Overview of Ohio’s Assisted Living Waiver
Ohio’s Assisted Living Waiver provides long-term care in residential care facilities / assisted living residences for elderly or physically disabled adults who require assistance with daily living activities, such as bathing, personal hygiene, putting on / removing clothing, and using the bathroom. Services provided in these homelike environments prevent and / or delay the need for nursing home care and include meals, housecleaning, laundry, around-the-clock staff response, and personal care assistance. For nursing home residents who can reside in an assisted living residence with services via this waiver, assistance obtaining necessary home furnishings is provided. Furthermore, some assisted living residences have memory care units, which offer specialized care for persons with Alzheimer’s disease or a related dementia.
This waiver program is not an entitlement, 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 waitlist is not statewide. Rather, each residential care facility maintains its own waitlist.
Medicaid will not cover the cost of room and board in the assisted living residence. Not all assisted living residences in Ohio will accept Medicaid as a payer, meaning not all residences participate in this program.
The Assisted Living Waiver is a 1915(c) HCBS (Home and Community Based Services) Medicaid 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.
Benefits of the Assisted Living Waiver
Follows is a list of the benefits available via the Assisted Living Medicaid Waiver.
– 24-hour Staff Response
– Meals / Snacks
– Social / Recreational Activities
– Personal Care Assistance – help with bathing, dressing, eating, mobility, etc.
– Homemaker / Chore Services
– Medication Management
– Nursing Care
– Non-Medical Transportation
– Community Transition – assists persons moving from a nursing home to an assisted living residence with essential items, such as household furnishings
Medicaid will not cover the cost of room and board in the assisted living residence. Program participants must be able to pay this cost.
Eligibility Requirements for Ohio’s Assisted Living Waiver
The Assisted Living Waiver is for Ohio residents who are elderly (65+), or between 21 and 64 years old and physically disabled, that are at risk of nursing home placement. Persons must be willing to live in a residential care facility approved by the program. 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 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. 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 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 $3,259.50 / month are not entitled to a spousal income allowance.
Program participants must be able to pay the monthly cost of room and board. This cost is equivalent to the current FBR ($794.00) minus $50 as a personal needs allowance. In 2021, this puts the room and board cost at $744.00 / month. ($794.00 – $50.00 = $744.00) Income in excess of this amount, minus a spousal allowance if applicable, must be paid to the assisted living residence towards the cost of care.
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 Medicaid will take their home. Fortunately, for eligibility purposes, Medicaid considers the home exempt (non-countable) in Ohio 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.
– The applicant’s spouse lives in the home.
– The applicant has an adult child (over 21 years of age) who is blind or disabled and living in the home.
– The applicant has a child under 21 years old 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 Assisted Living Waiver, the tool used to determine if this level of care need is met is the Adult Comprehensive Assessment Tool (ACAT). Generally, the necessity of supervision or assistance with completing the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating) and assistance with instrumental activities of daily living (i.e., preparing meals, grocery shopping, accessing transportation, etc.) indicates one requires this level of care. While persons with Alzheimer’s disease or a related dementia might meet the functional need for care, 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 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. Medicaid asset protection trusts are another option that protects assets from Medicaid’s asset limit. 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.
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 Ohio 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 for family as inheritance. These strategies protect assets from Medicaid’s estate recovery program, but often violate Medicaid’s 60-month look back rule. Therefore, they 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 Ohio’s Assisted Living Waiver
Before You Apply
Prior to submitting an application for the Assisted Living 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 Assisted Living Waiver is not an entitlement program, there may be a waitlist for program participation. The waiver is approved for an approximate maximum of 5,583 beneficiaries per year. In the case of a waitlist, an applicant’s access to a participant slot is based on the assisted living facility and the date of Medicaid application.
To enroll in the Assisted Living Waiver, an applicant must apply and be approved for Ohio Medicaid. Persons can apply online here at Ohio Benefits. Persons can also apply via their local County Department of Job and Family Services (CDJFS) Office. Contact information can be found here. Alternatively, persons can call the Consumer Helpline at 1-844-640-6446 (OHIO). On the application there is a question asking, “Are you requesting waiver/long-term care or nursing home care”. It is important that one responds “yes” to this question.
A list of Medicaid-approved residential care facilities in one’s county are maintained by their local area agency on aging (AAA) office. AAA contact information can be found here, or alternatively, persons can call 1-866-243-5678. As mentioned previously, any waitlist is facility specific. Therefore, it is suggested that applicants contact several facilities in their area to determine if there is a waitlist, and if so, the approximate wait time for admission. Some facilities require a resident pay privately for several months or even years prior to accepting Medicaid as a payment. Therefore, it is essential to enquire about this as well.
Once an assisted living residence is found and a Medicaid application submitted, one should contact their local AAA to schedule a functional needs assessment. For additional information about the Assisted Living Waiver, click here.
The Ohio Department of Medicaid and the Ohio Department of Aging administer the Assisted Living Medicaid Waiver. Residential care facilities are licensed by the Ohio Department of Health and certified by the Ohio Department of Aging.
Approval Process & Timing
The 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.