What is a Medicaid Waiver?

Amanda Cavanagh
Director, Research & Business Development


What is a Medicaid waiver?
Home and Community Based Services are available through waiver programs.  Centers for Medicare and Medicaid (CMS) allows states to “waive” certain Medicaid requirements and pay for home and community based services as an alternative to institutions, nursing homes or hospitalization.  These Medicaid waivers help provide services and to allow people to receive long-term care in the community and in their homes.  Waivers are also ways states can test new or existing ways to deliver and pay for health care services in Medicaid and the Children's Health Insurance Program (CHIP).


Types of Medicaid waivers
There are four primary types of waivers and demonstration projects:

1. Section 1115 Research & Demonstration Projects: States can apply for program flexibility to test new or existing approaches to financing and delivering Medicaid and CHIP.
2. Section 1915(b) Managed Care Waivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit people's choice of providers.
3. Section 1915(c) Home and Community-Based Services Waivers: States can apply for waivers to provide long-term care services in home and community settings rather than institutional settings.
4. Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to simultaneously implement two types of waivers to provide a continuum of services to the elderly and people with disabilities, as long as all Federal requirements for both programs are met.

Medicaid HCBS can be provided as part of state-plan services or through waivers. State plan HCBS include mandatory services (all states must offer them), and optional services (offered at state discretion). Whether the services are mandatory or optional, if they are provided under the state plan, they must be offered to all eligible individuals. Services provided under waivers may be restricted to specific groups based on geographic region, income, or type of disability. Waivers may include a wider range of service types than can be provided under state plans. Individuals may receive both state plan and waiver services.


How iLIFE supports Medicaid waiver programs
iLIFE offers a full range of financial services to support federal and state Medicaid Waiver programs.  iLIFE helps people in Medicaid Waiver programs by: 

• guiding employers through the hiring process.
• ensuring workers are qualified caregivers.
• receiving time reports.
• issuing payments.
• handling tax responsibilities.
• detecting and preventing fraud and abuse.

References:
http://medicaidwaiver.org
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/hcbsfindings/hcbsfind3.html

Building Better Caregiver Relationships

Matt Queen
Communications Manager

As I meet with people that receive long-term care services and supports, I am shocked to hear the number of people that say they do not get along with their caregiver.

Sometimes it is a family member or a friend.  Other times it is somebody they hired from an agency or found in their community.

Part of what we do at iLIFE is educating people about what they should expect from their caregivers.  Employer authority is an emerging topic and an important skill for people who want to self-direct their care. Making expectations clear to caregivers from the start creates a solid foundation for a good working relationship.

In partnership with the Wisconsin Long Term Care Workforce Alliance, we met with two caregivers and their employer to learn more about creating positive relationships.

Our entire three-part film series on caregiver best practices is on the iLIFE YouTube channel.  Share with your colleagues to help improve caregiver relationships.

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Fraud: Identification and Prevention

Casey Wheeler

Fraud Specialist

Fraud is not a victimless crime. Fraud violates all of the taxpayers who support state and federal long-term care programs. We all have the responsibility to look for fraud and protect the integrity of the programs and people we serve.

What is fraud?

Fraud is the wrongful or deceptive intention to make financial or personal gain. With the pressures in today’s society, some people feel that the only way they can make ends meet is to commit an act of fraud. They rationalize their intentions by thinking that they deserve this money and that their actions do not hurt anybody. Once they see an opportunity to commit fraud, they take it. Unfortunately, a single act of fraud often leads to additional violations.  Fraud’s short-term benefits bring serious long-term consequences, including felony charges, large fines and restitution.

What is the most common form of fraud we see?

The most common fraud we currently see is billing for hours that are not worked. How does this work?

• The program participant makes a deal with one of their employees.
• The employee records more hours than they actually worked (if worked at all).
• The employee gives the participant the money resulting from the extra hours being billed.

Sometimes participants think their allocation is their money. It is not. The allocation reflects the amount of services that the participant is able to receive within that given total.

What can we do to prevent fraud?

There are many ways we can help program participants understand fraud.  Within IRIS, the state of Wisconsin’s self-directed care program, care consultants meet with their assigned participants and complete a participant education form. Once the participant has gone over the material and understands it, they sign the form so all parties can be on the same page.

As a financial management services provider, we educate participants about fraud.  Resources like this info-graphic give participants the information and knowledge to successfully self-direct their services.

Looking out for fraud and reporting suspected activity protects people receiving care, supports those providing care, and strengthens the integrity of long-term care programs.

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Changes at the VA: What We Can Learn and How We Can Improve

Gerianne Prom
VP, Long Term Care Services

On Veterans Day, social media was full with messages of genuine support, respect, and affection for veterans, current members of the military, and their families.

On the eve of Veterans Day, there was big news from the U.S. Department of Veterans Affairs, as they announced major reforms addressing inadequacies in veteran supports and services.

VA Secretary Bob McDonald announced the creation of a Chief Customer Service Officer, who will simplify internal coordination, enhance customer service, and allow veterans to navigate VA without having to understand the inner workings of the department.

The VA also unveiled an intranet web tool called MyVA Idea House, designed for VA employees to log on and provide feedback in a secure manner.

I think both of these reforms will not only help VA services, but similar policies can also benefit other human service and long-term care programs across the country.

Many people we serve navigate their way through a variety of government and private programs to determine eligibility, as well as access and coordinate ongoing services and supports.  Creating a role similar to the VA’s Chief Customer Service Officer can help guide participants towards the services and supports they need.

It is also good wise to encourage employee feedback through internal websites.  Direct service professionals see things within programs or organizations that need to be changed.  However, they may not feel empowered to discuss problems or suggest improvements.  Continuous feedback from consumers and all layers of an organization will yield optimal opportunities for improvement.

Organizations serving people with disabilities should review these reforms and consider adopting similar simplifying initiatives.

For further reading: Defense One: "Ahead of Veteran's Day, VA Announces Major Reforms"