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.
The Montana Big Sky Medicaid Waiver program allows elderly and physically disabled individuals that require nursing home level care to receive that care in their home or community rather than in a nursing home. A wide variety of care services and non-care support is provided both to the program participant and to their primary caregiver. This allows program participants to live at home, in an assisted living residence, or in an adult foster care home. Even minor home modifications, which can decrease the beneficiary’s reliance on other people, are considered an allowable expense.
Under this waiver, Montana residents have the option of self-direction, or said another way, consumer direction. This means participants have the right to choose their care providers. However, care providers are subjected to approval by the state. Interestingly, certain family members are eligible to be hired as personal care attendants. Typically, spouses are excluded from this option, but under certain circumstances they can be paid providers. More commonly, the adult children who are caring for aging parents are paid as caregivers. Care providers must be qualified to provide care. Therefore, the types of care family members can be paid to provide is usually limited to personal care or homemaker services.
Montana’s Senior and Long Term Care Division, which is within the Department of Public Health & Human Services, administers the Big Sky Waiver. This waiver is also referred to as the Elderly/Physically Disabled Waiver and the Medicaid Home and Community Based Services (HCBS) Waiver. In 2019, the state extended the waiver expiration for 5 years until 2024.
Did You Know?
2 out of 3 individuals will become physically or cognitively impaired at some point in their life and 1 out of 3 will enter a nursing home. HCBS Waivers are designed to reduce that rate.
The following guidelines are current for the year 2022. Montana Medicaid allows for multiple pathways into the waiver program. One can be categorically needy or medically needy. These two pathways differ only in the income limits and that the medically needy pathway allows one to “spend down” their income on medical bills / care to meet the income limit. This is explained in more detail below.
Age – There are no specific age requirements. However, the type of services available may depend on the applicant’s age. In addition, those up to the age of 64 must be physically disabled.
Level of Impairment – Applicants are given a medical review. Those found to require the level of care provided in a nursing home are eligible.
Financial Assets – Unmarried (or widowed) applicants must have $2,000 or less in countable assets. Married applicants, with both spouses applying, are able to retain up to $4,000 in assets. (Each spouse is allowed up to $2,000 in assets). Married couples, with only one spouse applying, are allowed a higher level of assets to prevent a healthy spouse from becoming impoverished. This higher resource limit is referred to as the Community Spouse Resource Allowance, and is set at $137,400. Jointly held assets up to this amount can be allocated to the healthy spouse. The applicant spouse is still able to retain up to $2,000 in assets.
Note that these limits are for Countable Assets; there are also assets that Medicaid does not count towards this limit. Most notable is the home. The homeowner’s equity value in his / her home is not counted provided a) the equity value is less than $636,000 and b) the homeowner remains living in the home. Therefore, single applicants who reside in assisted living, not at home, will have their homes counted toward the asset limit. One exception is if the homeowner expresses intent to return home. Married applicants, if one or both spouses remain in the home, will not have the home’s value counted towards the limit. Other non-countable assets include items furnishing the home, personal goods, and a vehicle.
It is very important to note that applicants must not give away assets or sell them for less than they are worth in an effort to meet Medicaid’s asset limit. This is because Montana has a 60-month look back period from the date of one’s application in which all past transfers are considered. If it is found that one has violated this look back period, there will be a penalization in the form of a period of Medicaid ineligibility.
Categorically Needy Income Limit – Categorically Needy recipients must have monthly income less than 100% of the SSI Federal Benefit Rate, which, for a single applicant is set at $841 / month. Married couples with both spouses applying can have up to $1,682 / month. (Each spouse is treated as an individual applicant and is allowed up to $841 / month each). Married couples with a single applicant will also have their incomes considered separately. Stated differently, the income of a non-applicant spouse will not be counted towards the income limit for the applicant spouse.
In order to prevent a non-applicant spouse, also called the community spouse or healthy spouse, from having too little income to live on, there is something called a Monthly Maintenance Needs Allowance. In over simplified terms, the applicant spouse can transfer up to $3,435 / month in income to his / her non-applicant spouse. This not only prevents the community spouse from becoming impoverished, but also lowers the applicant’s income towards eligibility purposes.
Medically Needy Income Limits – Medically Needy recipients have recurring, required medical costs equal to or near their monthly income limits so that they have inadequate income remaining to cover standard living expenses. The income limit for the medically needy eligibility pathway is $525 / month. Therefore, individuals / married couples must spend down their income to the level mentioned above. This is often thought of similarly to a monthly deductible.
Families Over the Limits
Families who exceed these limits may still qualify for Medicaid by employing a Medicaid planning professional. Read more about this option.
Benefits and Services
All beneficiaries are eligible to receive case management services. Other services are determined case by case and can include the following. Not every applicant is eligible for every service.
- Adult Residential Living / Assisted Living / Adult Foster Homes (but only care costs, not room and board)
- Adult Day Health Care
- Consumer Goods and Services
- Day Habilitation / Residential Habilitation Services
- Dietetic Services
- Home Delivered Meals
- Homemaker / Chore Services
- Home Modifications (to improve access and safety)
- Pain and Symptom Management
- Personal Care Assistance
- Personal Emergency Response Service (also called Medical Alert services)
- Private Duty Nursing
- Psychosocial Counseling
- In-Home and Out-of-Home Respite Care (to give the primary caregiver a break)
- Therapy (respiratory, occupational, physical, speech)
- Senior Companion
- Specialized Medicaid Equipment / Supplies
- Transition Services (from a nursing home back into the community)
- Transportation Assistance and Coordination
- Vehicle Modifications
How to Apply / Learn More
Residents throughout Montana are eligible for assistance, regardless of county. HCBS Waivers have enrollment caps, which means a waiting list may exist. Priority is given to those with the greatest needs for services.
One can learn more or apply by visiting the state website or calling 800-219-7035. One can also contact Mountain Pacific Quality Health (MPQH-Montana) at 800-219-7035 for a screening to determine if the applicant meets the level of care need.