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 Assisted Living Waiver Program is an Ohio Medicaid program that covers the cost of care in assisted living facilities for eligible residents. The waiver program is popular both with the state, as it reduces costs, and with participants, as they prefer the flexibility and recreational activities that group living provides. However, that popularity has a downside.
The program has a waiting list that can extend for months. Although it’s not unusual for Medicaid waivers to have a waiting list, in Ohio it exists for a different reason. The bottleneck is not with an enrollment cap. Instead, there exists a limited number of slots because assisted living providers have been slow to come on board to this program. The reimbursement rate offered by Ohio Medicaid is presumably significantly less than the private pay price for residency at their communities.
Waiting lists exist at the facility level; these are not statewide. When considering a move to assisted living, or to a new residence, advisers recommend contacting multiple assisted living providers to determine if they have a waiting list, its expected duration, and any other conditions relevant to accessing the program. Assisted living providers must be certified by the Ohio Department of Aging. In Ohio, the local Area Agencies on Aging maintain lists of the certified providers in their coverage area.
This program only covers the cost of some of the services provided at an assisted living facility. It does not cover the cost of room and board, as it is barred by federal Medicaid laws. Waiver participants, or their families, are expected to pay for this portion of the monthly fee.
Did You Know? According to the National Center for Assisted Living (NCAL), approximately three-quarters of assisted living residents are female, more than 50% of the residents are 85+ years old, and their average length of stay is almost two years.
The Assisted Living Waiver Program is intended for Ohio residents who are age 21 and over. In addition to these requirements, applicants are evaluated based on their level of impairment and their financial need.
Level of Impairment
The State Medicaid office asses applicants to determine their functional abilities and decide whether they qualify. Persons 21 to 64 years of age must by physically disabled, while those 65 and older do not have to be disabled. However, all applicants must require a nursing home level of care.
Generally, those who require assistance to complete the Activities of Daily Living, such as bathing, eating, mobility, and maintaining continence, are qualified. However, should their needs be so advanced that it would be difficult to care for them in an assisted living residence, they will be referred to a program that provides a higher level of care.
When considering an applicant’s finances, their monthly income, their financial and property holdings, and their ability to pay for the care they require are all measured.
In 2022, applicants are permitted a monthly income of up to $2,523. This figure is three times the Federal Benefit Rate / Supplemental Security Income Rate, which changes annually.
When a married person’s spouse requires the additional care provided in an assisted living environment, then only his or her spouse’s income is considered when assessing eligibility. If the healthier spouse (also called a “community spouse”) at home has little income in his or her name, then the applicant’s income may be used to supplement the at-home spouse’s monthly income. As of 2022, this figure may be as much as $3,435 a month. This is called a Monthly Maintenance Needs Allowance and is meant to ensure the community spouse has enough income on which to live adequately .
In assets, single applicants are limited to countable resources of $2,000. One’s primary vehicle (used for transportation) and various other personal effects are exempt assets, and not countable resources. One’s home, given the waiver participant has a spouse living in it, is also considered exempt. However, one exception remains for single applicants: Individuals can sign a sworn statement that they have intent to return home after a short-term stay in an assisted living facility.
As with income, there is a spousal asset protection in place for married couples with just one spouse applying for Medicaid waiver services. While all assets of married couples are considered jointly owned, the non-applicant spouse is able to retain up to $137,400 in joint assets. This is referred to as the “Community Spouse Resource Allowance.” The applicant spouse is still able to keep up to $2,000 in assets.
Please Note: For applicants over the asset limit, it is very important that they not attempt to meet the limit by giving away their assets. This is because of a 5-year Medicaid look-back period in which all past asset transfers are checked to ensure this has not happened. If it has, or if assets were sold for less than they are worth, a period of Medicaid ineligibility is the penalty.
Over the Financial Limits?
If a Medicaid applicant is “over income” or “over assets,” it is possible he or she can still qualify by working with a Medicaid advising professional. One can use techniques to qualify sooner and to allocate income over the limit to a special qualified income trust. Interested individuals can determine if they are Medicaid eligible and if working with a Medicaid planner is right for them by clicking here.
Benefits and Services
In addition to case management, this program pays for the cost of care in approved assisted living residences, but it does not include the monthly fees for room and board. Services provided in assisted living include:
- Health assessments and monitoring
- Personal care
- Medication reminders and assistance
- 3-meals per day
- Skilled nursing as required
- Housekeeping and laundry
- Recreational / social activities
- Non-medical transportation
- On-site response around the clock
The Assisted Living Waiver can also provide financial assistance to help persons currently residing in nursing homes to transition into an assisted living residence.
How to Apply / Learn More
The Assisted Living Waiver Program is managed by the Ohio Department of Aging and is available to residents statewide. As previously mentioned, waiting lists for enrollment often exist, and not all assisted living communities in Ohio accept the Medicaid waiver. Search for certified residences here. More general information about the assisted living waiver can be found here.
To apply for the waiver, individuals should contact their local PASSPORT Administrative Agency or call 1-866-243-5678.
Ohio residents unable to gain entrance into this program may be interested to know that free assistance is available to help them find assisted living within their budgets.