Medicaid Waivers Introduction

Virginia’s Medicaid Waivers for Individuals with Developmental Disabilities

Are you or your family member in need of services such as respite, personal care, assistive technology, employment, nursing or behavioral supports? If so, you need to find out about Medicaid Waivers. Virginia’s Medicaid Waivers pay for a variety of supports and services for children and adults with developmental disabilities and their families who need long-term support systems to live successfully in the community rather than in institutional settings.

Don’t worry about the financial Medicaid requirements! For children and adults with developmental disabilities, the family’s income is NOT considered.

Already have a waiver? See the waiver types on the right side of this page for information about waiver operations.

What are the Medicaid Waiver Programs?

Virginia offers multiple Medicaid waiver programs. There are three waiver programs that are most commonly used by people with developmental disabilities.  They are:

1.  Developmental Disabilities

2.  Elderly OR Disabled with Consumer Direction

3. Technology Assisted  

Scroll down for a description of the three waiver programs.

1.Developmental Disabilities Waiver Program serves individuals of any age with a developmental disability and children (birth through age 9) with a substantial developmental delay or specific congenital or acquired condition.  Within the Developmental Disabilities Waiver Program, there are three waivers that provide a continuum of services. They are the Building Independence (BI), Family & Individual Support (FIS) and Community Living (CL) waivers. The Developmental Disabilities (DD) Waiver Program provides supports and services options for successful living, learning, physical and behavioral health, employment, recreation and community inclusion.

Click to view the DD Waiver Services & Descriptions.

Eligibility Requirements, How to Apply & Waiver Assignment Process

To be eligible for the waiver:

To apply for the Developmental Disabilities Waiver services contact your local Community Services Board and waiver experts.  The Community Services Board (CSB) staff will determine if you: 1.meet the definition of a developmental disability  2. meet the functional criteria as assessed on the VIDES screening tool.

The Waiver Assignment Process is coordinated by your local Community Services Board. Waivers are assigned based on support needs. Individuals who meet the eligibility criteria are often placed on the waiting list due to the limited number of waivers funded.  It is not a chronological waiting list.

What happens when you are placed on the waiver waiting list?

1. The Community Services Board(CSB) staff will assess your situation with you to establish your Priority Level of 1, 2, or 3 on the waiting list. Contact your case manager/support coordinator when your support needs change or you move. Your priority level may change as your needs change.

2. IF you are in Priority Level One, your needs will be assessed by the CSB/case manager to generate a priority needs score on the Critical Needs Summary. The Critical Needs Summary is reviewed and updated annually and whenever your needs change which may result in a different priority needs score. It is important that you contact your case manager when your needs change.

3. When waiver slots are available for assignment, individuals with the highest priority needs scores in each local CSB, are considered for a waiver. If you are in the pool of people with the highest scores, then your case manager will prepare a written summary of your needs and situation on the Slot Assignment Review FormDiscuss the information requested on the Slot Assignment Review Form with your case manager. Note: priority needs scores are relative to the individuals in priority one at your local CSB.

4. When waiver slots are available for assignment, your anonymous Slot Assignment Review Form is distributed to your local Community Services Board’s Waiver Slot Assignment Committee. The Waiver Slot Assignment Committee scores each individual on the Waiver Slot Assignment Scoring Summary to determine who is assigned a waiver slot.

Emergency Waivers are assigned by the VA Dept. of Behavioral Health & Developmental Services (DBHDS) to individuals who meet the Emergency Waiver Criteria.  There are a limited number of emergency waivers.

P.S. When you are on the waiting list you are eligible for the Individual and Family Support Program.

Advocacy Tips for individuals/families requesting services and on the waiting list:

  • Review the VIDES, Priority Level Determination, Critical Needs Summary and Slot Assignment Review forms so that you are prepared to report the information required to the Community Services Board screener and case manager.
  • Review the completed documents for accuracy and request copies for your records.
  • Communicate changes in your situation in a timely manner to your case manager so that your support needs are accurately documented on the VIDES, Priority Level Determination, Critical Needs Summary and the Slot Assignment Review forms applicable to your status.

Resources While You Wait

  • Explore the Elderly OR Disabled (EDCD) and Technology Assistive Waiver Programs below. Individuals may be on the DD Waiver Wait List and receive waiver services from another waiver program.
  • Crisis services for all ages with developmental disabilities and behavioral or mental health challenges, provide prevention and stabilization supports. Click to view the REACH Program.
  • The Individual and Family Support Program (IFSP)  provides funding for those on the wait list for the Developmental Disability Waiver Program.  It is not known at this time when the IFSP application for the 2016-2017 fiscal year will open.  Check frequently for updates on the website for VA Dept. of Behavioral Health and Developmental Services.
  • Housing Options and Flexible Funds are available to those 18 years and older who are on the Developmental Disability (DD) waiver waiting list or receiving DD Waiver services.  Click to view information on Housing & Flexible Funds.

Appeal Rights:  You have the right to challenge decisions and actions regarding Medicaid.  An Appeal must be requested within 30 days of the decision or action that you disagree with. Click to view Medicaid Appeal information.

Regulations: Click to view the Developmental Disability Waiver Emergency Regulations starting on p. 97.

Reimbursement Rates for DD Waiver Program with Methodology

2Elderly OR Disabled with Consumer Direction (EDCD) Waiver Program serves individuals with a disability and significant medical needs; and it serves adults over age 65 with significant medical needs. Services include respite, personal assistance, personal emergency response system, adult day health care and transition services if enrolled in Money Follows the Person.

Click to view the EDCD Waiver Services.

Eligibility Requirements and How To Apply

To be eligible for the EDCD Waiver:

  • You must have a medical or nursing need(s).
  • If under age 65, you must also have a disability. (Note: mental illness solely does not qualify as a disability for this waiver).
  • You must meet the criteria for the Uniform Assessment Instrument.
  • To utilize the waiver, individuals must  apply for and qualify for Medicaid if not already enrolled in Medicaid.  You do not have to be enrolled in Medicaid when you apply for a waiver.

To apply for the EDCD waiver, contact your local Departments of Health OR Social Services. Requests for the waiver may also occur if the individual is hospitalized.  There is no waiting list for this waiver.

Advocacy Tips for individuals/families requesting the waiver

  • Review the Uniform Assessment Instrument (UAI) in advance of the screening. To view additional information about the screening click here: UAI Screening Guidance. Request a copy of your completed UAI for your records.
  • If you are not found eligible for the EDCD Waiver, explore the Developmental Disabilities Waiver Program.

Appeal Rights:  You have the right to challenge decisions and actions regarding Medicaid.  An Appeal must be requested within 30 days of the decision or action that you disagree with. Click to view Medicaid Appeal information.

Regulations: Click to view the EDCD Waiver Regulations

3. Technology Assisted Waiver Program serves individuals who need a medical device for the loss of a vital body function and substantial and ongoing skilled nursing care. Services include nursing, assistive technology, environmental modifications, personal assistance, respite and transition services if enrolled in Money Follows the Person. Click to view the Technology Assisted Waiver Services.

Eligibility Requirements and How to Apply

To be eligible for the Technology Assisted Waiver:

  • You must need a medical device to compensate for the loss of a vital body function
  • You must need substantial and ongoing skilled nursing care.
  • You must meet the criteria for the Uniform Assessment Instrument.  For additional guidance on waiver screening click to view UAI Screening Guidance.
  • To utilize the waiver, individuals must  apply and qualify for Medicaid  if not already enrolled in Medicaid. You do not have to be enrolled in Medicaid when you apply for a waiver.

To apply for the waiver contact your local Health Dept. to request the Technology Assisted Waiver.  There is no waiting list for the Technology Assisted Waiver.

Advocacy Tips for individuals/families requesting the waiver:

  • Familiarize yourself with the Uniform Assessment Instrument (UAI) in advance of the screening. Request a copy of your completed UAI for your records.
  • If you are not found eligible for the Technology Assisted Waiver, explore the Developmental Disabilities and Elderly OR Disabled with Consumer Direction (EDCD)  Waiver Programs described above.

 Appeal Rights:  You have the right to challenge decisions and actions regarding Medicaid.  An appeal must be requested within 30 days of the decision or action that you disagree with. Click to view Medicaid Appeal information.

 Regulations: click to view the Technology Assisted Waiver Regulations

 

 

 

Other Important Resources