Medicaid waivers are for people with disabilities and chronic health conditions. They allow healthcare professionals to provide care in a person’s home or community instead of a long-term care facility.
Medicare is a federal program. To be eligible for Medicare, a person must be age 65 years or above. People younger than age 65 years may also be eligible, but only if they have specific health conditions.
- adults with low incomes
- older adults
- people with disabilities
- pregnant people
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
The Medicaid waiver program allows states to choose groups of people with particular needs and health conditions to receive tailor-made healthcare options at home or within the community.
For example, some states provide waivers for care relating to developmental disabilities, traumatic brain injuries, AIDS, and substance use disorders.
Following federal guidelines, individual states can implement home- and community-based service (HCBS) waivers. States can choose how many HCBS waivers they would like and must demonstrate that the waiver service:
- does not cost more than the same service in a healthcare facility
- ensures a person’s health and welfare
- provides reasonable and adequate standards to meet a person’s needs
- uses an individualized plan of care centered on the person
A waiver program allows the state to waive some requirements to meet the needs of individuals. For example, a waiver may help a person with an increased likelihood of requiring long-term care, such as those with behavioral issues or technologically dependent children.
Under the HCBS program, states can also offer a variety of non-medical services, including:
- case management
- homemaker services
- home health aides
- respite care
- personal care
- adult daycare
States may also include any other services that help individuals maintain as much independence as possible.
Medicaid waivers are available in all U.S. states, including Puerto Rico. Medicaid maintains a list of waivers that a person can search by state and type.
The Medicaid waiver program’s eligibility rules vary, but a person must meet their state’s level of care requirement. This means that an individual qualifies for full-time inpatient care at an appropriate facility but remains at home.
A person can check their eligibility online or by contacting Medicaid. They can learn about eligibility requirements and how to apply in their state. Many states allow people to apply online.
In some cases, a person’s income may be too high to qualify for Medicaid, but they may still be able to find help in other community resources so that they can stay at home.
Department of Health and Human Services
The number and type of resources available for older adults will vary from state to state, but the Department of Health and Human Resources may help find community resources. A person can search for local services using their zip code.
State Health Insurance Assistance Programs
Program of All-Inclusive Care for the Elderly
The Program of All-Inclusive Care for the Elderly (PACE) is a joint Medicaid and Medicare program designed to help meet a person’s healthcare needs in the community. The program uses a team of healthcare providers to coordinate and deliver care.
A person can have Medicare, Medicaid, or both to be eligible for PACE. They must also:
- be 55 years of age or older
- live in a PACE service area
- require a nursing home level of care
- be able to live safely in the community with assistance
A person with Medicare but not Medicaid will have to pay a monthly premium for the benefit. If an individual has Medicaid only, they will not have to pay a monthly premium.
Supplemental Security Income
Some people may be eligible for Supplemental Security Income (SSI), which is a monthly benefit paid by the Social Security Administration.
This benefit is not the same as retirement or disability benefits. It is available to people with disabilities and blindness who have limited incomes and resources. People aged 65 years and older may also qualify if they meet the income level requirements.
A person can be eligible for Medicaid and Medicare at the same time. This is known as dual eligibility. In these instances, an individual can expect significantly lower healthcare costs.
Medicare is also working with individual states to offer health plans to those who have Medicare and Medicaid, making it easier to obtain healthcare services. They are called Medicare-Medicaid plans, and they include prescription drug coverage.
Medicaid is a joint federal and state program. Medicaid waiver programs help people who qualify for inpatient care to receive healthcare services at home.
Each state can develop its own waiver programs, so some rules and eligibility criteria may vary.
However, some rules are the same in each state. For example, a person meeting the level of care required to be considered an inpatient applies in all cases.
Medicaid waivers help pay for standard medical and non-medical care, including personal care services, respite care, and adult daycare.
People who do not qualify for a Medicaid waiver program may still be eligible for help from resources such as the PACE or SSI.