Overview of the Persons who are Elderly Waiver
Illinois’ Persons who are Elderly Medicaid Waiver provides home and community-based services (HCBS) for senior residents who are at risk of being being placed in a nursing home (“institutionalized”). Intended to assist the elderly in maintaining independence at home, assistance with daily living activities, such as basic housecleaning, meal preparation, grocery shopping, bathing, and transportation for medical appointments and essential errands, is provided. A valuable benefit for program participants who have informal caregivers is adult day care, which allows the caregivers to continue to work outside the home. Benefits can be provided for persons residing in their own home or the home of a loved one, but cannot be provided in assisted living or adult foster care.
The Elderly 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.
Many long-term care Medicaid programs allow program participants the option of self-directing their own care, specifically hiring the caregiver of their choosing. Unfortunately, this is not an option through the Persons who are Elderly Waiver.
The Persons who are Elderly Waiver is formally called the HCBS Waiver for Persons who are Elderly. It is a 1915(c) Medicaid waiver and is part of a bigger state program called the Community Care Program (CCP). CCP provides the same services as does the Persons who are Elderly Waiver, but is the non-Medicaid, state-funded part of the program, while the Elderly Waiver is the Medicaid-funded counterpart. Approximately half of CCP program participants receive services via the waiver.
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 Persons who are Elderly Waiver
Follows is a list of the benefits available via the Persons who are Elderly Medicaid Waiver. An individual care plan will determine which services and supports a program participant will receive. Meeting waiver requirements does not guarantee receipt of all services and supports.
– Adult Day Care – also called adult day service. Provides daytime supervision and assistance in a community-based group setting.
– Automated Medication Dispenser (AMD) – includes installation and monthly service fees
– Emergency Home Response – includes installation and monthly service fees
– Homemaker Services – also called in-home service. Includes planning and preparation of meals, light housecleaning, shopping for essentials, medication reminders / assistance with self-administration, and personal care assistance.
Eligibility Requirements for Persons who are Elderly Waiver
The Persons who are Elderly Waiver is for Illinois residents who are elderly (65+), or if physically disabled, between the ages of 60 and 64 at the time of enrollment. Full eligibility criteria are available below.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $1,073. When both spouses are applicants, the monthly income limit for the couple is $1,452. 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. Only the applicant spouse’s income is considered, which is limited to $1,073 / month. 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 in 2021 is $2,739 / month. This spousal allowance 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 $2,739 / 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, the asset limit is $3,000. 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 $109,560. 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, Illinois 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.
– The applicant has a spouse that lives in the home.
– The applicant has a disabled or blind adult child that lives in the home.
– The applicant has a child under 21 years old that lives 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 Persons who are Elderly Waiver, a needs assessment to determine one’s level of care requirement is completed by a Community Care Unit (CCU) contracted by the state. The tool used is the Determination of Need (DON). To assess functional needs, one’s ability / inability to independently complete the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) and instrumental activities of daily living (i.e., housework, laundry, preparing meals) is considered. A Mini-Mental Status Examination (MMSE) considers one’s cognitive functioning, such as sense of awareness and memory, which is relevant for persons with Alzheimer’s disease or a related dementia. 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.
Illinois has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, the HCBS Waiver for Persons who are Elderly will pay for care services and supports.
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. Some couples who have a significant amount of countable assets opt for a Medicaid Divorce. 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 Illinois 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. 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 Persons who are Elderly Waiver
Before You Apply
Prior to submitting an application for the Persons who are Elderly 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 HCBS Waiver for Persons who are Elderly Waiver is not an entitlement program, there may be a waitlist for program participation. The waiver is approved for a maximum of approximately 85,000 beneficiaries per year. In the case of a waitlist, it is thought that an applicant’s access to a participant slot is based on the date of Medicaid application.
To apply for the Persons who are Elderly Waiver, one must apply for IL Medicaid. This can be done via one’s local Department of Human Services’ Family Community Resource Center (FCRC). One can find their local office here. Alternatively, persons can apply online via the ABE (Application for Benefits Eligibility) portal here. As part of the application process the Department on Aging will arrange an in-person needs assessment to determine if the nursing home level of care need is met.
For additional information about the Elderly Waiver, click here. Persons can also contact the Senior Helpline at 1-800-252-8966 or their local Area Agency on Aging (AAA). Contact information for AAA’s by area can be found here.
The Illinois Department of Healthcare and Family Services (HFS) and the Illinois Department on Aging (IDoA) administer the Persons who are Elderly Waiver.
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.