West Virginia Medicaid Aged and Disabled Waiver (ADW)

Last updated: June 23, 2022

 

Overview of West Virginia’s Aged and Disabled Waiver

West Virginia’s Aged and Disabled Waiver (ADW) is a statewide Medicaid program for seniors and disabled adults who are at risk of institutionalization (nursing home admission). Intended as a nursing home diversion program, long-term services and supports (LTSS) are available to assist persons in continuing to live at home. LTSS include personal care assistance, personal emergency response systems, and skilled nursing. Transitional services to assist nursing home residents in moving back into the community are also available.

Program participants can reside in their own private home or that of a loved one. They cannot live in an assisted living facility or adult family care home (adult foster care home).

The services offered under ADW may be received via the Traditional Model, in which services are provided by licensed agency providers, or via a participant-directed model called Personal Options. Via Personal Options, program participants receive an individualized monthly budget with which to employ their own caregivers. While friends and select relatives can be hired, such as adult child, a spouse is excluded. A financial management services agency handles the financial aspects of employment responsibilities, such as tax withholding and caregiver payments.

West Virginia’s Aged and Disabled 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.

 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 Disabled Waiver

Follows is a list of long-term services and supports available via ADW. An individualized service plan determines which benefits a program participant receives. The benefits that can be self-directed are marked with an asterisk.

– Case Management
– Community Transition Services – covers the cost of moving expenses, security deposit, utility deposits, essential household furnishings for persons returning to the community from a facility, such as a nursing home
– Nursing Assessment / Supervision
– Personal Attendant Services* – assistance with daily living activities, such as bathing, eating, light housecleaning
– Pre-Transition Case Management – to ensure services are in place right away upon transition into the community from a facility
– Skilled Nursing*
– Transportation Services (Non-Medical)*

 

Eligibility Requirements for West Virginia’s Aged and Disabled Waiver

ADW is for West Virginia residents who are seniors (65+ years old) or between 18 and 64 and physically disabled. Disabled persons can continue to receive waiver services as an aged individual upon turning 65. Additional eligibility criteria is as follows.

 The American Council on Aging provides a quick and easy Medicaid eligibility test for WV seniors

 

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 2022, an applicant, regardless of marital status, can have a monthly income up to $2,523. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,523 / 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. While most states allow the applicant spouse to transfer monthly income to their non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance (MMNA), West Virginia does not. This is because the applicant spouse can retain 100% of their income as a personal needs allowance, eliminating the need for a non-applicant spouse MMNA.

Assets
In 2022, 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 2022, the CSRA allows the non-applicant spouse to keep 50% of the couple’s assets, up to $137,400. If 50% of the couple’s assets falls under $27,480, 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.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our WV Medicaid 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 it. Fortunately, for eligibility purposes, Medicaid in WV considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has intent to return, and in 2022, their home equity interest is no greater than $636,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– The applicant has a spouse living in the home.
– The applicant has a dependent relative living in the home. This could be a child, grandchild, parent, aunt/uncle, sibling, or niece/nephew.

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 Aged and Disabled Waiver, a registered nurse completes an in-home assessment utilizing the Pre-Admission Screening (PAS). An applicant must have 5 functional deficits in order to meet the level of care need. A number of potential deficit areas are considered, which include stage 3 or 4 decubitus ulcers (bedsores), the ability / inability to independently complete activities of daily living (ADLs), such as bathing, dressing, walking, eating, and continence, the ability to leave a building if there is an emergency, skilled needs in specific areas (i.e., sterile dressings, tracheostomy, irrigations), and the inability of self-administering medications. 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.

 For more information about long-term care Medicaid in West Virginia, 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 WV 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.

West Virginia has a medically needy pathway to eligibility for Medicaid applicants who have high medical expenses relative to their income. Also known as a Spenddown 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 Aged and Disabled Waiver will pay for care services and supports.

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. Another option are annuities, which take a lump sum of cash and convert it to a monthly income stream. 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 the state of West Virginia 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 West Virginia’s Aged and Disabled Waiver

Before You Apply

Prior to submitting an application for ADW, 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 West Virginia’s Aged and Disabled Waiver is not an entitlement program, there may be a waiting list for program participation. This waiver is approved for a maximum of approximately 7,026 beneficiaries per year. Seventy-six of these spots are reserved for persons residing in a nursing home who which to transition to a private home. In the case of a waiting list, called a Managed Enrollment List, an applicant’s access to a participant slot is based on date of application.

 

Application Process

To initiate the ADW application process, an applicant must have their doctor complete and submit an Aged and Disabled Waiver Program Medical Necessity Evaluation Request (MNER). In turn, the applicant will receive a letter confirming receipt of the MNER. A financial eligibility form will be included, which should be completed and returned to one’s county DHHR office along with a copy of the letter confirming receipt of the MNER. If an applicant is determined financially eligible, they will be contacted to schedule an in-home Pre-Admission Screening (functional needs assessment).

Additional information about the Aged and Disabled Waiver can be found here and here. Persons can also call 866-767-1575 to reach the Bureau of Senior Services’ Medicaid helpline.

The Bureau for Medical Services (BMS) within the West Virginia Department of Health and Human Resources (DHHR) administers the Aged and Disabled Waiver. West Virginia’s Bureau of Senior Services operates it. County DHHR offices determine financial eligibility.

 

Approval Process & Timing

The West Virginia 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. 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). However, 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.

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