All states have at least one home and community-based service waiver program that provides general health coverage plus coverage for certain services to help you stay at home or in a community-based setting (for example, in an assisted living facility). Such services may include personal care, homemaker services, case management, adult day care, personal care, skilled nursing care and therapy services. Home modifications, respite care, and help with chores may also be covered. The amount and type of services that Medicaid will cover for you vary by state.
You may qualify for help from a Medicaid home and community-based service (HCBS) waiver program if you:
- meet your state’s level-of-care or functional eligibility requirements for home and community-based services; and
- have income and assets below certain guidelines.
Different states have different level-of-care or functional eligibility standards for determining whether you need home and community-based waiver services. Most states require you to need a nursing-home level of care to qualify, but you may be able to need less care in some states and still qualify for Medicaid coverage. States will also usually look at your ability to function. For example, your state will probably assess whether you need help with activities of daily living (i.e., basic everyday activities such as getting in and out of bed, dressing, bathing, eating and using the bathroom).
While Medicare covers home health care, it is only covered if you meet certain criteria, such as if you need skilled care and are homebound. Even if you qualify for Medicare-covered home health care, Medicare may not cover enough supportive services to keep you in your home, and 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 home and community-based service waiver program.
When you qualify for a Medicaid home and community-based service waiver program, Medicare will still pay for most of your medical services beyond your home health care. For example, when you need to go to the doctor or hospital, Medicare will pay first and Medicaid will pay second by covering your remaining costs, such as the Medicare coinsurances, copayments and deductibles. Medicaid may also pay for some medical services that are not covered by Medicare, such as routine dental care.
In order to qualify for a Medicaid home and community-based service waiver program, you will need to meet financial guidelines in addition to functional eligibility guidelines. If you need home and community-based waiver services, you might be able to have higher income than you would if you did not need long-term care and still qualify for Medicaid. Your state may have:
- higher Medicaid income guidelines for people who need home and community-based waiver services than for those who do not need long-term care; and/or
- a “spend-down” or “medically needy” program. Spend-down programs are meant for people who have income higher than would normally qualify them for Medicaid coverage, but who have medical expenses that significantly reduce their usable income.
Some things to keep in mind if you are thinking of applying for a Medicaid home and community-based service waiver program:
- Medicaid home and community-based service waiver programs may consider you and your spouse together when looking at 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 home and community-based service 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 home and community-based service waiver program waiting list.