Aids Waiver Program Fact Sheet

WHAT IS A WAIVER?

A process by which states may apply to the Centers for Medicare and Medicaid Services (CMS) for approval to implement a program (s) to provide home and community-based services to a targeted group of Medicaid recipients.

WHAT IS THE AIDS WAIVER?

The AIDS Waiver is a home and community-based waiver program that offers additional services to those living with symptomatic HIV or AIDS, in order to provide an alternative to hospitalization or institutional care.

TO BE ELIGIBLE FOR THE AIDS WAIVER, RECIPIENTS MUST MEET THE FOLLOWING REQUIREMENTS:

Eligible for Medical Assistance, or who are trying to obtain Medical Assistance in conjunction with the AIDS waiver application
Diagnosed with Symptomatic HIV or AIDS
Be 21 years of age or older
Require the level of care that would usually be provided in the hospital, skilled nursing facility, or an intermediate care facility
Effective July 1, 2003, consumers may have In-patient Hospitalization, including Medicare
Be determined to benefit from medically necessary waiver services
May not be in a hospice program

WHAT SERVICES ARE COVERED BY THE AIDS WAIVER?

Supplemental skilled nursing visits, above those approved by MA
Supplemental home health aide visits, above those approved by MA
Homemaker services
Nutritional Consultations
Durable medical equipment and supplies
Transitional Services

WHAT ARE HOME HEALTH NURSING VISITS?

Supplemental home nursing visits beyond the maximum number of visits permitted through the state plan. Nursing visits provided through the waiver can only be authorized by the AIDS Waiver staff, after a denial is obtained from prior authorization, for services beyond the regular state plan. Waiver authorized nursing visits will be reviewed at intervals not to exceed sixty (60) days.

WHAT ARE SUPPLEMENTAL HOME HEALTH AIDE VISITS?

Supplemental home health aide visits beyond the maximum number of visits permitted through the state plan. Home Health aide visits provided through the waiver can only be authorized by the AIDS Waiver staff, after a denial is obtained from prior authorization, for services beyond the regular state plan. Waiver authorized home health aide visits will be reviewed at intervals not to exceed sixty (60) days.

WHAT ARE HOMEMAKER SERVICES?

Homemaker services are non-medical services for the recipient who has lost daily functioning abilities, i.e. bathing, dressing, light housekeeping, meal preparation, washing dishes, grocery shopping, instructional services (nutrition) and care giver relief. This service will be provided through enrolled AIDS Waiver home health agencies, personal care agencies, or homemaker agencies. Homemaker visits will be authorized by the AIDS Waiver Unit staff, with a minimum visit of 1 hour per day, and a maximum or 10 hours per day, or 70 hours per week.

WHAT ARE THE SPECIALIZED EQUIPMENT AND SUPPLIES?

Specialized Medical Equipment and Supplies to include devices, controls, or appliances, specified in the plan of care, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live.

This service also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State plan. Items reimbursed with waiver funds shall be in addition to any medical equipment and supplies furnished under the State plan and shall exclude those items which are not of medical or remedial benefit to the individual. All items shall meet applicable standards of manufacture, design and installation.

WHAT ARE NUTRITIONAL CONSULTATIONS?

Initial nutritional assessment, reassessment, or nutritional counseling can be provided to a waiver client. This service is reimbursable to Medical Assistance registered dietitians who are enrolled as 0192-AIDS Waiver Providers. Services are to be provided in 15-minute blocks with each waiver client limited to 90 minutes of nutritional consultations per calendar month.

ARE NUTRITIONAL SUPPLEMENTS COVERED BY THE WAIVER?

The waiver does not provide for coverage of five categories of Medicare approved nutritional supplements. They are part of the State Plan and are covered through Medical Assistance for eligible consumers.

WHAT IS TRANSITIONAL SERVICES?

It is a one time expense, not to exceed $4000 per consumer. These are set up expenses for individuals who make the transition from an institution to their own home or apartment in the community. The funds may be used to pay the necessary expenses for an individual to establish his or her basic living arrangement and to move home. This service may not include ongoing payment for rent.

Such items include:

Equipment, essential furnishings, and household products
Moving Expenses
Security deposits or other such payments that are required to obtain a lease on an apartment or home
Set-up fees or deposits for utility or service access (e.g. telephone, electricity, heating)
Environmental health and safety assurances, such as pest eradication, allergen control, onetime cleaning prior to occupancy
Personal Health and safety assurances, such as personal health maintenance supplies, personal times for inclement weather

HOW DOES A CLIENT GAIN ACCESS TO AIDS WAIVER SERVICES?

A client gains access to AIDS Waiver services by requesting and completing an AIDS Waiver application form.

The application may be obtained from the Department's Office of Medical Assistance Programs, local County Assistance Office, a case manager, or the local AIDS service organization or by printing them from the DPW website at www.dpw.state.pa.us/omap
All information entered on the application must be certified by the attending physician
A completed application represents the client's plan of care. The application must be returned to the Department for a determination of eligibility. Clients should seek assistance with completing the application from a Medical Assistance case manager, AIDS service organization case manager, discharge planner, etc.

IS PARTICIPATION IN THE AIDS WAIVER PROGRAM REQUIRED FOR ALL CLIENTS WHO ARE CERTIFIED FOR ACUTE HOSPITAL, SKILLED NURSING OR INTERMEDIATE LEVEL OF CARE?

No, participation is optional
A client's physician and/or case manager will inform the client of the treatment alternatives
The client will be given the choice of being treated in an institution or applying for home and community-based services through the AIDS Waiver
To receive services the client must meet the criteria outlined in eligibility requirements

WHAT DO YOU MEAN BY COST EFFECTIVE?

Cost effective means that the annual cost of all Medical Assistance services while on the waiver cannot exceed the average annual cost of services for a comparable group of clients not participating in the waiver.

APPROVAL FOR WAIVER SERVICE:

The Department will send an approval letter to the client and a copy to the client's case manager and physician
Clients applying for the Waiver are encouraged to participate in the Medical Assistance Targeted Case Management Program. If the client is not enrolled in the Case Management Program, the client will be informed of the program, offered an opportunity to enroll, and provided with a list of case managers in the local area to select one of his/her choice

IS CASE MANAGEMENT A WAIVER SERVICE?

No, case management is not a waiver service
However, all clients that are on the Waiver are also eligible to be in the Case Management Program and will be encouraged to participate
The case manager can assist recipients in obtaining needed care and can monitor the client's condition to ensure timely access to needed care

RE-EVALUATIONS:

If a client is certified for one of the required levels of care, how long is the certification valid?
The level of care must be re-certified by the physician, at least once every twelve months
Every 30 days the case manager must evaluate the need for continued waiver services when reviewing the Service Coordination Plan

WHO CAN THE CLIENT CONTACT FOR MORE INFORMATION FOR THE WAIVER?

Additional Information may be obtained from the Waiver Implementation Unit at the following address:

AIDS Waiver Program
PO Box 2675
555 Walnut Street, 5th Floor
Harrisburg, PA 17105-2675

By calling
717-787-8091

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