by Diane Weinberg, Esq.
People hearing the term “Medicaid” often associate this word with a government program that provides medical services to individuals with low income. Medicaid1 encompasses a series of programs that provide more than just medical insurance for an indigent population. Georgia offers over 30 types of Medicaid programs, called classes of assistance (“COA”s). About half of these programs provide care for families with children who have limited income and resources, and these programs are referred to as “Family Medicaid.” The remaining programs provide benefits to individuals who are over age 65 or who have a disability. These programs are known as “Aged, Blind and Disabled Medicaid” (“ABD Medicaid”). Each ABD Medicaid program is designed to benefit a target population comprised of individuals who satisfy specific criteria. Family Medicaid benefits happen automatically, and elder law attorneys generally do not work with these COAs. However, elder law attorneys are generally well-versed in ABD Medicaid and the benefits offered through these programs.
In addition to programs providing medical care, ABD Medicaid offers several programs designed to help individuals with disabilities who are appropriate for institutionalization remain in the community. These programs are referred to as “waiver” programs. These waiver programs can be divided into two categories. The first category of waiver programs provides services to help individuals with disabilities remain in the community (“service waiver programs”). Service waiver programs include the New Options Waiver (“NOW”) program and Comprehensive Supports Waiver Program (“COMP”) Waivers (collectively called the “NOW/COMP” waiver), the Independent Care Waiver Program (“ICWP”), the Elderly and Disabled Waiver Program (“EDWP”) which is actually the result of the merger two programs that were formerly separate programs known as the Service Options Using Resources in Community Environments or “SOURCE” and the Community Care Services Program or “CCSP” waiver programs), and the Georgia Pediatrics Program (“GAPP”). Two other waiver programs, which are called the Deeming or “Katie Beckett” Waiver and the Money Follows the Person (“MFP”) waiver, help individuals access the benefits of the service waiver programs.
While each waiver program benefits a specific target population, the waiver programs have similar eligibility requirements.
- Level of Care. As mentioned above, individuals eligible for a Medicaid waiver program must be appropriate for what is called an “intermediate level of care.” These individuals may be appropriate for nursing home care but have needs that can be met in a community setting, such as in the individual’s residence or a group home. An example of someone who satisfies these criteria would be someone who needs medication or nutritional management (e.g., a diabetic) and who also requires another person’s help to walk. Individuals with dementia or similar memory problems usually satisfy these criteria as well.
- Community Support. An important aspect of a waiver program is that the recipient of these benefits must have community support. Waiver programs do not offer 24-hour care. Rather, they provide supplemental services to help an individual be as independent as possible. Someone in the community, such as a relative or friend, must be available to provide the care and oversight not offered by the waiver program.
- Cost-effective. Another important aspect of a waiver program is that the services provided to an individual must cost less than providing those services to the individual in an institutional setting. Most potential beneficiaries will be able meet this requirement because the cost of institutional care is so high. According to the Georgia Council of Aging, Medicaid pays an average of $20,499 per year to keep an individual in a nursing home. By comparison, Medicaid pays $4,398 annually for an individual to receive care under CCSP.2
- Income and resources. Individuals seeking waiver program benefits must satisfy the same financial eligibility requirements as individuals applying for nursing home care. In 2019, applicants must have a monthly income less than the monthly income cap, which is $2,313 in 2019, and countable resources less than $2,000. If the applicant is married, the community spouse may have countable resources of less than the community spouse resource allowance, which is $126,420 in 2019. A community spouse’s income is not used to determine eligibility for Medicaid. Individuals who are not financially eligible should not abandon hope, however. A variety of planning options to address excess income and resources exist (a discussion of these options is well-beyond the scope of this article).3
A. The Service Waiver Programs: NOW/COMP, ICWP, EDWP, and GAPP.
The five service waiver programs provide services beyond simple medical care to adults and children. They are intended to help the beneficiaries remain in a community setting instead of being institutionalized. These services include personal support services, meal services, educational services, vocational rehabilitation services, adult day health care services, respite care, evidence-based health and wellness programs, case management services, and even adaptive equipment for home and car. The service and number of hours of that service that each individual receives is based on that individual’s needs. Caseworkers work with the individual, the caregivers, and family members to help determine what services to provide. The caseworker also will reach out to the individual’s physician to ask the physician’s opinion as to what services the individual needs.
While the services provided by these waivers are generous, recipients need to be aware of the limitations.
- The services are not unlimited. An individual may only be able to receive a certain number of hours of a particular service (e.g., three mornings of care in an adult day health care facility). Also, service costs within the program may be capped. For example, in 2017, an individual receiving ICWP benefits could receive up to 20 hours of behavioral management services per week. Likewise, for an individual wanting an emergency response system (i.e., “I’ve fallen and I can’t get up”), Medicaid paid $75.00 for the initial purchase of the system and $25.00 per month for the subscription.
- There is a co-payment. Depending on the benefit received, the recipient may have a monthly co-payment, called a “patient liability” or “cost share.” The co-payment is calculated by taking the applicant’s income, subtracting a personal needs allowance, subtracting the cost of any health insurance premiums and non-covered medical expenses, and subtracting any funds that are deemed to belong to a community spouse or dependent child. The balance of income remaining after subtracting these amounts is paid to the service provider.
Occasionally, I have a client who only needs someone to come in and help her get up in the morning and get ready for bed at night. In this situation, I sit down with the client and evaluate whether she will benefit from the waiver program or whether she should continue privately paying for home care.
- Applicants can determine their care providers. Medicaid increasingly allows the applicant or her representative to determine which company will provide services. My clients report that the caseworker provides them with a list of providers that accept Medicaid. Be aware that, if selecting this option, Medicaid may also require that the applicant accept financial support services to ensure that the payments to vendors are being made as appropriate.
- Applications to waiver programs consist of two parts. First, the applicant submits an initial application to an organization that screens to determine an individual’s eligibility for that program. After the applicant is accepted into the program, the applicant needs to apply waiver COA through the Department of Family and Children Services in the county in which the applicant resides.
1. The NOW/COMP Waivers. Most parents consider the NOW/COMP waivers to be the gold standard because of the level of support these provide. As mentioned above, these waiver programs are only designed for individuals with intellectual or developmental disabilities. Among the services provided are physical therapy, occupational therapy, behavioral support, community living supports, respite care, specialized medical equipment and supplies, supported employment, and vehicle adaptation. COMP provides additional supports to individuals living in the community, including, for example, residential staff services and nutrition services.
Eligibility for this waiver program is a source of confusion. To be eligible, the applicant must have developed an intellectual or developmental disability before age 18 or 22, depending on the type of disability. Also, the applicant must demonstrate that deficits in one or more areas of adaptive functioning appeared before age 22. Adaptive functioning includes conceptual skills (language, reading, writing, money, time, and number concepts); social skills (interpersonal skills, social responsibility, gullibility, ability to follow rules and laws, social problem solving); and practical skills (ability to perform activities of daily living and personal care, occupational skills, use of the telephone, ability to follow routines).
One of the easiest ways to show the onset of a disability and the deficits in adaptive functioning is to provide Medicaid with a copy of the child’s Individualized Educational Program (“IEP”). The same skills that are measured for determining whether a child needs an IEP are used by Medicaid to determine eligibility for the NOW/COMP waivers. I recommend that parents have their children with special needs receive a psycho-educational evaluation by age 18, to determine whether the child will be eligible for this benefit.
2. The Independent Care Waiver Program. ICWP provides services to members of two target populations who are between ages 18 and 65: individuals with physical disabilities and individuals with traumatic brain injuries (“TBIs”). TBIs include any brain injury that arises from a “blunt or penetrating trauma or from acceleration-deceleration forces.” TBIs do not include injuries to the brain caused by illness, such as a tumor, although an individual with a brain tumor may receive ICWP benefits or other waiver benefits if the tumor causes physical disabilities. Certain services, such as behavior management and adult day care, are only available to TBI patients.
3. Elderly and Disabled Waiver Program (which is comprised of the CCSP and SOURCE waiver programs). Effective July 1, 2018, the CCSP and SOURCE waiver programs were combined to create the Elderly and Disabled Waiver Program.4 In many respects, the merger makes sense because the two programs provide the same benefits to similar target populations. SOURCE provides benefits to individuals who already receive Medicaid through a different class of assistance, such as through SSI Medicaid. CCSP, by contrast, provides services to individuals who are not receiving Medicaid benefits. The programs are so similar that the CCSP rules for providers and services govern the SOURCE providers and services as well. Although the merger became effective last year, the programs still have separate operation manuals, and it is not clear as of the time of this writing when the merger will be complete.
SOURCE and CCSP offer their beneficiaries services such as adult day health care and alternative living services in a licensed personal care home, intermittent home health delivered services, and personal support services. Additional services include out-of-home respite care, including overnight care; emergency response systems, and home-delivered meals. CCSP also offers skilled nursing services by a home care provider when a home health agency is unable to provide that service.
SOURCE targets “[p]hysically disabled individuals who are functionally impaired, or who have acquired a cognitive loss, that results in the need for the assistance in the performance of the activities of daily living (ADLs) or instrumental activities of daily living (IADLs)….” This includes individuals over age 65 and those who are under age 65 with physical disabilities. Although the waiver application approved by the federal government does not mention an age limit, the manual states that the target audience for SOURCE is individuals above age 65. There is no waitlist for individuals eligible for SOURCE, and individuals receiving SOURCE benefits have no copayment.
As mentioned above, CCSP targets a similar audience, though the manual does not provide a preference for individuals over age 65. Unlike SOURCE, funding for CCSP is provided annually by the Georgia legislature, and there can be a waitlist for services. CCSP also has co-payments.
4. GAPP. GAPP is designed to provide services to medically-fragile children or children who require regular nursing care. Private practice attorneys rarely encounter individuals appropriate for GAPP. Typically, social workers in hospital or working with medical providers help eligible children apply for this benefit. This program targets children under age 18. Periodically benefits have been extended to children aging out of the program whose needs cannot be met by another waiver program.
B. The Access Waivers.
1. The Deeming Waiver (also known as the Katie Beckett waiver). Parents with children under the age of 18 may be familiar with this waiver program but usually cannot identify what services the Katie Beckett waiver provides. As discussed above, to qualify for waiver programs, the child with special needs must satisfy specific financial criteria. By law, when determining whether a child is financially eligible to receive waiver benefits, a parents’ income and resources are deemed to be the child’s own resources and the child’s own income. This usually results in the child being deemed financially ineligible for the waiver programs. With the Katie Beckett waiver, Medicaid agrees to not deem the parents’ income and resources to belong to the child, and to look only at the child’s actual income and resources, which often results in the child being deemed financially eligible for the benefits. Once the child reaches age 18, the parents’ income and resources are no longer deemed to belong to the adult child, and so from that point on only the child’s own income and resources are considered. In other words, the Deeming Waiver does not actually provide any services to a minor child with disabilities; instead, it allows that child to receive benefits through another waiver program even though the child would otherwise be financially ineligible because of her parents’ income or resources.
2. The MFP Waiver. Sometimes individuals in an institution or skilled nursing facility can transition to a residential environment where they can live with the assistance of a support waiver program. The Money Follows the Person waiver program provides services to help individuals transition to their new home. The funds can be used to pay for moving expenses, to purchase household furnishings, to pay security deposits, and to set up utilities. Other funds are allocated for long-term success, such as providing life skills coaching, specialized medical supplies, vehicle adaptations, and caregiver outreach and education.
While MFP can offer over $70,000 in benefits, each benefit is capped. For example, in 2017, an individual could receive as much as $850 to pay for moving expenses, $500 to pay for utility deposits, and $1,500 to purchase household furnishings.
At this time, the future of MFP is unclear for two reasons. First, MFP’s funding will end in 2020. MFP became effective on April 22, 2010, and it received funding through 2016. Congress extended that funding through September 2019.5 Georgia’s grant for MFP services will end on September 30, 2020.6 At this time, it is not clear whether the grant will be renewed beyond that date. Second, MFP faces housing challenges. There is a shortage of available community housing for individuals with disabilities. An individual who is appropriate to live in the community may still be unable to find a place to live where she has the support needed for her to receive a Medicaid waiver benefit.
Medicaid provides more than medical care for low-income individuals. With Medicaid waiver programs, individuals can remain in the community with their families. I have had as clients an aging husband who could spend his final days with his spouse in their family home. Another waiver recipient was able to stay home with her teenage son and saw him off to college on a football scholarship. Another mother with a degenerative condition and a young child was able to spend additional months with her child at home before going into a nursing facility. I see individuals with intellectual disabilities who thrive in group homes or apartments because of the services they receive through these waivers. By allowing people to remain in the community, Medicaid waiver programs can remove some of the financial burden of families caring for individuals with disabilities and provide everyone with a better quality of life.
If you or someone in your family may be eligible for Medicaid waiver benefits and wants to learn more, please contact Cheryl Hess at CHess@morgandisalvo.com or our main office (678) 720-0750 to schedule a consultation with Diane Weinberg. Please note that, because Medicaid programs vary from state to state, Diane is only able to provide consultations for individuals who currently reside in or who plan to move to Georgia.
1The term Medicaid will be used for efficiency throughout this article even though a number of organizations are involved in the oversight and administration of Medicaid programs. The Georgia Department of Community Health and the agencies it oversees administer most Medicaid programs, though the Department of Behavioral Health and Developmental administers the NOW/COMP waiver and related programs. The programs discussed in this article should not be confused with the Home and Community Based Services found through the Aging and Disability Resource Connection.
2Kathy Floyd, Georgia Council on Aging, “Legislative Update,” Presentation to the Georgia Chapter of the National Academy of Elder Law Attorneys (Sept. 13, 2019).
3Diane Weinberg, “Medicaid Rules as Explained by a Trusted Colleague,” Morgan & DiSalvo, P.C. (Oct. 10, 2017) https://morgandisalvo.com/medicaid-rules-as-explained-by-a-trusted-colleague/.
4See Diane Weinberg, “The Department of Community Health Introduces the Elderly and Disabled Waiver Programs,” Morgan & DiSalvo, P.C. (9/18/2019) (https://morgandisalvo.com/the-department-of-community-health-introduces-the-elderly-and-disabled-waiver-program/).