All states have at least one Medicaid home and community-based service (HCBS) waiver program that provides general health coverage and coverage for certain services to help you stay at home or in a community-based setting (for example, in an assisted living facility Assisted living facilities are long-term care facilities designed to assist people with activities of daily living who can otherwise take care of themselves. They are different from nursing homes, which also provide skilled care. Medicare does not cover room and board in an assisted living facility. ). Remember that Medicare only covers home health care Home health care is care provided at home to treat an illness or injury. Medicare will only cover home health care if you are homebound and have a need for skilled care, including skilled nursing and/or skilled therapy services. if you meet certain criteria, such as being homebound Medicare considers you homebound if: you need the help of another person or medical equipment (such as a walker or wheelchair) to leave your home, or your doctor believes that your health could get worse if you leave your home; and it is difficult for you to leave your home and you typically cannot do so. A doctor must evaluate and certify this condition. Leaving your home for medical treatment, religious services, and special non-medical events such as a family reunion or funeral does not mean that you are not homebound. and needing skilled care Skilled care is medically necessary care that must be performed by a skilled professional, or under their supervision. Skilled nursing includes care from registered nurses and licensed practical nurses. Skilled therapy includes care from licensed physical, occupational, and speech therapists. . Even if you qualify for Medicare-covered home health care, you may need additional services. Medicaid can be used to supplement the amount and kind of services you get. If you do not meet Medicare’s requirements for home care, you still may be eligible for a Medicaid HCBS waiver program.
Services covered through an HCBS waiver program may include:
- Personal care Personal care, also known as unskilled care, is assistance with activities of daily living. Providers of personal care (home health aides) are not required to undergo medical training. Medicare only covers personal care if you are homebound and receiving skilled care.
- Homemaker services
- Case management
- Adult day care
- Skilled nursing care
- Therapy services
- Home modifications
- Respite care Respite care provides relief for caregivers of hospice patients by arranging a brief period (up to five days) of inpatient care for the patient. Medicare only covers respite care under the hospice benefit.
- Help with chores
The amount and type of services that Medicaid may cover varies by state.
You may qualify for help from a Medicaid HCBS waiver program if you:
- Meet your state’s functional eligibility requirements for home and community-based services
- And, have income and assets Assets are resources such as savings and checking accounts, stocks, bonds, mutual funds, retirement accounts, and real estate. below certain guidelines (remember, your state may have higher Medicaid income guidelines if you need long-term care, or a spend-down program to help you qualify)
States have different functional eligibility standards for determining whether you are eligible for home and community-based waiver programs. Most states require you need a nursing home level of care to qualify, but you may be able to need less care and still qualify for Medicaid coverage. States will also usually assess your need for help with activities of daily living (such as toileting, bathing, and dressing).
When you qualify for a Medicaid HCBS waiver program, Medicare still covers medical services you may need beyond your home health care. For example, if you need to go to a doctor or specialist A specialist is a doctor who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems. ’s office, Medicare will pay first for most of these services, and Medicaid will pay second by covering your remaining costs, such as coinsurances, copayments, and deductibles.
There are a few things you should keep in mind before applying for a Medicaid HCBS waiver program:
- Medicaid HCBS waiver programs may consider you and your spouse together when counting your income and assets, but you may be able to set aside a certain amount of your income and assets for your spouse to keep. If your state allows you to set aside a certain amount for your spouse, this amount will not be counted when you apply for Medicaid.
- If you own your home, be sure to talk to an elder law attorney about how your Medicaid coverage will be affected. The equity from your home may count as an asset when you are being screened for Medicaid eligibility.
- Even if you meet the eligibility guidelines for a Medicaid HCBS waiver program, there are generally limits on the number of people who can receive these benefits in your state. Check with your local Medicaid office to see if there is a Medicaid HCBS waiver program waiting list.