Developmental Disabilities Medicaid Waiver

In Florida, the most significant services for persons with developmental disabilities are provided through the Developmental Disabilities Home and Community-Based Service Medicaid Waiver (“DD Waiver.”) Operated by the Agency for Persons with Disabilities (“APD”), this program now has an enrollment of approximately 30,000 people, with another 20,000 determined to be eligible but on a waiting list. Over the last decade, the DD Waiver has been in a continual state of change, with another overhaul currently in process. As an advocate, I keep track of changes and how they are implemented to ensure compliance with federal and state laws.

How is eligibility determined?

To qualify, an individual must meet all of the following criteria, set forth in §393.063, Florida Statutes:

  • Be over the age of 3;
  • Have been diagnosed with one of six different developmental disabilities that occurred before the age of 18: mental retardation (IQ of 59 or less, or between 60 and  69 with a handicapping condition), cerebral palsy, autism, spina bifida, Prader-Willi Syndrome or Down Syndrome; AND
  • Have substantial limitations in at least three life activities: self-care, learning, mobility, self-direction, understanding and use of language, and capacity for independent living.

Like all Medicaid programs, there is also an income and asset limit, although the individual is treated as a “household of one” when finances are considered.

If the waiting list is so long, what’s the point of applying for the DD Waiver? 

People do eventually get off the waiting list, although it can take years. For applicants who are eligible, however, there is a process known as “crisis enrollment” that, in essence, moves the applicant to the top of the waiting list. Crisis priorities involve homelessness or risk of homelessness, behavior that may be life-threatening or cause medical injury to self or others, or caregivers being unavailable or under extreme duress. There also may be limited assistance available to persons on the waiting list through general revenue funds.

What services are offered through the DD Waiver Program? 

The DD Waiver provides services that allow a person with developmental disabilities to live in the family home, their own home, or a small group home rather than in an institution. Service options include personal care services and respite, services that provide a “meaningful day activity” (e.g., adult day training), consumable medical supplies (e.g., diapers), durable medical equipment (e.g., a wheelchair), behavioral and mental health services, occupational/physical/speech/respiratory therapies, and environmental modifications, among others.

How are services approved? 

Each client has a waiver support coordinator who acts as a case manager to help select appropriate services, monitor the service providers, and deal with any changes in the client’s condition or circumstances. All services must be pre-approved and determined to be medically necessary before they are authorized.

In April 2011, APD implemented a “cost plan freeze” that required documentation of certain crisis criteria in order to receive an increase in services that exceeds the current annual cost plan.  That has now been replaced by a new system that requires justification of “supplemental funding,” or any request that would require an increase in an individual’s annual funding amount.

What are my rights under the DD Waiver? 

Medicaid services can’t be withheld or taken from you without due process of law.

If you have been:

  • Denied eligibility for the DD Waiver or denied crisis enrollment
  • Had your services denied, reduced or terminated
  • Requested services but the agency has failed to respond with “reasonable promptness”
  • Been transferred or discharged from a group home

Then you are entitled to:

  • Timely adequate written notice
  • A pre-termination hearing
  • Opportunity to present witnesses, evidence, oral argument and cross-examination
  • An impartial decision-maker
  • A written decision

In addition, the decision of the agency must not conflict with state laws and regulations. In some cases, violation of federal laws can also create a separate cause of action.

How is the DD Waiver funded? 

Like all Medicaid programs, the federal government pays more than half of Medicaid expenses. The other portion is provided by the state under a budget managed by APD.

What is the iBudget? 

In 2010, the Florida Legislature adopted a redesign of the DD Waiver program called “iBudget, moving away from the system of four “tiers” with different annual spending caps. Sec. 393.0662, Fla. Stat. The concept in the iBudget statute is to use an algorithm derived from an assessment of the person’s characteristics – for example, age, living situation, ability to ambulate — to come up with base amount. Part of the rationale for this approach was to equalize services among people with similar needs. There is an important second step, however, because no formula could forecast the unique needs of this population. After the algorithm is calculated, there must be a review to determine whether the individual has any “extraordinary needs” that will not be adequately covered by the algorithm amount.

The iBudget gives the individual and his or her family more flexibility to make service changes among categories of similar services. Once a person’s iBudget allocation is in place, an increase in that allocation (or request for “supplemental funds”) has a high standard for approval.

How has APD transitioned clients into iBudget?

The transition to iBudget has been a bumpy road so far, involving negotiations between advocates and APD, various lawsuits, and some settlement agreements.  As of October 2013, APD is preparing to send out revised notices to all clients for whom funding cuts are being proposed.  APD has also adopted rules to implement iBudget, although those rules are currently being challenged on appeal. Check under my Current News section for updates.

 

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