT'S SOMEONE WHO WOULD REQUIRE A NURSING FACILITY
LEVEL OF CARE.
SO WE'RE TALKING ABOUT HELP WITH BATHING,
HELP WITH FEEDING, HELP WITH GETTING DRESSED,
TOILETING, THOSE KINDS OF, YOU KNOW,
MOBILITY ISSUES.
THE SERVICES ARE ATTENDANT CARE SERVICES,
HENCE THE NAME OF THE WAIVER--
BATHING, CLEANING, MEAL PREPARATION, SHOPPING,
LAUNDRY, YOU KNOW, THOSE KINDS OF SERVICES;
SOME SUPPORTS COORDINATION, PERSONAL EMERGENCY RESPONSE
SYSTEM--SO, YOU KNOW, I'VE FALLEN AND I CAN'T GET UP
KIND OF THINGS THAT MY MOTHER NOW WEARS BECAUSE
SHE'S 86; AND COMMUNITY TRANSITION SERVICES.
SO THESE ARE SERVICES THAT SORT OF ALLOW SOMEONE TO,
YOU KNOW, MAINTAIN THEIR PRESENCE IN THE COMMUNITY
AND, YOU KNOW, GO TO THE LIBRARY OR,
YOU KNOW, PARTICIPATE IN A VARIETY OF THINGS.
QUESTIONS ON THIS?
THESE ARE--THESE ARE-- I REMEMBER NOW WHAT I DID
WITH THE SLIDE.
OK.
SO COMMUNITY SERVICES PROGRAM FOR PEOPLE
WITH DISABILITIES.
THAT'S WHAT THOSE-- ALL THOSE LETTERS STAND FOR.
COMMUNITY SERVICES PROGRAM FOR PEOPLE WITH DISABILITIES
WAIVERS.
THERE ARE A COUPLE OF THESE.
ONE IS THE OBRA WAIVER, WHICH STANDS FOR THE
OMNIBUS BUDGET RECONCILIATION ACT.
IT'S JUST THAT PARTICULAR YEAR.
IT WAS COVERED IN THIS SORT OF END OF CONGRESS,
OMNIBUS--YOU KNOW, THEY THREW A BUNCH OF MONEY
TOGETHER AND PUT SOME LANGUAGE TO IT.
OBRA IS THE WAY THAT WE'VE EXPANDED MEDICAID
ELIGIBILITY.
IT'S THE WAY FOR PREGNANT WOMEN AND FOR KIDS.
I MEAN, THEY GO BACK TO THE LATE '80S,
EARLY '90S.
BUT THIS, FOR WHATEVER REASON,
HAS STUCK AS THE NAME OF THIS PARTICULAR WAIVER.
INDEPENDENCE WAIVER, AND THE COMMCARE WAIVER,
WHICH KATHY REFERRED TO EARLIER.
FOR ALL OF THESE, AND WE'LL GO INTO EVEN
MORE DETAIL, YOU MUST HAVE A PHYSICAL DISABILITY,
A TRAUMATIC BRAIN INJURY, OR OTHER RELATED CONDITION.
YOU HAVE TO HAVE AT LEAST THREE SUBSTANTIAL FUNCTIONAL
LIMITATIONS IN THE FOLLOWING AREAS.
SO, YOU KNOW, THESE ARE NOT GOING TO BE NEW OR ROCKET
SCIENCE: MOBILITY, COMMUNICATION,
SELF-CARE, LEARNING, SELF-DIRECTION,
AND THE CAPACITY FOR INDEPENDENT LIVING.
SO YOU NEED TO BE LIMITED IN THREE OF THOSE AREAS.
THE OBRA WAIVER.
JUST CALL IT THE OBRA WAIVER.
DON'T--I MEAN, WHATEVER YOU DO,
DON'T GO INTO--I BET HALF OF THE PEOPLE YOU WOULD TALK TO
WOULD NOT KNOW WHAT OBRA ACTUALLY STANDS FOR, EITHER.
SO THIS IS FOR DEVELOPMENTALLY DISABLED
INDIVIDUALS WHO ARE 18 OR OLDER.
THE DISABILITY HAS TO HAVE MANIFESTED BEFORE AGE 22.
ALL RIGHT.
SO MY DAUGHTER'S FORMER CLIENT TROY,
WHO HAS A TRAUMATIC BRAIN INJURY THAT RESULTS IN
MENTAL RETARDATION, DOESN'T QUALIFY BECAUSE HE WAS 34
WHEN HE WAS INJURED.
SO DISABILITY IS LIKELY TO CONTINUE INDEFINITELY.
SO IT'S NOT GETTING BETTER AND,
AGAIN, RESULTS IN LIMITATIONS IN THESE
OF THOSE FUNCTIONAL AREAS.
PRIMARY DIAGNOSIS IS NOT A MENTAL HEALTH OR MENTAL
RETARDATION DIAGNOSIS.
WE WILL GET TO SOME OF THOSE LATER.
IT SOMETIMES HELPS FOR FOLKS WHO HAVE BEEN PLACED
IN A NURSING HOME BUT DIDN'T REALLY NEED THAT LEVEL
OF CARE OR FOR COMMUNITY RESIDENTS WHO WOULD MEET
AN INSTITUTIONAL LEVEL OF CARE WITH A HIGH NEED
FOR HABILITATION SERVICES.
ARE PEOPLE FAMILIAR WITH THE TERM HABILITATION,
BECAUSE IT'S A RELATIVELY NEW ONE?
WE TALK ABOUT REHABILITATION, RIGHT?
REHABILITATION IS, YOU KNOW, YOU'VE HAVE A STROKE,
YOU'VE LOST YOUR SPEECH, YOUR RIGHT SIDE IS WEAK,
AND YOU DO PHYSICAL THERAPY AND SPEECH THERAPY TO GAIN
THOSE FUNCTIONS BACK.
HABILITATION, WHICH PRIMARILY-- IT AFFECTS A LOT OF PEOPLE.
IT'S PARTICULARLY IMPORTANT TO KIDS BECAUSE,
WHEN WE TALK ABOUT HABILITATION FOR CHILDREN,
WE'RE TALKING ABOUT HAVING THEM MEET THE AGE
APPROPRIATE FUNCTIONS THAT THEY NEVER HAD.
SO FOR THE TWO-YEAR-OLD WHO HAS NOT YET LEARNED TO WALK,
PHYSICAL THERAPY IS HABILITATION.
FOR SOMEONE WHO HASN'T MANAGED A SHOPPING TRIP ON
THEIR OWN OR CAN'T NAVIGATE THE BUS SYSTEM BUT CAN LEARN
THAT, THAT'S HABILITATIVE SERVICES.
SPEECH THERAPY IS DEFINITELY HABILITATION FOR TODDLERS,
ADULTS WHO HAVE NEVER SORT OF MANAGED THEIR SPEECH
IN A GOOD WAY.
IT'S ALSO A WAY TO MAINTAIN FUNCTION.
SO IF YOU NEED SOME REGULAR COACHING OR SOME REGULAR
PHYSICAL THERAPY TO KEEP YOURSELF GOING,
THOSE ARE HABILITATION, NOT REHABILITATION, SERVICES.
ALL RIGHT.
THIS IS ACTUALLY GOING TO COME UP BIG UNDER OBAMA CARE,
BUT THAT'S FURTHER DOWN THE ROAD,
ALSO FURTHER DOWN THE SLIDE SHOW.
ALL RIGHT.
AVAILABLE SERVICES UNDER THE OBRA WAIVER,
LOTS OF THEM.
ALL RIGHT.
CLEARLY, SERVICES THAT ARE DESIGNED TO KEEP SOMEONE
IN THE COMMUNITY AND SUPPORT THEM THERE, ALL RIGHT.
SO THEY INVOLVE, YOU KNOW, ADULT DAY SERVICES,
A PLACE TO GO AND OTHER PEOPLE TO BE WITH,
YOU KNOW, THE IDEA THAT YOU CAN BEHAVE IN THE COMMUNITY,
YOU KNOW, AND THAT THE COMMUNITY IS READY TO
RECEIVE YOU, PERSONAL ASSISTANCE SERVICES,
EDUCATION SERVICES, YOU KNOW,
CHANGES TO YOUR ENVIRONMENT, A RAMP,
A SHOWER CHAIR, OR, YOU KNOW,
ONE OF THOSE WONDERFUL LIFTS THAT TAKE YOU FROM HERE TO
THERE IN YOUR OWN HOUSE OR IN AND OUT OF YOUR CAR,
PREVOCATIONAL SERVICES, SO THOSE THINGS YOU MIGHT NEED
TO DO OR LEARN BEFORE YOU CAN GO INTO JOB TRAINING,
AND VISITING NURSE SERVICES.
WE TALKED ABOUT PT/OT, SPEECH,
BEHAVIOR THERAPY.
SUPPORTED EMPLOYMENT CAME UP BEFORE.
NON-MEDICAL TRANSPORTATION, SO IF YOU NEED TO GO
TO THE LIBRARY OR TO WORK OR TO THE GROCERY STORE.
RESPITE SERVICES FOR THE FOLKS WHO ARE TAKING CARE
OF YOU THE REST OF THE DAY, AND ASSISTIVE TECHNOLOGY,
AND THEN, AGAIN, THAT SORT OF I'VE FALLEN AND I CAN'T
GET UP SERVICES.
SORRY.
I'M STANDING A LITTLE TOO CLOSE TO THE MICROPHONE.
I GESTURE A LOT, SO I TRY NOT TO TAKE IN TOO MUCH STUFF.
GOOD?
RIGHT?
SO THIS IS A GREAT--THE OBRA WAIVER IS A GREAT WAIVER.
I MEAN, IN TERMS OF SUPPORTING PEOPLE
IN THE COMMUNITY, IT'S PRETTY GOOD.
DID I GO THE WRONG WAY?
YOU KNOW, I MAY HAVE ACTUALLY--YEAH,
TWO DUPLICATE SLIDES.
THERE'S 45 SLIDES, SO IT'S HARD FOR ME TO MANAGE.
INDEPENDENCE WAIVER--AND AGAIN,
WE'RE STILL IN THAT SAME--THESE THREE WAIVERS
KIND OF ALL GO TOGETHER.
AGAIN, AGE 18 OR OLDER; AGAIN,
THAT ISSUE OF NURSING FACILITY LEVEL OF CARE.
YOU NEED A SEVERE DISABILITY WHICH IS LIKELY TO CONTINUE
INDEFINITELY, SO, YOU KNOW, IT CAN'T BE SORT
OF TEMPORARY AS A RESULT OF A CAR ACCIDENT,
FOR INSTANCE.
THE DISABILITY, AGAIN, RESULTS IN THOSE LIMITATIONS
IN AT LEAST THREE OF THOSE MAJOR LIFE ACTIVITIES,
YOU KNOW, WE SAW BACK BEFORE.
AND AGAIN, THE PRIMARY DIAGNOSIS IS NOT MENTAL
HEALTH OR MENTAL RETARDATION.