Medicaid Home and Community Based Waivers: Care at Home Instead of a Nursing Home

A lot of families hear one thing about Medicaid and long-term care. They hear that Medicaid pays for a nursing home. That is true, but it is not the whole truth. Each state also runs waiver programs. A waiver can pay for care in your own home. It can pay for care in a small home-like setting in the community. The point of the waiver is the same in each state. A person who needs a nursing-home level of care can get help where they live, in place of a move to a facility. This guide shows how waivers work at the federal level, who they serve, and how to ask your state about one. Our Paying for Care section holds more guides on Medicaid and care costs.

Why the word waiver is used

Medicaid law was built around care in facilities. The base rules pay for care in a nursing home. They do not, on their own, pay for a wide set of services in a private home.

In 1983, Congress added section 1915(c) to the Social Security Act. That part of the law lets a state ask for a waiver of the facility rules. With the waiver in hand, the state can pay for home and community based services. Those services help a person stay at home in place of a facility stay.

States have more than one path to pay for care at home. Some states put home services in the state Medicaid plan. Some states use waiver paths with names such as 1915(i), 1915(j), and 1915(k). The 1915(c) waiver is the path most tied to the nursing-home choice. CMS, the federal agency for Medicaid, works with states on the quality of these programs.

Who a waiver serves

A waiver is not open to all who want help at home. It serves set groups. The group test has two parts.

The first part is the level of care test. The person must need the level of care a nursing home gives. A state worker or a state tool scores that need. The score looks at health needs and at help needed with daily tasks, such as bathing, dressing, and eating. A person who needs light help only will not pass this test in most states.

The second part is the group test. Each waiver names the groups it serves. Common groups are older adults, adults with a physical disability, and people with brain injury or deep support needs. A state can run more than one waiver. Each waiver can serve a distinct group.

Money rules sit on top of both tests. Medicaid is a program for people with low income and few resources. The individual resource standard is $2,000, and the couple standard is $3,000 (Ledger D3). How that standard is counted for a waiver applicant is a state rule. Some states count in the same way as for nursing-home care. Some states use a distinct count for waiver care. Ask the state office which count fits the waiver you want.

Our guide on Medicaid estate recovery shows a cost that can come later. A state can seek pay back from the estate of a person who got long-term care paid by Medicaid. That rule can touch waiver care too. Read it before you sign up, so the full picture is in front of you.

What a waiver can pay for

The service list is set by the state in its waiver plan. No two states list the same set. Services a state may list are:

A waiver does not pay rent. It does not pay for food at home. It pays for care and for aids to care. The room and board part of life at home stays with the person and the family.

• Personal care help at home, such as help with bathing, dressing, and meals.
• Homemaker help, such as cleaning, laundry, and shopping.
• Adult day care in a center in the community.
• Respite care, so a family caregiver can rest.
• Home changes that aid safe care, such as grab bars or a ramp.
• Rides to care and to day programs.
• Case management, a worker who sets up and tracks the care plan.
• Care in a small home-like setting, in some states, in place of a facility.

Slots, caps, and wait lists

A nursing-home benefit in Medicaid is an entitlement. If you qualify, the state must serve you. A waiver is not built that way. Federal law lets a state cap the count of people a waiver serves. The cap is called slots.

When slots fill, the state can start a wait list. Names go on the list in the order the state sets. Some states serve the list in date order. Some states move urgent cases up. A wait can run from weeks to years, based on the state and the waiver. That range is a hard fact of this system. It is a reason to ask early, long before a crisis.

A wait list is not a denial. Your name on the list holds your place. Keep your phone and address current with the office while you wait. A missed letter can cost you your place in some states.

How to ask your state about a waiver

Our guide on getting paid to care for a parent shows one path some waiver plans open. In some states, a waiver plan can pay a family member who gives care. The rules are the state's. Ask about that path when you call.

• Call your state Medicaid office. Ask for the home and community based waiver list for your state.
• Name the person who needs care. State their age group and their main needs. Ask which waiver serves that group.
• Ask for the level of care test. Ask who scores it and how long the score takes.
• Ask if slots are open. If a wait list is in use, ask how to join it and how the list moves.
• Ask which money count the waiver uses. Ask how the $2,000 individual resource standard (Ledger D3) is applied in that waiver.
• Ask about estate recovery for waiver care in your state, so you know the later cost.
• Write down each name, date, and answer. Keep the set in one file.

Who pays for what

• Medicaid, run by your state with federal funds, pays for waiver services on the state list for people who qualify and hold a slot.
• Medicare pays for health care first for people who have it. A waiver does not take the place of Medicare. It pays for long-term care help that Medicare does not cover.
• A Medigap policy pays toward the costs Original Medicare leaves. It does not cover a service on its own, and it does not pay for long-term care at home.
• You and your family pay for rent, food, and home costs at home. A waiver pays for care, not for room and board.
• Private pay can add hours or services past the waiver plan. Families often mix waiver care with paid help.
• A state can seek pay back from the estate after death for long-term care it paid for. That is the estate recovery rule, and it can reach waiver care.

Sample situation

Ruth is 82. She had a stroke last year. She needs help with bathing, dressing, and meals each day. Her daughter, Pam, lives near her and helps at night. A hospital worker tells Pam that Ruth meets a nursing-home level of care. Pam does not want a facility move. She calls the state Medicaid office. The office names a waiver for older adults in their state. A state worker scores Ruth's needs. Ruth passes the level of care test. The office checks the money rules. Ruth's resources sit under the $2,000 individual resource standard (Ledger D3). One slot is open. Ruth starts waiver care the next month. A paid aide comes each morning for personal care. Ruth goes to an adult day center two days a week. Pam gets one respite day each month. Ruth stays in her own home. Pam keeps the office letters in one file, with the date of each call and the name of each worker she spoke with.

Ask early

The waiver path rewards an early ask. Slots fill. Wait lists grow. A call made in a calm month can set up care that a crisis month cannot wait for. If a person in your family may need a nursing-home level of care in the year ahead, call the state office now. Ask the waiver names. Ask about slots. Get on a list if a list is the path. Home can stay home for a long time with the right help in place.

Sources

• https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities
• https://www.medicaid.gov/medicaid/eligibility-policy/estate-recovery
• https://www.medicaid.gov/medicaid/long-term-services-supports/self-directed-services