MassHealth (Massachusetts Medicaid) Frail Elder Waiver (FEW)

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. A program participant living with an informal family caregiver, however, might be eligible for respite care, such as adult day care. Specific to persons with Alzheimer’s disease or a related dementia, a home based wandering response system might be ideal.

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.

FEW services may be provided by licensed agency workers, or alternatively, program participants have the option to self-direct some of their services. This participant-directed option allows the hiring of a relative or friend to provide companion and homemaker services. While one’s adult child can be hired, a spouse or other legally responsible person cannot be hired. A financial management services agency handles the financial aspects of employment responsibilities, such as background checks, tax withholding, and caregiver payments.

Elderly program participants (aged 65+) 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; meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, there are a limited number of participant enrollment slots, and when they 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.

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” determines which services and supports a program participant receives. With the exception of case management, no waiver service is an entitlement. This means meeting waiver eligibility 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
– Assistive Technology – for Telehealth. Also Electronic Comfort Animals.
– 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 / Independence 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.
– Laundry
– 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 (aged 65+) or younger (aged 60-64) if physically disabled and at risk of nursing home placement. Additional eligibility criteria are as follows.

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases annually in January. In 2024, an applicant, regardless of marital status, can have a monthly income up to $2,829. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,829 / 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. 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.

Assets
In 2024, 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 still limited. This is because all assets of a married couple are considered 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 (CSRA) to prevent spousal impoverishment.

The CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $154,140. If 50% of the couple’s assets falls under $30,828, the non-applicant spouse can keep all of the couple’s assets, up to $30,828.

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. Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. 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 home, and in 2024, their home equity interest is no greater than $1,071,000. 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 child under 21 years old who lives in the home.
– The applicant has a blind or disabled child of any age who lives in the home.

While the home is likely exempt while one is receiving Medicaid benefits, it may not be safe from Medicaid’s Estate Recovery Program. Learn more about the potential of MassHealth taking the home 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 these activities 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 Medically Needy 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 for the remainder of the spend-down period.

When persons have assets over the limit, Irrevocable Funeral Trusts (IFTS) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are Medicaid-Compliant Annuities, which turn countable assets into a stream of income. There are many other options when the applicant has assets exceeding the limit. If 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 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 Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, bank statements up to 60-months prior to application, and proof of income. 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 20,000 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.

Application Process

To apply for the Frail Elder Waiver, applicants must be eligible for MA Medicaid / MassHealth. Seniors can apply for MassHealth online or print the Application for Health Coverage for Seniors and People Needing Long-Term Care Services. 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. See a list of ASAPs and the areas they serve. Alternatively, persons can contact the MassOptions Call Center at 1-800-243-4636 for local ASAP contact information

Learn more about the Frail Elder Waiver. They 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. 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, if a waitlist exists, approved applicants may spend many months or longer waiting to receive benefits.