What is a Medicaid Waiver? Your Guide to Medicaid Home and Community Based Services

What is a Medicaid waiver, anyway? Let us help you discover what you need to know about Medicaid waivers and how to access home and community based services.

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.

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 three types of Medicaid waiver, all of which have different purposes.

  • HCBS waiver: Also known as a Section 1915(c) waiver, this kind of waiver is designed to allow states to provide home and community based services (HCBS) 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.
  • Freedom of choice waiver: A Section 1915(b), or “freedom of choice,” waiver lets states provide care via managed care delivery systems, thus limiting the individual’s ability to choose their own providers.
  • Research and demonstration waiver: Otherwise referred to as a Section 1115 waiver, this lets states test out new approaches to delivering Medicaid care and financing.

We’re going to be focusing on HCBS waivers and how they can help people get better and more appropriate long-term care.

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.

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
  • Chore and homemaking services, such as shopping, laundry and cleaning
  • Hot meal delivery services
  • Respite care to relieve a primary caregiver
  • Home and/or vehicle modifications, such as ramps and safety rails, to increase independence
  • Access to senior centers or adult group day care
  • Transport to and from non-emergency medical appointments

Who is Eligible for an HCBS Waiver Program?

The good news is that all states have some type of HCBS waiver program but, unfortunately, not everybody is eligible.

Each state has its own programs, but most states offer HCBS waivers to elderly people (aged 65 or over), physically disabled people, adults and children with developmental disabilities, medically fragile people (who require life support or other extensive medical equipment) and adults with traumatic brain injuries.

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 nursing home or other institution if they didn’t receive in-home or community care.

Plus, there are financial criteria to meet. While states don’t have to require the individual to be in regular receipt of Medicaid, many 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.

Benefits of Medicaid Waivers

For those who are a part of an HBCS program, the main benefit is they get to stay in their own home or community, instead of being sent to a care institution.

According to the American Association of Retired Persons, almost 90 percent of over 65s say they want to stay in their own homes for as long as possible as they age, so this is clearly something that’s important to the majority.

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 place – often by up to 50 percent.

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 an institution, the HCBS waiver program is deemed a privilege rather than a right. As such, most people spend several years on a waiting list before they receive care.

While a lot of help is available, some responsibility often falls to family members when an individual receives care in their own home. So, if the individual has no willing or able family, there may be some shortfalls in their care.

There can also be a lack of appropriately trained and qualified caregivers available, especially in rural areas.

How Do You Apply for a Medicaid Waiver Program?

First thing’s first: if you want to apply for a Medicaid HCBS waiver program, you need to contact your state’s Medicaid agency.

You’ll then be given information on how to submit an official application – a process which differs from state to state.

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