Overview of Utah Medicaid New Choices Waiver
Utah’s New Choices Waiver is a statewide Medicaid program for seniors and persons with disabilities currently residing in nursing home facilities, assisted living residences, medical institutions (not an institution for mental disease), and small health care facilities (Type N, which limits residents to three). Intended to help these persons transition to living at home, the home of a loved one, or another community based residence for more independent living, a variety of long-term home and community based services are available. The exact benefits a program participant receives is dependent on the individual’s unique needs and existing supports. Examples of available benefits include adult day care, personal emergency response systems, respite care, residential care services, and home modifications for safety and accessibility.
In addition to private homes, program beneficiaries can live in small health care facilities, community residential treatment facilities, independent living facilities, assisted living residences, and adult foster care homes, and receive New Choices Waiver services. This includes memory care units, specific to persons with Alzheimer’s disease and related dementias.
While the services offered under this program can be managed by an agency provider, participant-directed care is also an option for those receiving personal attendant care and homemaker services. Self-directed care allows program participants to hire and manage the individual of their choosing, including friends and relatives. As long as an adult child does not serve as their parent’s legal guardian, they can be hired to provide both personal care assistance and homemaker services. In some cases, even spouses can be hired to provide personal care. A Financial Management Services Agency handles the financial aspects of employment responsibilities such as background checks, tax withholding, caregiver payments.
The New Choices Waiver 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 waitlist for program participation forms.
Utah’s New Choices Waiver is a 1915(c) Home and Community Based Services (HCBS) 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 New Choices Waiver
Follows is a list of long-term services and supports available via the New Choices Waiver. While all program participants receive case management, an individual assessment determines which other services and supports a program participant receives.
– Adult Day Care – daytime supervision and care in a community group setting
– Adult Residential Services – homemaker services, personal care assistance, 24/7 on-site response
– Assistive Technology Devices – i.e., amplified phones, video phones, safety alarms, portable access ramps
– Attendant Care – personal care assistance
– Caregiver Training – for unpaid caregivers
– Case Management
– Chore Services – i.e., cleaning carpets and windows, moving the lawn
– Community Living Services – i.e., essential household items, moving expenses, security deposits
– Consumer Preparation Services – assistance in arranging for, directing, and managing services
– Financial Management Services – for persons self-directing their care
– Habilitation Services
– Home Delivered Meals
– Homemaker Services – assistance with basic housecleaning, meal preparation, laundry, grocery shopping
– Home Modifications – for safety and accessibility
– Medication Assistance Services – i.e., medication reminder system, medication set-up
– Non-Medical Transportation
– Personal Budget Assistance
– Personal Emergency Response Systems
– Respite Care – in-home and out-of-home care to relieve a primary caregiver
– Specialized Medical Equipment / Supplies
– Supportive Maintenance / Home Health Aide
– Vehicle Modifications – for safety and accessibility
While services can be provided in a variety of community-based settings, including assisted living residences, the cost of room and board is not covered by the New Choices Waiver.
Eligibility Requirements for Utah’s New Choices Waiver
The New Choices Waiver is for Utah residents who are 18-64 years old and disabled, or 65+ years old. Persons with disabilities who enroll prior to turning 65 can continue to receive Waiver services upon turning 65. Applicants must meet one of the following criteria.
– Resides in a Medicaid-funded nursing home and has been there at least 90 days.
– Receiving Medicare-funded care in a medical institution (not an institution for mental disease) for a minimum of 30 days and will be discharged to a Medicaid-funded nursing home for a minimum of 60 days.
– Resides in an assisted living residence and has been there at least 365 days.
– Resides in a small health care facility (Type N) and has been there at least 365 days.
Additional eligibility criteria for persons 65+ 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 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. Furthermore, monthly income from the applicant spouse can potentially be transferred to the non-applicant spouse as a Spousal Income Allowance. This is called a Monthly Maintenance Needs Allowance and is intended to ensure the non-applicant spouse does not become impoverished.
Utah has set a minimum income allowance of $2,555 / month (eff. July 2024 – June 2025). This allows an applicant spouse to supplement their non-applicant spouse’s monthly income, bringing their income up to this amount. The state also sets a maximum income allowance, which in 2024, is $3,854 / month. While this potentially allows a non-applicant spouse a higher income allowance, any additional amount above the minimum income allowance is dependent on one’s shelter and utility costs. A Spousal Income Allowance, however, can never push a non-applicant’s total monthly income over $3,854.
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 $4,000. 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 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.
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 UT 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’s spouse lives in the home.
– The applicant has a dependent relative 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 New Choices Waiver, the tool used to determine if this level of care need is met is the InterRAI MINIMUM DATA SET – HOME CARE (MDS-HC). It is completed by a registered nurse. To meet a NFLOC, two of the following conditions must be met.
1) The individual has a diagnosed medical condition that results in the need for a significant amount of hands-on assistance with the Activities of Daily Living (ADLs). ADLs include toileting, bathing, dressing, transferring, mobility, and eating.
2) The individual’s doctor has determined their orientation to time, place, and person is poor enough that either nursing facility care is required or care equivalent to that through New Choices Waiver services.
3) The individual’s medical condition and level of care required indicate their care need is great enough that their needs cannot safely be met without New Choices Waiver services.
While it is common for persons with Alzheimer’s Disease or a related dementia to meet the nursing facility level of care need, a diagnosis of dementia in and of itself does not mean one will automatically meet it.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for UT 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.
Utah has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also called 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 New Choices Waiver will pay for care services and supports.
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-Compliant Annuities, which turn countable assets into a stream of income, is another option. There are many other 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 Utah 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 the New Choices Waiver
Before You Apply
Prior to submitting an application for the New Choices 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 New Choices Waiver is not an entitlement program, there may be a waitlist for program participation. This Waiver is approved for a maximum of approximately 2,500 beneficiaries per year. Of these slots, approximately 540 are reserved for applicants currently living in a nursing home or a medical institution (with the exception of a medical institution for mental disease). If the reserved slots are filled, persons can apply for a non-reserved slot. In the case of a waitlist, an applicant’s access to a participant slot is based on how long they have lived in their current setting. Persons with longer lengths of stay will be permitted a participant slot prior to those with shorter lengths of stay.
Application Process
Persons who reside in a nursing home can apply for the New Choices Waiver after residing there for 60 days. Those living in assisted living and Type N residences can apply after 365 days as a resident. Persons can apply online at UtahID. An account must be created to do so. Alternatively, persons can call the New Choices Waiver program at 800-662-9651 (option 6) to request a program application.
Learn more about the New Choices Waiver here. Persons can also call the New Choices Waiver program office at 800-662-9651 (option 6). The Utah Department of Health & Human Services’ Division of Medicaid and Health Financing administers the New Choices Waiver.
Approval Process & Timing
The Utah 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 wait-lists may exist, approved applicants may spend many months waiting to receive benefits.