South Dakota Medicaid Home & Community Based Options and Person Centered Excellence (HOPE) Waiver

Overview of South Dakota’s HOPE Medicaid Waiver

South Dakota’s Home & Community Based Options and Person Centered Excellence Waiver, or HOPE Waiver, is a statewide Medicaid program for seniors and adults with disabilities who are at risk of institutionalization (nursing home admission). Intended to prevent premature nursing home admissions, a variety of long-term care benefits are available to assist persons in living as independently as possible. These services and supports might include adult day care, personal care services, homemaker services, and respite care. Transitional services, to assist persons in relocating to a less restrictive setting, such as from a nursing home to an assisted living residence or from assisted living to a private home, is also provided.

In addition to living at home or the home of a loved one, a program participant may live in an assisted living facility, a community living home, or a structured family caregiving home. A program participant cannot live in an adult foster care home.

Many long-term care Medicaid programs allow program participants the option of self-directing their own care, specifically hiring the caregiver of their choosing. Unfortunately, this is not an option through the HOPE Waiver. However, a friend or relative, including an adult child or spouse, may be hired to provide some care services if they are employed by a Medicaid provider agency.

South Dakota’s HOPE Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. It is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. The number of participant enrollment slots are limited, and when these slots are full, a waiting list for program participation forms.

Benefits of the HOPE Waiver

Follows is a list of home and community based services available via the HOPE Waiver. An individualized care plan determines which benefits a program participant receives.

– Adult Companion Services
– Adult Day Health Care
– Assisted Living Services
– Chore Services
– Community Living Home Services – allows up to 4 persons to live and receive care in a home-like setting
– Community Transition Coordination / Support – assists program participants in moving to a less restrictive environment
– Emergency Response Systems
– Home Delivered Meals
– Homemaker Services
– Home Modifications – i.e., wheelchair ramps, grab bars, widening of doorways
– Personal Care
– Nursing Services
– Nutritional Supplements
– Respite Care – residential and in-home care to relieve a primary caregiver
– Specialized Medical Equipment / Supplies
– Structured Family Caregiving – allows one to live with a primary caregiver, either in their own home or that of the caregiver. A program participant’s adult child or spouse can be hired to serve in this role.

While program participants can reside in assisted living residences, community living homes, and structured family caregiving homes, the HOPE Waiver does not cover the cost of room and board.

Eligibility Requirements for SD HOPE Waiver

The HOPE Waiver is for SD residents who are elderly (65+ years old) or disabled (18 – 64 years old). Persons who enroll as a disabled adult can continue to receive waiver services under the aged category when turning 65. Additional eligibility criteria is 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 each 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. However, in some cases, income can be allocated to the non-applicant spouse from the applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance (MMNA).

In South Dakota, there is a minimum income allowance, effective 7/1/24 – 6/30/25, which is set at $2,555 / month. This allows the applicant spouse to transfer up to $2,555 / month to their non-applicant spouse in order to bring the non-applicant’s total monthly income up to $2,555. The state also sets a maximum income allowance, which in 2024, is $3,853.50 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount they can receive is dependent on their shelter and utility costs. However, a Spousal Income Allowance can never push a non-applicant’s total monthly income over $3,853.50.

Assets
In 2024, 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 still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can have $2,000 in assets, while 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.

In 2024, 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 this amount.

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.

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, Medicaid in SD considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $713,000. 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 living in the home.
– The applicant has a minor child (under 21) living in the home.
– The applicant has a disabled or blind child of any age living 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 Medicaid taking the home here.

Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC). For the HOPE Waiver, the Home Care Assessment (HCA) tool is utilized to make this determination. The need for any of the services below is indicative of a NFLOC need.

– Continuing direct care services, such as monitoring, daily management, and complex nursing procedures, that have been ordered by a doctor and must be provided by or under the supervision of a nurse.
– Assistance with Activities of Daily Living (ADLs). ADLs include bathing, dressing, mobility, eating, and toiletry.
– Skilled therapies, such as physical, speech / language, and occupational, or skilled mental health services.

While persons with Alzheimer’s disease or a related dementia might need a NFLOC, a diagnosis of dementia in and of itself does not mean one will automatically meet this level of care need.

Learn more about long-term care Medicaid in South Dakota.

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for SD 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 Qualified Income Trusts, 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 (IFTs) are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts (MAPTs), which must be implemented well in advance of the need for care, are trusts that protect assets from Medicaid and Medicaid’s Estate Recovery Program. If persons do not have a significant amount of excess assets, they might choose to “spend down” extra assets on ones that are Medicaid exempt. Examples include home repair projects, purchasing personal items, such as clothing, and buying new household furnishings and appliances. There are additional Medicaid planning strategies available 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 South Dakota to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Some of the strategies violate Medicaid’s 60-month Look-Back Rule, and therefore, should only be implemented with careful planning. 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 South Dakota’s HOPE Medicaid Waiver

Before You Apply

Prior to submitting an application for the HOPE 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 delayed is required documentation is missing or not submitted in a timely manner.

Since South Dakota’s HOPE Waiver is not an entitlement program, there may be a waiting list for program participation. This waiver is approved for a maximum of approximately 2,840 beneficiaries per year. In the case of a waiting list, it is thought an applicant’s access to a participant slot is based on the date of Medicaid application.

Application Process

Persons can apply for the HOPE Waiver through one’s local Department of Social Services office. A Long Term Care (LTC) Application can be found here.

The HOPE Waiver is administered by South Dakota’s Department of Social Services (DSS). It is operated by the Department of Human Services’ (DHS) Division of Long-Term Services and Supports (LTSS). More information about the HOPE Waiver is located here.

Approval Process & Timing

The South Dakota 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, as a waiting list may exist, approved applicants may spend many months waiting to receive benefits.