Division of Aging Waiver Programs

Indiana’s Medicaid waiver program began in 1981, in response to the national trend toward providing home- and community-based services. In the past, Medicaid paid only for institutional-based, long-term care services, such as nursing facilities and group homes. Under the Waiver program, it now pays to provide community-based services to people with disabilities who meet specific criteria. Those services are provided in a person-centered manner and are designed to respect the Individual's personal beliefs and customs. Specifically, the Waiver program is meant to assist a person in:

• Become integrated in the community where he/she lives and works
• Developing social relationships in the person's home and work communities
• Developing skills to make decisions about how and where the person wants to live
• Being as independent as possible
  

In Indiana, the Division of Aging waivers are administered by the Indiana Family and Social Services Administration (FSSA) through the Division of Aging (DA). The DA oversees two waivers, the Aged & Disabled Waiver (A&D) and the Traumatic Brain Injury Waiver (TBI).

The Indiana Home and Community Based Services is intended to afford an individual to reside in a community setting, rather than residing in a facility setting. The supports available under the waiver are intended to provide educational, rehabilitative, or therapy services aimed at improving an individual’s independence or functioning level. Other forms of supports are available throughout the State of Indiana. The IPMG Care Manager will work with you and the support team to identify any potential resources available to help alleviate the identified needs. IPMG maintains a database of nearly 1000 community resources which Care Managers can reference to identify potential and appropriate resources to meet the individual’s needs. Additionally, Care Managers will refer individuals to seek assistance from Social Security, Public Housing Assistance, Food Stamp Program, etc.

The A&D waiver provides an alternative to nursing facility admission for adults and persons of all ages with a disability. Individuals meeting Nursing Facility Level of Care and Medicaid eligibility requirements must meet at least one of the following criteria to receive services through the A&D waiver:

• Age 65 or older, or
• Have a substantial physical disability

The A&D waiver is designed to provide services to supplement informal supports for people who would require care in a nursing facility if waiver or other support was not available. A&D waiver services can be used to help individuals remain in their own homes, and can also assist individuals living in nursing facilities to return to community settings such as their own homes, apartments, assisted living or Adult Family Care.

Services available through the A&D waiver are:

Adult Day Services (ADS): Adult Day Service (ADS) are community-based group programs designed to meet the needs of older adults who need structured, social integration through a comprehensive and non-residential program. The service plan will identify the need through the person-centered assessment (PCA) process and evident through the assessment tool. The purpose for ADS is to provide health, social, recreational, supervision, support services, and personal care. Meals and/or nutritious snacks are required.

Adult Family Care (AFC): Adult Family Care (AFC) is a comprehensive service in which a participant resides with an unrelated caregiver. The participant and up to three (3) other participants who have physical and/or cognitive disabilities, and who are not members of the provider’s or primary caregiver’s family, and/or reside in a home that is owned, rented, or managed by the AFC provider. AFC provides an environment that has the qualities of a home, including privacy, safe place that is free of environmental hazards such as pests, habitable environment, comfortable surroundings, and the opportunity to modify one’s living area to suit one’s participant preferences.

Assisted Living (AL): Assisted living service is defined as personal care and services, chore, attendant care and companion services, medication oversight (to the extent permitted under State law), therapeutic social and recreational programming, provided in a congregate residential setting in conjunction with the provision of participant paid room and board. This service includes 24-hour on-site response staff to meet scheduled and unpredictable needs. The participant retains the right to assume risk. Participants selecting Assisted Living service may also receive Care Management service, Specialized Medical Equipment and Supplies service and Community Transition services through the waiver.

Attendant Care: Attendant Care services (ATTC) are provided to participants with nursing facility level of care needs. ATTC provides direct, hands-on care to participants for the functional needs with ADLs. The participant is the employer for Participant Directed ATTC or appoints a representative to be the employer on their behalf.

Care Management: Care Management is a process of assessment, discovery, planning, facilitation, advocacy, collaboration, and monitoring of the holistic needs of each individual, regardless of funding sources.

Community Transition Services: Community Transition Services (CTS) include but are not limited to, reasonable, set-up expenses for Individuals who make the transition from an institution to their own home where the person is directly responsible for his or her own living expenses in the community and will not be reimbursable on any subsequent move. Reimbursement is limited to a lifetime cap for set up expenses up to $1,500. For those receiving this service under the waiver, reimbursement for approved Community Transition expenditures are reimbursed through the local AAA or DA approved provider who maintains all applicable receipts and verifies the delivery of services.

Home Modifications: Home modifications are physical adaptations to the home, as required by the participant's service plan, which are necessary to ensure the health, welfare and safety of the participant, and which enable the participant to function with greater independence in their home, and without which the individual would require institutionalization. Incidental structural repairs to facilitate modifications may be included in this service. There is a minimum requirement to gather 2 bids for any expected amount over $5,000.00. Home Modification Maintenance (HOMM) - limited to $1,000.00 annually for the repair and service of environmental modifications that have been provided through a HCBS waiver. A lifetime cap of $20,000 is available for environmental modifications, however, the cap on any single project is $15,000.

Home Modification Assessment: This service will be used to objectively determine the specifications for a home modification that is safe, appropriate, and feasible in order to ensure accurate bids and workmanship. All participants must receive a home modification assessment, if a provider is available in that county, with a certified waiver provider selected by the participant prior to any subsequent home modifications, as well as a home modification inspection upon completion of the work. A home modification will not be reimbursed until the final inspection has been completed. The assessor will be responsible for writing the specifications, review of feasibility and the post-project inspection.

Integrated Health Care Coordination: Integrated Health Care Coordination is to promote improved health status and quality of life, delay/prevent deterioration of health status, manage chronic conditions in collaboration with physicians, and integrate medical and social services. Development and oversight of a healthcare support plan which includes coordination of medical care and proactive care management of both chronic diseases and complex conditions such as falls, depression and dementia. Skilled nursing services are provided within the scope of the Indiana State Nurse Practice Act.

Home and Community Assistance: Home and Community Assistance provides instrumental activities of daily living (IADL) for the participant in their home. The services are provided when the individual is unable to meet their needs or when the informal caregiver/helper is unable to perform these needs for the participant.

Home Delivered Meals: A Home Delivered Meal is a nutritionally balanced meal. Home Delivered Meals will be provided to persons who are unable to prepare their own meals and for whom there are no other persons available to do so or where the provision of a home delivered meal is the most cost effective method of delivering a nutritionally adequate meal and it is not otherwise available through other funding sources. Home delivered meals may include but are not limited to: No more than two meals per day will be reimbursed under the waiver, Diet/ nutrition counseling provided by a registered dietician, Nutritional education based on needs of each participant, Diet modification according to a physician’s order as required meeting the individual’s medical and nutritional needs

Nutritional Supplements: Nutritional Supplements include liquid supplements, such as “Boost” or “Ensure” to support participants in maintaining their health in order to remain in the community. Supplements must be ordered by a physician, physician assistant, or nurse practitioner. There is an annual cap of $1,200. Reimbursement for approved Nutritional Supplement expenditures are reimbursed through the local AAA or an approved DA provider, who maintains all applicable receipts and verifies the delivery of services.

Personal Emergency Response Systems (PERS): Personal Emergency Response System (PERS) is an electronic device which enables certain participants at high risk of institutionalization to secure help in an emergency. The participant may also wear a portable help button to allow for mobility. The system is connected to the person’s phone and programmed to signal a response center once a button is activated. The response center is staffed 24 hours daily/ 7 days per week by trained professionals.

Pest Control: Pest Control services are designed to prevent, suppress, or eradicate anything that competes with humans for food and water, injures humans, spreads disease and/or annoys humans and is causing or is expected to cause more harm than is reasonable to accept. Pests include, but are not limited to, insects such as roaches, mosquitoes, fleas; bed bugs, insect-like organisms, such as mites and ticks; and vertebrates, such as rats and mice. Services to control pests are services that prevent, suppress, or eradicate pest infestation. An annual cap of $4,000 is available for pest control services. Reimbursement for approved Pest Control expenditures is reimbursed through the local AAA or other approved DA provider, who maintains all applicable receipts and verifies the delivery of services.

Respite: Respite services are those services that are provided temporarily or periodically in the place of the usual caregiver. Respite can occur in home and community-based settings. For those Individuals receiving the service of Adult Family Care, Structured Family Caregiving, or Assisted Living waiver service, funding for respite is already included in the per diem amount and the actual service of respite may not be billed. The level of professional care provided under respite services depends on the needs of the Individual and caregiver determined in the PCA.

RHHA: A participant who is eligible for State Plan Home Health Services (HOHE) should be considered for respite home health aide under the supervision of a registered nurse.

RSKNU: A participant who is eligible for State Plan Nursing Services (SKNU) must be considered for respite nursing services.

Authorized hours will roll over month to month through the duration of the Annual Service Plan. If a request for an increase in Respite during the annual care plan is needed the CM must coordinate with the agency to verify unused hours before requesting the additional hours. If there are unused hours they must first be used before requesting additional hours.

If respite occurs in a HCBS certified facility targeting children and young adults twenty-two (22) and younger, staff to participant ratio cannot be greater than 1 staff per 2 participants. When respite is provided in this environment the intent is to provide support to families in an effort to avoid institutionalization of their children.

Structured Family Caregiving: Structured Family Caregiving means a caregiving arrangement in which the principal caregiver, who may be a non-family member or a family member, lives with the participant in the private home of the participant or the principal caregiver. Necessary support services are provided by the principal caregiver (family caregiver) as part of Structured Family caregiving. Only agencies may be Structured Family Caregiving providers, with the home settings being assessed and accessible, and caregivers being qualified as able to meet the participant’s needs. Structured Family Caregiving service will not be reimbursed when provided by a parent of a minor child participant.

Specialized Medical Equipment & Supplies: Specialized Medical Equipment and Supplies are medically prescribed items required by the participant's service plan, which assist the participant in maintaining their health, welfare and safety, and enable the participant to function with greater independence in the home. Specialized Medical Equipment provides therapeutic benefits to a participant in need, because of certain medical conditions and/or illnesses. Specialized Medical Equipment primarily and customarily are used to serve a medical purpose and are not useful to a person in the absence of illness or injury. Participants requesting authorization for this service through utilization of Home and Community Based Services (HCBS) waivers must first exhaust eligibility of the desired equipment or supplies through Indiana Medicaid State Plan, which may require Prior Authorization (PA). There should be no duplication of services between HCBS waiver and Medicaid State Plan. Maintenance is limited to $1000 annually for the repair and service of items that have been provided though the HCBS waiver.

Transportation: Services offered in order to enable participants served under the waiver to gain access to waiver and other non-medical community services, activities, and resources, specified by the service plan. Transportation services must follow a written service plan addressing specific needs determined by the participant’s PCA and whenever possible, family, neighbors, friends, or community agencies which can provide this service without charge will be utilized. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State plan, if applicable, and shall not replace them.

Vehicle Modifications: Vehicle Modifications are the addition of adaptive equipment or structural changes to a motor vehicle that will empower a participant to safely transport in a motor vehicle. Vehicle modifications, as specified in the Service Plan, may be authorized when necessary to increase an Individual’s ability to function in a home and community-based setting to ensure accessibility of the Individual with mobility impairments. These services must be necessary to prevent or delay institutionalization. The necessity of such items must be documented in the Service Plan by a physician’s order. Vehicles necessary for an Individual to attend post-secondary education or job-related services should be referred to Vocational Rehabilitation Services. A lifetime cap of $15,000.00 is available for vehicle modifications. In addition to the applicable lifetime cap, $1000 will be allowable annually for repair, replacement, or an adjustment to an existing modification that was funded by a Home and Community Based Services (HCBS) waiver.

The TBI Waiver provides home and community-based services to individuals who, but for the provision of such services, would require institutional care.

Indiana defines a traumatic brain injury as a trauma that has occurred as a closed - or open - head injury caused by an external event that results in damage to brain tissue, with or without injury to other body organs. Traumatic brain injury means a sudden insult or damage to brain function, not of a degenerative or congenital nature. The insult or damage may produce an altered state of consciousness and may result in a decrease in cognitive, behavioral, emotional, or physical functioning resulting in partial or total disability not including birth trauma related injury.

Individuals meeting Nursing Facility Level of Care and Medicaid eligibility requirements must meet at least one of the following criteria to receive services through the TBI waiver:

• Have a diagnosis of Traumatic Brain Injury, or
• Meet intermediate care facility requirements for individuals with intellectual disabilities
  

Services available through the TBI waiver are:

Adult Day Services (ADS): Adult Day Service (ADS) are community - based group programs designed to meet the needs of older adults who need structured, social integration through a comprehensive and non-residential program. The service plan will identify the need through the person-centered assessment (PCA) process and evident through the assessment tool. The purpose of ADS is to provide health, social, recreational, supervision, support services, and personal care. Meals and/or nutritious snacks are required.

Adult Family Care (AFC): Adult Family Care is a comprehensive service in which the Individual supported resides with an unrelated caregiver. The Participant and up to three (3) other Individuals who have physical and/or cognitive disabilities who are not members of the provider’s or primary caregiver’s family, reside in a home that is owned, rented, or managed by the adult family care provider. AFC provides an environment that has the qualities of a home, including privacy, safe place that is free of environmental hazards such as pests, habitable environment, comfortable surroundings, and the opportunity to modify one’s living area to suit one’s participant preferences.

Assisted Living (AL): Assisted Living Service is defined as personal care, chore, attendant care and companion services, medication oversight (to the extent permitted under State law), therapeutic social and recreational programming, provided in a congregate residential setting in conjunction with the provision of participant paid room and board. This service includes 24-hour on-site response staff to meet scheduled or unpredictable needs. The participant retains the right to assume risk.

Attendant Care Service: Attendant Care services (ATTC) are provided to participants with nursing facility level of care needs. ATTC provides direct, hands-on care to participants for the functional needs with ADLs. ATTC id provided to participant with either nursing facility or ICF/IID level of care needs.

Behavior Management/ Behavior Program and Counseling: Behavior Management includes training, supervision, or assistance in appropriate expression of emotions and desires, assertiveness, acquisition of socially appropriate behaviors, and the reduction of inappropriate behaviors. This service includes observation of the individual and environment for purposes of development of a plan and subsequent revisions and training staff, family members, roommates, and other appropriate individuals on the implementation of the behavior support plan.

Care Management: Care Management is a process of assessment, discovery, planning, facilitation, advocacy, collaboration, and monitoring of the holistic needs of each individual, regardless of funding sources.

Community Transition Services: Community Transition Services include reasonable, set-up expenses for Individuals who make the transition from an institution to their own home where the person is directly responsible for his or her own living expenses in the community and will not be reimbursable on any subsequent move. Reimbursement is limited to a lifetime cap for set up expenses up to $1,500.

Home Modifications: Home Modifications are physical adaptations to the home, required by the Individual’s Service Plan, which are necessary to ensure the health, welfare and safety of the Individual, or enable the Individual to function with greater independence in the home, and without which the Individual would require institutionalization. Maintenance is limited to $500 annually for the repair and service of environmental modifications that have been provided through the waiver. A lifetime cap of $20,000 is available for home modifications, however, the cap on any single project is $15,000. The cap represents a cost for basic modification of a participant’s home for accessibility and safety and accommodates the participant’s needs for housing modifications.

Integrated Health Care Coordination: Health Care Coordination is to promote improved health status and quality of life, delay/prevent deterioration of health status, manage chronic conditions in collaboration with physicians, and integrate medical and social services. The purpose of Health Care Coordination is development and oversight of a healthcare support plan which includes coordination of medical care and proactive care management of both chronic diseases and complex conditions such as falls, depression and dementia.

Home and Community Assistance: Home and Community Assistance services provide instrumental activities of daily living (IADL) for the participant in their home. The services are provided when the individual is unable to meet their needs or when the informal caregiver/helper is unable to perform these needs for the participant.

Home Delivered Meals: Home Delivered Meals are nutritionally balanced meals. Home delivered meals may include but are not limited to: No more than two meals per day will be reimbursed under the waiver, Diet/ nutrition counseling provided by a registered dietician, Nutritional education based on needs of each participant, Diet modification according to a physician’s order as required meeting the individual’s medical and nutritional needs.

Nutritional Supplements: Nutritional Supplements include liquid supplements, such as “Boost” or “Ensure” to maintain an Individual’s health in order to remain in the community. Supplements should be ordered by a physician, physician assistant, or nurse practitioner. Reimbursement for approved Nutritional Supplement expenditures are reimbursed through the local AAA or an approved DA provider, who maintains all applicable receipts and verifies the delivery of services. There is an annual cap of $1,200.

Personal Emergency Response Systems (PERS): Personal Emergency Response Systems (PERS) are electronic devices which enable certain Participants at high risk of institutionalization to secure help in an emergency. The Participant may also wear a portable help button to allow for mobility. The system is connected to the person’s phone and programmed to signal a response center once a “help” button is activated. The response center is staffed 24 hours daily/ 7 days per week by trained professionals.

Pest Control: Pest Control services are designed to prevent, suppress, or eradicate anything that competes with humans for food and water, injures humans, spreads disease and/or annoys humans and is causing or is expected to cause more harm than is reasonable to accept. Pests include but are not limited to insects such as roaches, mosquitoes, and fleas; insect-like organisms, such as mites and ticks; and vertebrates, such as rats and mice. Reimbursement for approved Pest Control expenditures is reimbursed through the local AAA or other approved DA provider, who maintain all applicable receipts and verifies the delivery of services There is an annual cap of $4,000.

Residential Based Habilitation: Residential Based Habilitation service provides training to regain skills that were lost secondary to the traumatic brain injury. Residential Based Habilitation services must follow a written service plan addressing specific measurable goals and objectives to help with the acquisition, retention, or improvement of skills that were lost secondary to the TBI. Residential Based Habilitation services must be monitored monthly. Habilitation services must be performed by persons who are supervised by a Certified Brain Injury Specialist (CBIS) or Qualified Mental Retardation Professional (QMRP) or a physical, occupational, or speech therapist licensed by the state of Indiana and have successfully completed training or have experience in conducting habilitation programs.

Respite Care: Respite Care services are those services that are provided temporarily or periodically in the absence of the usual caregiver. Respite occurs in home and community-based settings. For those Individuals receiving the service of Adult Family Care or Assisted Living waiver service, funding for respite is already included in the per diem amount and the actual service of respite may not be billed.

RHHA: A participant who is eligible for State Plan Home Health Services (HOHE) should be considered for respite home health aide under the supervision of a registered nurse.

RSKNU: A participant who is eligible for State Plan Nursing Services (SKNU) must be considered for respite nursing services.

Authorized hours will roll over month to month through the duration of the Annual Service Plan. If a request for an increase in Respite during the annual care plan is needed the CM must coordinate with the agency to verify unused hours before requesting the additional hours. If there are unused hours they must first be used before requesting additional hours

Specialized Medical Equipment & Supplies: Specialized Medical Equipment and Supplies are medically prescribed items required by the participant's service plan, which assist the participant in maintaining their health, welfare and safety, and enable the participant to function with greater independence in the home. Individuals requesting authorization for this service through the waiver must first exhaust eligibility of the equipment or supplies through the Indiana Medicaid State Plan. There should be no duplication of services. Maintenance is limited to $1000.00 annually for the repair and service of items that have been provided though the HCBS waiver.

Structured Day Program: Structured Day Program is assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills, which takes place in a non-residential setting, separate from the home in which the Individual resides. The program services shall focus on enabling the Individual to attain or maintain his or her functional level. Structured Day Program services serve to reinforce skills or lessons taught in school, therapy, or other settings. The services are normally furnished four (4) or more hours per day on a regularly scheduled basis, for one (1) or more days per week unless provided as an adjunct to other day activities included in an Individual’s Service Plan.

Supported Employment: Supported Employment Services consist of paid employment for persons for whom competitive employment at or above the minimum wage is unlikely, and who, because of their disabilities, need intensive ongoing support to perform in a work setting. Supported Employment is conducted in a variety of settings, particularly work sites where persons without disabilities are employed. The service includes activities needed to sustain paid work by Individuals receiving waiver services, including supervision and training.

Transportation: Transportation Services enable Individuals supported under the waiver to gain access to waiver and other non-medical community services, activities, and resources, specified by the Service Plan.

Transportation services under the waiver shall be offered in accordance with an Individual’s Service Plan and whenever possible, family, neighbors, friends, or community agencies which can provide this service without charge will be utilized. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State plan, if applicable and shall not replace them.

Vehicle Modifications: Vehicle Modifications are the addition of adaptive equipment or structural changes to a motor vehicle that will empower a participant to be safely transported in a motor vehicle. Maintenance is limited to $1000 annually for repair and services of items that have been funded though the HCBS waiver. A lifetime cap of $15,000.00 is available for one (1) vehicle per every ten (10) year period for a participant’s household.