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DD Waiver and Customized Rates�

Gina Koke, Customized Rate Consultant

Virginia Department of Behavioral Health

and Developmental Services

DBHDS Vision: A life of possibilities for all Virginians

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Agenda

Introduction
What is a Waiver?
Customized Rate

What is it
What does is cover
How to apply

Questions/Feedback

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What is a Waiver?

Prior to 1980 all Medicaid funded services for people with Developmental Disabilities took place in institutions.

What is being “waived” is the requirement that Medicaid funds are used solely in an institutional setting.

Partly as a result of the Department Of Justice Settlement Agreement & partly because it was the right thing to do, Virginia redesigned its system of waivers for people with Developmental Disabilities between 2014 and 2016.

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Customized Rate Development

During the Waiver Redesign, people realized that the reimbursement structure would capture the support needs for the majority of individuals receiving services… but not all.

There are individuals whose support needs are greater than the standard rate that was developed during the redesign.
These individuals with greater support needs have been defined as “Outliers”.

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Customized Rate Development

These “outliers” include:

Individuals with highly complex medical and/or behavioral support needs.

These supports needs increase the cost of providing services.

Individuals who require greater expertise or training and/or increased staffing.

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SOLUTION

In an effort to support individuals identified as ‘outliers’, the customized rate was developed and approved by The Center for Medicaid and Medicare Services

Effective

June 1^st, 2017.

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WHAT IS A CUSTOMZIED RATE?

The customized rate is a higher reimbursement rate than the standard rate.
It is funded by the waiver.
It is based on the individual’s level and tier.
The customized rate replaces the standard rate.
The rate is approved by a committee of subject matter experts which include:

Medical
Behavioral
Service Authorization
Integrated Support
Regional Support Specialist

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Supports

The customized rate is approved to support the following:

1:1 staffing ratio
2:1 staffing ratio
Combination of 2:1 and 1:1
‘Specialized’ direct support staff

Staff with higher level of expertise related to the individual’s needs

Programmatic oversight

Management level staff who have higher level expertise related to the individual’s needs

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WHAT THE CUSTOMIZED RATE IS NOT

The customized rate is NOT

The first choice for support
Crisis or temporary funding – if the issue is temporary then crisis funds should be used.
Appropriate for all individuals

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SERVICES ELIGIBLE

Family & Individual Supports Waiver	Community Living Waiver
Community Coaching	Community Coaching
Group Day	Group Day
In-Home Supports	In-Home Supports
Supported Living	Supported Living
x	Group Home
x	Sponsored Residential

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How to Apply

Applications must be submitted in WaMS
The application must be submitted by the waiver provider.
The application must include documented evidence that the individual is an outlier such as, but not limited to:

Behavior data
Medical records

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Getting Help

Go to our website:

https://dbhds.virginia.gov -

“Getting Help”

“Developmental Services”

“Waiver Services”

Provider guide
Required forms

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