Alaskans Living Independently (ALI) Medicaid Waiver: An Alternative to Nursing Home Care

Last updated: February 16, 2024


Overview of the Alaskans Living Independently (ALI) Medicaid Waiver

The Alaskans Living Independently Waiver, or ALI Waiver, is a statewide Medicaid program for seniors and physically disabled adults who are at risk of institutionalization (nursing home admission). Intended to prevent and delay the need for nursing home care, a variety of long-term services and supports are available to assist persons in living independently. Examples include adult day care, home modifications for safety and accessibility, respite care to relieve an informal (unpaid) caregiver, and specialized private duty nursing services.

Program participants can live at home, the home of a loved one, or an assisted living residence. Alaska does not offer adult foster care homes.

Many long-term care Medicaid programs offer a participant-directed option, allowing program participants to select and manage the caregiver of their choosing. This, unfortunately, is not an option through the ALI Waiver. Instead, all services and supports are provided by agency providers.

The Alaskans Living Independently Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. It is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. The number of participant enrollment slots are limited, and when these slots are full, a waiting list for program participation forms.

 What are 1915(c) HCBS Medicaid Waivers?
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, such as the elderly, disabled, or persons with Alzheimer’s, who require a Nursing Home Level of Care and are at risk of institutionalization. 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 Alaskans Living Independently Waiver

Follows is a list of home and community based services available via the ALI Waiver. An individualized care plan determines which benefits a program participant receives.

– Adult Day Health Care
– Case Management
– Home Modifications – i.e., wheelchair ramps, grab bars, widening of doorways
– Meal Services – congregate settings / home delivered
– Residential Supported Living Services – assisted living services
– Respite Care – in-home and out-of-home care to relieve a primary caregiver
– Specialized Medical Equipment
– Specialized Private Duty Nursing
– Transportation

While a program participant can reside in an assisted living residence, the ALI Waiver does not cover the cost of room and board.

 Additional Options: Alaska seniors might also want to consider the State Plan Personal Care Services Program (SP-PCS) and Community First Choices Program (CFC), both of which offer in-home personal care assistance. Persons who receive services via Alaskans Living Independently can simultaneously receive personal care services via CFC if they qualify.


Eligibility Requirements for the Alaskans Living Independently (ALI) Medicaid Waiver

The ALI Waiver is for Alaska residents who are elderly (65+ years old), or physically disabled and between 21 and 64 years of age. Persons who enroll as a disabled adult can continue to receive Waiver services under the aged category when turning 65. Additional eligibility criteria is as follows.

 The American Council on Aging provides a quick and easy Medicaid Eligibility Test for AK seniors


Financial Criteria: Income, Assets & Home Ownership

The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR). In 2024, an applicant, regardless of marital status, can have a monthly income up to $2,829. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,829 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income-eligibility of their spouse. However, in some cases, income can be allocated to the non-applicant spouse from their applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance (MMNA).

In Alaska, the maximum amount of income that can be transferred to the non-applicant spouse is $3,853.50 / month. For clarification, this allowance is intended to bring a non-applicant’s monthly income up to $3,853.50. If a non-applicant’s own income is equal to or greater than this amount, they are not entitled to a Spousal Income Allowance.

In 2024, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can have $2,000 in assets, while the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment. In 2024, the CSRA allows the non-applicant spouse to keep up to $154,140 of the couple’s assets.

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.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Medicaid Spend Down Calculator.


Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for eligibility purposes, Medicaid in Alaska considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $713,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child (under 21) living in the home.
– The applicant has a disabled or blind child of any age living in the home.

While one’s home is generally safe from Medicaid’s asset limit, it is not safe from Medicaid’s Estate Recovery Program. Learn more about the potential of Medicaid taking the home here.


Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC). For the ALI Waiver, the Consumer Assessment Tool (CAT) is utilized to determine if one meets this level of care need. One’s ability / inability to complete Activities of Daily Living (ADLs), such as bathing, dressing, mobility, eating, and toiletry, and Instrumental Activities of Daily Living (IADLs), like meal preparation, laundry, and shopping for essentials, is considered. Other considerations include the need, and frequency of need, for medications, professional nursing services, and treatments. Relevant to many persons with Alzheimer’s disease or a related dementia, memory, cognition and behavioral issues, such as wandering, are also considered. To be clear, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 Learn more about long-term care Medicaid in Alaska.


Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for AK 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 Qualified Income Trusts, can help. Specific to Alaska, they are called Irrevocable Income Trusts. “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 (IFTs) are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts (MAPTs), which must be implemented well in advance of the need for care, are trusts that protect assets from both Medicaid and Medicaid’s Estate Recovery Program. Persons who do not have a significant amount of excess assets might consider “spending down” countable assets on ones that are exempt. Examples include purchasing household furnishings, appliances, and clothing. There are additional planning strategies available 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 Alaska to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of the strategies violate Medicaid’s 60-month Look Back Rule, and therefore, should only be implemented with careful planning. 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 Alaskans Living Independently (ALI) Medicaid Waiver

Before You Apply

Prior to submitting an application for the ALI 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 delayed is required documentation is missing or not submitted in a timely manner.

Since the Alaskans Living Independently Waiver is not an entitlement program, there could potentially be a waiting list for program participation. However, this Waiver is approved for 3,054 beneficiaries per year, and the current number of participants is well below this figure. If the state becomes close to approved capacity, rules would have to be implemented as to how applicants would be placed on a waiting list and how slots would be filled as they became available.


Application Process

Persons can begin the application process for the ALI Waiver by contacting the Aging and Disability Resource Center (ADRC) in their area. Persons can also call ADRC’s statewide number at 855-565-2017. If it seems likely one would be eligible for waiver services, they will receive a list of care coordinators who can provide application assistance.

Limited information about the ALI Waiver is located here. Persons can also call the Division of Senior and Disabilities Services to learn more.

The ALI Waiver is administered by the Alaska Department of Health (DOH) and is operated by the Department’s Division of Senior and Disabilities Services (SDS).


Approval Process & Timing

Alaska’s 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. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, if a waiting list were to exist, approved applicants could spend an even greater amount of time waiting to receive benefits.

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