Medicaid - Part 3

What can you do if you are denied eligibility?

If you are denied Medicaid, you have the right to appeal the decision. You may contact the local Medicaid office supervisor for a conference. You may also call the Constituent Services Representative for Medicaid, or file for a Fair Hearing.
For more information about Utah Medicaid see: http://www.health.utah.gov/medicaid/provhtml/general_info.html

Medicaid Waivers

Utah Medicaid also offers additional services for special populations. These special services are available through waivers. A waiver allows a state to set aside some of the federal rules that apply to the regular Medicaid program. Waivers differ from regular Medicaid in that the state is able to design a program that meets the needs of a particular group of people. The state defines the group of people who are eligible for benefits, the geographic area that the waiver will cover, the services to be offered, the amount of services provided, and the total number of people who can receive the services. The state must get approval from the Centers for Medicare and Medicaid Services (CMS) for any waiver. Unlike regular Medicaid, waivered services are not considered an entitlement. The number of people served under a waiver is dependent upon money received from the state legislature. This means that a person may qualify for the services, but is not made eligible to receive services until there is funding available to give him/her services. Once the person is given funding under the waiver, all services within that waiver and all regular Medicaid services (see above) are available if medically necessary. Utah Medicaid operates five Home and Community Based Services (HCBS) Waiver programs for people with severe disabilities. These waivers provide services to individuals who are Medicaid eligible and who would require care in a Nursing Facility (NF) or Intermediate Care Facility for the Mentally Retarded (ICF/MR). The waivers allow Medicaid to pay for services that help people live in their own home or in the community. Each of the waivers has different income and asset limits, and additional standards that an individual must meet.

Technology Dependent Children (Travis C.) Waiver

This Utah Medicaid Home and Community Based Services Waiver serves medically fragile children who are dependent upon medical equipment for either breathing or eating. The Department of Health, Bureau of Children with Special Health Care Needs administers this waiver. To be eligible for this waiver the child must:

  • Be a Utah resident
  • Be less than 21 years of age when entering the program. A recipient may continue to receive services after age 21.
  • Need the medical services provided in a Nursing Facility
  • Qualify for Medicaid based on his/her own income and resources at or below 100 % of the Federal Poverty Level after allowable deductions (spenddown is an option). Parents? income and assets are not counted.
  • Have at least one caregiver trained (or be able to be trained) and available to provide care in the home. The home must have enough space for the medical equipment and care staff to safely take care of the child.
  • Require skilled nursing or rehabilitation services (or a combination of both) at least five days per week.

What services are available through this waiver?

In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

  • Respite care
  • In-home respiratory care
  • Family support services
  • Nutritional evaluation and in-home treatment
  • Only a limited number of children may receive help through this waiver. A child may qualify, but may need to be placed on a waiting list until funding is available.
  • Where do I get more information about the Travis C. Waiver?
  • More detailed information about the waiver can be found at: http://health.utah.gov/cshcn/Travis/index.htm

Or call the Division of Community and Family Health Services, Community Based Services case manager at 801-584-8240 or outside the Salt Lake area at 1-800-829-8200.

Individuals with Mental Retardation and Other Related Conditions Waiver

This Utah Medicaid Home and Community Based Services Waiver provides services to children and adults with intellectual and related developmental disabilities (e.g. cerebral palsy, autism and severe epilepsy). The Department of Human Services, Division of Services for People with Disabilities (DSPD) runs this waiver. To be eligible for this waiver the individual must display symptoms of the condition before age 22 and:

  • Be a Utah resident
  • Have significant life long functional limitation in three of the following:
  • Self care (eating, toileting, bathing, dressing or grooming)
  • Receptive and expressive language (unable to communicate and understand simple requests)
  • Learning (a functional IQ measured at 70 or below)
  • Mobility (may require a wheelchair, scooter, or other assistive devices and requires assistance to exist an area during an emergency)
  • Self direction (not able to make appropriate decisions about safety, legal, financial or residential issues)
  • Incapable of independent living (does not have the necessary skills to live in the community, or is a danger to oneself or others)
  • Unable to become economically independent (receives disability benefits, or works part time, or requires assistance on the job and is paid less than minimum wage)
  • Needs the services provided in an Intermediate Care Facility for the people with mental retardation (ICF/MR)
  • Qualifies for Medicaid based on his/her own income and resources at or below 100 % of the Federal Poverty Level after allowable deductions (spenddown is an option). Parents? income and assets are not counted.

What services are available through this waiver?

In addition to the medical services available through regular Medicaid, this waiver provides the following special services:

  • Behavior consultation
  • Chore services (heavy duty housekeeping)
  • Companion services
  • Day supports
  • Environmental adaptations including home modifications, vehicle modifications and assistance dogs
  • Extended living supports (for someone who is not able to attend a daytime activity due to illness, or who is transitioning to another provider)
  • Family training and preparation services (training for the primary giver or family)
  • -Family and individual training and preparation services (a more intensive training when the family has numerous challenges)

Financial management services

  • Homemaker services (meal preparation and routine household care)
  • Living start-up costs for basic household items required by an individual moving from an institutional setting into the community
  • Massage therapy
  • Personal assistance
  • Personal budget assistance
  • Personal Emergency Response System (purchase, on-going fees, and testing)
  • Professional medication monitoring (supervision by a nurse)
  • Residential placements with appropriate supports
  • Respite care
  • Specialized medical equipment (rental or purchase)
  • Supported employment
  • Supported living
  • Transportation for non-medical needs
  • Waiver support coordination

While the list of available services is extensive, the services received are dependent on an individual's needs and assigned budget. No service may duplicate a similar service offered through the Medicaid State Plan. A service is made available through the waiver only if there is no other means of obtaining it. However, once someone is brought into this waiver, he or she is eligible for all services that are necessary for his or her health and safety.

A person may qualify to receive services through DSPD, however, he or she is not made eligible to receive services through the Individuals with Mental Retardation and Other Related Conditions Waiver until funding is available. Only a limited number of people can receive services through this waiver. DSPD maintains a waiting list of individuals who qualify for services and who are waiting to receive services through this waiver. Individuals are brought into services from the waiting list based on available funding and on their level of critical need. Utah State law requires DSPD to serve the most critical first. This often means that a person can be on the waiting list for many years before being brought into services.

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