Some of us need help in carrying out the basic tasks that we require each day to care for ourselves. As we age, the risk of our needing such “long-term care” is likely to grow. But when we do need long-term care, we normally don’t want to move to a nursing home to get the help we need. We want to remain in our own homes. We want to stay with our families and maintain our independence and dignity.
Unfortunately our long-term care system has long been structured to provide public financial support to us much more readily if we go to a nursing home. Now, the public financing system has begun to change, and both Pennsylvania and the federal government are trying to give people more of what they want—long-term care that is based at home or at least in the community, rather than in a nursing facility.
This article will describe one program that can help give frail seniors the support they need to stay in their homes and avoid the nursing home. This program is commonly called the "Aging Waiver."
What is the Aging Waiver Program
Pennsylvania receives federal Medicaid funding under programs that involve federal approval of “waivers” from standard Medicaid rules that allow states to provide long term care services to people in their homes. Pennsylvania has established many such Medicaid waiver programs. A listing of them is available on the Department of Public Welfare’s website at: http://www.dpw.state.pa.us/ServicesPrograms/MedicalAssistance/003670306.htm. See also, "Pennsylvania's Home and Community Based Services Initiatives."
The waiver program that is of most significance for seniors is the Home and Community-Based Waiver for Individuals Aged 60 and Over (“Aging Waiver).” Seniors who would otherwise need nursing home care, but who can have their needs met at home, can obtain government financed services and support if they meet the program’s qualification requirements.
The primary purpose of the Aging Waiver is to offer individuals the choice of receiving services in the community as an alternative to institutional care, and to achieve cost savings by delaying or avoiding institutionalization.
Aging Waiver services are provided at no cost, and no co-payments are required. However, the cost of services provided under the program are subject to Medicaid estate recovery. Fears of Medicaid estate recovery (which are often unwarranted) may deter individuals from applying for the Aging Waiver program, and consumers should discuss the potential for estate recovery with an elder law attorney to help alleviate these concerns.
To qualify for services provided under the Aging Waiver the applicant must meet Medicaid’s stringent financial and functional need requirements. The financial eligibility requirements for the Aging Waiver are similar to (but in some ways more restrictive than) Medicaid funded nursing facility care. Unlike qualification for nursing home care, the Aging Waiver recipient must normally have income below 300% of the federal poverty standard ($2,022 per month in 2011).
The Aging Waiver program imposes the same functional (level of care) requirements as for Medicaid nursing facility services. This means that an applicant must be determined to require the level of care normally provided by a nursing facility.
Overall administration of the Aging Waiver resides with the Office of Long Term Living(OLTL). Waiver enrollment and Level of Care determinations take place at the local Area Agency on Aging (AAA) with oversight by OLTL.
Services are provided through qualified providers that are enrolled as Medical Assistance providers. The contracting AAA monitors its enrolled waiver providers. Federal law gives individuals who are denied Aging Waiver services (or their provider of choice) the right to request a Fair Hearing under 42 CFR §431 Subpart E. The same hearing rights apply if a Waiver recipient’s services are suspended or reduced or terminated.
AAA care managers are responsible for Aging Waiver service plan development with input from the participant. Care managers are required to ensure that participants are receiving care and services to prevent institutionalization in accordance with 42 CFR Section 441.301.
Pennsylvania’s Aging Waiver is a Medicaid Home and Community-Based Services (HCBS) waiver program authorized under §1915(c) of the Social Security Act. Federal approvals of waiver programs, including Pennsylvania’s Aging Waiver, are limited in time. Each five years Pennsylvania must seek federal approval to renew its Aging Waiver. A copy of the Pennsylvania Aging Waiver that was approved in December 2008 is available online at http://www.paelderlaw.com/pdf/Aging_Waiver_Renewal.pdf.
To be eligible for the Aging Waiver, the applicant must be a Pennsylvania resident age 60 or older, who is determined to be nursing facility clinically eligible, and who can be cared for safely at home. An applicant must meet all of the following requirements:
- be age 60 and older,
- reside in the county in which the application is filed,
- require a nursing facility level of care,
- meet the financial requirements, including spousal resource attribution rules; in general, the applicant must have income not exceeding 300 percent of the current Federal Benefit Rate ($2022 in 2011) and $8,000.00 or less in countable assets,
- choose home care over facility placement.
Unlike Medicaid eligibility for care in a skilled nursing facility, the income of the applicant can often present an insurmountable barrier to qualification for Medicaid financed home care under the Aging Waiver. This is because the medical “spend-down” to eligibility rules that are applicable in the nursing facility context are not applicable for applicants seeking home care under the Aging Waiver. Note that the income of the spouse of an applicant is not considered in determining income eligibility for the Aging Waiver.
Medicaid transfer penalty rules apply to the Aging Waiver. Planning options to accelerate financial qualification for the Aging Waiver program are similar to those that apply to residents of nursing homes. Medicaid Estate Recovery rules also apply.
In order to qualify for the Aging Waiver Program the applicant must be assessed and determined to be clinically eligible for nursing facility care, but able to be cared for safely at home. The level of care determination is made through an assessment conducted by the Area Agency on Aging or its representative.
Services Provided Under the Aging Waiver Program
Following a complete assessment to determine eligibility, an area agency on aging care manager designs a care plan with the consumer and his or her representatives. The care manager will thereafter monitor the home services.
Upon enrollment in the waiver program, the care manager provides the consumer with listings of the providers who are included in the plan and certified by DPW to provide the home services. Consumers are able to choose which of the listed agencies they want to provide services. The following are some of the services that may be available to help individuals remain at home:
- home-delivered meals
- personal care
- cleaning/laundry/home support services
- home modifications
- home medical supplies
- caregiver respite services
- emergency response systems
- physical, occupational, and speech therapy
- adult day care
- home-health aides/companion services
- registered nurses
An applicant receiving hospice benefits can also qualify for the Aging Waiver program.
The Aging Waiver program can help you reside in your home, where you want to be, rather than in a nursing home. If you are a senior who lives in Pennsylvania, the experienced elder law attorneys at Marshall, Parker and Associates, can answer your questions and help you find the best way to qualify for the Aging Waiver, LIFE, and other programs that can help you stay in your home.