Medicaid Definitions: Waivers, Home & Community Based Services & Other Terminology

Last updated: May 15, 2023


What is Medicaid?

Medicaid is a federal and state funded health insurance program for low-income individuals and families. While the federal government sets specific program guidelines, each of the states is given the flexibility to run their Medicaid program as they see fit within the federally set parameters. 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, another for individuals with disabilities, and yet another for the elderly. Each of these programs offer different benefits to the participant, as well as have varying functional and financial eligibility criteria.

 Medicaid is confusing. Public & private assistance options are available that can demystify the program & eligibility.


Medicaid vs. Medicare

Since Medicare, a federal program, and Medicaid, a state and federal program, both provide health insurance benefits to the elderly, there exists much confusion about these two programs. Medicare is an optional health insurance program available to all Americans aged 65 or older. Income and assets are not considered for eligibility purposes. Medicaid is health insurance specifically designed for low-income persons with limited financial resources. Medicaid has strict income and asset limits and applicants’ finances are closely scrutinized.

It is possible to be eligible for both programs at the same time; these individuals are referred to as “dual eligibles”. Seniors who are enrolled in both programs generally have good health coverage. For instance, Medicare will not cover long-term care benefits, but Medicaid will. As an example, Medicare will cover skilled nursing home care, but only on a short-term basis, up to 100 days. In contrast, Medicaid does not limit the number of days they will pay for skilled nursing home care. Furthermore, while Medicare will not pay for in-home personal care and non-medical nursing home care, Medicaid will. Medicaid may also pick up some of the out-of-pocket costs that Medicare does not, such as Medicare premiums and co-payments. Note that some Medicare Advantage plans now offer some long-term care home and community based services, such as personal care assistance, as a supplemental benefit.


Nursing Home Care vs. Home and Community Based Services

Medicaid, in all states, 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 programs that provide services to individuals who live outside of nursing homes. Individuals enrolled in a HCBS program reside at home or in their community. Community, in this case, refers to living in the home of a caregiver or a family member, a board and care home, an assisted living residence, an adult foster care home, or a senior living community. The terminology, “Community,” is meant as a distinction between someone who does not live in their own home, but does not live in a nursing home.

Waivers are state-specific Medicaid programs that allow for services to be provided outside of nursing homes. Home and Community Based Services (HCBS) generally are provided via a type of Medicaid Waiver. However, some states provide long-term HCBS through their State Plan Medicaid program, and other states provide this type of care through both avenues.

To avoid confusion, it is worth mentioning that HCBS Waivers are also called 1915 (c) Waivers (because it is under section 1915 of the Social Security Act in which they are authorized), Waiver services, Waiver programs, and by any number of other state-specific names, such as the California (Medi-Cal) Assisted Living Waiver or the Ohio PASSPORT Waiver. Some states also offer home and community based services via 1115 Demonstration Waivers.

A very important distinction between Nursing Home Medicaid and Medicaid Waivers is that Nursing Home Medicaid is considered an entitlement program, while Waivers are not. Entitlement, in this situation, means that if one meets the eligibility requirements, they are entitled to receive benefits. With Medicaid Waivers, one might meet the eligibility requirements, but be unable to enroll in the program. This is because Waivers limit the number of individuals who are able to receive services. Therefore, an otherwise eligible person may be put on a waiting list to receive benefits, given the program’s enrollment cap has been met. Medicaid Waivers may also limit their services to specific geographic regions within a state, as well as to specific medical diagnoses, such as Alzheimer’s disease.


Managed Care Organizations (MCOs)

Many states have turned to managed care to deliver the services provided under their Medicaid programs. This means that the states’ Medicaid agencies work with Managed Care Organizations (MCOs). MCOs deliver needed services to Medicaid recipients through a network of care providers, which enables enrolled individuals to have all of their needs met through their MCO. This system is found to be less costly for the state, as well as provides a convenience to Medicaid enrollees. A common complaint among beneficiaries is the limited availability of their doctors under managed care.


Community Spouse & Institutional Spouse

When one spouse of a married couple applies for Medicaid and is need of institutional care (nursing home care) or home and community based services via a Medicaid Waiver, this individual in Medicaid terminology is called the “Institutional Spouse.” Another term one might hear to describe this same situation is “Needy Spouse.” The healthy spouse, who is not applying for Medicaid and does not require nursing home care or home and community based services, is called the “Healthy Spouse.” Other common terms include “Well Spouse” and “Community Spouse”.


Nursing Facility Level of Care

For Nursing Home Medicaid and many Medicaid Waivers, an eligibility requirement is that one requires a Nursing Facility Level of Care (NFLOC). This means that one requires the level of care that is provided in a nursing home. A functional needs assessment, often completed by a medical professional, is done to determine if one requires a NFLOC. Generally, this assessment is based on one’s ability to perform basic Activities of Daily Living, such as mobility, bathing, dressing, and toiletry. Each state, however, has its own criteria for establishing NFLOC.

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