SOUTH CAROLINA MEDICAID WAIVER PROGRAM:

A GUIDE FOR SELF ADVOCATES

The Medicaid Waiver Program is one of the primary avenues to get the services you need to live in the community. To be eligible for Medicaid waivers you must be eligible for Medicaid and require the level of care provided in a hospital, Nursing Facility or ICFMR/Intermediate Care Facility for the Mentally Retarded. Waivers are used to supplement services provided through the state Medicaid plan so it is essential to apply for Medicaid as well if you are not already receiving services. In addition, the EPSDT, (Early and Periodic Screening, Diagnosis and Treatment) Medicaid program provides comprehensive and preventive health services to Medicaid eligible children from birth to age 21 years.

South Carolina has five Medicaid waiver programs under the S.C. Department of Health and Human Services (DHHS)). Two state agencies administer the waivers. Community Long Term Care (CLTC), a division of DHHS, administers the Elderly/Disabled waiver, the HIV/AIDS waiver and the Mechanical Ventilator waiver. The Department of Disabilities and Special Needs (DDSN) administers the Mental Retardation or Related Disabilities (MR/RD) waiver and the Head and Spinal Cord Injury (HASCI) waiver. Initial application for Medicaid waivers is made through the corresponding agency.

South Carolina Medicaid Waivers:

1. Mental Retardation or Related Disabilities (MR/RD) Waiver Program

2. Head and Spinal Cord Injury (HASCI) Waiver Program

3. Elderly/Disabled Waiver Program

4. HIV/AIDS Waiver Program

5. Mechanical Ventilator Waiver Program

If you have not applied for a Medicaid Waiver before, it is important to do so as soon as possible. There are 5 Medicaid waivers in S.C.; each with its own set of criteria as well as specific services offered. It is very important to get everything in writing. When requesting a waiver do so in writing and keep a copy for your records. It is not permissible for anyone to deny your request over the phone or tell you the state is not taking applications at this time. Make sure that the agency sends you a determination in writing of whether or not you meet the criteria for the waiver.

If you have any questions or need further assistance, contact Protection and Advocacy for People with Disabilities, toll-free at 1-866-275-7273.

Prepared by the Community Integration Team, Protection and Advocacy for People with Disabilities. Adapted from the Community Living Outreach Kit prepared by the Disability Law and Policy Network, Lawrenceville, GA

MENTAL RETARDATION/RELATED DISABILITIES

(MR/RD) WAIVER PROGRAM

Who should apply:

Persons who have mental retardation or a related disability, are eligible for Medicaid, and who need home and community-based services in order to live in the community. Persons must also require the degree of care that would be provided in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). Persons must have needs that can be met by the provision of services funded by the waiver. If the cost of home and community based services exceeds the cost of a level of care in an ICF/MR, DDSN may be able to deny waiver services.

Services:

Adult Companion Services Adult Day Health

Adult Dental Services Adult Vision Services

Audiology Services Behavior Support Services

Day Habilitation Environmental Modifications

Personal Care Services Nursing Services

Occupational Therapy Services Physical Therapy Services

Prescribed Drugs Prevocational

Private Vehicle Modifications Psychological Services

Residential Habilitation Respite Care

Specialized Medical Equipment, Speech-Language Pathology

Supplies & Assistive Technology Supported Employment Services

How to Apply for a Mental Retardation/Related Disabilities (MR/RD) Waiver

Call your DSN service coordinator/early interventionist or local DSN board (see attached list).

Tell him/her you want to apply for the MR/RD waiver program and ask for any information they have regarding the waiver and the process. Write down the name of the person you talked to and mention that name in the letter you will send confirming your request for waiver services. (see sample letter “A”) Even if you are told no money or services are available right now, it is very important to put your request in writing and either have your name added to the waiting list or receive a denial in writing.

Confirm your request in writing

Follow up on your phone call with a letter saying that this letter is a confirmation of your request for the MR/RD waiver (see sample letter “A”). Keep a copy of this letter for your records.

Receive Written Response of Eligibility

Applicants should receive a written notice stating if you meet the criteria for the waiver program. Make sure you get a written response to your request, confirming or denying your eligibility. If you wait longer than 90 days for this determination contact Protection and Advocacy for People with Disabilities 1-866-275-7273 for possible assistance.

If Found Eligible for the Waiver

If you are found to meet the criteria for the waiver program, you will either receive waiver services or be placed on a waiting list for services. Since an applicant’s place on the list and priority category is the primary factor in determining when you receive services, it is appropriate to request an appeal if you feel a mistake was made in placing you in a particular category. Call your local DDSN coordinator for the DDSN appeal process. If you wait longer than 90 days for services to begin after being found eligible for the waiver program contact P&A for possible assistance.

Send a Letter Asking Status on the List

If you have been on the waiting list longer than 60 days without hearing from your service coordinator, you may want to write a letter to your service coordinator asking where you are on the waiting list. (see sample letter “B”) Ask for a written response. If your situation changes while you are on the waiting list, advise your DDSN coordinator of the situation.

How to Appeal a Denial

If you are found to be ineligible for waiver services, the written notice must include reasons why you’re being denied. The notice should also explain the appeal rights through the Medicaid appeal process. (See the attached document “C” re: the Medicaid appeal process). If you have reason to believe the denial is wrong because you do in fact meet the eligibility standards for the waiver, send an appeal letter to the Department of Health and Human Services no later that 30 days after the denial of your application. See sample letter “D”. Contact Protection and Advocacy for possible representation.

Letter Confirming Request for MR/RD Waiver

Date

DSN Service Coordinator

Address

Re: Mental Retardation/Related Disabilities Waiver Request

Dear Mr./Ms. _______________:

This is a letter to follow up on a conversation I had with_______________(DSN service coordinator/local board) on ____ regarding waiver services. Please consider this a confirmation of my request for Medicaid services under the MR/RD Waiver Program. I am _____ years old and am a person with_____(type of disability). I have lived in a ___________ (nursing home, regional center, etc.) since ______.

I am medically stable and need assistance with some daily living activities. I wish to live in the community because I want more choices available to me regarding work, friends, family, recreation, etc. I would like to be considered for any service under the MR/RD waiver program.

I am currently a resident of _______________and can be contacted at __________. My address is: _______________________________________.

Please provide me with a written list of criteria for the waiver. Also please let me know in writing when I will be assessed for the waiver. If I am placed on a waiting list, I request information on the criteria used to determine my status on the waiting list, approximately when I can expect to receive services and the process for checking my status on the waiting list.

Thank you very much for your kind assistance in this matter.

Sincerely,

Cc: DDSN, Jennifer Richey Duell, MR/RD Waiver Coordinator, P.O. Box 4706,

Columbia, SC 29240

Protection and Advocacy for People with Disabilities, Wendy Corry, Suite 101-A, 1 Chick Springs Rd., Greenville, SC 29609

MR/RD Waiver Status Letter

Date

DSN Service Coordinator

Address

Re: Status of MR/RD Waiver Request

Dear Mr./Ms. ___________:

I requested a MR/RD Waiver on ___________ and was placed on the waiting list to receive services. See attached letter of notification regarding the waiting list.

I am writing to obtain the status of my placement on the waiting list. Please notify me in writing as to my priority category, where I am on the list and the approximate date for receipt of services.

Thank you very much for your kind assistance in this matter.

Sincerely,

Cc: DDSN, Jennifer Richey Duell, MR/RD Waiver Coordinator, P.O. Box 4706,

Columbia, SC 29240

Protection and Advocacy for People with Disabilities, Wendy Corry, Suite 101-A, 1 Chick Springs Rd., Greenville, SC 29609

MEDICAID APPEAL PROCESS

As a Medicaid applicant/recipient you have the right to request a fair hearing regarding a decision affecting Medicaid eligibility or services. To initiate the appeal process, you or your representative must send a written request to the following address no later than 30 calendar days from the receipt of written notification for any action adversely affecting your Medicaid coverage. (see sample letter “D”)

Division of Appeals and Hearings

Department of Health and Human services

P.O. Box 8206

Columbia, SC 29202-8206

You may be eligible to receive continued Medicaid benefits pending a hearing decision. If you are interested in continued benefits you must contact your case manager within 10 calendar days of the effective date of the action. If the hearing decision is not in your favor, you may be required to repay Medicaid benefits received during the appeals process.

Please attach a copy of the written notification of the Medicaid waiver denial with your appeal request. In your request for a fair hearing you must state specifically what issue(s) you wish to appeal.

Unless a request is made within 30 calendar days of receipt of written notification, the decision will be final and binding. A request for a fair hearing is considered filed if postmarked by the 30^th calendar day following receipt of written notification. You will be advised in writing by the Division of Appeals and Hearings as to the status of your appeal request.

Please contact Protection and Advocacy for People with Disabilities at our toll-free #, 1-866-275-7273 if you would like our assistance with your appeal.

APPEAL LETTER TO HHS

Date

Division of Appeals and Hearings

Department of Health and Human Services

P.O. Box 8206

Columbia, SC 29202-8206

Re: Medicaid Waiver Appeal

Dear Sir or Madam:

I am writing to request a Fair Hearing regarding the decision of the Department of Disabilities and Special Needs denying me services under the MR/RD Waiver program. A copy of the denial is enclosed.

Please let me know if you need anything further to proceed with this request.

Sincerely,

Cc: DDSN, Jennifer Richey Duell, MR/RD Waiver Coordinator, P.O. Box 4706,

Columbia, SC 29240

Protection and Advocacy for People with Disabilities, Wendy Corry, Suite 101-A, 1 Chick Springs Rd., Greenville, SC 29609

LOCAL DISABILITIES AND SPECIAL NEEDS

(DSN) BOARDS

ABBEVILLE COUNTY

Emerald Center Multi-County DSN Board

864-942-8900

AIKEN COUNTY

Aiken County Board of Disabilities

803-642-8800

ALLENDALE COUNTY

Allendale/Barnwell County DSN Board

803-584-5050 Allendale

803-259-7472 Barnwell

ANDERSON COUNTY

Anderson County DSN Board

864-260-4515

BAMBERG COUNTY

Bamberg County DSN Board

803-793-5003

BARNWELL COUNTY

Allendale/Barnwell County DSN Board