Overview of the Structured Family Caregiving Waiver
The Missouri Structured Family Caregiving Waiver (SFCW) provides assistance for physically or cognitively impaired adults with Alzheimer’s Disease or related dementias who are at risk of institutionalization (nursing home care), but can live at home with long-term care services. Via SFCW, which can loosely be thought of as adult foster care, informal (unpaid) relative and non-relative live-in caregivers can receive financial support to provide supervision and assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs and IADLs include activities such as bathing, dressing, light housecleaning, laundry, shopping for essentials, and meal preparation.
Many Medicaid waiver programs offer a participant-directed option, allowing program beneficiaries to become the “employer” of a chosen caregiver, meaning they have the responsibility of hiring, training, managing, and even firing their caregiver. SFCW does not allow this option. However, a program participant’s current informal caregiver is the one who becomes a paid caregiver via SFCW. So in this regards, the program participant has already chosen the person from which care is provided. SCFW offers great flexibility, as even a spouse or legal guardian can be paid to provide care. Caregivers are employed and paid by a Structured Family Caregiving provider agency enrolled with the Missouri Department of Social Services (DSS).
Program participants and caregivers must live in the same home full time. This could mean the program participant moves into the private home of the caregiver or the caregiver moves into the program participant’s personal home. To be clear, program participants cannot live in any type of facility, group home, or boarding home. This includes an assisted living residence.
SFCW 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 Missouri Structured Family Caregiving Waiver is a new 1915(c) Home and Community Based Services (HCBS) Medicaid waiver program that began in July of 2021. Medicaid in Missouri is called MO HealthNet.
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 Structured Family Caregiving
In addition to case management, follows is a list of the benefits available via the Structured Family Caregiving Waiver.
– Attendant Care / Personal Care – assistance with bathing, dressing, grooming, personal hygiene, toileting, transitioning, mobility, eating
– Escorting Services / Transportation
– Homemaker Services – assistance with housecleaning, laundry, preparation of meals, shopping for essentials
– Medication Management
Eligibility Requirements for MO HealthNet Structured Family Caregiving Waiver
The Structured Family Caregiving Waiver is for Missouri residents who are 21+ years old who have been diagnosed with Alzheimer’s Disease or a related disorder. They must already have a live-in caregiver, who will continue to serve as their caregiver upon authorization to be paid via SCFW. Additional eligibility criteria are as follows and is relevant for seniors 65+ years of age.
Financial Criteria: Income, Assets & Home Ownership
The 2021 applicant income limit, which increases on an annual basis in April, is set at $913 / month. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $913 / 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. There is a minimum income allowance, set at $2,177.50 / month (effective July 2021 – June 2022), which is intended to bring a non-applicant spouse’s monthly income up to this amount. There is also a maximum income allowance, which is $3,259.50 / month (effective January 2021 – December 2021), and is dependent on the non-applicant spouse’s shelter and utility costs. This monthly maintenance needs allowance is intended to ensure the non-applicant spouse does not become impoverished.
In 2021, the asset limit is $5,035 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $5,035 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 $5,035 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 / MO HealthNet ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that MO 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 years old) living in the home.
– The applicant has an adult child (21+) who is blind or disabled (permanently and totally) 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 Structured Family Caregiving Waiver, the tool used to make this determination is the InterRAI HC (Home Care). 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 MO HealthNet’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.
When persons have income over the limits, Miller Trusts, also called a qualified 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. Another option are Medicaid Asset Protection Trusts in which assets are placed and no longer considered owned by the Medicaid applicant. While assets are not counted towards Medicaid’s asset limit and are also protected for family as inheritance, this option violates Medicaid’s 60-month look back rule. Therefore, it should be implemented 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 Missouri 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. While these strategies commonly violate the look back rule, there are some workarounds, such as the Modern Half a Loaf, 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 MO HealthNet Structured Family Caregiving Waiver
Before You Apply
Prior to submitting an application for SFCW, 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 Structured Family Caregiving Waiver is not an entitlement program, there may be a waitlist for program participation. The waiver is approved for a maximum of 300 beneficiaries each year. In the case of a waitlist, an applicant’s access to a participant slot is based on the date of referral to the program.
To apply for the Structured Family Caregiving Medicaid Waiver, persons must be eligible for MO HealthNet. Applicants can apply online at myDSS, over the phone at 1-855-373-4636, or at one’s local family support resource center. Persons can find their local office here. In addition to the Application for Health Coverage & Help Paying Costs, applicants must complete the Aged, Blind, and Disabled Supplement form.
Persons already enrolled in MO HealthNet should contact MO’s Division of Senior and Disability Services (DSDS) at 1-866-835-3505 to initiate the process of applying for SFCW.
For additional information about SFCW, click here. The Division of Senior and Disability Services (DSDS) within the Missouri Department of Health and Senior Services (DHSS) administers the MO Structured Family Caregiving Waiver.
Approval Process & Timing
The Medicaid / MO HealthNet 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.