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Effective: December 1, 2006 |
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03.40.25ar1 - Elderly Waiver (EW) (Archive) |
Archived: July 1, 2008 |
The Elderly Waiver (EW) program provides Medical Assistance (MA) funding for home- and community-based services for MA-eligible people who would otherwise need nursing facility care. To receive EW services, a person must meet all of the following:
l Be age 65 or older.
l Have a long-term care consultation (LTCC).
l Require a nursing facility (NF) level of care (NF-I or NF-II).
l Be able to remain in the community rather than a nursing facility.
l Have a cost to MA for community-based services that is less than the cost of institutional care.
l Choose community care.
A person who receives home care services through EW and has a community spouse is also referred to as a long-term care (LTC) spouse.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
Application Process (standard guidelines)
Follow standard MA guidelines.
Note: Because EW eligibility determinations can be especially complex, you may encourage the applicant or authorized representative to come in for an interview, but may not require this as a condition of eligibility.
The earliest begin date of elderly waiver eligibility is the date waiver services are approved through the LTCC.
Note: See Long-Term Care and Elderly Waiver (EW) for guidelines on when to begin LTC budgeting.
Renewals (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Social Security Number (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Residency (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Household Composition (standard guidelines)
Use a household size of one for all EW clients and their spouses when determining eligibility for either spouse for MA or the Medicare Savings Programs.
Example:
Beulah lives with her husband Henry and receives EW using only her income and assets and a household size of one.
Action:
If Henry requests MA for himself (with or without EW), use a household size of one and only his income and assets. Determine eligibility for the Medicare Savings Programs separately for each spouse as a household of one.
Use Method B to determine income and asset exclusions. For budgeting guidelines, see Long-Term Care (LTC) and Elderly Waiver (EW).
Asset Guidelines (standard guidelines)
Asset limit is $3000 (household size of one). When both spouses receive EW, each has a $3000 limit.
Note: See MA and GAMC Excess Assets for further information about how to treat excess assets for elderly waiver clients.
An asset assessment must be completed for elderly waiver clients who have a community spouse. See that section for further information.
The community spouse of a person receiving EW services is entitled to a community spouse asset allowance.
To determine eligibility for the SIS EW or EW, add together all monthly gross income of the applicant or enrollee before any exclusions. Do not include the income of the person's spouse.
Deductions/Disregards (standard guidelines)
If a need exists, the community spouse and certain family members who live with the LTC and community spouse may be entitled to an allocation from the income of the LTC spouse.
l People with gross income equal to or less than the special income standard (SIS) are eligible for MA without a spenddown, but must contribute any income over the maintenance needs allowance and other applicable deductions to the cost of services received under EW. This is known as the waiver obligation.
l If income exceeds the SIS, single people and married couples who both receive EW must qualify under the applicable Method B income standard (see 100% FPG, 75% FPG, and Single Elderly Waiver).
See Long-Term Care and Elderly Waiver (EW) for more information about calculating income, spenddowns, and waiver obligations.
If income exceeds the SIS, set the case up using a medical spenddown. Treat the projected amount of EW services for the month as a medical bill incurred on the first day of the month. See Spenddown Types.
Use an LTC spenddown for people with a community spouse. If the person's available income exceeds the monthly EW charges, determine eligibility using a combined LTC/medical spenddown.
Covered Services (standard guidelines)
EW funds the following services in addition to the standard MA services:
l Adult day care.
l Adult day care bath.
l Adult foster care (other than room and board costs).
l Assisted living.
l Assisted living plus.
l Caretaker training and education.
l Case management.
l Chore services.
l Consumer directed community supports.
l Corporate foster care (adult).
l Companion services.
l Equipment and supplies not covered by MA, Medicare, or the client. The equipment and supplies must help keep the client out of a nursing facility.
l Extended home health.
l Extended nursing services.
l Extended personal care.
l Extended transportation.
l Family foster care (adult).
l Home-delivered meals.
l Homemaker services.
l Home modifications and adaptations.
l Respite care (in-home/out-of-home/facility/hospital).
l Residential care.
l Transitional services.
Service Delivery (standard guidelines)
SIS EW enrollees with a waiver obligation (gross income is greater than the maintenance needs allowance but less than or equal to the Special Income Standard) are excluded from managed care enrollment, but may enroll voluntarily.
Note: SIS EW enrollees whose income is less than the maintenance needs allowance must enroll in managed care.
Not applicable.
See Long-Term Care (LTC) and Elderly Waiver (EW) for information on when to end the waiver obligation and LTC budgeting, and when to begin community budgeting if EW eligibility ends and MA continues under another basis.
Not applicable.
Alternative Care (AC), which provides funding for home- and community-based services for people who would otherwise need nursing facility care, may be an option for some EW clients.