All You Need to Know About Medicaid Waivers

21 February 2020 Assisted Living

People become sickly as they grow older, so it becomes challenging to handle long-term care, especially for people who belong to the lower-income bracket with limited resources. The silver lining is that people across the United States can still live fulfilling lives despite their medical issues, thanks to Medicaid waivers.

A popular program that helps the elderly and other people with health difficulties is called the Medicaid HBCS or Home and Community Based Services waiver. This allows people who have health issues to receive in-home care instead of being sent to a nursing home or an institution.

There are also other waivers that aid in long-term care in an assisted living facility. Medicaid and its waivers can be quite confusing to understand. Many people struggle applying for coverage because they don’t know what to do. Read below so you can find out more information about Medicaid waivers, including how to avail of HBCS.

Clarifying Medicaid

The first thing to know is many confuse Medicaid with Medicare. Both are government-run programs that offer health coverage to individuals using specific parameters to determine the scope of care. The two are funded by different branches of the government, as well.

However, the similarity ends there. Medicare is funded by the federal government, specifically for people who are sixty-five years and above, as well as people with disabilities of all ages, whatever their income.

In contrast, Medicaid is for people who have poor financial standing. Individual states also run Medicaid, and as such, specific eligibility requirements are dependent on where you live. The same applies for Medicaid Waivers.

People can be eligible for Medicare and Medicaid, so be sure to maximize both programs if you need additional healthcare insurance. Both have different scope and care coverage. To illustrate, Medicaid will pay for things like personal in-home care service, but Medicare does not cover this.

Getting In-Depth About Medicaid Waivers

They set this waiver for Medicaid up to help you or your loved one make healthcare management easier. You can find a waiver in a segment under the Medicaid law. This allows the federal government to waive specific rules to make it easier to access benefits under the Medicaid program.

The primary objective of the waiver is to permit states to accomplish their goals in providing quality care for marginalized people. Waivers encompass the following: reduce expenses, expand care coverage, or improve care for specific vulnerable groups like seniors and pregnant women.

These Medicaid waivers are heaven-sent because they allow states to provide services to residents that usually do not get coverage. A perfect example of this is in-home care for people they would send to an institution.

Learning the Types of Medicaid Waivers

It can be confusing to learn about Medicaid waivers because they come in several different kinds. They also serve different purposes. If you are thinking of applying for a waiver for yourself of your loved one, it is vital to familiarize yourself with its intricate details.

All waivers, no matter the type, purpose, or state it claims, are under the authority of special sections under the Social Security Act. More specifically, Medicaid waivers belong to Sections 1115 and 1915. Peruse the concise and informative explanations hereunder.

Section 1115 Waivers

Another term for this is research and demonstration waivers, which permits different states to test out new methods in providing their Medicaid care and financing. The requirement for approval is the budget must be unbiased and neutral for the federal government.

Simply put, it means that the federal government should not be spending more because the waiver is applied. These waivers have become extremely popular because of the Affordable Care Act. More states are finding new approaches to use additional funding from the federal government.

Section 1915(c) Waivers

This is the Home and Community-Based Services (HCBS) waiver, which is applied for by people in need of care but with limited resources. It is popular because it does what its name suggests. This waiver helps people in need of long-term care and allows them to stay home with their loved ones and continue to live in their communities. If you or your loved one needs long-term care, this waiver will let you stay in a family member’s home or an assisted living facility instead of going to an institution or nursing home.

Section 1915(b) Waivers

Dubbed as the Freedom of Choice Waivers, this permits states to provide care through the help of organizations that offer managed care delivery systems. These organizations have a contract with state Medicaid agencies. Payment comes from state Medicaid funds for giving healthcare services to their beneficiaries. Ironically, this limits the person’s choice when it comes to choosing his or her healthcare providers.

Combined Sections 1915(b) and 1915(c) Waivers

This merges the scope of coverage stipulated in both sections. These waivers give states the capacity to provide Home and Community-Based Services with the help of managed care organizations to qualified individuals, which will give them the best home health solutions with the aid of trained healthcare professionals.

Figuring Out the Popular HCBS

Among these waivers, the HCBS is the most popular because families want their loved ones to receive long-term care in the comforts of their own home and amidst their beloved communities where they find comfort and solace.

Advantages of HCBS

It is the most applicable one for you if you require a more extended care solution for your elderly, disabled, or sick loved ones but have limited income. This is the most humane approach as it lets these vulnerable individuals stay in a comfortable environment that they are familiar with.

Research indicates that people feel tons better when they are in a healthy home environment as opposed to being stuck in an institution. The HCBS Waiver programs allow states to provide qualified individuals in the community to stay in their own home, a family member’s house, or a senior living community as long as it is not a nursing home.

For your beloved senior, this waiver provides them the best solution because nursing facilities can be quite stifling for people who are in this environment. Most often, seniors feel neglected and depressed when they are in an institution.

Bringing care to them makes a lot more sense, especially if they are still mobile and alert. However, there are exceptional cases like dementia patients, where availing of nursing home care is the only solution. At this critical stage with reduced mobility and cognition, these individuals are a danger to themselves because they no longer have the right judgment and the strength of movement to face regular daily challenges.

The federal government encourages home care and recovery because this approach is cheaper than institutional care by at least 50 percent. Staying home improves recovery time from specific injuries and surgeries, and speeds up recuperation, reduces complications, and aids in a robust mental health condition.

Specific Benefits

Individuals who they accept to the HCBS program receive a broad range of medical and non-medical services. These care services depend on the health needs and lifestyle situation of the person, vis-a-vis the state guidelines.

It can include any of the following services like personal in-home care service, care services at an assisted living facility, home nurse or health aide, provision of medical supplies and equipment, help with house chores (including laundry, shopping, cleaning), delivery of hot meals, respite care to offer rest to the primary caregiver, counseling, home/vehicle modifications for increase independence (shower grab bars, ramps, rails, etc.), aid in transitioning from a nursing home to the community, access to senior centers and aged daycares, round trip transportation for check-ups and other medical appointments, non-medical related transport, and access to personal EMS.

Caveats of the Program

Remember, they don’t consider Medicaid waivers a right even though it falls under the healthcare category. You are not entitled to this, but you need to apply and prove that your situation really needs this kind of waiver.

To illustrate, someone who needs immediate nursing home assistance can quickly get into one because their health situation entitles them to this level of care. In contrast, the HCBS waiver is a privilege more than a right. Sometimes, people spend several years before they are deemed eligible to be part of the program.

Knowing the Eligibility Requirements for a Medicaid Waiver

Everyone will be happy to know that all states in America have their kind of Medicaid waiver program. As an example, they offer the HCBS waiver program in all states, which they set-up to help specific people with various types of special healthcare needs. Because what is endemic in particular states vary, HCBS eligibility will also depend on where you live.

Some states have more than one HCBS waiver program to help different groups that need varying levels of healthcare. In general, states offer this service for seniors over sixty-five years old, individuals with a developmental issue, and others with disabilities. They also supply aid for people that need medical equipment support like oxygen, life support, and the like.

Individual states also offer HCBS waiver programs that are diagnosis specific. For instance, in some areas, people diagnosed with HIV/AIDS, autism, and traumatic brain injuries can apply so they can continue to live a good life despite such a debilitating diagnosis. Medical care costs are daunting, more so for people with limited income.

You must remember that not everyone in this group will automatically be entitled to this service. You MUST need a certain level of care. Individuals must meet and pass specific criteria that would require them to be in a nursing home facility or institution if they are not receiving in-home care as of yet.

All states will require a medical abstract that will layout the diagnosis. On top of that, this document will indicate the applicant’s capability to actually complete and safely perform routine daily activities. States also look at the financial capacity with most waiver applicants already receiving Medicaid. They look at how much a family earns, along with life savings when assessing for HSBC qualification.

Applying for a Medicaid Waiver

The process of applying for a Medicaid waiver once again varies depending on the type of waiver you want to avail of, along with the state you reside in. The first step is to apply for Medicaid itself, which needs you to outline your disposable family income, family size, disabilities of the applicant, and other assets.

You can apply for Medicaid anytime at your state’s Medicaid agency, which is nearest to your home. There is no need to wait for the open enrollment period to commence. After this, the agency will answer your queries and help you figure out which benefits apply to you.

Once you do this, you can apply to the specific waiver programs that may help you. Be prepared to give your personal information again, along with the medical certificate from your provider describing the health condition and how they go about their daily activities. You will also need to prepare other supplementary documents like bank accounts, a list of assets, and the like.

Final Word

If you are applying to any Medicaid waiver program, you must learn to be patient because each state has a cap of how many people they can serve, depending on your program. If you are waiting for your HCBS waiver eligibility, you must manage your expectations because the application process is stringent. They don’t approve every application, and they don’t award all benefits.

In cases of extreme need, most states do have priority handling for those people in extremely dire situations. However, do prepare to wait it out because there is a long line of people waiting for their chance to avail of this eligibility waiver.

Your other recourse is you may need to spend your own money on private in-home care, short-term stay, or nursing home care. Be sure that you go for a trusted facility like Bethany Home Care, which offers a broad range of services, so you can rest assured that your loved ones will be taken care of, so they can enjoy life despite their health and physical limitations.