Re: Deeming waiver process

October 8, 2003

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DFACS made me go back and apply for SSI, before they would do the paperwork for T's Deeming Waiver. I had to have a letter of denial present before I could get the packet. We almost missed her window bc of this.

Karyn

Deeming waiver process

From Bowen

See the following correct information about the Deeming waiver. It is very long but has accurate information. It is not necessary to apply for SS and be turned down before applying for the waiver. It states in these instructions that you must only use deemed resources to show that you would be turned down for SS if you applied. If you are absolutely sure that you will be over the limit, be sure to tell the SS worker this right away and they can lead you in the right direction to bypass this process. I hope this clarifies some of the information that you received earlier. Let me know if I can answer any questions.

DEEMING WAVIER

When we send back for additional information, for how long is the original

DMA-6 good? Many times it is almost a year before they get all the information back to the Georgia Medical Care Foundation (GMCF).

If GMCF has not received the information within ninety days of the original submission date, the recipient will need to submit a new DMA-6 form.

What is the acceptable time frame of an Individualized Education Program (IEP)?

All initial IEPs must be current within thirty days of submission. We can accept a continued placement IEP that was done for the school year, but outside our thirty- day limit as long as the school reviews and signs to show that the plan is still current.

What is the time frame for a psychological? Sometimes, especially if the school does the psychological, we will receive an evaluation that may be two years old.

All documentation must be current within one year. Mental Health guidelines state that psychologicals must be done every three years for persons under the age of 18. We will accept the psychological as current anytime during that three period as long as the school system reviews and signs that the psychological evaluation represents the child’s current level of functioning.

What time frames apply to therapy notes?

PT, OT and speech therapy notes must be dated annually and current within thirty days of submissions. We need to look at these notes the same as a care plan/ISP/IEP.

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THE KATIE BECKETT WAIVER

The Beckett Waiver is a way to get Medicaid for a child when the parent’s income is too high for them to qualify for Supplemental Security Income (SSI). Beckett is a little girl who has many medical and physical complications. Her parents wanted her to come home from the hospital to live with them.

The family income was higher than social security allows in determining SSI; however, the income was not early enough to cover all the medical bills. This special waiver was granted so that Beckett could live at home with her family.

The Beckett Waiver takes the parent’s income out of the picture and looks solely at the need of the child. It is very important to document the child’s needs for medical treatment and therapy. The application should be detailed.

DEEMING WAIVER ( Beckett) CLASS OF MEDICAID

Basic Eligibility Criteria:

1. The child must be DISABLED.

The child must be a resident of Georgia. The child must be a U.S. citizen or an alien lawfully admitted to be a permanent resident or otherwise permanently residing in the U.S. under color of law. The child must assign their rights to all payments of medical benefits from all third party resources (medical insurance) to the Georgia Department of Medical Assistance (DMA) to the extent medical expenses are paid by the Medicaid program. The child must apply for and accept any benefits for which they may be entitled. The child must furnished or apply for a Social Security Number.

Special Eligibility Criteria

The child must be under 18 years of age AND The child must be chronically impaired to the extent of being a suitable candidate for nursing home care AND The child must be receiving appropriate home care less costly than nursing home care AND The child must be ineligible for Supplemental Security Income (SSI) in a private living arrangement due to income and/or resources including that deemed from the parents.

STEP BY STEP APPLICATION PROCESS

Application (Form 268) is completed by the responsible relative.

2. The interview is conducted. Financial information on the parents and child is requested.

3. SSI eligibility is determined using deemed income and resources of the parent(s) or by obtaining an SSI denial letter.

a. If the child is SSI eligible, MAO is denied and the family referred to the Social Security Administration.

b. If the child is ineligible for SSI, the application proceeds.

4. Financial eligibility is determined WITHOUT deemed income and resources.

The Medicaid CAP is used

The worker determines eligibility under all other basic SSI criteria.

6. The worker determines the child is appropriate for nursing home placement by obtaining an approved DMA-6.

a.. The family is given a DMA-6 by the worker.

b. The child’s physician completes the form.

c. The DMA-6 is sent to the Georgia Medical Care Foundation (GMCF) for approval.

d. GMCF returns the form to the eligibility worker.

*If GMCF denies a level of care, the application is denied.

The child’s physician completes a Physician’s Referral Form. The

form includes an estimate of monthly costs for home care for the child.

The Deeming Waiver request form is completed by the eligibility worker. The form compares the cost of home health care to the cost of nursing home care to the cost of nursing home care. The family can choose the nursing home to use in this step.

a. If in-home care is more costly, then the application is denied.

b. If in-home care is less costly, then the application is approved.

9. Eligibility for the three months prior to the application month is determined if requested (there are unpaid medical bills).

DMA is notified of eligibility of the child.

The family is notified of eligibility via form 116.

Special Reviews:

a. The case is reviewed annually for eligibility.

b. A new DMA-6 is required annually (Level of Care).

c. Any anticipated changes in income or SSI eligibility are reviewed.

d. The age limitation of this class of assistance cannot be exceeded.

Where to apply:

DeKalb County DEFACS Fulton County DFACS

178 Sams Street 501 Pulliam Street, SW

Decatur, GA 30030 Atlanta, GA 30312

ATTN: Adult MAO ATTN: Adult MAO

Supervisors:

Marilyn Horton: Sweat:

Margie :

O’Callaghan:

Information:

WHO SHOULD APPLY FOR THE KATIE BECKETT WAIVER?

Some families receive SSI except in months where there are five Fridays. The extra payday puts the income over the limit. You can apply for the Beckett Waiver to cover those months with five Fridays.

Even if you have good insurance coverage, you can apply for the Beckett Waiver. Most insurance companies have a lifetime cap. It will help to have gone through the process of getting the waiver before you reach the limit. It is good to have the Medicaid to pay for the 20 percent of expenses that your insurance doesn’t pay. This can save a family if an expensive surgery or illness arises.

I know families who just make a little over the limit and I know families who make over $60,000/year who have both been approved for the Waiver.

HOW TO APPLY FOR THE KATIE BECKETT WAIVER

1. Call the Social Security Office and make an appointment for Supplemental Security Income (SSI). Look to see if your income and number of people in the household put you over the allotted income level. If you think your income is more than allowed, be sure to tell the Social Security worker immediately. This will save you from having to complete the entire SSI application.

You must be rejected for SSI before you can apply for the Beckett Waiver, (request the denial in writing). As early as the next day, they can send you an informal denial based on the income information you gave them.

2. Contact your County Department of Family and Children Services (DFACS). Tell them you want to talk to the Medicaid worker to apply for the Beckett Waiver. Some DFACS offices will tell you they do not know what you are talking about. Some DFACS offices share Medicaid workers between two difference counties, (example; Benita Watkins works in County most of the time but occasionally goes to Oconee County to take applications). Ask when that person will be available.

3. Schedule a time to go to the Department of Family and Children Services

to fill out the application. Set aside two or three hours for this appointment. The application is long and is instructive. The application consists of varied questions for which you may need to take the following information or documents with you:

a. Proof of income – check stubs (they may give you a statement for your employer to sign)

b. Name, address, and phone number of all physicians who have seen your child

c. Bank account numbers or safety deposit box numbers

d. Assets that you have (cars, boats, house, etc.).

e. Child’s birth certificate

f. Your denial letter from Social Security

g. Your child’s Social Security Number

4. The Development Services Team (sometimes called Area Resources Team) in your area can help you gather information that can document your need for the Beckett Waiver. They will need to do the following:

A Social History You or the Social Worker will complete.

A Psychological The report must be done by a PhD Psychologist or a Behavior Specialist through the Department of Human Resources (DHR). One may be available at the school. The report must be done on DHR letterhead. This is an incurred expense, but if it is done by DHR they might wait and bill you after the Beckett Waiver is approved so Medicaid would pay you. You need a psychological if your child has mental retardation or cerebral palsy, only. If the disability is only medical or physical in nature, a psychological is not required.

An Individual Habilitation Plan This is a service plan that states the child’s strengths, needs, and recommendations. It is attached to the medical form as a treatment plan.

A Physician Referral Form This compares the cost of living at home versus living in an institution.

A MDA-6 Medical Form Have the nurse help you complete this form, then take it to your child’s doctor and have him/her to sign it. Be sure to let the doctor sign in all appropriate places, but he/she does not have to date it. The DEFACS worker can date it when he/she is ready to send it in for certification.

5. Take the DMA 6 Form and the Physician’s Referral Form to the doctor who knows your child best. Have both forms signed and be sure you sign them also. Be sure to let the doctor know that you are not trying to place the child in a nursing home, because both forms mention nursing home. Let them know you are just trying to get Medicaid for your child. The completed forms just show that it is cheaper to live at home than it is to live in a nursing home.

6. Get all these reports back the DFCS worker as quickly as you can. The DFCS worker will send the medical form and other documentation to Atlanta. They will receive certification if your child qualifies and they will notify you. Call them periodically to see what the status is. It helps to keep it fresh on their minds. I had one family who after waiting 5 months found out that the forms were still in the worker’s desk drawer and had never been submitted. It seems like these waivers are being processed a little faster now. It has taken up to a year to find out; our most recent one only took two months to receive notification.

WHAT CAN MEDICAID DO FOR YOUR CHILD?

Medicaid will pay for doctor and hospital bills.

Medicaid will pay for up to six prescriptions per month.

Medicaid will pay for physical therapy, occupational therapy, and speech therapy.

Medicaid will pay for a variety of adaptive equipment.

WRITING A SOCIAL HISTORY

DEMOGRAPHIC INFORMATION

Name:

Birth Date:

Social Security Number:

Address:

Telephone Number:

Parents:

PRESENTING PROBLEMS

Description of the Disability:

Need for the Beckett Waiver:

FAMILY INFORMATION

Dad: Name, age, education, occupation, health

Mom: Name, age, education, occupation, health

Siblings: Name, age, grade in school, health

Home: Type (apartment, mobile home, house)

Location (in town, in the country, in a subdivision)

Size (number of bedrooms, acres of land)

BIRTH AND EARLY DEVELOPMENT

Pregnancy: Prenatal care, any problems, full term or premature

Delivery: C-Section, vaginal or breech

Hospital: Physician, baby’s weight, length of hospital stay

When child’s problems were first detected:

a. Developmental delays

b. Problems in feeding, movement, sleeping, health

MEDICAL INFORMATION

Allergies

Immunizations

Physicians who see the child

Health problems

Medications

Hospitalizations

Surgeries

Other Medical Treatments (MRI, CT Scan, Lab Work, EKG, EEG)

Vision

Hearing

Adaptive Equipment Used

TRAINING/EDUCATION

School Program: Teacher, classroom, Special Education Goals,

Support Services (OT, PT, Speech, Adaptive PE)

Early Intervention

Therapy: Physical Therapy How Often

Occupational Therapy Where (hospital, home health)

Speech Therapy Therapists’ names

CURRENT FUNCTIONING

Self Help (eating, bathing, dressing, toileting, grooming)

Language/Speech (understanding what is said expressing wants)

Motor Skills (using hands, sitting, walking, climbing, etc.)

Social Skills (recognizing people, sociable, doesn’t like to separate from mom)

Cognitive (learning, how they learn best, seeing things, hearing things, etc.)

Describe whether the child is dependent, needs assistance, or is independent in different areas. Be sure to compare how the child is doing in relation to other children their age… The child may have made lots of progress, but still may be behind others. It is important to note how much assistance is needed and whether it is a verbal reminder or physically assisting the child.

SUMMARY CONCERNING CHILD

Age

Disability or areas of delay

Importance of medical care and therapy in promoting development

*Stress the need for Medicaid

INDIVIDUAL HABILITATION PLAN

(Child’s Name)

STRENGTHS

1. Positive assets (examples: good vision, alert, etc.)

2. Personality traits (examples: sociable, persistent, good natured)

3. Has received good medical treatment or services that have had an impact

4. Parent/Family Involvement (as advocates, getting services, care)

NEEDS AND RECOMMENDATIONS

1. Child needs to: improve balance

strengthen muscles

develop head control

evaluation for adaptive equipment

It is recommended that the child receive physical therapy on a regular basis.

2. Child needs to: use hands functionally in daily living activities

develop oral motor skills

increase texture of food that is eaten

decrease sensitivity to touch or texture

It is recommended that the child receive occupational therapy on a regular basis.

3. Child needs to: express his/her wants and needs

increase vocabulary

develop language concepts

follow simple verbal directions

It is recommended that the child receive speech therapy on a regular basis.

4. Child needs to have a physician monitor:

seizures heart

shunt hyperactivity

vision lungs

hearing allergies

It is recommended that the child continue to see or consult with (neurologist, cardiologist, pediatrician, neonatologist, urologist, orthopedist, ophthalmologist, etc.).

5. Child’s family needs financial assistance in paying for medical and therapy expenses.

It is recommended that the Beckett Waiver be granted so that this child will receive Medicaid.

PHYSICIAN’S REFERRAL FORM

Name of Child:

Diagnosis: List all the problem areas

Examples: Vision Impairment

Downs Syndrome

Cerebral Palsy

Developmental Delay

Mental Retardation

Spina Bifida

Speech Impairment

Prognosis: Will the child’s problems be one’s that will effect his/her

throughout their lifetime? If so, state that fact. (Example: Downs Syndrome or CP will be lifelong)

a. Will the condition improve with treatment? (Example: cleft palate repair or heart surgery).

b. Will additional surgery be required (Example: Shunt revision will need to be done when the child gets older).

Costs Monthly:

a. Doctors Visits: Range of Costs (Example - $35-$80 per visit)

b. How often does the child to the doctor?

c. If it isn’t monthly, just list the range of costs.

Adaptive Equipment:

a. List equipment needs and cost.

b. Be sure to put one time expense rather than on going.

Other:

a. Therapy costs

b. Medication costsc.

c. Tests (lab work, EKG, EEG, CT Scan, MRI) costs

Monthly cost of in-home care – put a range of expenses

Try to keep it under $1500 if possible, this is about what nursing homes receive from Medicaid monthly to care for a person. If expenses are higher, you will want to use the Medicaid reimbursement for an institutional placement; it can be as much as $168 per day.

Institution or home better, check “home”

Make a statement like this:

Child’s parents do an excellent job arranging support services

to meet the child’s medical and physical needs. The home is a

loving and caring environment where the child’s individual needs are being addressed. The parents provide stimulation to promote the child’s cognitive, motor, social, and language development.

Doctor’s Signature:___________________________________________

DO NOT DATE THIS…LET THE DFCS WORKER DATE IT WHEN IT IS READY TO BE SENT FOR CERTIFICATION.

NOTE: Doctors usually appreciate this form being filled out for

their signature. If you need help with the medical terminology for the diagnosis, ask the doctor’s nurse to help you.

NOTE: Sometime doctors are uncomfortable saying that a condition is lifelong. If they hesitate, ask them if they can say if the condition will better in a year, five years, ten years, etc. We just need to show that this condition is not a very temporary type of problem that will go away in a few weeks.

DMA 6 MEDICAL FORM

(Physician’s Recommendation Concerning Skilled Nursing Home Care, Intermediate Care or Intermediate Care for the Mentally Retarded)

Don’t be intimidated by this form. It is the same form that is used to determine whether people are eligible for nursing homes, but it in no way means that your child will have to go into a nursing home. Beckett Waivers just use this form to document the child’s medical needs.

Here is a step-by-step way of completing this medical form:

1. Facility’s Name and Address:

a. Put in the local DFCS office and their address

b. Put the county where you live in county_________

2. Leave this blank unless your child has Medicaid in months that only have

a. Fridays and not in months that have 5 Fridays.

3. Social Security Number

a. Put your child’s social security number; if your child does not have one, apply for one when you call Social Security to get your denial.

b. If it has been applied for but not received, put “applied for”

4. Sex: Male or Female

Age of the child (years or months if under one year of age)

4a. Birthdate – Specify by Month/Day/Year

5. Only one box will be checked:

a. Nursing Facility – If your child has significant medical problems that

require close monitoring (example: oxygen, respirator, or heart monitor, etc.). If you child is dependent for assistance in daily care (eating, dressing, toileting, bathing) and has some medical concerns such as seizures, or a shunt that need monitoring, check this box.

ICF/MR Intermediate Care for the Mentally Retarded – If you child has mental retardation or is significantly developmentally delayed and needs therapies (OT, PT, Speech) and special education to meet his/her needs, check this box.

6. Type of Recommendation Mark Initial

Under #5 and #6 there is space to write your address and phone number. Also, write the mother’s maiden name in the space allowed.

Date of Medicaid Application: LEAVE THIS BLANK

Patient’s Name: Put your child’s name

Last name

First name

Middle initial

Date of Nursing Home Admission: LEAVE THIS BLANK

9.Patient Transferred from: LEAVE THIS BLANK

9A and 9B LEAVE BLANK

10. A parent must sign this. It only has to be one parent.

11 .Date: DO NOT DATE THIS. LET THE DFCS WORKER DATE IT WHEN THE FORM IS READY TO BE MAILED TO ATLANTA.

6. Diagnosis:

a. Primary

b. Secondary

c. Other

List all problems: examples seizure disorder

cerebral palsy

mental retardation

visual impairment

speech delay

chronic respiratory infections

If you know the medical terminology, use it. It can make it more specific (cerebral palsy, spastic quadriplegia). If you have more than three, continue it in #13 where there is extra space.

7. Treatment Plan:

Write in (see attached). This will refer to the Individual Habilitation Plan

Hospital Diagnosis – LEAVE THIS BLANK

Medications:

Name Dosage Taken Frequency

List all medications ____mg by mouth 2 x day

by injection 4 x day

Diagnostic and Treatment Procedures:

List all tests that the doctors run and how often (every three months or as needed)

CT Scan EEG Lab Work (blood levels

MRI EKG for seizure medication)

List therapy the child receives and how often (3 times per week or 2 hours per week)

Speech therapy

Occupational therapy

Physical therapy

Adaptive Physical Education

8. Check the one that best describes the child’s needs:

a. Skilled Care very involved nursing care (oxygen, monitors, etc)

b. Intermediate needs lots of assistance in daily living, some medical

problems (seizures, shunt, etc.)

c. Intermediate Care for the Mentally Retarded for people with mental retardation who need lots of assistance with daily living and judgment of safety. This can also include behavior problems.

15. Check Permanent

16. Check Yes

17. Check the box by “could not” and by “community care” and “home health services”. This is stating that the child’s needs are more significant than could be met by an occasional visit from a nursing aide. It takes into account all the supports that families provide in caring for their child.

18. Have the doctor sign here.

Choose the doctor that is most convenient or who knows your child best.

19. Fill in the doctor’s name and address.

20. Date: Again, Do Not Date It. The DFCS Worker will date it when she is ready to mail the form. The form is only good for 60 days so that way there will be maximum time for processing.

21. Doctor: fill in his/her License number and phone number. The nurse can help you with the license number.

22. What kind of diet?

a. Check the one that fits. If it is not listed, put “other” and write in the type

of diet; for example: puree or specify that the child has a difficult time with meat textures.

23. Is the child toilet trained for bowel movements?

a. If he/she is, check “continent”

b. If he/she has some accidents, check “occasional incontinent”

c. If he/she is not trained and wears diapers, check “incontinent”

d. If he/she has a colostomy, check “colostomy”

24. Overall condition:

a. If the child is doing okay, check “stable”

b. If the child’s health is up and down, check “fluctuating”

c. If the health issues are getting worse, check “deteriorating”

d. If the child’s health condition is serious, check “critical”

e. If the child has a terminal illness, check “terminal”

25. Restorative Potential (this refers to the child’s potential to be completely without problems).

a. Usually do not mark above “fair”

26. Mental and Behavioral Status (these are words that describe the child).

Mark all of the ones that apply.

27. Decubiti This refers to bed sores

a. Usually this is marked “no”

b. Some kids who sit in wheelchairs all day have some skin breakdown; if

this is the case, mark “yes”.

28. Is the child toilet trained for urination?

a. If the child is toilet trained, check “continent”

b. If the child has some accidents, check “occasional incontinent”

c. If the child is not toilet trained and wears diapers, check “incontinent”

d. If the child is catheterized, check “catheter”

29. How many hours a day is the child out of bed?

If the child needs any of the items listed, check the one that are used.

30. How many times per week does your child receive these and how many times they really need the service?

a. Physical therapy

b. Occupational therapy

c. Remotive therapy Don’t use this category

d. Reality Orientation Don’t use this category

e. Speech therapy

f. Bowel and bladder retrain Don’t use this category

g. Activity Program If your child is in a day program or an educational class, put how many times per week he/she attends.

If a person works with your child in the home, specify how often the person comes

per week.

31. Impairments:

Sight Hearing Speech Limited Paralysis

Motion

Mark the boxes as follows:

a. If the problem is severe, put a #1

b. If the problem is moderate, put a #2

c. If the problem is mild, put a #3

d. If there is not a problem in that area, put a #4

Examples:

For a child who is deaf: For a child who has cerebral palsy:

Sight 4 Sight 4

Hearing 1 Hearing 4

Speech 1 Speech 3

Limited Motion 4 Limited Motion 1

Paralysis 4 Paralysis 4

Activities of Daily Living:

Eats Wheelchair Transfers Bath Ambulation Dressing (getting in (walking)

and out of bed,

or wheelchair)

Mark the boxes as follows:

If the person is dependent (needs someone to do it for them) check #1.

If the person needs assistance, check 2__

Examples:

Someone is needed to push the wheelchair

Someone is needed to fix the person’s plate

Someone is needed to run the water in the tub

If the person is independent in these activities, check __3__

If the item does not apply to the person, check 4__

For example: If a person doesn’t use a wheelchair, mark #4 in the box for

wheelchair.

32. Leave this blank

33. Leave this blank

34. Have the Doctor sign here, too

35. Again, do not date this form

October 8, 2003