Pennsylvania Department of Public Welfare -
Medicaid Waivers

What is a Waiver?

Waiver is a shortened term for the Medicaid Home and Community Based Waiver Program which provides funding for mental retardation supports and services to help you to live in your home and community.

The name Waiver comes from the fact that the federal government waives Medicaid rules for institutional care in order for the state to use the same funds to provide supports and services for people in the community. The state must make specific assurances to the federal government when requesting a Medicaid Waiver.

Federal and state funds are combined in Medicaid Waivers. The federal and state shares are not the same in each state and they are adjusted each year. In Pennsylvania it is generally a 50/50 split.

In Pennsylvania, the Office of Developmental Programs (ODP), formerly the Office of Mental Retardation (OMR) operates three waivers: Consolidated Waiver, Person/Family Directed Support Waiver and Infants/ Toddlers and Families Waiver. Each waiver has its own unique set of eligibility requirements and services.

Why Should I Apply For Waiver Funding?

Waivers are the primary funding source for mental retardation supports and services in Pennsylvania. Waivers offer an array of services and benefits such as choice of qualified providers, due process, and health and safety assurances.

To Whom Does the Person/Family Directed Support Waiver (P/FDS) and the Consolidated Waiver Provide Funding?

Both of these mental retardation waivers provide funding for supports and services to eligible persons with mental retardation who are age three and older so they can remain in their home and community. People can live in the home of their choice such as their family home or an apartment or home of their own, with people they choose.

Pennsylvania has set criteria to determine eligibility for mental retardation Medicaid waiver funding that is the same in all counties. Financial eligibility is based only on the income of the individual, not the income of the parents.

If you have questions about waiver eligibility you can call your Supports Coordinator at the County Office of Mental Retardation.

How Does the Department of Public Welfare, Office of Developmental Programs get these Waivers?

The Department of Public Welfare (DPW), Office of Developmental Programs (ODP) must apply to the Centers for Medicare and Medicaid Services (CMS) to have waivers approved and they are then monitored by this federal agency. Waivers are approved for an initial period of 3 years and are renewed for a 5 year period. Waiver renewals are based on satisfactory provision of waiver services, meeting State assurances and a written application that describes how services will be provided during the renewal period.

Before a waiver ends, ODP must submit a renewal request to CMS in order to continue to receive waiver funding.

What Do Waivers Mean To Me?

• Waivers can provide funding for the supports and services that you need in order for you to remain in your home and community.
  
• You will have a choice of the approved waiver services you receive in order to meet your needs. These needs are identified when you do person centered planning that looks at your total life.
  
• You will have a choice of qualified people or agencies that provide supports or services that you need.
  
• Your health and safety will be assured.
  
• Supports and services will be monitored for quality. You will play an important role in deciding if you are receiving quality supports and services. If you are not satisfied with the quality, then you need to talk with the person or agency that provides your supports about improving the quality. You may also decide to choose a different provider. Supports Coordinators, County MH/MR Programs, the Independent Monitoring Team for Quality in your county and the Office of Developmental Programs all monitor for quality.
  

How Can I Use Waiver Funding?

Both the P/FDS and the Consolidated Waiver can provide modifications to your home and vehicle and make them accessible. These modifications include such things as ramps, widening of doorways, bathroom modifications, and vehicle lifts. They also can provide day services such as a support person to assist you in participating in a wide range of activities in the community. Job coaching with someone to help you on the job either long or short term, can also be funded by the waivers. In addition, waivers can be used for transportation, respite care and physical, occupational and speech therapy.

Residential services are only available under the Consolidated Waiver.

This is not a complete list of services that can be paid for with waiver funding. You can check with your Supports Coordinator to see if other things you need are eligible to be funded under the waiver.

After I Apply for Waiver Funding, What Happens Next?

If you are found eligible for waiver services and there is sufficient funding and capacity, you will begin to receive services. If there is not sufficient funding and/or capacity to serve you, you will be placed on a waiting list.

Your county will determine your place on the waiting list based upon the Prioritization of Urgency of Need for Services (PUNS) form that you complete with your Supports Coordinator.

How Long Will it Take to Get the Supports and Services That I Need?

The primary factors that determine when you receive services are whether funding is available in your county and the urgency of your need. Each county gets an annual allocation of state and federal funds from DPW. Counties must prioritize people in the emergency and critical categories and enroll them in services up to the limit of their allocation.

Your urgency of need for services is determined from your completed PUNS form. There are 3 categories of need. The first, "Emergency Need" means you need support immediately. The second, "Critical Need" means you need support within one year. The third, "Planning for Need" is when your need for supports or service is more than a year away.

The number of people on Emergency and Critical lists ahead of you also influences how long you will have to wait for services.

Completing a PUNS form annually is important because it establishes your need and enables the county and state to prepare a budget request for expansion. For more information in completing the PUNS and the PUNS process, go to the Services and Supports Section under Mental Retardation Services.

If I Have P/FDS Waiver Funding and My Needs Increase, How do I Get Additional Funding?

The amount of funding you receive is based on your Needs Assessment and Plan of Care. Since your needs are different from those of other people, the amount of funding you receive will be different from the funding received by other people.

The P/FDS Waiver has an upper funding limit of $22,225 per person approved by CMS. If there are changes in your life and it is determined that the services and supports you need cost more than this amount, then a new PUNS form will be completed, and you may apply to enroll in the Consolidated Waiver. Your Supports Coordinator will complete this form with you.

Does the Consolidated Waiver Have an Upper Funding Limit?

The Consolidated Waiver has no upper limit of funding for an individual. Funding is based on your Needs Assessment and Plan of Care. Since your needs are different from those of other people, the amount of funding you receive will be different from the funding received by other people.

States must assure the federal government that, on an aggregate basis, the total costs for people receiving services in the Home and Community Based Waiver is less than the cost of services in an institution.

What Will an Individual Budget Mean to Me?

In the P/FDS Waiver you should have your own budget. It will allow you to prioritize which services are most important to you and dedicate more of your budget to those services. In the future people in the Consolidated Waiver will also have an individual budget.

You can look outside of the mental retardation system for people to provide some supports. After you find someone who can provide the supports you need, you can go to the county and ask them to contract with the new provider. Some agencies will work with you so that you can interview and hire people from the agency to provide your supports.

You are not limited to your county when you are looking for supports and services. You can choose a qualified person or provider agency that is located in a county near your home, if they are willing to provide the supports that you need.

Can I Hire Family Members and Pay Them With Waiver Funding?

Siblings and other relatives who do not live with you, can be paid with waiver funding to provide supports to you that are part of your Plan. Relatives who provide supports will have to meet some qualifications. People cannot be paid with waiver funding to provide supports that they normally would provide for free.

Parents, under specific conditions, can provide services to their own children (including minors) in the Consolidated Waiver. They must meet some qualifications and carry out the individual's plan.

Questions: For questions on eligibility you may call the ODP Customer Service Number.

PA DPW

Last update: July 2, 2007