What is a Medicaid Waiver?
For persons with limited financial resources, Medicaid pays for nursing home care. For those who wish to live at home or in assisted living, sometimes Medicaid will pay for care in those locations if it can be obtained at a lower cost than in a nursing home. It does this through “Medicaid Waivers,” which are also called Home and Community Based Services (HCBS) Waivers or Waiver Funded Services.
Waiver Description
This program helps individuals who would otherwise require nursing home placement to remain living at home.
The DC Office on Aging offers a single Medicaid waiver that is relevant to aging District residents: the Elderly and Persons with Physical Disabilities Waiver, more commonly referred to as the EPD Waiver or the HCBS Waiver. This waiver is intended to allow beneficiaries who would otherwise require nursing home care to receive care services outside of that environment and to instead remain living in their homes or in assisted living communities. The waiver does so by providing personal care, supportive services, and personal emergency response services, which increase the program participant’s independence.
The EPD Waiver contains an option called “Services My Way” for program participants who live in their homes. Services My Way allows beneficiaries to “participant direct” their care, or phrased another way, participants have the option to choose from which care providers they receive care services. Family members, including the adult children, may be hired and paid to provide care services. (Spouses cannot be hired to provide care). It is worth noting that this model of care is also referred to as Consumer Directed or Cash and Counseling.
Medicaid waivers, unlike regular Medicaid or nursing home care, are not entitlement programs. Each waiver is approved with a limited number of available participant slots. In previous years, a waiting list has existed for the EPD Waiver. In 2021, the number of available slots is approximately 5,560. Prioritization on the wait list is based on a first-come, first-serve basis, not based on urgency of need.
Eligibility Guidelines
EPD Waiver qualifications consider both the functional ability and the financial status of the applicant. Residents of the District of Columbia must have a medically documented need for nursing home level care and be over 65 years of age or over 18 and be officially disabled. From a financial perspective, the District considers the applicant’s income, financial resources or “countable assets”, and past asset transfers, dating as far back as 60 months preceding one’s date of application. This “Look Back” Period is intended to prevent applicants from giving away or selling assets under fair market value in order to reduce assets for qualification purposes.
Income Rules – Monthly income for a single applicant is limited to 3x the Supplemental Security Income / Federal Benefits Rate. In 2021, this limit is equal to $2,382 / month. A married applicant whose spouse is not also receiving Medicaid assistance is permitted to give his/her non-applicant spouse a monthly spousal allowance. If, for example, the Medicaid applicant lives in assisted living and his/her spouse does not, the non-applicant spouse is permitted to receive some of his/her spouse’s income to continue to be able to afford to live independently. This is called the Minimum Monthly Maintenance Needs Allowance and is the minimum amount of income to which a non-applicant spouse is entitled. Effective July 2020 – June 2021, this figure is $2,155 / month. Under certain circumstances, the applicant spouse may transfer as much as $3,259.50 / month in income to his/her non-applicant spouse. (This figure is effective January 2021 – December 2021).
D.C. offers an alternative pathway to Medicaid eligibility called the Medically Needy pathway. This is also referred to as a Medically Needy Spend-Down. For persons with high, recurring care costs, which consume the majority of their monthly income, the Medically Needy pathway can apply. In 2021, should the difference between care expenses and monthly income be less than $689.54 (the medically needy income limit for an individual), it is likely the individual will qualify.
Asset Rules – “Countable” assets for a single applicant are limited to $4,000. However, countable assets exclude an applicant owner-occupied home, given his/her equity interest is valued at less than $906,000. The home is also exempt, regardless of applicant circumstances, if a non-applicant spouse lives in the home. Other exempt items include most home furnishings, some personal items, a car, and up to $10,000 for burial funds. Married couples are permitted to have much higher countable assets. This is because Medicaid rules allow a non-applicant spouse to claim a larger part of jointly held assets. This is called a community spouse resource allowance, and in 2021, the spouse who is not applying for benefits is permitted up to $130,380 in assets. This is in addition to the $4,000 in assets the applicant spouse is able to keep.
Persons whose income or assets exceed Medicaid’s limits, but still cannot afford their care, should consider working with a Medicaid Planner to become eligible. Learn more.
Benefits and Services
Each beneficiary of the EPD Waiver has different care requirements and will be approved for different care and support services by their case manager. Under the EPD Waiver, the following forms of assistance are available.
- Adult Day Health
- Assisted Living Services (Room and board are not covered by this waiver program)
- Case Management
- Chore Services (Washing windows, nailing down loose flooring, etc.)
- Community Transition (From a nursing home facility back into the community)
- Environmental Accessibility Adaptations (Home modifications, such as making the home wheelchair accessible)
- Homemaker Services (Light housekeeping and meal preparation)
- Personal Care (Assistance with activities of daily living, such as eating, bathing, and dressing)
- Participant Directed Services / Goods
- Personal Emergency Response Services (PERS)
- Respite Services (up to 480 care hours per year)
- Therapy (Physical and occupational)
How to Apply / Learn More
To apply for the EPD Waiver, interested parties should contact the Washington DC Department of Aging and Community Living’s Aging and Disability Resource Center at 202-724-5626. Information about this program is available on the District’s Department of Aging and Community Living’s website. A complete handbook for the program that offers very detailed information, including a step-by-step description of the application process, is available for download here.
