Medicaid Definitions: Waivers and Home & Community Based Services

Medicaid is a federal and state funded health insurance program for low income individuals and families.  Most states have several different Medicaid programs that target different audiences.  For example, one program may be designed for low income families, another for pregnant women and a third for the elderly.  Each of these programs will offer different benefits to the participant and have different functional and financial eligibility criteria.

Medicaid vs. Medicare
Since both Medicare and Medicaid provide health insurance benefits to the elderly there exists much confusion about these programs.  Medicare is an optional health insurance program available to all Americans aged 65 or older.  Medicaid is health insurance specifically designed for low income persons with limited financial resources.  It is possible to be eligible for both programs; these individuals are referred to as “dual eligibles”.

Nursing Home Care vs. Home and Community Based Services
Medicaid pays for care for individuals that reside in nursing homes; this is often referred to as Long Term Care Medicaid, LTC Medicaid or Institutional Medicaid.  Medicaid also offers Home and Community Based Services (HCBS), which are Medicaid programs that provide services to individuals that live outside of nursing homes, they instead reside at home or in their community.  Community, in this case, can refer to living in the home of a caregiver, a family member, a board and care home, an assisted living residence, adult foster care or senior living community.  Community is meant as a distinction between someone who does not live in their own home but does not live in a nursing home.

Medicaid Waivers
Waivers are state specific Medicaid programs that allow for services to be provided outside of nursing homes.  The previously mentioned, Home and Community Based Services (HCBS) are a type of Medicaid waiver.  To avoid confusion, it is worth mentioning that waivers are also referred to as 1915 waivers (for the Social Security Act), HCBS waivers, waiver services, waiver programs and by any number of other state-specific names such as the Pennsylvania Department of Aging (PDA) Waiver or the Texas STAR Plus.

A very important distinction between nursing home Medicaid and waivers is that nursing home Medicaid is considered an entitlement while waivers are not.  Entitlement, in this situation means that if one meets the eligibility requirements, then they are entitled to receive benefits.  With waivers, one might meet the eligibility requirements however the waivers may only be available to a certain number of individuals and therefore the person may be put on a waiting list to receive benefits.  They are not immediately entitled to those benefits.