Overview of the Elderly and Disabled Waiver
Alabama’s Elderly and Disabled Waiver (E&D Waiver) provides home and community-based services (HCBS) for elderly and disabled Alabama residents who are at risk of being institutionalized (being placed in a nursing home). The benefits received vary based on the needs and circumstances of the program participant. For example, one might receive in-home personal care and homemaker services 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.
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, caregiver payments. Persons who are qualified to be hired as caregivers include sons, daughters, adult grandchildren, nieces, nephews, and in some cases, a spouse.
Services cannot be provided in institutional-like settings, but they can be provided in residential settings. This means services can be provided at home, in adult foster care but congregate living arrangements such as assisted living may require special arrangements. However, this waiver program will not cover the cost of room and board in these settings.
The E&D 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. A portion of these slots are reserved specifically for persons residing in nursing home facilities who wish to transition back to community living.
The E&D Waiver is formally called the Alabama Home and Community-Based Elderly and Disabled Waiver. It 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 Elderly and Disabled Waiver
Follows is a list of the benefits available via the Elderly and Disabled 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.
– 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
– Homemaker Services* – Assistance with housecleaning, preparing meals, grocery shopping, paying bills, etc.
– Personal Care Services* – Non-medical assistance with personal hygiene, toileting, meal preparation, housework, etc.
– Skilled Respite Care – In-home, short-term medical care to alleviate a primary caregiver
– Unskilled Respite Care* – In-home, short-term non-medical care to alleviate a primary caregiver
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 assisted living or adult foster care.
Eligibility Requirements for Alabama’s Elderly and Disabled Waiver
The E&D Waiver is for Alabama residents who are elderly (65+) or younger if disabled that are at risk of nursing home placement. 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 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / 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 $2,177.50 / month (effective July 2021 – June 2022) 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 $2,177.50 / month are not entitled to a spousal income allowance.
In 2021, 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 $130,380. 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.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. 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.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC). For the E&D 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, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are annuities that turns countable assets into a stream of income. There are 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 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 Elderly and Disabled Waiver
Before You Apply
Prior to submitting an application for the Elderly and Disabled 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 the Medicaid eligibility test.
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 E&D Waiver is not an entitlement program, there may be a waitlist for program participation. The E&D Waiver is approved for a maximum of 9,355 beneficiaries 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 E&D 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). Completed applications should be mailed to one’s Medicaid district office. Click here to find yours. Applicants will be contacted by a Medicaid caseworker for an interview following the receipt of application.
For additional information about the E&D 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 and Alabama Department of Senior Services (ADSS) administer the E&D Medicaid waiver, and 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.