An Introduction to Medicaid Waivers
Waiver services allow people with disabilities to receive long-term care services in the most integrated setting in their communities, rather than receiving care in an institutional setting. These programs “waive” or remove some of the usual requirements for getting Medicaid services. (Source: DOH). There are a variety of Medicaid waivers that serve children, adults, individuals of all ages. Additionally, they may serve individuals with certain conditions, including physical and mental disabilities, developmental disabilities, traumatic brain injuries, and medically complex conditions.
Named after the section of the Social Security Act that authorized it, the 1915c Medicaid Home and Community-Based Waiver (HCBS) Program allows States to design Medicaid funded programs as alternatives to institutionalization.
There are specific eligibility requirements, guidelines and rules, funding limitations, and participation limits for each of New York State’s current waivers. Generally, the cost of receiving services through a waiver needs to be less than the cost of services if the individual were placed in a nursing home or other institutional setting (18).
To be eligible for a Medicaid waiver, generally, an individual: (29)
- Needs to be eligible for institutional level of care because of their disability
- Has a disability that causes a “functional impairment,” as determined by the local Department of Social Services and is based on a review of the person’s Activities of Daily Living (ADL)
- Must be eligible for Medicaid
- A person has limited financial resources and assets. This eligibility could include a cost sharing based on a aperson’s monthly income.
- In some pediatric programs such as Care at Home, a child may be Medicaid-eligible based on his/her parent’s income and/or resources -OR- the child is ineligible for Medicaid due to the parents’ excess income and/or resources, but becomes eligible when parents’ income and/or resources are not counted. (Source: DOH)
The Role of State and Local Agencies
The New York State Department of Health manages all of the New York State Medicaid waivers either directly or through other state agencies (OPWDD, Office of Children and Family Services, Office of Mental Health).
For children and youth enrolled in Medicaid waiver programs, enrollment is conducted through the State Department of Health (NYSDOH) through the local Department of Social Services; or the Office For People With Development Disabilities (OPWDD) through the regional Developmental Disability Services Organizations (DDSO).
Contact information for all of New York State’s DDSO’s can be found at: http://www.opwdd.ny.gov/document/hp_contacts.jsp
It is important for families to build a strong relationship with state agencies through their regional offices, and directly ask for assistance and up-to-date information to access the assistance and support they need long before their children reach the age limit for transition to adult programs. (Source: DOH)