Overview of the MassHealth Frail Elder Waiver
The Frail Elder Waiver (FEW) provides a wide variety of home and community-based services (HCBS) for elderly Massachusetts residents who are at risk of being institutionalized (being placed in a nursing home). Long-term services and supports received are specific to the needs and circumstances of the program participant. For example, in-home personal care assistance, homemaker services, a personal emergency response system, and a medication dispensing system might be approved for a senior who lives alone to promote independent living. In contrast, a program participant living with an informal family caregiver might be eligible for respite care, such as adult day care. Specific to persons with Alzheimer’s disease or a related dementia, a program participant may be eligible to receive a home based wandering response system.
Program participants can receive services in their home, the home of a relative or caregiver, an adult foster care home, or in congregate housing (shared living). Services cannot be provided in institutional or residential settings, such as nursing home facilities, assisted living residences, or rest homes (similar to assisted living), with the exclusion of short term respite care.
Many long-term care Medicaid programs allow program participants the option of self-directing their own care. This generally means hiring the caregiver of their choosing to provide personal care services. Unfortunately, this is not an option through the Frail Elder Waiver.
Program participants do have the option of enrolling in MassHealth Senior Care Options (SCO), a managed care program, and receiving their long-term care waiver services and supports via a managed care organization (MCO). Program participants who are “dual eligible”, meaning eligible for both Medicaid and Medicare, can receive benefits from both programs via SCO.
The Frail Elder 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.
The Frail Elder Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid waiver. Medicaid in Massachusetts is called MassHealth.
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 MassHealth Frail Elder Waiver
Follows is a list of the benefits available via the MassHealth Frail Elder Waiver. A “comprehensive service plan” will determine which services and supports a program participant will receive. With the exception of case management, no waiver service is an entitlement. This means meeting waiver requirements does not guarantee receipt of all services and supports.
– Alzheimer’s & Dementia Coaching – educational services and supports for persons with dementia (and their caregivers) for successful home and community living.
– Chore Services – minor home repairs, window washing, moving heavy furniture, etc.
– Companion Care – companionship, supervision, and minimal assistance with some household tasks, such as preparing meals and doing laundry
– Complex Care Training and Oversight – intermittent management of medications and development / management of Home Health Aide Plan of Care
– Evidence Based Education Programs – to help program participants better manage chronic conditions
– Goal Engagement Program – individualized services to increase a program participant’s safety and independence
– Grocery Shopping / Delivery
– Home Based Wandering Response Systems
– Home Delivery – prepared meals and pre-packaged medications
– Home Health Aides – healthcare and personal care assistance
– Home Safety / Independent Evaluations – in-home evaluation by an occupational therapist
– Homemaker Services – essential shopping, meal preparation, laundry, etc.
– Home Modifications – may include wheelchair ramps, grab bars, widening of doorways, etc.
– Medication Dispensing Systems
– Orientation / Mobility Services – for persons who are legally blind or vision impaired
– Peer Support – for persons with a behavioral health diagnosis
– Personal Care Services – non-medical assistance with personal hygiene, bathing, dressing, toileting, medication reminders, preparing meals, etc.
– Personal Emergency Response Services – Cellular Personal Emergency Response System, which may include fall detection
– Respite Care – in-home and out-of-home short-term care to alleviate a primary caregiver. Out-of-home respite care may be provided in several settings, such as adult day health care, adult foster care, and assisted living.
– Supportive Day Program – for program participants with a chronic illness or recovering from a serious illness / injury
– Supportive Home Care Aides – personal care assistance, homemaker services, and emotional support for persons with dementia
– Transitional Assistance – assistance with security deposits, utility set-up fees, moving expenses, etc. for program participants transitioning from a nursing home to a private home
– Transportation – medical and non-medical
Eligibility Requirements for the MassHealth Frail Elder Waiver
The Frail Elder Waiver is for Massachusetts residents who are elderly (65+) or younger (60-64) if physically disabled and at risk of nursing home placement. Additional eligibility criteria are as follows.
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 2022, an applicant, regardless of marital status, can have a monthly income up to $2,523. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,523 / 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. While the non-applicant spouse of a waiver applicant generally is entitled to a monthly maintenance needs allowance from their applicant spouse, MA is unique and does not extend this spousal income allowance to non-applicant spouses. This is because applicant spouses are able to retain all of their monthly income instead of contributing their income towards their cost of care.
In 2022, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $2,000 in assets. 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 $137,400. 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, Massachusetts 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 $955,000 in 2022. 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 21 years old living in the home.
– The applicant has a blind or disabled child living in the home.
To learn more about the potential of MassHealth taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC). For the Frail Elder Waiver, the tool used to determine if this level of care need is met is the Comprehensive Data Set (CDS). An applicant’s ability to independently complete activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is one area of consideration. Examples of ADLs and IADLs include personal hygiene, mobility, dressing, meal preparation, and housework. Relevant to persons with Alzheimer’s disease or a related dementia, cognitive deficits, such as memory, decision making, and judgment, 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 MassHealth’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.
Massachusetts 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” can be thought of as a deductible. Once one’s “deductible” has been met, the Frail Elder Waiver 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. There are many other options when the applicant has assets exceeding the limit. In the case where a couple has a significant amount of “excess” assets, a Medicaid divorce might be considered.
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 Massachusetts 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 MassHealth Frail Elder Waiver
Before You Apply
Prior to submitting an application for the Frail Elder 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 Frail Elder Waiver is not an entitlement program, there may be a waitlist for program participation. FEW is approved for a maximum of approximately 19,200 beneficiaries per year. In the case of a waitlist, it is thought an applicant’s access to a participant slot is based on the date of Medicaid application.
To apply for the Frail Elder Waiver, applicants must be eligible for MA Medicaid / MassHealth. To apply for MassHealth, seniors must complete the Application for Health Coverage for Seniors and People Needing Long-Term Care Services, which can be found here. The completed application can be mailed, faxed, or dropped off at the MassHealth Enrollment Center. The fax number and addresses can be found on the application.
A functional assessment is required as part of the application process for FEW. Applicants should contact their local Aging Services Access Point (ASAP) to initiate the assessment and enroll in FEW. A list of ASAPs and the areas they serve can be found here. Alternatively, persons can contact the MassOptions call center at 1-800-243-4636 for local ASAP contact information.
For additional information about the Frail Elder Waiver, click here. Persons can also contact their local ASAP agency or the MassHealth Customer Service Center at 1-800-841-2900. The Massachusetts Executive Office of Elder Affairs (EOEA) administers the Frail Elder Waiver.
Approval Process & Timing
The MassHealth / 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.