Overview of the Community Options Waiver
The Maryland Home and Community Based Options Waiver (HCBOW), also called the Community Options Waiver, provides home and community-based services (HCBS) for Maryland residents who are elderly and disabled, require assistance with their Activities of Daily Living (ADLs), and are at risk of nursing home admittance. ADLs include bathing, grooming, dressing, toileting, mobility, transitioning, and eating. Intended to prevent and / or delay the need for nursing home care, the program provides assistance and supports to promote independent living or to supplement care that is already being provided by informal (unpaid) caregivers. Potential benefits include adult day health care, respite care, and personal care assistance and homemaker services in assisted living residences.
Many Waiver programs offer a participant-directed option, allowing program beneficiaries to select their own caregivers, including friends and relatives. The Community Options Waiver does not. Waiver services are provided by licensed agency providers.
Services can be received in one’s home, the home of a loved one, or an assisted living residence. The Community Options Waiver will not cover the assisted living room and board cost. It is thought that one cannot reside in an adult foster care home and receive Waiver services.
The Community Options Waiver is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. The Waiver has a limited number of participant enrollment slots, and currently these slots are full. Therefore, there is a statewide waitlist (a waiver services registry) to apply for this program. There is one exception. Persons receiving Medicaid-funded nursing home care can still apply.
Maryland’s Community Options Waiver, which persons might see abbreviated as the CO Waiver, is formerly called the Maryland Home and Community Based Options Waiver (HCBOW) It is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. This waiver was previously called the Waiver for Older Adults. Medicaid in Maryland is called Medical Assistance (MA).
Benefits of the Community Options Waiver
Follows is a list of long-term services and supports available via the Community Options Medicaid Waiver. An individual care plan determines which services and supports a program participant receives.
– Adult Day Health Care / Medical Day Care – daytime supervision and care, including nursing services, in a community group setting
– Assisted Living Services – i.e., personal care assistance, homemaker services, and medication management in an assisted living facility
– Behavior Consultation Services – to assist a program participant’s caregiver in understanding and managing behavioral issues.
– Case Management
– Day Habilitation / Senior Center Plus – a structured program, usually in a senior center, that provides care and supervision, socialization, and activities. Unlike with Adult Day Health Care, medical services are not provided.
– Family Training – training and counseling for unpaid family caregivers
– Nutritionist / Dietician Services
– Respite Care – short-term, out-of-home care to relieve a primary caregiver
Persons eligible for the Community Options Waiver may also be able to receive other Medicaid services, such as physician visits, hospitalization, home health care, laboratory services, durable medical equipment, and disposable medical supplies. Additional long-term services and supports via the Community First Choice Program might also be available to Waiver participants. This may include in-home personal care assistance, home modifications, personal emergency response systems, nurse monitoring, home delivered meals, transition services to assist with moving from a nursing home back home, and more.
While services may be provided in an assisted living residence, the cost of room and board is not covered by the Community Options Waiver.
Eligibility Requirements for Maryland’s Community Options Waiver
The Community Options Waiver is for Maryland residents who are elderly (aged 65+) or younger (aged 18-64) if physically disabled and at risk of nursing home placement. Persons who are disabled who enroll prior to turning 64 years old can continue to receive Waiver services upon turning 65. Additional eligibility criteria are as follows below.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases annually in January. In 2023, an applicant, regardless of marital status, can have a monthly income up to $2,742. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,742 / 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. 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.
There is a minimum income allowance, set at $2,288 / month (eff. July 2022 – June 2023). This allows an applicant spouse to supplement their non-applicant spouse’s monthly income, bringing their income up to this amount. There is also a maximum income allowance, which in 2023, is $3,715.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount above the minimum income allowance is dependent on one’s shelter and utility costs. A Spousal Income Allowance, however, can never push a non-applicant’s total monthly income over $3,715.50.
In 2023, 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 retain up to $2,000 in assets and the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance.
The CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $148,620. If the non-applicant’s share of assets falls under $29,724, they can keep 100% of the assets, up to $29,724.
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 MD considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “Intent” to Return home, and in 2023, their home equity interest is no greater than $688,000. 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 who lives in the home.
– The applicant has a minor child who lives in the home.
– The applicant has a disabled relative who lives in the home.
Medical Criteria: Functional Need
An applicant must require a Nursing Facility Level of Care (NFLOC). For the Community Options Waiver, the assessment tool used to make this level of care determination is the interRAI Home Care (HC). This assessment contains twelve categories relative to daily living. Points are assigned based on the amount and level of assistance required. The higher the score, the greater the level of care need. Several categories are Activities of Daily Living (ADLs), which are essential for day-to-day functioning, and include mobility, eating, toileting, bathing, and dressing / grooming. Relevant to many persons with Alzheimer’s disease or a related dementia, cognition, such as decision making ability, memory, and comprehension, are also considered. 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 MD 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.
Maryland 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, 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. For married couples with a significant amount of “excess” assets, Medicaid Divorce is an option. There are many other 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 Maryland to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning techniques 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 Maryland’s Community Options Waiver
Before You Apply
Prior to submitting an application for the Community Options 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.
As mentioned previously, the Community Options Waiver is not an entitlement program and there is a waitlist for program participation. This Waiver is approved for a maximum of approximately 6,348 beneficiaries per year. Priority is given to nursing home residents who can transition to community living with Waiver services.
Currently, applications for the Community Options Medicaid Waiver are only being accepted for persons who are currently receiving Medicaid-funded nursing home care and have received such care a minimum of 30 days. To apply, nursing home residents (or their representative), should call MD Medicaid’s Office of Long Term Services and Support at 877-463-3464 or 410-767-1739.
Persons living in the community can call the Maryland Access Point (MAP) at 1-844-627-5465 to be screened and added to the registry (waitlist). As participant slots become available, persons will be contacted by the Maryland Department of Health to let them know they can apply.
Additional information about the Community Options Waiver can be found here. Persons can also contact their local Maryland Access Point (MAP), or alternatively, they can call 1-844-627-5465. The Maryland Department of Health’s (MDH) Office of Long Term Services and Support administers the Community Options Waiver
Approval Process & Timing
The Maryland 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. 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, as an extensive waitlist for persons living in the community exists, persons might spend many years waiting to receive benefits from the Community Options 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.