Washington State Medicaid (Apple Health) New Freedom (NF) Waiver

Overview of the New Freedom Waiver

Washington State’s New Freedom (NF) Waiver is a “participant-directed” Medicaid program for King County and Pierce County residents who are elderly or disabled and at risk of nursing home admission. Program participants are allotted an individualized budget, which enables them to select in-home services and supports to increase their independence and delay or prevent relocating to a nursing home. Examples of ways in which persons might use their budget include hiring a caregiver to provide personal care assistance and homemaker services, making home modifications for safety and accessibility, having prepared meals delivered, or purchasing a personal emergency response system.

Participant-directed means program participants have the option of hiring a personal care provider via a licensed home care agency or hiring an “individual provider”. With the individual provider option, the care recipient is the “employer”. This enables the individual to hire, supervise, and even fire, the caregiver of their choosing. While friends and select relatives can be hired as the individual provider, they must be 18+ years old, qualified to provide such care, and have a contract with the Washington State Department of Social and Health Services (DSHS). Spouses and legal guardians, unfortunately, cannot be hired as the caregiver.

Program participants who cannot make decisions on their own behalf, such as persons with Alzheimer’s disease with cognitive decline, can select a representative to do so for them. However, this person cannot also be paid to be the caregiver.

Program participants / representatives work with a “care consultant” who helps to manage their budget and select appropriate services and supports to meet their needs. A Financial Management Services Agency handles the financial aspects of employment responsibilities such as tax withholding and issuing caregiver and vendor payments.

Program participants must live in their own home or the home of a loved one. Unfortunately, persons cannot reside in an adult family home (similar to adult foster care) or an assisted living residence.

The New Freedom Waiver is not an entitlement program; meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, there are a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.

The New Freedom (NF) Waiver is a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver. Persons might also hear this program called New Freedom Budget-Based Participant Directed Services. Medicaid in Washington State is called Apple Health.

Benefits of the New Freedom Waiver

Based on one’s individual needs, New Freedom Waiver program participants are given a monthly budget, also called a “spending plan”. In addition to care consultation, the following long-term services and supports are available to program participants. This list is not exhaustive. It is possible that a program participant requires a good or service not mentioned below and still be able to purchase it with their spending plan. Some purchases may require approvement by one’s doctor.

– Adult Day Care
– Assistive Technology / Equipment
– Community Transitional Services – assistance for persons relocating to a private home from a nursing home. May include security deposit, utility set-up fees, essential home furnishings, etc.
– Home-Delivered Meals
– Home Modifications – i.e., wheelchair ramps, grab bars, widening of doorways, replacement of standard bathroom sink for pedestal sink
– Nurse Delegated Tasks – specific nursing tasks assigned by a registered nurse to a home care aide / nursing assistant. These tasks include administering medications, blood glucose monitoring, and insulin injections.
– Personal Care Assistance – assistance with the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Examples include bathing, personal hygiene, dressing, toileting, eating, mobility, shopping for essentials, housecleaning, and laundry.
– Personal Emergency Response Systems
– Training / Education – to promote one’s health and ability to live independently
– Transportation Assistance – non-medical and medical
– Treatment / Health Maintenance Supports – i.e., acupuncture, physical therapy, dental, audiology, vision
– Vehicle Modifications – i.e., door widening and adaptive vehicle controls

Eligibility Requirements for the New Freedom Waiver

The New Freedom Waiver is for Washington State residents residing in Pierce County or King County who are elderly (65+) or younger (18-64) if disabled and at risk of nursing home placement. Persons with disabilities who enroll in the Waiver prior to the age of 65 can continue to receive program benefits upon turning 65. Additional eligibility criteria are below.

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases annually in 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 be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance.

WA has set a minimum Spousal 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 to bring their income up to this amount. 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 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 $3,853.50.

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 the assets of a married couple are considered 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 $68,301. 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.

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

– The applicant lives in the home or has “Intent” to Return home, and in 2024, their home equity interest is no greater than $1,071,000. Home equity is the current value of the home minus any outstanding mortgage. The applicant’s home equity interest is the portion of the home’s equity value that is owned by the applicant.
– A spouse lives in the home.
– The applicant has a disabled or blind child living in the home.
– The applicant has a child under 21 years old 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 Freedom Waiver, the Comprehensive Assessment Reporting Evaluation (CARE) tool is used to determine if this level of care need is met. Persons must require daily nursing care OR assistance with their Activities of Daily Living / ADLs (i.e., transferring from the bed to a chair, repositioning oneself in bed, mobility, eating, toileting, bathing, and medication management). With ADLs, substantial assistance with at least 2 or some assistance with 3 or more is required. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive impairments, such as memory loss, lack of focus, and difficulty making plans, can result in the need for assistance. In this case, supervision is required as well as substantial assistance with one ADL. 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 Apple Health (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.

Washington State has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also known as 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” each month can be thought of as a deductible. Once one’s “deductible” has been met for the spend down period, the New Freedom Waiver will pay for care services and supports. More.

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-Compliant 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 to meet Medicaid’s financial eligibility criteria without violating Medicaid’s 60-month Look-Back Period and 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, preserving them instead for family as inheritance. As an example, Lady Bird Deeds are a good option to protect one’s home.

While some of these strategies, such as Medicaid Asset Protection Trusts, do violate the Look-Back Rule and should be implemented well in advance of the need for long-term care, there are some workarounds. WA State Medicaid Planners are well aware of them, and therefore, it is highly suggested persons consult one 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 Freedom Waiver

Before You Apply

Prior to submitting an application for the New Freedom 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 Freedom Waiver is not an entitlement program, there may be a waitlist for program participation. The program is approved for a maximum of approximately 675 program participants per year. In the case of a waitlist, persons residing in nursing homes who wish to return to their homes are given priority. Persons outside of nursing homes are given priority based on level of need.

Application Process

To apply for the New Freedom Medicaid Waiver, WA State residents must be enrolled in Medicaid / Apple Health. Persons can apply online or via their Pierce County or King County Home and Community Services (HHS) office. The Pierce County office can be reached at 1-800-442-5129 or 253-476-7200. The King County office can be reached at 1-800-346-9257 or 206-341-7600. The Washington Apple Health Application for Aged, Blind, Disabled / Long-Term Care Coverage is available here. A functional needs assessment is completed as part of the application process.

Persons already enrolled in Medicaid should call their case manager to begin the application process for the New Freedom Program.

Once eligibility for the New Freedom Waiver has been established, a care consultant will be assigned to the program participant.

Additional information about the program is available here.

The Washington State Department of Social and Health Services’ (DSHS) Aging and Long-Term Support Administration (ALTSA) administers the New Freedom Medicaid Waiver. Program eligibility is determined by the division of Home and Community Services (HCS) within the ALTSA. The local Area Agencies on Aging (AAA) offices in Pierce and King Counties provide case management.

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. 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.