Page Reviewed/Updated: Aug. 26, 2022
The financial burden of long-term care is daunting for many, particularly those with low income and limited resources. Thankfully, all across the United States, there are programs available to help people get the long-term care they need to live fulfilling lives.
One such program is Medicaid Home and Community Based Services – a Medicaid waiver that helps people stay in their home instead of receiving care in a nursing home or other institution.
But Medicaid and its waiver programs can be difficult to understand, and applying for coverage can be a confusing process for many to navigate. So let us help you discover everything you need to know about Medicaid waivers and how to access home and community-based services.
Medicaid Explained
Medicaid is a federal and state program that provides health coverage to some individuals who have limited income and resources.
But it’s important to realize that Medicaid is not the same as Medicare. They are separate, government-run programs that typically serve different groups of people and are funded by different parts of the government.
Medicare is a federal program that provides health care to all individuals over the age of 65 as well as people with disabilities under the age of 65. Medicaid, on the other hand, is for people with very limited resources and income. Because Medicaid is run by each individual state, the specific eligibility requirements and programs available vary from state to state. States are also able to opt-out of new Medicaid funding and requirements.
If you’re eligible for both Medicare and Medicaid, you can have and use both for the services you need. While both programs provide health insurance, the services they cover are not always the same. For example, Medicaid offers coverage for things like personal care services while Medicare does not.
A Definition of Medicaid Waivers
A Medicaid waiver is a provision in Medicaid law which allows the federal government to waive rules that usually apply to the Medicaid program. The intention is to allow individual states to accomplish certain goals, such as reducing costs, expanding coverage, or improving care for certain target groups such as the elderly or women who are pregnant.
Thanks to these waivers, states can provide services to their residents that wouldn’t usually be covered by Medicaid. For instance, in-home care for people who would otherwise have to go into long-term institutional care.
What Are the Different Types of Medicaid Waiver?
There are several different types of Medicaid waivers, all of which serve different purposes. All waivers, no matter what type or state, are under the authority of Sections 1115 and 1915 of the Social Security Act.
- Section 1115 waivers – Often referred to as research and demonstration waivers, these allow states to temporarily test out new approaches to delivering Medicaid care and financing. For these waivers to be approved, they must be budget neutral for the federal government – meaning that the federal government can’t be spending more because of the waiver than they would if it wasn’t in place. As more states look for new ways to utilize the additional federal funding provided with the Affordable Care Act, these waivers have become more popular.
- Section 1915(c) waivers – Home and Community-Based Services (HCBS) waivers are designed to allow states to provide home and community-based services to people in need of long-term care. This means they can stay in their own home or a community setting (such as a relative’s home or a supported living community) instead of going into a nursing facility.
- Section 1915(b) waivers – “Freedom of choice waivers” allow states to provide care via managed care delivery systems. These organizations contract with state Medicaid agencies, and are paid from the state Medicaid fund for providing health care services to the beneficiaries, thus limiting the individual’s ability to choose their own providers.
- Combined Section 1915(b) and 1915(c) waivers – These waivers allow states to provide home and community-based services by contracting with the managed care organizations that are defined in Section 1915(b). The contracted managed care organizations deliver the home and community-based health care services to qualifying individuals.
In this article, we’re going to be focusing on HCBS waivers and how they can help people get better and more appropriate long-term care in their own homes.
What Care is Provided Under an HCBS Waiver Program?
As outlined above, the purpose of an HCBS waiver is to let states provide care to certain individuals in the community, rather than putting them into institutional care. Beneficiaries may live in their own home, at a relative’s home, or in a senior living community that isn’t a nursing home.
Those who are accepted into their state’s HCBS waiver program will receive a range of medical and non-medical care, which can vary depending on the individual’s needs and situation, as well as state guidelines. This may include:
- Personal care services and supervision, at home or in an assisted living facility
- A home health aide
- Nursing
- Medical supplies and medical equipment
- Chore and homemaking services, such as shopping, laundry, and cleaning
- Hot meal delivery services
- Respite care to relieve a primary caregiver
- Counseling services
- Home and/or vehicle modifications, such as ramps and safety rails, to increase independence
- Support and case management
- Assistance transitioning from a nursing home into the community
- Access to senior centers or adult group day care
- Transport to and from non-emergency medical appointments
- Non-medical transportation services
- Personal emergency response systems
Services provided may vary on a case by case basis and will be affected by the state in which the beneficiary resides.
Benefits of Medicaid Waivers
For those who are a part of an HBCS program, the biggest benefit is they get to stay in their own home or community, instead of being sent to a care institution. Staying at home has been shown to have many quality of life benefits, especially for seniors who get to age in place. Home is comfortable and familiar, allowing those to feel at ease compared to the jarring change of environment that a nursing home or other residential facility can bring. Not only has this been shown to improve recovery time after an injury or surgery, but it’s also been shown to improve mental health and reduce complications from dementia.
According to the American Association of Retired Persons, almost 90% of people over 65 say they want to stay in their own homes for as long as possible as they age. Relatives often prefer that their loved one stays at home as long as possible too, because they’ll be in a community they know and are comfortable with, rather than alone and unhappy in an institution.
The federal government isn’t complaining, either, because the cost of care in the home or an assisted living facility is cheaper than a nursing home – often by up to 50%.
Problems Associated with Medicaid Waivers
Medicaid waivers aren’t considered an entitlement. Whereas someone in need of nursing home care would be automatically entitled to a place in a facility, the HCBS waiver program is deemed a privilege rather than a right. As such, there are a limited number of spots available, and people can spend several years on a waiting list before they receive care.
Who is Eligible for an HCBS Waiver Program?
The good news is that all states have some type of HCBS waiver program. But states create HCBS programs to target specific populations with particular needs, so eligibility for HCBS programs will vary from state to state.
Most states have more than one HCBS program, and each one will target different groups of the population and offer varying levels of service. Generally, states offer HCBS waivers to elderly people (age 65 or over), physically disabled people, adults and children with developmental disabilities, and medically fragile people (who require life support or other extensive medical equipment). Some states also offer HCBS programs to individuals based on a diagnosis, such as HIV/AIDS, traumatic brain injuries, or autism.
Even so, not everybody within these groups is automatically eligible for Medicaid waiver programs; they must also require a certain level of care. Usually, the individual needs to meet medical criteria that would require them to be in a nursing home or other institution if they didn’t receive in-home or community care. This is because Congress created HCBS waivers specifically to help keep people in their own homes and communities instead of receiving institutional care, so benefits aren’t awarded to people who aren’t at risk of institutionalization. The rules about the institutional level of care vary from state to state, but the majority of states require medical evidence of diagnosis as well as a professional assessment regarding the applicant’s ability to safely complete the activities of daily living.
In addition to these qualifying factors, there are financial criteria to meet. While states don’t have to require the individual to be in regular receipt of Medicaid, most of them do. And in those states that don’t, there are still caps on how much someone can be earning and have in savings/financial assets to qualify for an HCBS program.
If an applicant is denied HCBS benefits, they still have the right to appeal the decision. You’ll need to understand why the application was denied, and then prepare more supporting documents to prepare for your hearing.
How to Apply for A Medicaid Waiver
The application process for a Medicaid waiver will vary depending on the specific waiver that you’re applying for and the state that you reside in.
Applying for Medicaid
The first step is to often apply for Medicaid itself. Each state has different factors that determine eligibility. In addition to your household income, you’ll likely need to provide information about your family size, disabilities, and other assets. To find out if you qualify for Medicaid in your state, visit healthcare.gov.
Once you’re ready to begin the application process, you should create an account and apply through the Health Insurance Marketplace. You can apply for Medicaid at any point of the year, there’s no need to wait for the open enrollment period to begin.
If you qualify for Medicaid, the Health Insurance Marketplace will send your information to the Medicaid agency in your state. That agency will then reach out to you about enrollment and be able to help you navigate the benefits as well as answer any questions you may have.
You can also apply for Medicaid directly with your state Medicaid agency. Contact your state’s Medicaid agency to speak with an agent who will guide you through the application process.
Applying for Waivers
While nearly all states have some form of HCBS waivers, the specific programs and application process for each varies.
Regardless of what state you’re in, all applicants should be ready to provide information that proves they are in need of the services that the program provides. This will likely include a detailed report from a physician describing the applicant’s condition, how well they get around, and any other supporting documents to be submitted with the application.
To begin the application process for a Medicaid HCBS waiver program, contact your state Medicaid office. You can visit the Centers for Medicare & Medicaid Services to find the contact information for your state. You’ll then be given information on how to submit an official application.
Since each individual state decides the maximum number of people that can be served under any given HCBS waiver program, it may take some time before an application is approved and benefits are awarded. Some states have very long wait lists for various programs, while others do not use a traditional wait list process. Either way, most states do have priority designations that help individuals in extreme situations get the funds they need in a timely manner.