To better understand Medicaid Waivers, it is helpful to start with an overview of the regular state plan Medicaid program. Medicaid is a jointly funded state and federal government health care program for low-income persons of all ages. The rules governing Medicaid are federally set and require that all states provide assistance to specific groups of beneficiaries, such as pregnant women, disabled persons, others with developmental disabilities, those with behavioral health issues and seniors, who meet the eligibility requirements, and for certain services not covered by Medicare. All states must provide statewide nursing facility institutional care and home health care for those that demonstrate a functional and financial need and a physical at some level of care. However, each state sets their own income and asset limits within the government set parameters, which means eligibility criteria is not consistent across state Medicaid programs.
Medicaid Waivers, which are approved by the federal government, allow Medicaid state plans even more flexibility to run their Medicaid programs. Waivers allow states to “waive” certain gov rules. They enable states to expand their coverage to specific groups of people, make certain benefits available only to select groups, limit coverage to specific geographic regions within the state, and test other ways to run their Medicaid services.
Waivers can extend long-term Home and Community Based Services (HCBS) care services to seniors and disabled persons who require assistance to live at home or in the community. Care provided by waivers may include attendant care, supervision, adult day care, respite care, and homemaker services. Prior to waivers, the only option for long-term care may have been nursing home care.
Offering HCBS through community-based services waiver applications ideal for both enrollees and their families. Most elderly people prefer to age at home or in their communities. Long-term care benefits through waivers help to prevent and / or delay the need for nursing home care. Services and support in the community setting provided via HCBS Waivers is commonly complimented by unpaid care assistance from family members or other loved ones. Assistance through HCBS Waivers takes some of the pressure off of family caregivers. These supportive services not only gives them a break from caregiving, but can also allow them to continue to work outside of the home and provides peace of mind knowing that their loved one is safe, supervised, and receiving needed care assistance. This arrangement is also beneficial for the state, as receiving care via Medicaid Waivers is more cost efficient than is nursing home care, or even assisted living.
Many Medicaid Waivers allow for consumer direction, also called cash and counseling, or self-directed care. This allows care recipients to choose from whom they receive services. This often includes the ability to hire relatives, and in many states, even one’s spouse can be paid to provide care.
Unlike a state’s Regular Medicaid program, waiver programs are not entitlements. Waivers have participant enrollment caps; meeting eligibility criteria does not mean one will receive program benefits. Once all the enrollment slots are filled, waiting lists form. The wait for services can be several months to many years.
While the exact long-term care benefits are waiver-specific, many Medicaid Waivers offer a similar set of services and supports. Examples include case management, personal care assistance, home health aides, adult day care / adult day health, respite care, home / vehicle modifications, durable medical equipment, skilled nursing care, homemaker / chore services, meal delivery / congregate meals, non-emergency transportation, personal emergency response systems, and transitional services from an institution back into the community.
Many of these benefits are relevant not only to frail, elderly persons and individuals with disabilities, but also to persons with Alzheimer’s disease and other related dementias. In the earlier, and sometimes middle stages of the diseases, persons can continue to live independently with waiver support.
The settings in which a senior can live and receive support vary based on the waiver. However, this may include one’s home, the home of a loved one, an adult foster care home / adult family care home, an assisted living residence, and even a memory care unit (also called an Alzheimer’s unit). Medicaid Waivers will not cover the cost of room and board in a community setting, but may cover the cost of long-term care to support independent living.