II. Waiver Services
DDS Waiver eligibility has six (6) aspects:
Be at least 18 years of age or older
Be a person with intellectual disability as determined by DD
Be eligible for a Medicaid card under the state Medicaid plan. In Massachusetts, not all individuals who are eligible for Medicaid can enroll in a HCBS waiver. Only individuals who are in certain Medicaid eligibility "categories" can potentially be eligible for the HCBS waiver for persons with intellectual disabilities.
Agree that you want to receive services in the community rather than in an institution. This means that the individual would need, and qualify for institutional services in a Medicaid funded setting if they didn't receive the home and community‑based services. (This does not mean that the person either has to request or want institution-based services.)That is, without the supports and services the waiver provides, the person could be eligible for services in an institution. This regulation allows states to serve both individuals who are residing in institutions who wish to leave as well as divert individuals from entering institutions
Be assessed by DDS to need one or more Waiver Program services
Other Criteria may apply.
The State Decides the Size of the Waiver - How many people a waiver serves is usually the result of how much funding the Massachusetts Legislature appropriates for Department of Developmental Services' services. The state dollars available limit the number of people that a state can serve. Of course the number is also affected by whether individuals are Medicaid eligible and can meet the level of care and/or other target group requirements too.
The Amount of Funding is Related to Intensity of Needs - The amount of funding any individual gets relates to their intensity of their need for supports. Individuals living in out-of-home placements who have no family or other non-paid supports may need more money for services. The exact amount is based on an assessment and an individualized, person-centered plan. Many states use what is known as a functional needs assessment to assign a budget amount for the person.
The federal program rules require that states not spend more on HCBS waiver services than would have been spent for institutional services. But states can and do decide to limit the amounts available. For example, at least 25 states have what are called "supports" waivers. These programs are intended to help children and adults who do not need 24-hour care (either due to their level of need or the availability of family and other supports). The amount any one individual has may vary based on their support plan, but there is a cap on the total amount any one individual can spend for their services. As long as the supports are adequate to assure the person's health and safety, the funding the state authorizes can be limited.
The State Decides Which Services Will Be Offered -The HCBS waiver can provide a wide variety of services. States typically offer in-home and out-of-home residential services, personal care, supported employment, respite, transportation, housing modifications and accessibility adaptations and equipment. The federal guidelines for the waiver offer a long list of suggested services and definitions, but states can propose their own service definitions and add to the list (which, as noted earlier, must be approved by CMS).
What specific services any one individual gets is determined through their individual service plan. Under federal law, services that must otherwise be delivered under the Individuals with Disabilities Education Act (IDEA) or through other federally funded programs such as Vocational Rehabilitation and foster care cannot be covered under the waiver.
The State Decides just like with the service descriptions, the state decides which individuals or organizations are qualified to provide services. Individuals enrolled in the waiver have a right to use any provider they choose as long as the provider meets the qualifications and is willing to enter into an agreement with the state to provide services.
The State Decides Whether Family Members Can Be Service Providers - Relatives and family members must also be qualified providers, thus they need to meet any standards the state sets for the type of service they want to provide. It is at state discretion whether or not family members-particularly legally responsible relatives--can become paid providers. In Massachusetts legally responsible relatives can not become paid providers.
Generally, Medicaid rules do not permit paying a legally responsible relative (such as the parent of a minor child) for personal care-type services. But under the HCBS waiver , a state may choose to make payment for personal care or similar services when such services are deemed "extraordinary care." The federal rules define "extraordinary care" as "care exceeding the range of activities that a legally responsible individual would ordinarily perform in the household on behalf of a person without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the participant and avoid institutionalization." The state has to specify how they will distinguish "extraordinary care" from the typical kind of care a parent would generally give. The federal waiver application rules also note that, " providing for payments to legally responsible individuals is a state option, not a federal requirement".
This information is provided by the Department of Developmental Services.