Oregon Health Plan (Medicaid) Aged & Physically Disabled (APD) Waiver

Last updated: October 20, 2021

 

Overview of Oregon’s Aged and Physically Disabled Waiver

The Aged and Physically Disabled Waiver (APD Waiver) assists elderly and physically disabled Oregon nursing home residents in moving back home or to another community setting, such as an assisted living residence or an adult foster care home. In addition to case management services to assist in the transition, assistance may be provided in finding housing and ensuring it is a safe living environment. Furthermore, the cost of security deposits, utility set-up fees, and essential household items, such as furniture and kitchenware, may be covered.

The APD Waiver also used to provide a variety of home and community based services, such as home modifications, home delivered meals, and assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs and IADLs include activities such as bathing, dressing, mobility, toileting, eating, meal preparation, light housecleaning, and laundry. However, with the approval of the state’s Community First Choice Option / K Plan, many of these previously available benefits are now available under the K Plan. APD program participants can simultaneously receive home and community based services via the K Plan.

Many waiver programs offer a participant-directed option, allowing program beneficiaries to select their own providers, including friends and relatives. The APD Waiver does not. However, program participants who simultaneously receive home and community based services via Community First Choice / K Plan are able to hire the caregiver of their choosing. This may include an adult child or potentially even a spouse.

 Persons who receive assistance via the APD Waiver can also receive home and community based services via Oregon’s Community First Choice Option / K Plan. Other options of Medicaid-funded long-term care in Oregon include the Independent Choices Program (ICP), the Client-Employed Provider Program (CEP), and the Spousal Pay Program, all of which allow a spouse to be hired to provide care. Via ICP and CEP, other family members, such as adult children, and friends can also be hired as the caregiver.

The APD Waiver is not an entitlement program. This 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 Aged and Physically Disabled Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid waiver. This waiver might also go by the name of Aging and People with Disabilities Waiver.

 What are 1915(c) HCBS Medicaid Waivers?
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 Aged and Physically Disabled Waiver

The following benefits are available via the APD Waiver.

– Case Management
– Housing Support Services – i.e., assistance with searching for housing, ensuring it provides a safe environment, and the housing application process
– Transition Services – assists persons in transitioning from a nursing home to a private home. May include security deposits, utility set-up fees, and essential furnishings.

While the ADP Waiver can assist persons in transitioning to an assisted living residence or an adult foster care home, the program does not cover the cost of room and board in these settings.

 

Eligibility Requirements for Aged and Physically Disabled Waiver

The APD Waiver is for Oregon residents who are elderly (65+), or between the ages of 18 and 64 and physically disabled, who reside in a nursing home and wish to return to the community. Additional eligibility criteria are as follows below.

 The American Council on Aging provides a quick and easy Medicaid eligibility test for Oregon seniors requiring ongoing assistance. Start here

 

Financial Criteria: Income, Assets & Home Ownership

Income
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.

In Oregon, there is a minimum income allowance, which is set at $2,177.50 / month (effective July 2021 – June 2022). This 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. To be clear, a non-applicant spouse’s own monthly income combined with the income allowance from the non-applicant spouse cannot exceed $3,259.50.

Assets
In 2021, 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 $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.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator

Home Ownership
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 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 disabled or blind child (any age) living in the home.
– The applicant has a minor child (under 21) 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 APD Waiver, the tool used to determine if this level of care need is met is the Client Assessment and Planning System (CAPS). An applicant’s ability to complete activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, bathing) and instrumental activities of daily living (i.e., housekeeping, medication management, shopping, laundry) are assessed. Relevant to some persons with Alzheimer’s disease or a related dementia, behavioral problems, such as regular attempts to leave the facility or removal of one’s clothes, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC. A service priority level is generated during the assessment process. There are 18 levels, with 1 being the highest level of assistance required and 18 the least. For the APD Waiver, an applicant must receive a service priority level between 1 and 13.

 For more information about long-term care Medicaid in Oregon, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for OR Medicaid / Oregon Health Plan. 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, they can “spend down” excess assets on ones that are exempt (not counted). While this includes purchasing clothing and home furnishings, irrevocable funeral trusts (IFTs) are another option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. 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 Oregon 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 Oregon’s Aged and Physically Disabled Waiver

Before You Apply

Prior to submitting an application for the Aged and Physically Disabled 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 APD Waiver is not an entitlement program, there may be a waitlist for program participation. The waiver is approved for a maximum of approximately 38,589 beneficiaries. In the case of a waitlist, it is thought an applicant’s access to a participant slot is based on service priority level. In some cases, persons who submitted an application at a later date than other applicants may be awarded a participant slot first if their needs are greater.

 

Application Process

To apply for the APD Waiver, applicants must be eligible for OR Medicaid / Oregon Health Plan. The Application for Oregon Health Plan Benefits can be found here. Alternatively, a paper application can be requested by calling OHP Customer Service at 800-699-9075. Persons can also apply online here.

Although very technical and not intended for a consumer audience, additional information about the APD Waiver can be found here. Persons can also contact their local AAA (Area Agency on Aging) or Aging and People with Disabilities office. Contact information can be found here. The Oregon Health Authority (OHA) administers the HCB Waiver, and the Oregon Department of Human Services (ODHS) operates it.

 

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. 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 a wait-list may exist, approved applicants may spend many months waiting to receive benefits.

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