Overview of Indiana’s Aged and Disabled Waiver
The Aged and Disabled (A&D) Waiver from Indiana Medicaid (Hoosier Care) provides home and community-based services (HCBS) for elderly, blind, and disabled Indiana residents who are at risk of being institutionalized (being placed in a nursing home). The available long-term services and supports are many and the exact benefits that program participants receive are based on their needs and circumstances. Benefits may include in-home personal care assistance, adult day care, home modifications for safety and accessibility, personal emergency response systems, and homemaker services. Assistance with security deposits and utility set-up fees for persons who wish to move back home or to another community living setting from a nursing home facility is also available.
Some services, such as attendant care, can be participant-directed via the Aged and Disabled Medicaid Waiver. Persons may hear this option referred to as Self-Directed Attendant Care or the Consumer Directed Attendant Care (CDAC) Program. Participant-directed care allows program participants to hire the caregiver of their choosing to provide personal care assistance and help with other daily living activities, such as mobility and preparation / cleanup of meals. While relatives, such as adult children can be hired, spouses and persons legally responsible for the program participant cannot be hired as the caregiver. Persons who cannot self-direct their own care can choose someone to do so on their behalf. A financial management services agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.
Services can be received in one’s home, the home of a loved one, an adult family care home (adult foster care), or an assisted living residence. However, this waiver program will not cover the cost of room and board in these settings.
The A&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 are transitioning back to community living via a demonstration grant called “Money Follows the Person”.
Indiana’s Aged & Disabled Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. In IN, the Medicaid program is also called Indiana Health Coverage Programs (IHCP).
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 Aged and Disabled Waiver
Follows is a list of the benefits available via the Aged and Disabled Medicaid Waiver. An individual care plan will determine which services and supports a program participant will receive.
– Adult Day Health – provides daytime supervision and assistance in a community group setting
– Adult Family Care (Adult Foster Care) Services – program participants live with an unrelated caregiver. Up to 4 care recipients can live in the same home.
– Assisted Living Services
– Attendant Care – hands on assistance with activities of daily living
– Case Management
– Community Transition Services – for persons moving home from a nursing home facility – will cover the cost of security deposit fees, utility set-up fees, essential furnishings, etc.
– Home Delivered Meals
– Home Modifications – i.e., grab bars, stair lifts, adaptive switches, wheelchair ramps, door alarms
– Home Modification Assessments
– Homemaker Services – assistance with housecleaning, laundry, preparing meals, essential errands, etc.
– Nutritional Supplements
– Integrated Health Care Coordination
– Participant Directed Home Care Service – health-related services for persons with chronic medical needs
– Personal Emergency Response Systems
– Pest Control
– Respite Care – to relieve a primary caregiver of caregiving duties
– Specialized Medical Equipment / Supplies – i.e., lift chairs, adult diapers, medication dispensers
– Structured Family Caregiving – the program participant lives with a caregiver, which may be a relative, but not a spouse or legal guardian.
– Transportation- non-medical
– Vehicle Modifications – i.e., wheelchair lifts, wheelchair hoist, raised roof
While services may be provided in an adult foster care home or assisted living, the cost of room and board is not covered by the A&D Waiver.
Eligibility Requirements for Aged and Disabled Waiver
The A&D Waiver is for Indiana residents who are elderly (65+) or younger if disabled that are at risk of nursing home placement. Additional eligibility criteria follow.
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 $3,260 / month (effective July 2021 – June 2021) 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 this amount 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 $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 in Indiana 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 spouse lives in the home.
– The applicant has a child under 18 years old living in the home.
– The applicant has a disabled or blind 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 A&D Waiver, a care manager from one’s local Area Agency on Aging (AAA) does the screening to determine one’s functional care need. In order to meet the NFLOC need, one of the following statements must be true for the applicant.
– Has an unstable physical condition that changes, requiring medical observation and assessment from a doctor
– Has a significant medical condition
– Requires direct assistance due to a medical condition that is unstable and complex, such as comatose condition, decubitus ulcers, or management of extremely bad pain
– Requires direct assistance with a ventilator, tube feeding, I.V., suctioning, or other medical equipment
– Requires direct assistance with treatments that are prescribed or require a special routine, like acute rehabilitation conditions, continuous oxygen administration, and tracheotomies
When considering NFLOC, an inability to independently complete the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) is a strong consideration. Furthermore, cognitive impairments, such as those commonly seen in persons with Alzheimer’s disease or a related dementia are also taken into account. To be clear, 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 IN 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 or qualifying 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. Medicaid asset protection trusts, which protect assets from being counted, can also be utilized, but must be created well in advance of the need for long-term care. 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 Indiana 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 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 Indiana’s Aged and Disabled Waiver
Before You Apply
Prior to submitting an application for the Aged 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 A&D Waiver is not an entitlement program, there may be a waitlist for program participation. This waiver is approved for a maximum of 31,855 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 one’s application.
To apply for the A&D Waiver, applicants must be eligible for IN Medicaid. Persons can apply for Medicaid by completing the Indiana Application for Health Coverage. This can be done online, over the phone at 1-800-403-0864, or in person at one’s local Division of Family Resources (DFR) office.
The functional assessment for A&D is completed by one’s local AAA (Area Agency on Aging) / Aging and Disability Resource Center, and as such, persons should contact their AAA office. Contact information can be found here. One’s local AAA office can also assist with the Medicaid application process.
For additional information about the A&D Waiver, click here. Indiana’s Family and Social Services Administration (FSSA) Division of Aging (DA) administers the A&D Medicaid Waiver.
Approval Process & Timing
The Indiana 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.