Medicaid long-term care benefits are not just provided to persons in nursing homes. A Medicaid Home and Community Based Service (HCBS) Waiver can help a variety of people receive and pay for care at their home or other non-nursing home residence.
Elderly patients are eligible for HCBS Waivers, but this type of Medicaid Long Term Care is also available to a range of people who need nursing home level care but would prefer, or be better served by, receiving that care at home. This includes people with Alzheimer’s disease, Autism, brain injury, dementia, HIV/AIDS, mental illness, medical fragility, serious emotional disturbances, technological dependence, and other developmental, physical or intellectual disabilities.
The parameters for the “nursing home level care” mentioned above vary by state, but in general it means needing assistance with everyday living activities such as bathing, dressing, walking and eating. In addition to the functional eligibility criteria, there are also financial criteria an applicant must meet (detailed below) in order to qualify for HCBS Waivers.
In addition to knowing the eligibility criteria, there is a lot to know or learn about waivers such as which waiver is right for your loved one, is there a wait-list and if so how long and how does prioritization work? What benefits are available, and how many hours of care can one receive? Who provides that care? The rules and regulations are complicated and also differ by state. Consulting with a Certified Medicaid Planner (CMP) can be extremely helpful to answer these and other questions. To schedule a free consultation with a CMP, start here.
The Truth About Waiver Wait Lists
HCBS Waivers provide states with flexibility in terms of how and to who they can offer Medicaid benefits. Waivers also provide flexibility to the care recipients and their families by allowing them to remain at their home or in the community and receive case-specific help. While Nursing Home Medicaid and Regular Medicaid (also known as Aged, Blind, Disabled Medicaid) are entitlements, meaning the government must provide benefits to applicants who qualify for either of these long-term care programs, HCBS Waivers are not an entitlement. Waivers have enrollment caps, which means once all the designated enrollment slots are filled, wait lists form. In other words, even if the applicant meets all financial and functional criteria (detailed below) and submits a correctly filled out application does not mean that applicant will receive a Medicaid HCBS Waiver.
The wait can be months or years, and how the wait list is managed varies by situation. Some wait lists are managed on a first come first serve basis, while others are handled by a needs-based priority – someone with a life-threatening brain injury, for example, might go to the top of a waiting list. Most states have multiple waivers depending on the applicant’s medical situation – waivers for those with intellectual disabilities, for children, for the technologically dependent, etc. – and those waivers may all have separate wait lists that are managed in different ways.
Since candidates can apply for more than one Waiver, and because those Waivers can all have different wait lists, this is another area where a Certified Medicaid Planner can help. A CMP will understand enrollment caps, wait list management and what Waivers make sense for which applicants, and they may also have a relationship with and a nuanced understanding of their local Medicaid office, they can be especially beneficial when it comes to Waivers, wait lists, when it makes sense to wait and when it doesn’t.
Services Covered by HCBS Waivers
Each HCBS Waiver applicant is unique, and so are the Waivers they ultimately receive and the benefits those waivers carry. However, there are plenty of common services that waivers in most states will cover, and those are listed below. This is not a comprehensive list, and some benefits may be called different things in different states. “Home modifications,” for example, may also be referred to as “environmental adaptation.” Because of the vagaries in nomenclature and benefits by state, consulting with a CMP can help you understand what is available to you or your loved one when it comes to HCBS Waivers.
Adult Day Care
Assistive Technology and Devices
Attendant / Personal Care
Chore / Homemaker Services
Community Transition Services
Durable and Home Medical Equipment
Financial Management Services
Home Delivered Meals
Home Health Care
Home Modifications (Environmental Accessibility Adaptations)
Meal Delivery / Congregate Meals
Personal Emergency Response Systems (PERS)
Where Can One Receive Benefits from HCBS Waivers?
Like the benefits themselves, the setting where one can receive benefits from a HCBS Waivers varies by case. These settings include the applicant’s home, the home of a loved one, adult foster care home, adult family care home, assisted living residence or a memory care / Alzheimer’s unit.
Eligibility Criteria for HCBS Waivers
Most states require an applicant to show a need for a nursing home level of care in order to be eligible for HCBS Waivers. The state will conduct a functional assessment of the applicant to see if they meet that criteria.
There are also two financial criteria that must be met – an asset limit and an income limit. These vary by state, year, marital status, and if one or both spouses are applying for HCBS Waivers.
In most states for 2022, single applicants are allowed to have $2,000 in countable assets, which includes all savings accounts, checking accounts, stocks, bonds, certificates of deposit, vacation properties and cash. Exempt assets include the applicant’s primary home (as long as they are living there), furniture, appliances, clothing and primary automobile. If both spouses of a married couple are applying, they can have up to $3,000 in combined assets and still be eligible for HCBS Waivers, although that also differs by state – Massachusetts allows for a combined $4,000, and the maximum is $24,600 in New York (a state where single applicants are allowed $16,800 in assets).
When the applicant is married but their spouse is not applying for Medicaid, the asset limit in most states (including California, Florida and Texas) for 2022 is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse, also known as the community spouse. These limits also vary by state – in South Carolina the applicant can keep $2,000 but the non-applicant only $66,480; in Illinois the limits are $2,000 and $109,560; in New York it’s $16,800 and $137,400. The applicant spouse is allowed to transfer assets into the community spouse’s name up to that limit, which is just one of the strategies applicants can use to reduce assets in order to become Medicaid eligible. This is another complicated process and applicants would be advised to consult with a Certified Medicaid Planner before attempting to do this on their own.
Home Ownership Rules
The applicant’s primary home is the most important exempt asset for most people applying for HCBS Waivers. If the applicant is living in the home with a spouse, minor child, or child who is blind or disabled, it will not counted among the assets considered for the asset limit. There are home equity limits by state when it comes to Medicaid (the equity value of a home is the fair market value minus any debts on the home, like a mortgage). However, since some Waivers allow beneficiaries to live in assisted living residences, they may not live in their home and their home may count against them and disqualify them for Medicaid. This is a complicated area especially if a spouse or other family members lives in the home. It is advised to consult with a Medicaid expert in this situation.
The 2022 income limits for HCBS Waiver eligibility vary in almost every state, although the federally-set maximum is $2,523 per month (which is 300% of the Federal Benefit Rate). Marital status and if one or both spouses is applying for a waiver also impact the income limit. For 2022 for single applicants in Florida and Texas, the income limit is the maximum $2,523 per month; for married applicants with both spouses applying it’s $5,046 per month (double the single limit); and for married applicants with just one spouse applying its $2,523. In California, the income limit is $1,481 per month; for married applicants with both spouses applying it’s $2,003 per month (double the single limit); and for married applicants with just one spouse applying it’s $1,481. In New York, the limit is $934 per month; for married applicants with both spouses applying it’s $1,367 per month (double the single limit); and for married applicants with just one spouse applying its $934. As you can see in these examples, the income for the non-applicant spouse never impacts the income limit when only one partner in a married couple is applying.
Countable sources of income for this limit include Social Security benefits, pension payments, IRA distributions, employment earnings, alimony, interest payments, estate income and dividends from bonds and stocks. There are some revenue sources that Medicaid does not count as income, like tax refunds, stimulus checks (COVID-19 or otherwise) or funds received from need-based programs like Temporary Assistance for Needy Families (TANF).
While the asset limit eligibility criteria for a HCBS Medicaid Waiver is very similar to the asset limit criteria for Nursing Home Medicaid, that’s not the case when it comes to income limits. Nursing Home Medicaid applicants are also allowed to have a maximum of $2,523 per month income with limits varying by state, but they must pay most of that income to the nursing home where they are being cared for and can only keep a small “personal needs allowance,” which is usually $30-$150 per month. HCBS Waiver applicants, however, are allowed to keep most or all of their income, especially when they are still living at home and have expenses like mortgages (or rent), utilities and food that need to be covered.
If one is over the income limit, there are still ways to “spend down” and get under that limit to become Medicaid eligible. Again, this is a complex process and consulting a Certified Medicaid Planner is recommended.
Digging Deeper Into Waivers
HCBS Waivers were introduced in 1983 when Congress added Section 1915(c) to the Social Security Act, which is why HCBS Waivers are also called Section 1915(c) Waivers. But there are also other types of Waivers that have been created by lawmakers to expand Medicaid’s Waivers program.
Some states offer Waivers through their Regular Medicaid program, which makes them an entitlement, meaning anyone who meets the eligibility is guaranteed to receive benefits without a wait list. The 1915(i) and 1915(k) Community First Choice Waivers are both examples of state plan options that are entitlements that allow participants to direct their own care.
Section 1915(b) Waivers, also called Freedom of Choice Waivers or Managed Care Waivers, also allow participants to direct their own care, but they must do it through a managed care network. This type of Waiver does not allow the same flexibility as the Waivers mentioned above, and it does not authorize home and community based serviced. However, a 1915(b) Waiver may be used in conjunction with a 1915(c) Waiver to allow for long-term care services at home or in the community, but it’s important to note that these 1915(c) benefits are not an entitlement when combined with a 1915(b) Waiver.
Research and Demonstration Waivers, also known as 1115 Demonstration Waivers, allow states to waive almost any requirement in their Medicaid program with the goal of testing new ways to improve that program. This kind of waiver allows states to expand their Medicaid coverage in multiple ways. In addition to using a 1115 Waiver for home and community based services, participants can also use it for nursing home care, primary care, emergency care and behavioral health services.