Provided by Debbie Milhouse-Slaine, Director Children's Waiver Program; Resource shared by Penny Ray, a parent.

 
I. LEGAL AUTHORITY

Home and Community-Based Services (HCBS) waivers are authorized under Section 1915 of the Social Security Act via Section 2176 of the Omnibus Budget Reconciliation Act of 1981 (OBRA '81). HCBS waivers allow states to provide services to individuals, who without such services, require or are at risk of institutionalization. The Children's Waiver Program (CWP) is approved by the Centers for Medicare and Medicaid Services (CMS) under these provisions.

II. KEY PROVISIONS

The Children's Waiver enables Medicaid to fund necessary home and community-based waiver services for children, under the age of 18, who have a developmental disability, meet criteria for an Intermediate Care Facility for the Mentally Retarded (ICF/MR) and reside with their birth or legally adoptive parents but are at risk of placement out of their home without the services of a home and community-based waiver.  The parent's income is waived when determining financial eligibility for Medicaid. Eligible children will receive both regular Medicaid services, as well as waiver services, provided that the average annualized cost to Medicaid of providing such services does not exceed the costs that Medicaid would have incurred without the waiver, if the child was placed in an (ICF/MR).

Application for the CWP is made through local Community Mental Health Services Programs (CMHSP). When a child is invited to apply for the waiver the CMHSP is the responsible agency for assessing and evaluating eligibility. The CMHSP makes a recommendation to the Department of Community Health (DCH) by submitting a Waiver Certification form that provides a recommendation for the waiver. The CMHSP is also responsible for the coordination of the child's waiver services. A planning team that consists of the CMHSP services coordinator, the child and his/her family, friends, and other professional members, as determined necessary, work together to identify the child's needs and secure the informal and formal supports necessary to meet those needs.

The DCH reviews and determines eligibility for the waiver program. They also review and authorize waiver services for those children who meet eligibility criteria for Category I of the Decision Guide and/or are authorized to receive "enhanced" or "exception" hours.

When there is a disagreement between the child and his/her family and the members of the CMHSP regarding the appropriateness/medical necessity of a waiver service, the child and family have the right, under the Michigan Mental Health Code to appeal a negative action to the director of the CMHSP. They may also request that the CMHSP attempt to resolve the dispute through a local grievance or complaint process. This process must not supplant or replace the child's and parent's right to file an Administrative Hearing request with DCH.

Federal law requires the availability of a fair hearing for any beneficiary enrolled in Medicaid, when that beneficiary is the subject of a negative action. A negative action is when a Medicaid covered service or benefit is denied, terminated, suspended or reduced. The Medicaid beneficiary is notified of the negative action and of their right to an appeal through an administrative hearing process. This appeal process may occur simultaneously with a CMHSP administrative appeal process. Individuals and their family are encouraged to resolve disputes regarding waiver services at the local CMHSP level.

III. CURRENT PARAMETERS

The CWP current parameters include the following:

A. The overall annual waiver costs may not exceed the state's projected costs of serving the waiver beneficiaries in an ICF/MR were there no waiver.

B. CWP hourly care services may be provided in accordance with the CWP Decision Guide for Determining Amount of Publicly Supported Hourly Care, described in Medicaid Bulletin-CMHSP 98-01.

C. The current CWP has CMS approval through April 30, 2006.

D. CWP services costs are paid up to established Medicaid screens.

E. The CMHSP will approve waiver services for children who meet eligibility criteria for Categories II, III and IV of the Decision Guide.

F. The DCH Clinical Review Team will review and authorize waiver services for those children who meet eligibility criteria for Category I of the Decision Guide and/or are authorized to receive "enhanced" or "exception" hours. The DCH Clinical Review Team consists of a medical doctor, registered nurse, a limited license psychologist, and a master's level social worker.

G. The CMHSP is responsible for assessment of potential waiver candidates. They are also responsible for referring potential waiver candidates by working with the family to complete the CWP Prescreen form and sending it to the DCH to determine priority rating score for the waiting list.

IV. ELIGIBILITY

The following eligibility requirements must be met:

A. The child must have a developmental disability (as defined in Michigan state law and Federal law), meet criteria for an ICF/MR and be less than 18 years of age;

B. The child must have a score on the Global Assessment of Functioning (GAF) Scale of 50 or below;

C. The child must reside with his/her birth/adoptive parent or with a relative that has been named the legal guardian, under the laws of the State of Michigan, provided that the relative is not paid to provide foster care for that child.

D. The child's is at risk of being placed into an ICF/MR facility due to the intensity of the child's care needs and the lack of needed support, or the child currently resides in an ICF/MR facility, or other out of home settings but with appropriate community support could return home.

E. The child's parents are able to maintain their child at home with home and community-based services;

F. Safe and appropriate care can be provided in the birth/adoptive home or home of legal guardian at a cost less than that in an ICF/MR facility for that same child;

G. The child must meet or be below Medicaid income and asset limits when viewed as a family of one (the parent's income is waived);

V. WAIVER SERVICES

The following waiver services may be provided to a child enrolled in the CWP when the service is identified in the child's Individual Plan of Services and Supports.

A. Specialty Services

This is an alternative service that can be used in lieu of or in combination with traditional professional services. The focus of specialty services is to interact with the child, family and staff to accomplish the goals identified in the POS. This may be used in addition to the traditional professional therapy model included in state plan Medicaid coverage's. The POS ensures the child's health, safety and skill development and maintains the child in the family home. Services must be directly related to an identified goal in the POS and approved by the physician. Providers are identified through the person-centered planning/family centered practice and participate in the development of a POS based on strengths, needs and preferences of the child and family. Specialty services may include the following activities: child and family training, coaching and supervision, monitoring of progress related to goals and objectives, and recommending changes in the POS. Services provided under Specialty Services include: Music Therapies, Recreation Therapies, Art Therapies, and Massage Therapies. Service providers must meet provider qualifications.

Under very limited circumstances and on a time limited basis, parents and step-parents, who possess appropriate licensure/certification, special skills, documented training and are considered a qualified provider (refer to provider qualifications at the end of this section), may function and be paid as a provider for this service. This would require documentation that: the service being provided is not personal care; the service was not provided during time that the family is responsible to provide the care; other qualified non-familial providers of these services are not currently available. This may not exceed a three-month period and may not be used more than twice in one year.

B. Community Living Supports (CLS)

CLS provides assistance to the family in the care of their child, while facilitating the child's independence and integration into the community. The supports, as identified in the POS, are provided in the child's home and may be provided in community settings when integration into the community is an identified goal. Skills development related to activities of daily living such as bathing, eating, dressing, personal hygiene, household chores and safety skills may be included. It may also promote mobility, sensory-motor, communication, socialization and relationship-building skills, and participation in leisure and community activities. These supports must be provided directly to or on behalf of the child enabling the child to attain or maintain their maximum potential. The supports listed above may serve to reinforce skills or lessons addressed in school, therapy, or other settings.

C. Transportation

Transportation costs are included in the CLS rate and may not be billed separately. Transportation costs may be covered when other staff (e.g. respite worker) transports a child to community services and activities as specified by the POS. Transportation services under the CWP shall be offered in accordance with the child's POS. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge will be utilized. Transportation may not be billed separately when CLS services are billed. Parents of children served by the CWP are not entitled to mileage reimbursement.

D. Respite Care

Respite care services are provided to the child on an intermittent or short-term basis because of the absence or need for relief of the parent. Respite is intended to support the parent who is the primary caregiver. This service can be provided in the child's home, foster home, group home, licensed respite care facility, licensed camp, or the home of a friend or relative. Parents or guardians may not be considered a provider nor be reimbursed for this service. In addition to the maximum monthly respite allocation of 96 hours, vacation respite can be used up to 14 days per year.

Respite provided in an institution (i.e., ICF/MR, nursing home, or Child Caring Institute [CCI]) is not covered by the CWP.

When a child requires skilled nursing interventions on a 24 hour basis the maximum daily amount that one nurse can provide is 16 hours. When the family is not available to provide the additional 8 hours of care a second nurse will be required to cover the remainder of the 24-hour period.

E. Psychological/Behavioral Treatment

This service provides coaching, supervision and monitoring of hourly care staff by professional staff (LLP, MSW, or QMRP). The hourly care staff previously included under psychological/behavioral treatment is now covered under CLS. The professional staff will work with parents and CLS staff to implement the POS that addresses services designed to improve the child's social interactions and self-control, by instilling positive behaviors in the place of behaviors that are socially disruptive, injurious to the child or others, or that cause property damage.

F. Family Training/Didactic Services

This service provides training and counseling services for the families of children served by the CWP. For purposes of this service, "family" is defined as the persons who live with or provide care to a child served by the CWP and may include a parent or siblings. "Family" does not include individuals who are employed to care for the child. Training includes instruction about treatment regimens and use of equipment specified in the POS and shall include updates as necessary to safely maintain the child at home.

It is also a counseling service directed to the family and designed to improve and develop The family's skills in dealing with the life circumstances of parenting a child with special needs.

G. Enhanced Medical Equipment and Supplies

Specialized medical equipment and supplies may include devices, controls, or appliances, Specified in the POS, which enable the child to increase their abilities to perform activities of daily living or to perceive, control or communicate with the environment in which they live. This service also includes items necessary for life support, ancillary supplies and equipment necessary for the proper functioning of such items and durable and non-durable medical equipment not available under the Medicaid State Plan. Items that are not of direct medical or remedial benefit to the child are excluded.

H. Environmental Accessibility Adaptations (EAA)

EAAs include those physical adaptations to the home, specified in the POS that are necessary to ensure the health, welfare and safety of the child, or enable them to function with greater independence in the home and without which the child would require institutionalization. Home adaptations may include the installation of ramps, widening of doorways, modification of bathroom facilities or installation of specialized electric and plumbing systems, that are necessary to accommodate the medical equipment and supplies necessary for the welfare of the child. In the event that DCH/CWP staff determines that the home cannot be made accessible within the existing structure and all other housing options have been exhausted, home additions may be considered.

VI. CLINIC SERVICES

A. Psychological Testing

Psychological tests ordered by a physician (M.D. or D.O.) must be rendered by full, limited-licensed or temporary-limited-licensed psychologist.

B. Other Assessment & Testing

Generally accepted professional assessments or tests, other than psychological tests, that are conducted for the purposes of determining level of functioning and treatment needs of the child's are covered.

C. Periodic Review of Treatment

This includes activities of the case managers and the physician based on program observations, staff and child/family interviews, for the purpose of analyzing the child's progress over the previous period and discussing trends for the past months. These reviews may involve adjustments to the POS, if necessary.

D. Psychiatric Evaluation

A psychiatric evaluation is a comprehensive evaluation, performed face-to-face by a psychiatrist, that investigates the child's clinical status including the presenting problem; the history of the present illness; previous psychiatric, physical, and medication history; relevant personal and family history; personal strengths and assets; and mental status examination.

E. Individual Therapy

Individual therapy is treatment activity designed to reduce maladaptive behaviors, to maximize behavioral self-control, or to restore normalized psychological functioning, reality orientation and emotional adjustment, thus enabling improved functioning and more appropriate interpersonal and social relationships.

F. Child Therapy

Child therapy is treatment activity designed to reduce maladaptive behaviors, to maximize skills in behavioral self-control or to restore normalized psychological functioning, reality orientation and emotional adjustment, thus enabling the individual to function more appropriately in interpersonal and social relationships.

G. Crisis Intervention

Crisis intervention is an unscheduled activity used for responding to a crisis situation requiring immediate attention. Crisis intervention includes only services performed by qualified mental health professionals. Activities include crisis response, crisis line, assessment, referral and direct therapy.

H. Occupational Therapy-Evaluation

Activities provided by a qualified occupational therapist to determine the child's need for services and to recommend a course of treatment including environmental accessibility adaptations and assistive devices.

I. Occupational Therapy-Individual or Group

Occupational therapy is the application of occupation-oriented or goal-oriented activity to achieve optimum functioning, to prevent deterioration and to promote health. The term occupation, as used in occupational therapy, refers to any activity used for identifying, evaluating and recommending a course of treatment. This services may be provided on an individual or group basis by an occupational therapist, certified occupational therapy assistant, or aide under the direct supervision of a therapist.

J. Speech, Hearing, Language Therapy-Evaluation

Activities provided by a speech pathologist or audiologist to determine the child's need for services and to recommend a course of treatment.

K. Speech, Hearing, Language Therapy-Individual or Group

Diagnostic, screening, preventive, or corrective services may be provided on an individual or Group basis as appropriate, when referred by a physician (M.D., D.O.)

L. Health Services-Individual or Group

Health services are provided for purposes of improving the child's overall health and ability to care for health-related needs. This includes nursing services (on a per visit basis, this does not include ongoing hourly care), dietary/nutrition services, maintenance of health and hygiene, teaching self-administration of medication, care of minor injuries or first aid and teaching the child to seek assistance in case of emergencies. Services must be provided by a physician, registered nurse, physician's assistant, nurse practitioner, or dietitian, according to scope of practice. Health services must be carefully coordinated with the child's health care plan.

M. Behavior Management Review

The Behavior Management Committee (BMC) meets to review and approve individual behavioral treatment program plans conducted according to the requirements of the DCH guidelines governing BMCs. This includes activities that are part of the initial behavioral treatment plan review and subsequent periodic reviews by the committee. The child does not have to be present for this review.

N. Physical Therapy-Evaluation

Activities provided by a qualified physical therapist to determine the child's need for services and to recommend a course of treatment including the use of assistive devices.

O. Physical Therapy

The practice of physical therapy means the evaluation or treatment of an individual using Physical agents (e.g., heat, water, etc.) and therapeutic exercises for the purpose of preventing, correcting, or alleviating an identified physical need. This service may be provided on an individual or group basis by an physical therapist, certified physical therapy assistant, or aide under the direct supervision of a therapist.

P. Medication Administration

Medication administration is the process of giving a physician-prescribed oral medication, Injection or topical medication treatment to a child.

Q. Treatment Planning

Activities associated with the development and annual review of the child's POS. This Includes identifying goals, objectives, designing treatment strategies and data collection methodologies, attending team meetings and related documentation.

R. Health Assessment

A health assessment can be provided by a physician, registered nurse, physician assistant, Nurse practitioner or dietitian to determine the child's need for services and to recommend a course of treatment.

S. Medication Review

This includes evaluating and monitoring medications, their effects, and the need for continuing or changing the medication regimen. Medication prescriptions must be ordered by the physician with a copy of the prescription maintained in the child's record. Medication review may be done by a physician (M.D. or D.O.), physician assistant, registered nurse, or pharmacist.

T. Case Management

Case management services are those services that will assist beneficiaries in gaining access to needed medical, social, educational and other services. Core elements of case management include assessment, development of an individual POS, linking/coordination of services, advocacy, re-assessment and follow-up, and monitoring of services and supports. Case management must be provided by a qualified mental retardation professional (QMRP) as defined in 42 CFR 483.430, or by a professional with a bachelor's degree in a human services field functioning under the supervision of a QMRP.

U. Children's Crisis Residential Services

Crisis residential services are intended to provide a short-term alternative to inpatient psychiatric services for persons experiencing an acute psychiatric crisis. Services may only be used to avert a psychiatric admission, or to shorten the length of an inpatient stay. Services must be designed to resolve the immediate crisis and improve the functioning level of the child to allow him/her to return to their family home. The covered crisis residential services include: psychiatric supervision, therapeutic support services, medication management/stabilization and education, behavioral services, milieu therapy, and nursing services. Nursing services must be available through regular consultation, and must be provided on an individual basis according to the level of need of the child. Services must be provided under the auspices of an enrolled CMHSP. The CMHSP must identify the crisis residential program as part of their provider enrollment process with DCH.

V. Intensive Crisis Stabilization Services

These services are structured treatment and support activities provided by a mental health crisis team and designed to provide a short-term alternative to inpatient psychiatric services. Services may only be used to avert a psychiatric admission or to shorten the length of an inpatient stay.

VII. STATE PLAN-PRIVATE DUTY NURSING SERVICE

Private duty nursing (PDN) is a Medicaid state plan benefit for a beneficiary under age 21 who meet the medical criteria for coverage. This PDN benefit must be provided by a private duty nursing agency or Medicaid enrolled registered nurse (RN) or a licensed practical nurse (LPN) working under the supervision of an RN (per Michigan Public Health Code).

July 2002