Operations Memorandum OPS970411
Waivers

04/28/97
SUBJECT: Office of Social Programs (OSP) New Statewide Waiver Program - OSP/Independence Waiver Program
TO: Executive Directors
FROM: Sherri Z. Heller, Deputy Secretary for Income Maintenance

PURPOSE:

To provide you with policy and procedures for the Office of Social Programs (OSP) Home and Community-Based Services Waiver for Independence, OSP/INDEPENDENCE Waiver Program, and to authorize implementation of the waiver beginning May 1, 1997.

BACKGROUND:

In an attempt to resolve the problems associated with waiver services to individuals who, in the absence of these services, are at risk of unnecessary institutionalization, the Department of Public Welfare (DPW) applied for and received approval for a Title XIX Home and Community-Based Services Waiver from the Health Care Financing Administration (HCFA).

DISCUSSION:

Effective May l, 1997, the OSP/INDEPENDENCE Waiver Program will be implemented statewide.

One of the major goals of the OSP/INDEPENDENCE Waiver Program is to prevent institutionalization. The most important goal, however, is to enable those persons with Other Related Conditions (ORC) to remain independent in their own homes or in other community living arrangements through the use of waiver services.

The procedures for the OSP/INDEPENDENCE Waiver Process are attached. Please share the procedures with appropriate staff.

NEXT STEPS:

1. Review the procedures for the OSP/INDEPENDENCE Waiver Program.

2. File the procedures in the Medical Assistance Eligibility Handbook, Chapter 389, Waivers, until the Handbook pages are issued.

3. Implement effective May l, 1997.

Attachments

389.7 HOME AND COMMUNITY BASED SERVICES WAIVER FOR INDEPENDENCE FOR PERSONS WITH OTHER RELATED CONDITIONS AND WHO CURRENTLY RESIDE IN THE COMMUNITY -- OSP/INDEPENDENCE WAIVER PROGRAM

The Home and Community Based Services Waiver For Independence provides a variety of services in the community as an alternative to nursing facility care. The OSP/INDEPENDENCE Waiver Program is for persons with other related conditions who need assistance with their daily living activities so that they may remain independent in their own homes or in other community living arrangements.

Persons with other related conditions are persons who have severe physical disabilities such as cerebral palsy or epilepsy or similar conditions. The disability must manifest before the age of 22 and must be expected to continue indefinitely.

The Office of Social Programs (OSP) has primary responsibility for the OSP/INDEPENDENCE Waiver Program for persons with other related conditions who wish to remain in the community as an alternative to institutionalization. At the county level, the OSP/INDEPENDENCE Waiver Program is the joint responsibility of the OSP's Waiver Services Provider and the County Assistance Office (CAO). The CAO will name a contact person and an alternate person to exchange information and resolve problems with OSP and the Waiver Services Provider. See Appendix H for a listing of the OSP/INDEPENDENCE Waiver Services Providers.

A person is eligible for the OSP/INDEPENDENCE Waiver Program if he:

> is 18 years of age or older;

> is a person with a severe physical disability such as cerebral palsy or epilepsy that results in a least three substantial functional limitations in the areas of mobility, communication, self-care, learning, self-direction or capacity for independent living. The disease must manifest before the age of 22 and must be expected to continue indefinitely.

> requires nursing facility services as determined by a physician and approved by the Department. The person must need two or more of the services available under this waiver;

> does not require a psychological evaluation;

> is not ventilator dependent;

> chooses to remain in his own home or other community setting;

> can be safely maintained in the community as determined by the Waiver Services Provider;

> is financially eligible for the Medical Assistance (MA) Program;

AND

> there is room in the Waiver for placement of the person.

NOTE: Waiver services may be denied to any person for whom it can reasonably be expected that the cost of the waiver services to that person will exceed $28,195.00 per year.

OSP and the Office of Medical Assistance Programs (OMAP) are under agreement with qualified providers to provide persons with the waiver services they need to live in the community. Approved providers are enrolled in the MA Program.

The OSP/INDEPENDENCE Waiver Program provides a variety of services which enable eligible persons to live independently in their own homes and communities rather than in nursing facilities. The services provided under the OSP/INDEPENDENCE Waiver Program include:

> Service Coordination - assist persons, who are eligible for waiver services, to gain access to needed waiver services, other State Plan services such as medical, social, educational, and other services regardless of the funding source for the service;

AND

working with, and at the direction of, the person to identify, coordinate, and facilitate waiver services;

> Daily Living Services - assist persons with eating, bathing, dressing, personal hygiene, and activities of daily living including assistance with the preparation of meals, but does not include the cost of the meals themselves. This service may also include such housekeeping chores as bedmaking, dusting and vacuuming, which are essential to the care furnished or which are essential to the health and welfare of the individual, routine wellness services relating to adequate nutrition, exercise, making and keeping medical appointments and taking appropriate medications. This service may also include health maintenance activities such as bowel and bladder routines, ostomy, catheter care and wound care;

> Respite Care;

> Environmental accessibility adaptations;

> Specialized medical equipment and supplies;

> Personal Emergency Response System Device;

> Therapies (Occupational, Physical, and Speech);

> Visiting Nurse Services.

Waiver services are available to persons who receive cash assistance, SSI or MA if they meet the specific qualifications under the OSP/INDEPENDENCE Waiver Program, and to medically eligible persons who are determined to be financially eligible for MA.

NOTE: The SSI recipient who is applying for the OSP/INDEPENDENCE Waiver Program must meet the level of care requirements for Waiver participation.

The person applying for services under the OSP/INDEPENDENCE Waiver Program who is not receiving SSI and who, based on information available may qualify for SSI, is referred to the Social Security Administration (SSA).

REMINDER: The person and the person's representative is responsible for reporting any changes in the person's circumstances to the Waiver Services Provider, the CAO and, if necessary, the SSA.

The Waiver Services Provider is responsible for determining the person's need for OSP/INDEPENDENCE waiver services.

The AAA has responsibility for determining the person's medical eligibility. This is accomplished by the review of the MA-51 and the OPTIONS Assessment.

NOTE: The AAA will complete the initial OPTIONS Assessment. All subsequent reassessments will be completed by the Waiver Services Provider.

The CAO is responsible for determining if the person is financially eligible for the OSP/INDEPENDENCE Waiver Program. Only the income and resources of the person eligible for the waiver services are considered.

NOTE: The CAO will not count the income or resources of an LRR. The Spousal Impoverishment Provisions and patient pay amounts toward cost of care do not apply to the OSP/INDEPENDENCE Waiver Program. However, the person is responsible for co-pay amount for other MA services (prescriptions, doctor visits, etc.)

The person in the OSP/INDEPENDENCE Waiver Program may also be eligible for food stamps. See the Food Stamp Handbook, Chapter 511.

389.71 INITIAL DETERMINATION FOR A PERSON APPLYING FOR THE OSP/INDEPENDENCE WAIVER PROGRAM

When considering the person's eligibility for the OSP/INDEPENDENCE Waiver Program, the Waiver Services Provider, the local AAA, and the CAO will cooperate in determining waiver eligibility, medical eligibility and financial eligibility as follows:

THE WAIVER SERVICES PROVIDER WILL:

l. Identify the person who chooses to receive the OSP/INDEPENDENCE Waiver services.

NOTE: The Waiver Services Provider will complete the PASARR-ID.

2. Verify the person's current eligibility status in the SSI, cash assistance, MA or Food Stamp Programs with the CAO and, if not receiving MA, assist in the completion of the Application of Benefits.

NOTE: For current recipients, the Waiver Services Provider and the CAO will discuss the need for a partial or full redetermination and completion of the Benefits Review Form or the Alternate Redetermination Form.

The Waiver Services Provider will mark "OSP/INDEPENDENCE WAIVER" in the upper right hand corner of the Application for Benefits.

REMINDER: While a current SSI recipient is financially eligible for MA, the Waiver Services Provider must determine the need for OSP/INDEPENDENCE Waiver services and medical eligibility for nursing facility care.

3. Provide person with the MA-51 for completion by the person's attending physician and return to the Waiver Services Provider.

4. Review the completed MA-51.

NOTE: If the completed MA-51 indicates eligibility for nursing facility care, the Waiver Services Provider will discuss the service preference form. The Waiver Services Provider will obtain the applicant's signature on the Service Preference Form. If the person chooses nursing facility services in place of waiver services, refer to AAA for PASARR package. AAA completes PASSAR and forwards package to OSP. OSP determines nursing facility eligibility and notifies person accordingly.

5. Review income and resources for persons not receiving MA or SSI or those pending SSI approval by applying the special gross income test to the person's gross monthly income. Use the same exclusions and limits as listed in 389 Appendices A and B.

- if the person's total gross income and countable resources are equal to or less than the limits in 389 Appendix B-l, refer the person to the CAO for a determination of financial eligibility for the OSP/INDEPENDENCE Waiver Program.

- if the person's total gross income and resources are more than the limits in 389 Appendix B-1, advise the person of his potential ineligibility for waiver services. Refer any person who wants to apply to the CAO for a determination of financial eligibility.

NOTE: A person whose income exceeds the gross limit in 389 Appendix B-1 may be eligible for OSP/INDEPENDENCE Waiver Program in the MNO category only if he has high medical expenses and can spenddown.

THE AAA WILL:

l. Review the MA-51 and OPTIONS Assessment cover sheet for appropriateness or the referral.

2. Schedule OPTIONS Assessment.

NOTE: The AAA will notify the person and the Waiver Services Provider regarding the scheduling of the appointment. The Waiver Services Provider assists the person through the assessment process and assists the AAA assessor with the person's special needs. The Waiver Services Provider staff person does not function as a co-assessor with input into the assessment during the interview or subsequent clinical nursing facility eligibility decision.

3. Complete the OPTIONS Assessment.

REMINDER: The AAA will complete the OBRA-EV only if the applicant selects nursing facility services.

4. Prepare the yes/no recommendation for nursing facility care. See 389 Appendix F.

5. Forward the yes/no recommendation to the Waiver Services Provider.

NOTE: The AAA will forward the original OPTIONS Assessment and the MA-51 to the Waiver Services Provider with the yes/no recommendation.

REMINDER: The Waiver Services Provider is responsible for all subsequent annual reassessments.

6. Assist in the completion of the Application for Benefits, if necessary.

7. Provide the Waiver Services Provider and the person with the address of the CAO located in the person's county of residence.

8. Advise the person and the Waiver Services Provider that if an application for benefits is filed with the CAO, the CAO will issue a Notice of Eligibility to the person and the Waiver Services Provider.

9. Participate in the DPW Fair Hearing Appeal Process, when applicable.

THE CAO WILL:

1. Review the Application for Benefits, MA-51 and the OPTIONS yes/no nursing facility recommendation for completeness and medical eligibility.

2. If the person is currently receiving MA or SSI benefits, the person is automatically financially eligible for the OSP/INDEPENDENCE Waiver Program.

NOTE: The current MA or SSI recipient MUST be medically eligible for Waiver services; i.e., have a YES on the OPTIONS nursing facility recommendation.

3. If the person is not receiving SSI benefits, determine eligibility based on the information on the Application for Benefits. Count only the income and resources of the person. Exclude the income and resources listed in 389 Appendix A, and the SSI-related exclusions of Chapter 340, Resources, and 350, Income.

REMINDER: CAOs MUST apply the look-back periods and the transfer of assets (income and resources) requirements to assets disposed of for less than fair market value.

4. Compare the countable gross monthly income to the special income limit and countable resources to the resource limit in 389, Appendix B.

> If the person's countable gross income and countable resources are more than the limits in 389, Appendix B, deny MA eligibility for the OSP/INDEPENDENCE Waiver Program.

> If the CAO does not receive adequate information to make a determination, the CAO will notify the Waiver Services Provider and the person of the information needed and the date by which it must be received by the CAO.

5. Determine the person eligible for the OSP/INDEPENDENCE Waiver Program if he meets the level of care requirements and his income and resources do not exceed the limits in 389, Appendix B.

NOTE: Under the OSP/INDEPENDENCE Waiver Program, there is no patient pay amount for waiver services. However, these persons are expected to pay any co-pay amounts for MA services (e.g., prescriptions, doctor visits, etc.)

6. Send the Notice of Eligibility for the OSP/INDEPENDENCE Waiver Program to:

> the OSP/INDEPENDENCE Waiver person (send the original);

> the Waiver Services Provider; AND

> the Office of Social Programs.

NOTE: Refer to Appendix H for the list of OSP/INDEPENDENCE Waiver Providers.

7. The CAO will authorize OSP/INDEPENDENCE waiver services as follows:

> for current Cash, MA or SSI recipients,update CIS by entering a 42 in the Facility Code field to indicate that the recipient is eligible for the additional services provided under the OSP/INDEPENDENCE Waiver Program.

> for new applicants who qualify under the NMP or MNO requirements, authorize in the respective category and enter a 42 in the Facility Code field to indicate that the person is eligible for the additional services provided under the OSP/INDEPENDENCE Waiver Program.

> for new applicants who qualify under the income and resource limits in 389, Appendix B, authorize in the NMP category and enter a 43 in the Facility Code field to indicate that the person is eligible for additional services provided under the OSP/INDEPENDENCE Waiver Program.

8. Enter the information about any third party resources into the TPL file.

389.72 ANNUAL FINANCIAL REDETERMINATION

If the person is receiving SSI benefits, an annual financial review by the CAO is not required. The SSA completes the annual review. If SSA notifies the CAO that an SSI recipient in the OSP/INDEPENDENCE Waiver Program is ineligible for SSI, the CAO will:

1. Immediately notify the Waiver Services Provider, in writing, that an application for the OSP/INDEPENDENCE Waiver is needed. The Waiver Services Provider will complete the steps indicated in Section 389.71, Initial Determination for a Person Applying for the OSP/INDEPENDENCE Waiver Program.

2. Close the case and send a notice to all parties.

3. Upon receipt of the completed Benefits Review Form, determine income and resource eligibility as indicated in Section 389.71, Initial Determination for a Person Applying for the OSP/INDEPENDENCE Waiver Program.

NOTE: All information should be handled as quickly as possible to avoid any interruption in the person's eligibility for the OSP/INDEPENDENCE Waiver Program.

4. Authorize in the respective category effective the day following the closure of the SSI budget, or, if later, the date the application is received and date-stamped or the earliest date the signature is obtained by the Waiver Services Provider.

5. Review the person's eligibility for food stamps if the person lives in a group living arrangement. See the Food Stamp Handbook, Chapter 511, Living Arrangements.

If the person is not receiving SSI, the CAO will:

l. Within 12 months of the initial OSP/INDEPENDENCE waiver services eligibility determination or the most recent financial redetermination, complete a financial determination based on the person's current income and resources.

NOTE: Send the notice of the interview date and time 14 days before the interview date. Send copies of the appointment notice to the person and the Waiver Services Provider. The Waiver Services Provider will assist the person in the completion of the Benefits Review Form or the Alternate Redetermination Form.

2. Upon receipt of the Application for Benefits, determine financial eligibility the same as for initial eligibility. See Section 389.71, Initial Determination for a Person Applying for the OSP/INDEPENDENCE Waiver Program (for the CAO steps 3 through 5.

> Continue eligibility if the person remains financially eligible.

> Close MA if the person no longer meets the financial requirements. Send the notice for closure effective the next semi-monthly issuance day following the 10-day period.

3. Review the person's eligibility for food stamp benefits. See Food Stamp Handbook, Chapter 511, Living Arrangements.

REMINDER: A person whose income exceeds the gross income limit in Appendix B-1 may be eligible for OSP/INDEPENDENCE waiver services in the MAO category only if he has high medical expenses and can spenddown.

389.73 ANNUAL REASSESSMENT FOR MEDICAL ELIGIBILITY FOR THE OSP/INDEPENDENCE WAIVER PROGRAM

The person in the OSP/INDEPENDENCE Waiver must continue to need waiver services and meet the level of care required under the Waiver Program.

The Waiver Services Provider is responsible for the annual reassessment. The Waiver Services Provider will complete the reassessment based on the same criteria as the initial OPTIONS Assessment.

The annual reassessment for medical eligibility for the OSP/INDEPENDENCE Waiver Program is completed as follows:

THE WAIVER SERVICES PROVIDER WILL:

1. Arrange for the completion of the MA-51.

2. Review the MA-51 for completeness and level of care.

3. Complete the OPTIONS Reassessment.

4. Assist in the completion of the Benefits Review Form or Alternate Redetermination, if necessary.

5. Complete Sections 27, 28 and 29 of the MA-51, as appropriate, and sign in Section 30, as the reviewer.

NOTE: If the person remains eligible for Waiver services, indicate "Recertified for OSP/INDEPENDENCE WAIVER" in Section 29. On all annual or interim reassessments for the OSP/INDEPENDENCE Waiver, the MA-51 replaces the clinical yes/no recommendation.

6. Forward the completed MA-51, the person's Benefit Review Form or Alternate Redetermination Form and necessary documentation to the CAO.

THE CAO WILL:

1. Upon receipt of the annual or interim recertification form, review the information provided by the Waiver Services Provider.

- If the form states that the person is recertified for the OSP/INDEPENDENCE Waiver Program, continue the waiver services if the person is financially eligible.

NOTE: On all annual or interim reassessments for the OSP/INDEPENDENCE Waiver Program, the CAO will accept the MA- 51 in lieu of the clinical nursing facility yes/no recommendation.

- If the person is not recertified for the OSP/INDEPENDENCE Waiver Program, close MA for the Waiver Program. Send the notice of closure effective the next issuance day following the 10-day period. Send the notice to the person and the Waiver Services Provider. Determine eligibility for continuing MA according to NMP, including Healthy Horizons, then MNO requirements.

2. If the Waiver Services Provider, the person and the person's physician determine that the person can no longer be safely maintained at home under the Waiver Program, close the OSP/INDEPENDENCE Waiver Program case. If the person seeks nursing facility placement, the CAO will open the case as continuing NMP-MA including Healthy Horizons or continuing MNO-MA case if the person is eligible. If the person enters a nursing facility in another county, transfer the case to the new CAO.

REMINDER: If the OSP/INDEPENDENCE Waiver Program person enters a nursing facility, the PASARR-EV form must be completed.

389.74 CHANGES IN WAIVER ELIGIBILITY

The Waiver Services Provider and the person receiving the waiver services are responsible for reporting all changes in the person's income, resources, and circumstances to the CAO.

If a change is reported for a person who is not an SSI recipient, the CAO will review the income and resources of the person. Employed persons, through the Waiver Services Provider, will provide verification of gross earnings and impairment-related work expenses to the CAO each month.

NOTE: The CAO will establish a reporting plan with the Waiver Services Provider or its designee and the person receiving waiver services.

If for any reason the person becomes ineligible for the OSP/INDEPENDENCE Waiver Program, the CAO will send the person the appropriate notice advising the person of the date of ineligibility.

NOTE: The CAO will send copies of all notices to the person receiving waiver services, the Waiver Services Provider and the OSP. Addresses for the OSP/INDEPENDENCE Waiver Services Providers and OSP may be found in 389, Appendix H.

If the person reapplies for the OSP/INDEPENDENCE Waiver Program following a period of ineligibility, the CAO will require a Recertification of Need for the OSP/INDEPENDENCE Waiver Program regardless of the length of time the person's enrollment in the Waiver Program has been closed.

REMINDER: In these situations, the Waiver Services Provider is responsible for the reassessment. The CAO will accept the MA-51 in lieu of the clinical nursing facility yes/no recommendation.

OSP/INDEPENDENCE WAIVER SERVICES PROVIDERS

CSPPPD CONTACT COUNTIES COVERED

WESTERN REGION

Ms. Roxanne Huss
Tri-County Partnership for Independent Living
69 E. Beau Street
Washington, PA 15301
Phone #(412) 223-5115
Fax #(412) 223-5119
Lawrence, Beaver, Washington, Greene and Fayette
Ms. Jean Ayers
Center for Independent Living of Southwestern Pennsylvania
7110 Penn Avenue
Pittsburgh, PA 15208-2134
Phone #(412) 371-7700
Fax #(412) 371-9430
Butler, Armstrong, Indiana, Allegheny and Westmoreland
Miss Miggy Wayne
Center for Independent Living of Southwestern Pennsylvania
3711 West 12th Street
Erie, PA 16505
Phone #(814) 838-9890
Fax #(814) 838-9779
Erie, Crawford, Mercer, Warren, Forest, Venango, Clarion, McKean, Elk, Potter, Cameron, Clearfield and Jefferson

SOUTHEAST AND NORTHEAST REGION

Ms. Linda Staroscik
Liberty Resources, Inc.
1341 Delaware Avenue, Suite 105
Philadelphia , PA 19125-6630
Phone #(215) 634-2000
Fax #(215) 634-6628
Bucks, Chester, Delaware, Montgomery and Philadelphia
Ms. Barbara Polzer
Liberty Resources, Inc.
Lehigh Valley CSPPPD Office
845 Wyoming Street
Allentown, PA 18103
Phone #(610) 432-3880
Fax #(610) 432-3824
Berks, Carbon, Lehigh, Northampton and Schuylkill
Mr. Marty Masters
Northeast Pennsylvania Center for Independent Living
431 Wyoming Avenue
Scranton, PA 18503
Phone #(717) 344-7211
Fax #(717) 344-7218
Bradford, Lackawanna, Luzerne, Pike, Sullivan, Susquehanna, Tioga, Wayne and Wyoming

CENTRAL REGION

Ms. Virginia Brown
United Cerebral Palsy Center, of Lancanster County
1900 Olde Homestead Road
P.O. Box 10485
Lancaster, PA 17605-0485
Phone #(717) 397-1841
Fax #(717) 293-1595
Lancaster, Lebanon, Clinton, Lycoming, Union, Snyder, Northumberland, Montour and Columbia
Ms. Mary Stoneroad
United Cerebral Palsy of the Capital Area
925 Linda Lane
Camp Hill, PA 17011
Phone #(717) 737-5504
Dauphin, Cumberland, Perry, Juniata and Mifflin
Ms. Linda Williams
United Cerebral Palsy of South Central Pennsylvania
839 Biglerville Road
Gettysburg, PA 17325
Phone #(717) 337-1591
Fax #(717) 337-3505
Adams, Franklin and York
Ms. Karen Budzina
United Cerebral Palsy of the Allegheny Region
616 Somerset Street
Johnstown, PA 15901
Phone #(814) 535-7708
Fax #(814) 536-8833
Cambria, Blair, Huntingdon, Somerset, Bedford and Fulton

HEADQUARTERS STAFF

Questions regarding the statewide administration of the OSP/INDEPENDENCE Waiver Program should be directed to:

Department of Public Welfare
Office of Social Programs
Bureau of Social Programs
Division of Special Programs

Ms. Helen Powers Phone #(717) 772-2094

Ms. Carolyn Potts Phone #(717) 772-2101

Ms. Suzanne Puzak Phone (717) 783-3173