Overview of the Community Transition Waiver
Alabama’s Community Transition Waiver (ACT Waiver) primarily provides home and community-based services (HCBS) for Alabama nursing home residents who are disabled or have long-term illnesses and want to return home or to the home of a family member. While program guidelines do not define “long-term illness”, it can be interpreted that Alzheimer’s disease and related dementias are likely qualifying illnesses, given that a nursing home level of care is required due to the dementia. The ACT Waiver also services Alabama state residents who are currently receiving services and supports from another Alabama HCBS Medicaid Waiver, such as the Elderly and Disabled Waiver, whose needs are not being met, and as a result, will need to be admitted to a nursing home if not for available benefits via the ACT Waiver.
The benefits received via the ACT Waiver vary based on the needs and circumstances of the program participant. For example, in-home personal care assistance, meal delivery, and home modifications might be benefits provided to promote independent living. In contrast, a program participant with an informal caregiver, such as a family member, might be eligible for adult day health care and respite care to supplement the care already being received by a family member. Services can only be provided in one’s home or the home of a family member with which a program beneficiary resides. To be clear, services cannot be provided in adult foster care homes or assisted living residences.
The services offered under this program may be provided by licensed care workers or program participants have the option to self-direct their personal care services via the Personal Choices Program. Personal Choices is an option that allows the hiring of a relative or friend to provide care. A financial management services agency handles the financial aspects of employment responsibilities such as background checks, tax withholding, and caregiver payments. Persons who are qualified to be hired as caregivers include sons, daughters, adult grandchildren, nieces, nephews, and in some cases, spouses.
The ACT Waiver is not an entitlement program, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the waiver has a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.
The ACT Waiver is a 1915(c) Medicaid waiver. The Personal Choices Program is a 1915(j) state plan option.
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for “Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a nursing home level of care and are at risk of institutionalization such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.
Benefits of the Community Transition Waiver
Follows is a list of the benefits available via the Community Transition Medicaid Waiver. However, an individual care plan will determine which services and supports a program participant will receive. With the exception of case management, no waiver service is an entitlement. This means meeting waiver requirements does not guarantee receipt of all services and supports. Some care services may be participant-directed, meaning the beneficiary is able to choose their care provider. These are indicated by an asterisk (*) below.
– Adult Day Health Care – Supervised care in a group setting a minimum of 4 hours / day. Transportation between home and the facility is provided.
– Assistive Technology – Devices / equipment used to increase functional ability ($15,000 lifetime limit)
– Case Management
– Companionship Services* – Supervision and limited assistance with non-medical daily living activities (i.e., bathing, dressing, mobility, meal preparation, laundry)
– Home Meal Delivery – Frozen and shelf-stable meals
– Home Modifications – Addition of wheelchair ramps, widening of doorways for wheelchair access, etc. ($5,000 lifetime limit)
– Homemaker Services* – Assistance with housecleaning, preparing meals, grocery shopping, picking up prescription medications, etc.
– Medical Supplies – As prescribed by a physician ($1,800 limit per year)
– Personal Assistance Service – Assistance for disabled persons with on-the-job, day-to-day activities
– Personal Care Services* – Non-medical assistance with personal hygiene, toileting, meal preparation, housework, etc.
– Personal Emergency Response Systems (PERS) – Includes installation and monthly charges
– Pest Control Service
– Respite Care* – Skilled / medical and unskilled / non-medical short-term care to alleviate a primary caregiver. Only unskilled respite care can be participant directed.
– Skilled Nursing
– Transitional Assistance Service – Financial assistance with security deposits, utility connection fees, moving expenses, etc. when relocating home from a nursing home
Services are offered in one’s personal home or the home of a family member. Special arrangements may be required to receive services in congregate living arrangements, such as adult foster care homes or assisted living residences.
Eligibility Requirements for Alabama’s Community Transition Waiver
The ACT Waiver is for Alabama residents who are elderly (65+) or younger if disabled. Applicants must reside in a Medicaid-certified nursing home or be receiving home and community based services via another Alabama Medicaid waiver that is not meeting their needs. Additional eligibility criteria are as follows:
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2022, an applicant, regardless of marital status, can have a monthly income up to $2,523. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,523 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred is $2,288.75 / month (effective July 2022 – June 2023) and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than $2,288.75 / month are not entitled to a spousal income allowance.
In 2022, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $2,000 in assets. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $137,400. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances. More.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $636,000 (in 2022). Home equity interest is the current value of the home minus any outstanding mortgage.
– A non-applicant spouse lives in the home.
– The applicant has a disabled child living in the home.
– The applicant has a dependent minor child living in the home.
Medical Criteria: Functional Need
An applicant must require at least one waiver service on a monthly basis and need a nursing facility level of care (NFLOC). For the ACT Waiver, the tool used to determine if this level of care need is met is the Alabama Home and Community Based Program Assessment (HCBS-1) form. From a list of 11 criteria, an applicant must meet two. One of the criteria commonly met is the regular need for assistance with at least one of the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating). Relevant to some persons with Alzheimer’s disease or a related dementia, behavioral problems, such as regular attempts to leave the facility or removal of one’s clothes, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limits, Miller Trusts, also called a qualified income trust, can help. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, but not a great deal of “excess” assets, they can be “spent down”. This turns countable assets into non-countable assets. Examples of ways to do this include home projects, such as modifying the home for independent living or updating the plumbing, purchasing new appliances or furniture, and paying off existing debt. Applicants can also purchase Irrevocable Funeral Trusts, which are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option, but for persons who have a large amount of assets above Medicaid’s asset limit, is the Modern Half a Loaf. This strategy is complicated and should not be attempted without very careful planning. There are also many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Alabama to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program and instead preserve them for family as inheritance. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for the Community Transition Waiver
Before You Apply
Prior to submitting an application for the Community Transition Waiver, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take a Medicaid eligibility test here.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Since the ACT Waiver is not an entitlement program, there may be a waitlist for program participation. The ACT Waiver is approved for a maximum of 675 participants per year. In the case of a waitlist, an applicant’s access to a participant slot is based on the date of Medicaid application and need for program benefits. In some cases, persons who submitted an application at a later date than other applicants may be awarded a participant slot first if their needs are greater.
To apply for the ACT Waiver, applicants must fill out Form 204/205, which can be found on this webpage. (Under the application form is “Tips for Applying”, which applicants might find helpful). Application assistance is available by calling Alabama Medicaid’s helpline at 1-800-362-1504. Completed applications should be mailed to one’s Medicaid district office. Click here to find yours. As part of the application process, a needs assessment will be completed by an ACT Waiver case manager and a nurse.
For additional information about the ACT Waiver, click here, and for more information about the Personal Choices participant directed option, click here. Persons can also contact their local AAA (Area Agency on Aging) at 1-877-425-2243 or 1-800-243-5463 for information and / or assistance.
The Alabama Medicaid Agency administers the ACT Waiver and the Alabama Department of Senior Services (ADSS) operates the program. The Personal Choices state plan option is administered by the Alabama Medicaid Agency, Alabama Department of Senior Services (ADSS), and Alabama Department of Rehabilitation Services (ADRS).
Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.