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• States make applications for Medicaid Waivers with the federal Medicaid agency, known as the Centers for Medicare and Medicaid Services (CMS). This enables states to waive the usual requirements that individuals must reside in an institution in order to receive Medicaid funding for services. In this way, Medicaid funds certain community-based alternatives to institutional care. 
• Virginia first applied for a Mental Retardation Waiver in 1990, with services beginning in early 1991. That year 130 people received services through the MR Waiver. Virginia’s MR Waiver was revised and new services were added in 1994. More recently, a new Waiver was developed by an MR Waiver Task Force, comprised of representatives of private provider agencies, Community Services Boards, individuals with mental retardation and their family members, advocacy groups and state government. The new Waiver included new services, in addition to some changes to existing services. It was submitted to CMS and approved in 2001. 
• The state agency that administers the MR Waiver in Virginia is the Department of Medical Assistance Services (DMAS). Day-to-day MR Waiver operations are managed by the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS). Locally, MR Waiver services for individuals are coordinated by case managers employed by Community Services Boards (CSBs) or Behavioral Health Authorities (BHAs). The actual services are delivered by CSBs/BHAs and private providers across the state.
• The proportion of costs a state must pay for waivers (“match”) varies from state to state based on per capita income and other factors related to revenue capacity. In Virginia, Federal Financial Participation (FFP) is approximately 50%, meaning the state must contribute about 50% of the cost in order to draw federal dollars. 
• Initially, state general funds were distributed to CSBs/BHAs and could be used for “match.” Each CSB could determine what portion of their funds would be used as match for Waiver services. The growth of the MR Waiver and cost of Waiver services was therefore controlled locally. 
•  In fiscal year 2001, all state general funds used to cover MR Waiver services were transferred to DMAS and funds are now managed at the state level.
• In order to receive MR Waiver services, an individual must meet eligibility requirements and a “slot” must be available. Currently the number of slots is limited by the availability of funding for MR Waiver services.

Individual Eligibility

An individual is deemed eligible for MR Waiver services based on three factors:

• Diagnostic Eligibility: Individuals six years of age or older must have a psychological evaluation completed by a licensed professional that states a diagnosis of mental retardation and reflects the individual’s current level of functioning. Individuals under age six must have a psychological or standardized developmental evaluation that states that the child has a diagnosis of mental retardation or is at developmental risk and reflects the child’s current level of functioning.
• Functional Eligibility: All individuals receiving MR Waiver services must meet the ICF-MR (Intermediate Care Facility [for persons with] – Mental Retardation) level of care. This is established by meeting the indicated dependency level in two or more of the categories on the “Level of Functioning Survey.” 
• Financial Eligibility: An eligibility worker from the local Department of Social Services determines an individual’s financial eligibility for Medicaid. Some individuals who would not ordinarily qualify financially for Medicaid may be eligible by receipt of MR Waiver services. 

Medicaid regulations specify that, once an individual has been determined eligible by the CSB/BHA case manager, he or she must be offered a choice between institutional and Waiver services. 

“Slots” and Slot Allocation

A “slot” is a term referring to an opening of Waiver services available to a single individual. Each MR Waiver recipient is assigned a slot. The Centers for Medicare and Medicaid Services (CMS) asks each state to determine a number of unduplicated recipients they expect to serve in order to determine the state’s slot allocation. In October 2001, Virginia requested an additional 150 slots, bringing Virginia’s slot total to 5,536. 

How Slots Are Distributed and Assigned

• Each CSB/BHA has a slot allocation equal to the total number of MR Waiver recipients for whom they provide case management services. Additional slots, beyond each CSB’s/BHA’s present allocation, will only be available through the budget process and after the Appropriation Act is signed. 
• As additional slots become available, they will be allocated to CSBs/BHAs based on their percentage of urgent cases when compared to the statewide total of urgent cases. CSBs/BHAs not having MR Waiver eligible individuals who meet the urgent criteria (see below for discussion of “urgent criteria”) will not be given additional slots until all individuals in the State who meet the urgent criteria have been served.
• If an assigned slot becomes vacant (e.g., through an existing MR Waiver recipient’s death, move to another state or refusal of MR Waiver services) or when a new slot is allocated, the CSB/BHA is responsible for assigning that slot to an individual who meets the urgent criteria.
• The CSB/BHA will determine from among the individuals meeting the urgent criteria, who is in most critical need of services at the time a slot becomes available and not on any predetermined numerical or chronological order.
• All applicants in the state meeting the urgent criteria must be served before anyone from the non-urgent list can be served. 
• CSBs/BHAs may not target a particular subcategory of applicants in the selection process when assigning slots (e.g., the selection of adults over children). DMAS and DMHMRSAS will evaluate the distribution of services to all eligible populations.
• There are a limited number of reserved slots assigned to individuals who have been discharged from state facilities. If one of these slots is vacated within 24 months, the slot returns to DMHMRSAS to be used for another individual ready for discharge. 

Waiting List Information

There are 3 classifications of waiting lists. 

DMHMRSAS maintains a Statewide Waiting List that includes the names of individuals meeting the urgent and non-urgent criteria. 

The CSB/BHA submits information to DMHMRSAS on individuals to be added to the Statewide Waiting List (names of individuals meeting the Urgent and Non-urgent criteria). 

CSBs/BHAs assess whether applicants are included in the urgent, non-urgent or planning category, based on the following criteria. 

The urgency of need of each individual on each CSB’s/BHA’s waiting list is to be evaluated quarterly by the CSB/BHA. Additions and deletions to the urgent and non-urgent categories will be made at this time and modifications forwarded to DMHMRSAS for inclusion on the Statewide Waiting List. 

1. URGENT

Criteria

The individual is considered to be at significant risk and the individual/family would accept services if they are offered. Criteria includes:

• Both primary caregivers are 55 years of age or older, or if there is one primary caregiver, that primary caregiver is 55 years of age or older; 
• The individual is living with a primary caregiver who is providing the service voluntarily and without pay and the primary caregiver indicates that he or she can no longer care for the individual with mental retardation;
•  There is a clear risk of abuse, neglect, or exploitation;
• One primary caregiver, or both caregivers, has a chronic or long-term physical or psychiatric condition or conditions which significantly limits the abilities of the primary caregiver or caregivers to care for the individual with mental retardation;
• The individual is aging out of a publicly funded residential placement or otherwise becoming homeless (exclusive of children who are graduating from high school); or
• The individual lives with the primary caregiver and there is a risk to the health or safety of the individual, primary caregiver, or other individuals living in the home due to either of the following conditions:

• The individual’s behavior or behaviors present a risk to himself or others which cannot be effectively managed by the primary caregiver even with generic or specialized support arranged or provided by the CSB/BHA; or
• There are physical care needs (such as lifting or bathing) or medical needs that cannot be managed by the primary caregiver even with generic or specialized supports arranged or provided by the CSB/BHA.

2. NON-URGENT

Criteria

• Meets diagnostic (i.e., has mental retardation) and functional (i.e., the Level of Functioning Survey) eligibility criteria
• Needs services within 30 days;
• Does not meet any of the urgent criteria. 

3. PLANNING

These lists are maintained internally by the CSBs/BHAs and are not considered part of the Statewide Waiver Waiting List.

Criteria

• Meets eligibility criteria;
• Will need Waiver services in the future, unless circumstances change.
• Does not meet the urgent or non-urgent criteria.

MR Waiver Services Available in Virginia

The following services are available to individuals meeting the specific service criteria who have been assigned an MR Waiver slot:

• Residential Support Services: training, assistance and specialized supervision, provided primarily in an individual’s home to help the person learn or maintain skills in activities of daily living, safety in the use of community resources, and behavior appropriate for home and the community.
• Day support: training, assistance and specialized supervision to enable the individual to acquire, retain or improve his/her self-help, social and adaptive skills. These services typically take place away from the home in which the individual resides and may be located in a “center” or in community locations.
• Supported employment: supports to enable individuals with disabilities to work in settings in which persons without disabilities are typically employed. It may be provided to one person in one job (e.g., a person working to bus tables in a restaurant) or to several people at a time when those individuals are working together as a team to complete a job (e.g., such as a grounds maintenance crew).
• Prevocational services: training and assistance to prepare an individual for paid or unpaid employment. These services are not job task-oriented. These are for individuals who need to learn skills fundamental to employment such as accepting supervision, getting along with co-workers, using a time clock, etc.
• Personal assistance: direct support with activities of daily living (e.g., bathing, toileting, personal hygiene skills, dressing, transferring, etc.), instrumental activities of daily living (e.g., assistance with housekeeping activities, preparation of meals, etc.), accessing the community, taking medication or other medical needs, and monitoring the individual’s health status and physical condition. These services may be agency-directed or consumer-directed.*
• Respite: services designed to provide temporary, substitute care for that which is normally provided by the family or other unpaid, primary caregiver of an individual. These short-term services may be provided because of the primary caregiver’s absence in an emergency or on-going need for relief. These services may be agency-directed or consumer-directed.*
• Companion: provide non-medical care, socialization or support to adults in an individual’s home or at various locations in the community. This service may be agency-directed or consumer-directed.*
• Assistive technology: specialized medical equipment, supplies, devices, controls and appliances, which enable the individual to better perform activities of daily living, to perceive, control or communicate with his/her environment, or which are necessary to his/her proper functioning.
• Environmental modifications: physical adaptations to an individual’s home or vehicle needed by the individual to ensure his/her health, welfare and safety or enable him/her to experience greater independence in the home and around the community.
• Skilled nursing services: nursing services ordered by a physician for individuals with serious medical conditions and complex health care needs. This service is available only for individuals for whom these services cannot be accessed through another means. These services may be provided in an individual’s home, community setting, or both.
• Therapeutic consultation: expert training and technical assistance in any of the following specialty areas to enable family members, caregivers, and other service providers to better support the individual. The specialty areas are: Psychology, Behavior, Speech and Language Pathology, Occupational Therapy, Physical Therapy, Therapeutic Recreation and Rehabilitation Engineering.
• Crisis stabilization: direct intervention (and may include one-to-one supervision) to a person with mental retardation who is experiencing serious psychiatric or behavioral problems which jeopardize his/her current community living situation. The goal is to avoid emergency psychiatric hospitalization or institutional admission or other out-of-home placement, as well as to stabilize the individual and strengthen the current living situation so the individual can be maintained during and beyond the crisis period.
• Personal emergency response systems (PERS): an electronic device that enables the individual who is alone to access a centralized, staffed emergency center in the event of an emergency.
  
  * Consumer-directed services offer the individual/family the option of hiring workers directly, rather than using traditional agency staff. 

Accessing MR Waiver Services

• Individual, family or representative requests services from the local CSB/BHA. 
• The case manager determines the preferred services and necessary supports by meeting with the individual and family (or other caregivers) and confirms diagnostic and functional eligibility by obtaining a psychological evaluation and completing an ICF/MR Level of Functioning Survey (LOF).
• Once the individual is determined eligible (including financial eligibility through the Department of Social Services), the case manager informs the individual and family of the full array of MR Waiver services and documents the individual’s choice of Waiver or institutional care.
• If the individual selects MR Waiver, the case manager submits required enrollment information to the DMHMRSAS Office of Mental Retardation Services (OMRS). If no slot is available to the CSB/BHA, the individual’s name will be placed on either the urgent or non-urgent Statewide Waiting List until such time as a slot becomes available. After receiving notification from OMRS, the case manager must notify the individual or family in writing within 10 working days of his/her placement on either list and offer appeal rights.
• Once an individual has been enrolled and it is determined that a slot is available, the individual selects providers for needed services. The case manager coordinates the development of a Consumer Service Plan (CSP) with the individual, family or other caregivers and the service providers within 30 days of enrollment. The CSP includes all the Individual Service Plans (ISPs) developed by this team and that describe the services that will be rendered.
• Prior to the start of services, the case manager forwards appropriate documentation to OMRS staff for review and authorization of the requested MR Waiver services.
• Once approved, OMRS enters service data in the DMAS computer system. This generates a notification letter to the providers and permits them to bill for approved services. Service provision should commence in 60 days. 

Waiver Funding

02/11/03

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