Medicare Waiver Programs

While I was a clinical coordinator at my previous employer, I managed nurses caring for 160 Wavier and 40 Options clients, most served by Philadelphia Corporation for Aging; also Delaware and Montgomery County Office of Aging programs.

A little background:

The Office of Aging Progams provide services to adults over 65 and disabled individuals aged 21 to 65 (onset of disability is important, be it before or after age 21 makes you eligible for certain services).

Federally funded programs are provided thru Act 150 Programs (clients don't meet medicaid eligibility requirements) and Attendant Care Medicaid Wavier services.

In PA programs known as Options (non- MA eligible or don't meet SNF level of services, provide up to 40 % of SNF costs to maintain at home) and Wavier (meet SNF and MA eligibility guidelines, provide up to 80% cost of SNF care). These programs grew significantly since ~ 1996 when Wavier program started in Philadelphia.

Their goal is to maintain disabled and elderly home bound residents in their own home with in-home personal assistace services such a bathing, dressing, grooming, meal preparation, housekeeping and limited brief skilled services (RN, PT, OT, ST: mainly skilled assessment of safety issues esp. equipment checkout and medication compliance review; Waiver also pays for dietician).

You need to:

1. Obtain a copy of your agency's contact with Medicaid Waiver to see what it's requirements are--- will include frequency of RN assessments, HH aide supervision requirements (once every two weeks Wavier, Once a month Options in my agency's 1998 contract ) and what services you are contracted to provide.

2. Attend Waiver sponsoring organization's Inservice Programs. In Philadelphia, I had to attend workshop before I was even allowed to see their patients --great education on community services available in my area: meals on wheels, housing, financial aide, respite services, law project, Protective Services, Elder Abuse, emergency heating and food etc

If they don't have a formalized program, ask to meet with someone in their office---great to put a face with their name and "pick their brains" about services they provide and best ways of working with the agency, list of contact information/ patient case managers.

3. Each patient under Waiver is assigned a Case Manager, usually Social worker, sometimes RN. All problems found in home, need for additional resources, need for home repair, problems with med non-compliance, lack of family support etc needs to be brought to their attention---along with any medical problems to attending doctor/ NP.

4. Understanding how to obtain Prescriptions, Medical Supplies, DME:

Prescriptions:

a. Speak to your own pharmacist to see if RN's are permtted to call in prescription refills from Physician orders--varies by state.

When I've done it, is based on Verbal order I send to Doctor for chart and phone conversation I record in my notes.

"Dr XYZ TVO repeated back renewing Lasix 40 mg OD" Called VO into ABC Pharmacy

Call to ABC Pharmacy

"This is Nurse Karen RN calling in VO of Dr XYZ renewing Lasix 40 mg, One tablet daily, dispense 100 tablets with 2 refills" = 6 month supply. Leave Doctors phone number in case of problems.

Need to discuss with Doctor: # of pills to be dispensed, 30 day supply need or 100 tablets (antibiotics called in for 7-10 day supply, dependent on type), refills permitted (if any) per state statute. I always try to maximize refills of chronic meds for three month supply (up to 100 pills) as many RX plans will pay for that amount, with one copay rather than monthly supply.

Narcotics usually need RX, some states will allow Darvocet, Tylenol #2 etc to be called in. When worked Hospice, developed good rapport with major pharmacies that carried Duragesic, High dose MSO4 etc. Was able to alert pharmacy of incomming RX, fax RX then dropped off written RX on my way home, next day.

b. Medical Supplies/ DME

LMN= letter of Medical Necessity

LMN written by doctor for specialized services (often Home health aide under MA), equipment like motorized wheelchair, lift chair (covered 1/2 under Medicare), special wound care supplies like burn garments, compression sleeves and boots etc.

LMN writtten on Drs letterhead, Dated and signed by physician:

"I request that Luke Skywalker be approved for 2 hours a day, 5 times a week HHA services. DX: Multiple sclerosis. Patient is chairbound, has permanent urinary incontinence. Caregiver works full time"

In PA incontinent briefs and chux covered under MA for those over age 4 with permanent urinary incontinence along with skin barrier ointment with RX---check your state. (This is done to prevent skin breakdown--cheaper that paying for cost of pressure ulcer treatment)

CMN- Certificate of Medical Necessity

Medicare required form generated by DME Company listing need for equipment: Oxygen, hospital bed, electric lift chair, Enteral pump + feedings, etc.

Needs Diagnosis and physican signature.

c. Wound care supplies

RX must be specific listing Diagnosis, wound locations if multiple amounts; list each wound supply and amounts to dispense, refills if indicated; specific wound care orders.

I have an inservice I prepared on the above topics --willing to share if desired, just PM me with email address.

--------------------

This article explains easily Waiver Programs under Medical Assistance , some specific to PA

Home and Community Based Services (HCBS) Waiver Programs

A manual for consumers and advocates ...

by Pennsylvania Health Law Project

http://www.phlp.org/education/waiver.pdf

Link to PA state Medical Assistance website + Waiver Programs: http://www.dpw.state.pa.us/general/hacbbroc.asp

------------------

List of State Waiver Programs:

http://www.geocities.com/HotSprings/Villa/1029/medicaid.html