Medicaid Waiver Programs
Authored By: North Mississippi Rural Legal Services
Medicaid Waiver Programs
States can establish special programs under Medicaid with the approval of the center for Medicare and Medicaid Services (CMS). These are called "waiver" programs, since federal statutory and regulatory requirements are waived by CMS in regard to these programs.
The Home and Community Based Waiver Programs are designed to provide service to certain populations as an alternative to institutionalization in nursing homes or regional centers. Mississippi currently has five home and community based waiver programs. The Elder and Disabled Waiver, the Independent Living Waiver, the Mentally Retarded/Developmentally Disabled Waiver, the Assisted Living Waiver, and the TBI/SCI Waiver.
In 1989 Congress amended the Medicaid laws to address the financial problem of the spouses of individuals in nursing homes (community spouses). These laws provided protections to prevent spousal impoverishment when an individual qualifies for nursing home care or home and Community Based Care (HCBC).
INCOME: The community spouse is entitled to a monthly maintenance needs allowance of up to $2,232/month (2002). This means that the income of the spouse in the nursing home or on HCBC can be given to the community spouse to make up the difference between the community spouse's income and the monthly allowance amount, before payment is made to the nursing home.
Children of divorced spouses are also entitled to a monthly maintenance needs allowance. The allowance can be applied regardless of whether there is a community spouse, as long as there is a dependent.
RESOURCES: The community spouse is entitled to a resource allowance of up to $89,280 (2002). (A greater amount can be protected through a fair hearing or by court order.)
The recipient must be 21 years of age or older, and must need assistance with three activities of daily living to qualify. The program provides services to individuals who, but for the provision of such services, would require the level of care provided in a nursing facility. Services offered under this program include additional home health visits beyond the limit of 60 authorized by other Medicaid programs, home delivered meals, homemaker services, institutional respite and adult day care. The recipient must need nursing home level of care. Information about this program is available at the local Area Agency on Aging. This program is administered directly by the Community Long Term Care Division of Medicaid. Case management services are provided by the area Agencies on Aging. The case management team is composed of a registered nurse and a licensed social worker who are responsible for identifying, screening and completing an assessment on individuals in need of at-home services. The plan of care is then approved by the Division of Medicaid. Clients are visited at least monthly.
Part of the assessment functions of the Area Agencies on Aging includes providing information to people about the alternative to nursing facility care.
The income level for this program is 300% of the federal Supplemental Security Income level or $1635 in 2002. Persons with income over the limit may qualify for this program through an income trust. Resource limits are $4000 for an individual and $6000 for a couple.
This is a new category pending approval with CMS. The program is for Forest, Harrison, Hinds, Lee, Bolivar, Sunflower and Newton Counties.
Individuals age 21 or over, living in level 1 assisted living facilities or personal care homes, needing Nursing Facility level of care, requiring assistance with 3 activities of daily living (ADLs) or diagnosed with Alzheimer disease or dementia with 2 deficits of ADLs will be eligible. The income eligibility level is 300% of SSI ($1635 in 2002) and resources allowance of $4000/individual in 2002. The individual contributes to cost up to a limit. Services offered are a wider variety than Home and Community Based Waiver. Examples of services include, medication oversight, therapeutic social and recreational programs, personal care services, homemaker services, intermittent skilled nursing services, transportation, attendant call systems, incontinent supplies.
A recipient must have an income of no more than 300% of SSI ($1635/month in 2002). Resources must not exceed $4000. The program is for neurologically and orthopedically impaired individuals. The program was created to assist severely orthopedically and neurologically impaired individuals to live independently, rather than in a nursing facility, through the services of a Personal Care Attendant. The person must be capable of directing his/her own care and possess some rehabilitation potential. This waiver is operated through the Department of Rehabilitation Services. Referrals for this program can be made through the Long Term Care Division of Medicaid or through the Department of Rehabilitation Services. The number of people who can be enrolled is limited: 450 in 2000; 550 in 2001; 650 in 2002.
This program is an alternative to institutionalization for individuals who, but for the services would require placement in an Intermediate Care Facility for the Mentally Retarded ((ICF/). Recipients of SSI, TANF, and the Medicaid disabled child living at home category are eligible for this benefit. The latter category requires a determination that the child needs institutional level of care and meets the financial requirements of Medicaid and disability determination requirements of the Disability Determination Service. All individuals must be certified by a Diagnostic and Evaluation team at a regional center. The process of evaluation is the same as it would be if the individual were going to be admitted to the institution. The program offers attendant care services, in-home respite (relief for the care giver), group home respite; ICF respite; physical therapy; occupational therapy; speech, language and hearing services; residential habilitation; day habilitation (teaching of habilitation skills, i.e. socialization and grooming skills); pre-vocational services, and supported employment. Referrals for this program can be made through the Long Term Care Division of Medicaid, The Bureau of Mental Retardation, or the waiver case managers located at each of the Regional ICF's. The program is operated through the Department of Mental Health, Bureau of Mental Retardation.
The TBI/SCI Waiver program provides services for individuals who have a traumatic brain or spinal cord injury. To qualify for this program, an individual must have a diagnosis of traumatic brain injury (defined as an insult to the skull, brain, or its covering resulting from external trauma) which produced an altered state of consciousness or anatomic, motor, sensory, or cognitive/behavioral deficit, or a spinal injury (defined as a traumatic injury to the spinal cord or cauda equina) with evidence of motor deficit, sensory deficit, and/or bowel and bladder dysfunction.) The lesions must have significant involvement with two of the above three. Additionally, the primary care physician must have certified that the individual is medically stable (absence of an active, life threatening condition, IV drip to control or support blood pressure or inter-cranial pressure or arterial monitoring.)
This program is administered by the Department of Rehabilitation Services. Services include: case management, in-home nursing respite, in-home companion respite, institutional respite, attendant care services, environmental accessibility adaptations and specialized medical equipment and supplies. The program is limited to serving 400 people in the fiscal year ending June 30, 2002 and is scheduled to expand to 450 in 2003 and 500 in 2004.