Medicaid Waivers for Individuals with Autism

What is a Medicaid Waiver?

A Medicaid Waiver is a program offered through Medicaid that gives special services to certain groups of people. Each state creates and runs its own Medicaid Waiver programs. However, the federal government has to approve these programs.

The name Medicaid Waiver refers to the fact that states are “waiving”, or giving up, some federal Medicaid rules in order to support certain groups of people in a different way. For example, in traditional Medicaid, states are not allowed to have waiting lists. This means that anyone who is eligible for Medicaid can get it.

However, states are allowed to have waiting lists for Medicaid Waivers. Also, states can allow waivers to cover services that are not paid for by traditional Medicaid, such as employment and community supports. These extra services are called home and community-based services.

States can decide what services people can get from their Medicaid Waivers. States also get to decide what group of people can be in a Medicaid Waiver. This means that the state can make a Medicaid Waiver for a specific group. Most Medicaid Waivers are for:

• older adults (over 65 years old)
• people with certain disabilities like autism
• people with illnesses that last a long time (like HIV/AIDS)

To get a Medicaid Waiver, people have to show that they need support in order to live and work in the community. States will do an assessment to learn how much support a person needs. This assessment will determine if the person is eligible for a Medicaid Waiver.

Medicaid Waivers are meant to serve people in their homes and communities instead of in an institution. Many people with disabilities, like autism, need home and community-based services
to be able to live independently in their communities.

In Pennsylvania, the following Medicaid Waivers and Programs are available for individuals with autism:

Bureau of Community Supports (BCS) Waivers

• Consolidated Waiver
• Person/Family Directed Support Waiver, or P/FDS
• Community Living Waiver

Bureau of Supports for Autism and Special Populations

• Adult Autism Waiver
• Adult Community Autism Program (ACAP is only available in four counties: Chester, Lancaster, Dauphin, and Cumberland).

These waivers have different eligibility requirements, offer different services, and have different benefits and limits. However, they are all meant to help people live independently in their homes and communities. All of these waivers are run through Pennsylvania’s Office of Developmental Programs (ODP).

Medicaid Waivers can help people with autism get home and community-based services. Some examples of home and community-based services are:

• Job coaching
• Transportation to a job or an appointment
• Building skills for independent living like getting dressed and showering
• Learning skills to help live in, work in, and be a part of the community

Medicaid (conocido también como “Medical Assistance” en Pensilvania) es un programa de seguro de salud público en los Estados Unidos. Cada estado administra su propio programa Medicaid con ayuda del gobierno federal. El programa Medicaid de Pensilvania se llama “Medical Assistance”. (Si desea recibir más información sobre qué es Medicaid y cómo funciona, visite nuestra guía “A Self-Advocate’s Guide to Medicaid” en www.paautism.org/MAguide)

Una Exención de Medicaid es un programa que se ofrece a través de Medicaid y que proporciona servicios especiales a ciertos grupos de personas. Cada estado crea y dirige sus propios programas de Exención de Medicaid. Sin embargo, el gobierno federal tiene que aprobar esos programas.

El nombre “Exención de Medicaid” se refiere al hecho de que se “exime” o se exonera a los estados del cumplimiento de algunas de las reglas federales de Medicaid con el fin de que puedan apoyar a ciertos grupos de personas de una manera diferente. Por ejemplo, en el programa Medicaid tradicional, los estados no tienen permitido tener listas de espera. Eso significa que cualquier persona que cumpla los requisitos de Medicaid puede obtener su cobertura.

Sin embargo, los estados pueden tener listas de espera para las Exenciones de Medicaid. Además, los estados pueden permitir a las exenciones cubrir servicios que el programa Medicaid tradicional no paga, como el apoyo para conseguir empleo o los apoyos comunitarios. Estos servicios adicionales se denominan servicios basados en el hogar y la comunidad.

Los estados pueden decidir qué servicios pueden obtener las personas a través de sus Exenciones de Medicaid. Asimismo, los estados deciden qué grupos de personas pueden beneficiarse con una Exención de Medicaid. Eso significa que el estado puede establecer una Exención de Medicaid para un grupo específico. La mayoría de las Exenciones de Medicaid son para:

• adultos mayores (de más de 65 años de edad),
• personas con ciertas discapacidades, como autismo, o
• personas con enfermedades que persisten por mucho tiempo (como HIV/AIDS).

Para obtener una Exención de Medicaid, las personas tienen que demostrar que necesitan apoyo para vivir y trabajar en la comunidad. Los estados llevan a cabo evaluaciones para saber cuánto apoyo necesita una persona. Esa evaluación determinará si la persona es elegible para obtener una Exención de Medicaid.

El propósito de las Exenciones de Medicaid es proporcionar servicios a las personas en sus hogares y comunidades, en lugar de hacerlo en una institución. Muchas personas con discapacidades como el autismo necesitan servicios basados en el hogar y la comunidad para poder vivir de manera independiente en sus comunidades.

En Pensilvania, las personas con autismo tienen a su disposición las siguientes Exenciones de Medicaid:

Exenciones de la Oficina de Servicios Comunitarios (BCS):

• Exención Consolidada (Consolidated Waiver)
• Exención de Apoyo Dirigido a la Persona/Familia (P/FDS)
• Exención para la Vida en la Comunidad (Community Living Waiver)

Programas de la Oficina de Servicios para el Autismo (BAS):

• Exención para Adultos con Autismo (Adult Autism Waiver)
• Programa de Autismo para Adultos en la Comunidad (ACAP) (Este programa está disponible solo en cuatro condados: Chester, Lancaster, Dauphin y Cumberland)

Estas exenciones tienen distintos requisitos de elegibilidad, ofrecen diferentes servicios, ofrecen diferentes beneficios y tienen distintos límites. Sin embargo, todos ellos tienen el propósito de ayudar a las personas a vivir de manera independiente en sus hogares y comunidades. Todas estas exenciones se administran a través de la Oficina de Programas para el Desarrollo (ODP) de Pensilvania.

Las Exenciones de Medicaid pueden ayudar a las personas con autismo a obtener servicios basados en el hogar y la comunidad. Estos son algunos ejemplos de servicios basados en el hogar y la comunidad:

• Coaching para el trabajo
• Transporte a un trabajo o a una cita
• Adquisición de habilidades para la vida independiente, como vestirse y bañarse
• Aprendizaje de habilidades que ayuden a vivir y trabajar en la comunidad y a ser parte de ella

Programs for Individuals of Any Age

Person/Family Directed Supports Waiver

• Diagnosis of an intellectual disability, autism, or developmental disability
• No age limit (except for developmental disability, which has an age limit of 0-8)
• Meet functional and financial eligibility
• Individual cost limit of $33,000 per person per fiscal year

Community Living Waiver

• Diagnosis of an intellectual disability, autism, or developmental disability
• No age limit (except for developmental disability, which has an age limit of 0-8)
• Individual cost limit of $70,000 per person per fiscal year

Consolidated Waiver

• Diagnosis of an intellectual disability, autism, or developmental disability
• No age limit (except for developmental disability, which has an age limit of 0-8)
• Meet functional and financial eligibility
• No individual cost limit

1. Contact your County Mental Health/Intellectual Disability (MH/ID) Office: In the phone book look for Intellectual Disability, Human Services or visit PAautism.org/MHID
2. Register with County MH/ID, they will schedule an appointment to gather more information.
3. What to bring to an appointment with the County MH/ID: Social Security Card, Birth Certificate, Proof of Residence and MA Card (proof of Medicaid).

Priority of Information of Needs (PUNS)

BCS uses a prioritization system to sort those on the waiting list based on their level of need. This system is called the Prioritization of Urgency of Need for Services (PUNS). PUNS collects information about your current and future service and support needs. PUNS helps the County MH/ID and state plan for your needs in comparison to others.

How is PUNS Information Collected?

The information is collected by your County MH/ID and is updated at least once a year with a Supports Coordinator (SC).

PUNS Levels

After you complete the PUNS form, the County MH/ID will see what your PUNS level is. This depends on what your service and support needs are in the next 5 years. The PUNS looks at many areas of a person’s life including: if they are getting services at the time, if a family/caregiver is able to give support, and if a person has a place to live safely.

• Emergency: Support needed immediately (within next 6 months).
• Critical: Support needed in next 2 years.
• Planning: Support needed within next 2-5 years.

Programs for Individuals Ages 21+

Adult Community Autism Program (ACAP)

• Available in Chester, Lancaster, Cumberland, and Dauphin counties.
• Confirmed autism diagnosis.
• Meet financial and functional eligibility.
• This is a managed care model program.*

Adult Autism Waiver (AAW)

• Available across Pennsylvania.
• Confirmed autism diagnosis.
• Meet financial and functional eligibility.

* A managed care model means that physical health services (like a doctors appointment) and services in the community (like a job coach) are both paid for by the same program.

1. Contact your County Mental Health/Intellectual Disability (MH/ID) Office: In the phone book look for Intellectual Disability, Human Services or visit PAautism.org/MHID
2. Register with County MH/ID, they will schedule an appointment to gather more information.

Important Note: There is a waiting list to receive the Medicaid waivers/programs in Pennsylvania. Individuals must be enrolled in one of the waivers/programs listed below to get these services. Some services may need approval before program participants can get them. The services that program participants get are based on their individual needs and must be approved and authorized in their plans. Also, the availability of providers by service may be different by county. Check the program provider directories to learn more.

The Person/Family Directed Support (P/FDS) Waiver is a Medicaid waiver that is available statewide in Pennsylvania. Participants in the P/FDS Waiver can get the following services:

• Advanced Supported Employment
• Assistive Technology
• Behavioral Support
• Benefits Counseling
• Communication Specialist
• Community Participation Support
• Companion
• Consultative Nutritional Services
• Education Support
• Family/Caregiver Training and Support
• Home Accessibility Adaptations
• Homemaker/Chore
• Housing Transition and Tenancy Sustaining Services
• In-Home and Community Support
• Music, Art, and Equine Assisted Therapy
• Participant-Directed Goods and Services
• Respite
• Shift Nursing
• Small Group Employment
• Specialized Supplies
• Supported Employment
• Supports Broker
• Supports Coordination
• Therapy
  • Physical
  • Occupational
  • Speech/Language
  • Orientation, Mobility and Vision
• Transportation
• Vehicle Accessibility Adaptations

There is a $33,000 cost limit per participant per year in the P/FDS Waiver for services. This does not limit Supports Coordination and Supports Broker Services. Participants can go over the cost limit by $15,000 for Advanced Supported Employment or Supported Employment services.

Important Note: Some services may need approval before program participants can get them. The services that program participants get are based on their individual needs. Also, the availability of providers by service may be different by county. Check the program provider directories to learn more.

The Community Living Waiver is a Medicaid waiver that is available statewide in
Pennsylvania. Participants in the Community Living Waiver can get the following services:

• Advanced Supported Employment
• Assistive Technology
• Behavioral Support
• Benefits Counseling
• Communication Specialist
• Community Participation Support
• Companion
• Consultative Nutritional Services
• Education Support
• Family/Caregiver Training and Support
• Home Accessibility Adaptations
• Homemaker/Chore
• Housing Transition and Tenancy Sustaining Services
• In-Home and Community Support
• Music, Art, and Equine Assisted Therapy
• Life Sharing*
• Participant-Directed Goods and Services
• Respite
• Shift Nursing
• Small Group Employment
• Specialized Supplies
• Supported Employment
• Supported Living*
• Supports Broker
• Supports Coordination
• Therapy
  • Physical
  • Occupational
  • Speech/Language
  • Orientation, Mobility and Vision
• Transportation
• Vehicle Accessibility Adaptations

*Available for participants who need less than 30 hours per week of services

There is a $70,000 cost limit per participant per year in the Community Living Waiver for services. This does not limit Supports Coordination and Supports Broker services.

Important Note: Some services may need approval before program participants can get them. The services that program participants get are based on their individual needs. Also, the availability of providers by service may be different by county. Check the program provider directories to learn more.

The Consolidated Waiver is a Medicaid waiver that is available statewide in Pennsylvania. Participants in the Consolidated Waiver can get the following services:

• Advanced Supported Employment
• Assistive Technology
• Behavioral Support
• Benefits Counseling
• Communication Specialist
• Community Participation Support
• Companion
• Consultative Nutritional Services
• Education Support
• Family/Caregiver Training and Support
• Home Accessibility Adaptations
• Homemaker/Chore
• Housing Transition and Tenancy Sustaining Services
• In-Home and Community Support
• (Licensed and Unlicensed) Life Sharing
• Music, Art and Equine Assisted Therapy
• (Licensed and Unlicensed) Residential Habilitation
• Respite
• Shift Nursing
• Small Group Employment
• Specialized Supplies
• Supported Employment
• Supported Living
• Supports Broker
• Supports Coordination
• Therapy
  • Physical
  • Speech/Language
  • Occupational
  • Orientation, Mobility and Vision
• Transportation
• Vehicle Accessibility Adaptations

There is no maximum amount (also known as a cap) of services that a participant can get in the Consolidated Waiver.

Important Note: Some services may need approval before program participants can get them. The services that program participants get are based on their individual needs. Also, the availability of providers by service may be different by county. Check the program provider directories to learn more.

The Adult Autism Waiver (AAW) is a Medicaid waiver that is available statewide in Pennsylvania. Participants in AAW can get the following services:

• Assistive Technology
• Career Planning
  • Job Finding
  • Vocational Assessment
• Community Transition Services
• Community Support
• Day Habilitation
• Family Support
• Home Modifications
• Nutritional Consultation
• Residential Habilitation
• Respite
• Specialized Skill Development
  • Community Support
  • Behavioral Specialist Services
  • Systematic Skill Building
• Supported Employment
  • Extended Employment Supports
  • Intensive Job Coaching
• Therapies (Speech, Language, and Counseling)
• Small Group Employment
• Vehicle Modification
• Transporation

Important Note: Some services may need approval before program participants can get them. The services that program participants get are based on their individual needs. Also, the availability of providers by service may be different by county. Check the program provider directories to learn more.

Adult Community Autism Program (ACAP): The Adult Community Autism Program (ACAP) is a managed care program available in four counties in Pennsylvania: Chester, Cumberland, Dauphin, and Lancaster. Participants in ACAP can get the following services:

• All Physician Services
• Assistive technology
• Career Planning
• Community Support
• Community Transition Services
• Day Habilitation
• Family Support
• Homemaker/chore services
• Medical supplies and durable medical equipment
• Non-medical transportation
• Personal assistance services
• Physical, occupational, vision and mobility, and speech therapies (group and individual)
• Residential Habilitation
• Respite
• Specialized Skill Development
• Supported employment
• Supports coordination

Pennsylvania’s Office of Developmental Programs (ODP) offers waiver programs for people who need extra support to live and work in their communities. In order to qualify for the ODP Waivers (P/FDS, Consolidated, and Community Living Waivers), you need to:

1. Have a diagnosis of an intellectual disability (ID) or autism from a qualified professional (children under age 8 can also qualify with a diagnosis of a developmental disability)
2. Meet financial eligibility
3. meet functional eligibility

What is Functional Eligibility?

To be eligible for waiver services, a person has to show that they need a certain level of support in order to live and work in the community. The level of support is measured by having substantial limitations in 3 or more major life activities:

• Self-care
• Understanding and use of receptive and expressive language
• Learning
• Mobility
• Self-direction
• Capacity for independent living

How is Functional Eligibility Measured?

Functional eligibility for the ODP waivers is measured when you apply for waiver services at your county Mental Health/Intellectual Disability (MH/ID) Office. The MH/ID office will determine functional eligibility by using an adaptive functioning assessment. There are two adaptive functioning assessments that counties use: the Vineland Adaptive Behavior Scale and the Adaptive Behavior Assessment System (ABAS).

How Can I Get an Adaptive Functioning Assessment?

If you or your family member has a recent Vineland or ABAS, you may be able to share that with your county MH/ID office. They will use those results to determine if you or your family member meet functional eligibility requirements for the ODP waivers.

If you do not have a recent Vineland or ABAS, you can call your County MH/ID to help you find out where you or your family member can get one of these assessments. If you or your family
member are still in school, you may be able to get one of these assessments done by the school psychologist.

In Pennsylvania, every county has a Mental Health/Intellectual Disability (MH/ID) office. The MH/ID office in your county is where you go to enroll yourself or your child in many different mental health or developmental services. This resource will help you learn about how your county MH/ID office can help you apply for and get the services and supports that you or your child needs, if you are found eligible .

What is an MH/ID Office?

MH/ID offices oversee some Medicaid-funded mental health and developmental services in a specific county. Sometimes the county MH/ ID office has a different name. For example, these offices can be called Mental Health/Intellectual Disability (MH/ID) office, Behavioral Health/Intellectual Disability (BH/ID) office, or the Developmental and Behavioral Health office. Sometimes you will also hear the MH/ID office called the “Administrative Entity”, or AE. Each county has a slightly different name for the MH/ID office, but every office can help you apply for services that you or your child need.

How do I Find My County’s MH/ID Office?

Each county has an MH/ID office. Sometimes multiple counties share one MH/ID office. For example, the Armstrong-Indiana Behavioral and Developmental Health Services Office serves both Armstrong and Indiana county. To find your county MH/ID office visit: www.paautism.org/mhid, and select your county from the list. You can also contact the ASERT Resource Center (info@paautism.org or 1-877-231-4244) to help you find your county MH/ID office.

Why is it Important That I Call My County MH/ID Office?

In Pennsylvania, Medicaid-funded mental health and developmental services are administered at the county level. To apply for these services in your county, you need to contact your county MH/ID office. If you or your child need services, your county MH/ID office will be able to help you apply, enroll, and get services if you or your child are eligible.

What Services Does My County MH/ID Office Offer?

Your county MH/ID office can help you apply for many services. They can help you apply for and get access to:

• Early Intervention Services (for kids younger than 3 years old). If you or your doctor have a concern about your child’s development, you can contact your county MH/ID office and ask about early intervention services. For more information about
  early intervention visit: www.paautism.org/earlyintervention.
• Behavioral Health Rehabilitation Services (BHRS, or wraparound) (for kids younger than 18 years old). BHRS provide one-on-one supports for children with serious emotional or behavioral challenges.
• Office of Developmental Programs (ODP) Waivers for people with autism, intellectual, and developmental disabilities (of all ages). This includes the Consolidated Waiver, Person/Family Directed Support Waiver (P/FDS Waiver), and the Community
  Living Waiver. Waivers are programs that provide services for people who need extra support to live independently in their communities.

County MH/ID offices also manage mental health services for children and adults, and substance use services.

When registering with the county for disability services in Pennsylvania, use this checklist to ensure you have the correct information and documentation.

Note: This checklist is a guide. You might be asked for other documents or information.

Documents with an Autism Diagnosis: A signed evaluation from a doctor or licensed clinician (i.e., licensed psychologist, developmental pediatrician, certified school psychologist, psychiatrist, licensed physician, licensed physician assistant or certified registered nurse practitioner) that indicates an autism diagnosis.

Adaptive Functioning Assessment: Indication of skill deficits in three or more areas (self care, receptive and expressive language, learning, mobility, self-direction, capacity of independent living) based on either:

• Vineland Adaptive Behavior Scales
• Adaptive Behavior Assessment System (ABAS)

Copy of Birth Certificate

Copy of Social Security Card or Other Documentation of Citizenship Status

Copy of MA Card and Other Insurance Cards if You are Also Covered by Private Insurance or Medicare: The MA card might be an ACCESS card or a card from a Managed Care Organization. Some examples of Managed Care Organizations are AETNA Better Health, AmeriHealth Caritas, Gateway Health Plan, etc.

Picture Identification

MA 51 Medical Evaluation: Completed by a licensed physician, physician’s assistant, or nurse practitioner that indicates the individual is recommended for ICF/ORC level of care.

Custody Documents (if applicable)

Proof of Address (for example, utility bill, lease, etc)

If you do not have documentation of an autism diagnosis or proof of adaptive functioning, the county will provide you with a resource list that will assist you in obtaining the necessary assessments.

If you have additional questions, please contact your county of residence.