Overview of Louisiana’s Adult Day Health Care Waiver
Louisiana’s Adult Day Health Care Waiver, abbreviated as ADHC, provides daytime care and supervision in a community-based setting for elderly and disabled persons who at risk of institutionalization (being placed in a nursing home). Adult day health care facilities provide nursing services, medication management, assistance with activities of daily living (i.e., using the toilet, walking, and eating), and in some cases, transportation to and from the facility. The ADHC Waiver also provides transitional services for persons who are currently residing in a nursing home and wish to move back into the community. Amongst other expenses, this benefit will cover the cost of one’s security deposit and necessary household furnishings. For families who serve as informal caregivers of a loved one, adult day health care can serve as respite care, allowing them a break from caregiving duties.
Adult day health care centers may be a standalone facility or affiliated with an assisted living residence, nursing home, or senior center. It is thought that a program participant is able to choose which adult day care center to attend based on the availability of facilities in one’s area.
Program beneficiaries can reside in their own home or the home of a loved one. It is unclear as to if a program participant can reside in an adult foster care home or an assisted living residence.
ADHC 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 waiting list for program participation forms. This waiting list is called a Request for Services Registry.
The Louisiana Adult Day Health Care Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid waiver. Medicaid in Louisiana is called Healthy Louisiana.
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 Adult Day Health Care Waiver
While adult day health care facilities generally provide daytime care on weekdays, some facilities may offer evening and / or weekend hours. Follows is a list of potential supports.
– Activities – i.e., recreational, social
– Case Management / Support Coordination
– Exercise Program – individualized
– Health / Nutrition Counseling
– Meals / Snacks – includes specialized diets
– Medication Management
– Nursing Services – i.e., monitoring of vital signs, medication administration
– Personal Care Assistance – assistance with toileting, mobility, grooming, eating
– Transition Services – assists persons approved for the ADHC Waiver in transitioning from a nursing home to a private home. May include security deposits, utility set-up fees, and essential furnishings.
– Transportation – to and from the facility and one’s home
Eligibility Requirements for Louisiana’s Adult Day Health Care Waiver
The ADHC Waiver is for Louisiana Residents who are elderly (65+) or younger (18-64) if physically disabled and at risk of nursing home placement. Disabled persons who enroll prior to turning 65 can continue to receive waiver services upon turning 65. Additional eligibility criteria are as follows below.
Financial Criteria: Income, Assets & Home Ownership
The 2021 applicant income limit, which increases on an annual basis in January, is set at $2,382 / month. 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 $3,259.50 / month (effective January 2021 – December 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 LA 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 spouse lives in the home.
– The applicant has a minor child (under 21) living in the home.
– The applicant has a blind or disabled 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 Adult Day Health Care Waiver, the assessment tool used to determine if this level of care need is met is the Minimum Data Set for Home Care (MDS-HC). There are several factors that are considered when determining this level of care need. This includes an applicant’s ability / inability to independently complete their activities of daily living (ADLs) (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating), unstable medical conditions, the need for rehabilitation therapies, and cognitive issues, such as short term memory deficiencies and difficulties making day-to-day decisions, which are commonly seen in persons with Alzheimer’s disease or a related dementia. However, 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 Healthy Louisiana’s / 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.
Louisiana has a Medically Needy Spend-Down Program for applicants who have high medical expenses relative to their income. Via this 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.
When persons have assets over the limits, Irrevocable Funeral Trusts are an option. These are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” countable assets in other ways in which they are not counted towards Medicaid’s asset limit. This includes making home accessibility modifications, updating the heating and plumbing systems in one’s home, and purchasing personal items, such as clothing. There are many other options when the applicant has assets exceeding the limit. Furthermore, some strategies will protect one’s home from Medicaid’s estate recovery program, allowing it to be preserved for family as inheritance.
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 Louisiana to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. While there are a variety of planning strategies, some do 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, such as Medicaid Half-a-Loaf, and Medicaid planners are aware of them. For all of these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid / Healthy Louisiana when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for Louisiana’s Adult Day Health Care Waiver
Before You Apply
Prior to submitting an application for the ADHC 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.
The Adult Day Health Care Waiver is not an entitlement. Although the program is approved for a maximum of approximately 935 beneficiaries each year, a waiting list exists. It is formally called the ADHC Waiver Request for Services Registry. An applicant’s access to a participant slot is based on priority. Priority is given in the following order: Persons with a referral from protective services who would otherwise require nursing home placement due to abuse or neglect, persons who have been hospitalized for a minimum of one night within the past 30 days, persons in Medicaid-funded nursing homes, and all other persons by date of request for services.
To apply for the Adult Day Health Care Waiver, applicants should call the Louisiana Options in Long Term Care at 877-456-1146. The state maintains a waiting list for this program, and therefore, applicants’ names will be added to the ADHC Waiver Request for Services Registry.
For more information about the Adult Day Health Care Waiver, click here. Alternatively, applicants can call 877-456-1146 and direct questions to Louisiana Options in Long Term Care. The Louisiana Office of Aging and Adult Services (OAAS) within the Department of Health operates the Adult Day Health Care Waiver.
Approval Process & Timing
The Medicaid / Healthy Louisiana 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 a waiting list exists, approved applicants may spend many months waiting to receive benefits.