As background, Medicaid is a state and federal funded health insurance program for financially needy persons, covering children, families, pregnant women, disabled persons, and seniors. For the purposes of this article, we will focus on persons with Alzheimer’s disease and related dementias (Parkinson’s disease dementia, Frontotemporal dementia, Lewy body dementia, etc.) and the need for assisted living (also called “Memory Care”).
While a few state Medicaid plans cover personal care assistance in assisted living residences, for the most part, long-term services and supports are provided via Home and Community Based Services (HCBS) Medicaid waivers.
HCBS Medicaid waivers, which are also referred to as 1915(c) Medicaid Waivers, are intended to prevent, or at the very least, delay the need for nursing home admissions by providing supportive services and benefits to promote independent living. These waivers provide long-term care benefits for the disabled and elderly, and often persons with dementia, in a variety of settings. These settings can include one’s home, the home of a relative, an adult foster care home, adult day care, group residential living, and the central focus of this article, assisted living / memory care. Via assisted living waivers, a variety of benefits are provided in assisted living / memory care, allowing persons who otherwise would not be able to live independently, to continue to live in the community.
Assisted Living Waivers DO NOT cover the cost of room and board. Rather, they cover the cost of benefits, such as assistance with the activities of daily living (ADLs, such as bathing, dressing, grooming, mobility, toiletry, eating), homemaker services, medication management, transportation, and activities (social, recreational, and educational). As a side note, assistance with activities of daily living may also be called personal care assistance, attendant care, or custodial care. Also important is that the benefits provided may vary based on the specific state’s assisted living waiver. Also, waivers providing may be called something other than an “Assisted Living Waiver”. For instance, in Alaska, it is called “Alaskans Living Independently Waiver”, and in Minnesota, it is called the “Minnesota Elderly Waiver”. Finally, not all states offer assisted living waivers.
It should be mentioned that HCBS Medicaid Waivers, unlike state Medicaid programs, are not entitlements. This means even if an assisted living waiver applicant meets all of the eligibility requirements, he / she may not be able to receive benefits immediately through the program. This is because waivers limit participant enrollment, which means once all of the participant slots have been filled, waitlists are formed.
In order to be eligible for an assisted living waiver, regardless if one has Alzheimer’s disease or another form of dementia, there are certain requirements (functional and financial) that must be met. This means, unfortunately, a diagnosis of Alzheimer’s disease does not equate to automatic eligibility. However, when a person with dementia meets the criterion, which is covered in the section below, it can be the difference between moving to a nursing home facility and continuing to live in the community.
As change can be particularly difficult for persons with dementia, the ability to live in a home-like setting (assisted living) and receive supervision and required care in this setting, rather than an institutional setting, can be beneficial. In addition, residing in an assisted living residence allows persons to maintain a greater degree of dependence than does skilled nursing homes. Some assisted living waivers offer dementia care, in which staff is specifically trained and equipped to handle the needs of persons with dementia. In addition, specific activities, such as music and art, may be organized to stimulate the memory. As an example, Illinois offers a Supportive Living Program that offers care in a dementia care setting, which are often called memory care units, Alzheimer’s care, or special care units.
In order to be financially eligible for a Medicaid assisted living waiver, there are both income and asset limits. While these limits vary slightly be state, generally speaking, the following guidelines hold true for the majority of the states. As of 2019 (these figures change annually), a single applicant must not have income greater than 300% of the Federal Benefit Rate, which is $2,313 / month. The asset limit (with some exemptions, meaning not all assets are counted towards this limit) is $2,000 for an individual. In most cases, primary homes are exempt. See state specific eligibility requirements here.
For married couples in which only one spouse is applying for the assisted living waiver, spousal impoverishment rules are in place to prevent the non-applicant (community) spouse from having too little income and assets from which to live. These rules include a Community Spouse Resource Allowance and a Minimum Monthly Maintenance Needs Allowance and not only ensures non-applicant spouses are financially stable, but also helps to lower the countable income and assets of applicant spouses.
Level of Care Requirements
In addition to the financial criterion, applicants of Assisted Living Waivers must also demonstrate a functional need for the assistance provided via these programs. In most cases, an applicant must demonstrate a level of care consistent to that which is provided in a nursing home residence. What nursing home level of care (LOC) means is not easily definable. This is because each state, and even various programs within a state, define this designation differently. For instance, nursing facility LOC could mean that an applicant requires assistance with three ADLs, such as bathing, putting on / taking off clothing, personal hygiene, mobility, transitioning, and using the toilet / cleaning up after oneself. On the other hand, a nursing home LOC could also be determined as such because a person with dementia is cognitively impaired and requires significant supervision. Learn more about nursing home level of care.
For persons with dementia who have income and / or assets over the Medicaid eligibility limit(s), this is not cause for automatic disqualification from an assisted living waiver or Medicaid in general. Rather, there are several planning techniques that can implemented in order to meet the financial eligibility requirements in the state in which one resides.
Qualified Income Trusts (QITs), also called Miller Trusts, and the Medically Needy Pathway, also known as Income Spend Down, are strategies to meet Medicaid’s income limit. However, they are state dependent meaning not all states allow Miller trusts, nor do all states permit the medically needy pathway.
QITs allow persons to deposit their “excess” income (the income over the asset limit) into an irrevocable trust, which is managed by someone other than the Medicaid applicant (commonly an adult child of the applicant). The money deposited in the trust is no longer thought of as the applicant’s income, and therefore, is not counted towards the income limit. In addition, the money in the trust can only be used for very specific purposes, such as paying for the care recipient’s uncovered medical expenses and long-term care costs. This is an oversimplified explanation of Miller Trusts. Learn more here.
The Medically Needy Pathway enables Medicaid applicants to “spend down” their income that is over Medicaid’s income limit on medical bills. The spend down period varies based on the state in which one resides, but may be 1 month, 3 months, or even 6 months. Once the Medicaid applicant has spent their income down to the income limit for the spend down period, he / she is eligible to receive benefits for the remainder of the spend down period.
There are a variety of ways to lower one’s countable assets. A simple and straightforward way to do so it to spend excess assets on assets that are not counted towards the limit. Examples include paying off debt, purchasing an irrevocable funeral trust, buying medical equipment not covered by insurance, and even taking a vacation. Learn more about asset spend down here.
It is important to mention that Medicaid has a 60-month look back period (30-months in California), in which Medicaid examines all past transfers immediately preceding one’s application for benefits. Simply stated, if an applicant gave away assets or sold them for less than market value during the “look back” period, the applicant will be punished with a period of Medicaid eligibility. This rule is in place to prevent persons from giving away their “excess” assets in order to meet the asset limit.
Medicaid planners are instrumental to the Medicaid application process in a number of ways. From explaining Medicaid benefits, to assisting with the application, to collecting required supporting documentation, to helping restructure finances to meet the financial requirements, Medicaid planners can be invaluable. This is particularly true when an applicant is over the income and / or asset limit(s). Remember, allowable planning strategies vary by state, and as mentioned above, not all states allow qualifying income trusts, nor do all states permit a medically needy pathway.
If one is over the financial eligibility limits, it is highly suggested one seek the counsel of an experienced Medicaid planner. In addition to helping Medicaid applicants meet the income and / or asset limit(s), professional planners also assist families in saving financial resources as inheritance. Some of these techniques are complicated and time consuming, and incorrectly implementing a planning strategy to meet Medicaid’s income and / or asset limit(s) can cause one to be ineligible for Medicaid. Learn about the different types of Medicaid planners here.
Following is a list of assisted living waivers are relevant to persons with Alzheimer’s disease and related dementias. Not all states offer assisted living waivers, and those that do, do not offer identical services. Therefore, a benefit offered by one assisted living waiver may not be available via another. Remember, room and board IS NOT covered under assisted living waivers. However, a variety of supportive benefits may be provided, including assistance with daily living activities, supervision, medication reminders, activities (therapeutic, recreational, social), meal preparation, transportation, companionship, and some health related services. In addition, some of the following waivers do offer specific supports (dementia care) for persons with Alzheimer’s care and related dementias. Also, remember that not all assisted living waivers are called “assisted living waivers”.
|Medicaid Assisted Living Waivers for Alzheimer’s / Dementia (Updated Sept. 2019)|
|Alaska||Alaskans Living Independently Waiver (ALI)
One of the benefits under the ALI waiver is assisted living home services (formally called residential supported living in Alaska) for persons a minimum of 21 years of age. This includes 24-hour supervision and security, assistance with activities of daily living (bathing, personal hygiene, mobility, etc.), medication management, social and recreational activities, and transportation as determined by one’s care plan.
|Arkansas||Living Choices Assisted Living
The Living Choices Assisted Living Waiver allows eligible applicants (physically disabled adults 21-64 years old and adults 65 and over) to live in private apartments within an assisted living facility. Around the clock supervision, attendant care, nursing evaluations and limited nursing services, non-medical transportation, medication oversight, and activities (therapeutic, recreational, and social) is provided.
|California||Medi-Cal Assisted Living Waiver (ALW)
Medi-Cal’s (California’s Medicaid program) ALW is intended for adults 21 years and older, but is currently only available in 15 counties within the state. This waiver provides a variety of supportive assistance, such as personal care, health related services, and housekeeping, in three types of assisted living facilities: Residential Care for the Elderly (RCFE), Adult Residential Facility (ARF), and Publicly Subsidized Housing (PSH). Some of these settings offer home-like memory care for persons with dementias, and in some instances, even a locked memory care facility adjacent to an assisted living facility is an option.
|Colorado||Colorado Elderly, Blind and Disabled Waiver
The Elderly, Blind, & Disabled Waiver (EBD) offers a variety of long-term care services and supports, and receiving such benefits in an alternative care facility (ACF) is one such support. While this wavier does not offer services that are specific to Alzheimer’s disease or related dementias, persons with these neurological diseases are eligible to live in ACFs. That said, based on the alternative care facility, special programming may be offered for persons with these conditions.
|Connecticut||Assisted Living Program under CHCPE
Assisted living services are provided in “Managed Residential Communities” (MRC) under the Connecticut Home Care Program for the Elderly (CHCPE) for persons who require assistance with daily living activities. Intended for persons 65 years of age and over, this waiver program is unique in that persons not eligible for Medicaid may also be program participants. For persons with Alzheimer’s disease or a related dementia, memory care is an option.
|District of Columbia||DC Elderly and Persons with Physical Disabilities (EPD) Waiver
In addition to providing home based services and supports, the EPD Waiver Program also provides benefits in assisted living facilities for elderly and disabled individuals who need assistance with daily living activities. Given persons with Alzheimer’s disease or related dementias meet the functional and financial requirements, they are eligible for assisted living services. It is not specifically stated if assisted living services can be provided in a memory care unit, but potentially, they could be provided in this setting.
|Florida||Statewide Medicaid Managed Care Long Term Care Program (SMMC LTC)
Florida previously had an Assisted Living for the Elderly Waiver, but in March of 2014, it was incorporated into the SMMC-LTC Program. The current program provides a variety of long term care services for physically disabled adults and frail elderly residents who require assistance with at least two daily living activities. One of the benefits is assisted living facility services, which includes personal care assistance, homemaker and chore services, and medication management. For persons who have dementia, but are not physically limited, cognitive issues resulting in the need for supervision are considered.
|Georgia||CCSP and SOURCE Programs
The Community Care Services Program and the Service Options Using Resources in a Community Environment Program operate under Georgia’s Elderly and Disabled Waiver. Both programs offer alternative living services, also known as assisted living services, and these services are provided in personal care homes, also known as assisted living residences. While both programs require an intermediate nursing home level of care and consider both cognitive and physical limitations, recognizing that these limitations can result from dementia, the difference between the two programs is that SOURCE is strictly for persons receiving SSI. Please note that CCSP and SOURCE program participants pay a monthly share of cost.
|Hawaii||Med-QUEST Integration Program
The Quest Integration Program is a managed care program that offers a variety of benefits, including home and community based services and supports, which includes an assisted living benefit. In these assisted living facilities, which are designed to be home-like, attendant care, light housecleaning, laundry, and preparation of meals, is provided for residents. While a diagnosis of Alzheimer’s disease or related dementia, such as Lewy Body dementia or Parkinson’s disease dementia, alone does not warrant meeting the functional eligibility requirement, persons with these diseases can qualify based on their level of care need.
|Illinois||HCBS Waiver for Supportive Living Facilities
The Supportive Living Program (SLP) provides “supportive living” benefits, such as personal care assistance and homemaker services, for physically disabled adults and seniors who require a nursing home level of care. Program participants can reside in board and care homes, assisted living residences, or residential memory care, the latter specifically for Illinois residents diagnosed with Alzheimer’s disease and similar dementias.
|Indiana||Aged and Disabled (A&D) Waiver
The A&D Waiver offers a variety of home and community based services, including assisted living services, for elderly and disabled Indiana residents who require a nursing home level of care. Persons with dementia are eligible to receive benefits, which include attendant care, homemaker and chore services, recreational activities, and onsite staff 24-hours / day in assisted living.
|Maryland||Community Options Waiver
The Community Options Waiver is also referred to as the Home and Community Based Options Waiver (HCBOW). This waiver provides assisted living facility services for adults 18 and over, including those with Alzheimer’s disease, who need assistance with their daily living activities and require a nursing home level of care. Memory care, specific to persons with dementia, is also a possibility, given there is facility that provides this type of care on the approved provider list.
|Michigan||Choice Waiver Program
Via the MI Choice Waiver, previously called the Home and Community Based Services for the Elderly and Disabled Waiver Program, “community living supports” are available to physically disabled state residents a minimum of 18 years old and frail elderly persons 65 and over. Provided in one’s home or a community setting, such as an assisted living residence, dementia care is offered in addition to assistance with personal care, managing finances, shopping for groceries, and preparing meals.
|Minnesota||Elderly Waiver (EW) & CADI Waiver
The Elderly Waiver and the Community Access for Disability Inclusion Waiver (CADI), also called the Community Alternatives for Disabled Individuals Waiver, offer “customized living services”, which can include services in assisted living residences. One important distinction between the two waivers is that CADI is intended for persons under 65 years old at the time of enrollment, while the EW is for persons age 65 and over. In addition to “customized living services”, there is also the option of “24-hour customized living services”, which includes around the clock supervision. For 24-hour customized living services, the level of care need is greater than for customized living services. However, with this option, services can be provided in memory care units.
|Mississippi||Assisted Living (AL) Waiver
The AL Waiver provides assistive services in personal care home-assisted living facilities, abbreviated as PCH-AL, for disabled adults and frail seniors who meet the level of care need that is provided in nursing homes. When considering functional eligibility, cognitive deficits and behavioral issues are considered, which are commonly seen in persons with Alzheimer’s disease. When coming up with a plan of care, the safety needs of those with dementia are taken into account.
|Nebraska||Aged and Disabled Medicaid Waiver
Formally called the HCBS Waiver for Aged and Adults and Children with Disabilities, assisted living services (housecleaning and laundry, personal care assistance, shopping for essentials, medication management, etc.) is one benefit available via this waiver. A person with Alzheimer’s disease who meets the level of care need (nursing facility) may be functionally eligible, given his / her (and the other residents) safety, health, and welfare is not jeopardized. In addition, an assisted living facility with a memory care unit may be enrolled as a Medicaid provider, which means it is possible for eligible wavier recipients to receive dementia specific care.
|Nevada||HCBS Waiver for the Frail Elderly (HCBS-FE)
The Nevada Home and Community Based Waiver for the Frail Elderly (HCBW-FE), formally called the Wavier for the Frail Elderly, offers an Augmented Personal Care (Assisted Living) benefit with four levels of care. Supportive services may include companionship, medication management, personal care assistance, homemaker services, and 24-hour supervision. Staff providing care for persons with dementia are required to be trained accordingly.
|New Hampshire||Choices for Independence (CFI) Waiver
The CFI Waiver, previously called the Home and Community Based Care Program for the Elderly and Chronically Ill (HCBC-ECI), offers residential care facility services, which includes supportive services (personal care assistance and supervision) in assisted living residences. Intended for New Hampshire residents who require a nursing home level of care, it is thought (though couldn’t be confirmed) that persons with dementia are able to access this benefit if eligibility requirements are met.
|New Mexico||Centennial Care Community Benefit
In New Mexico, Medicaid is called Centennial Care, and long-term home and community based services and supports are made available through what is called Community Benefit (CB). Assisted living services are available via CB, and program participants must require a nursing facility level of care (NF LOC). Dementias are stated as conditions that might be cause for a determination of NFLOC and include Alzheimer’s disease, Lewy Body, and Multi-Infarct.
|New Jersey||Managed Long Term Services and Supports (MLTSS)
In the state of New Jersey, the Medicaid program is known as NJ FamilyCare, and assisted living services are made available through the Managed Long Term Services and Supports (MLTSS) program. The MLTSS program is for persons of all ages who meet the functional need, and when considering this part of the eligibility process, cognitive deficits, which are commonly seen in persons with dementia, are a consideration.
|Ohio||Assisted Living Waiver Program and MyCare
The Assisted Living Waiver Program provides supportive services for persons 21+ years of age who require a nursing home level of care in assisted living facilities, commonly referred to as residential care facilities in the state of Ohio. Persons with Alzheimer’s disease and related dementias that meet the eligibility criteria can receive personal care assistance, housekeeping, non-medical transportation, health assessments and limited nursing care, and 24-hour on-site response in assisted living via this waiver. In addition, some facilities have memory care units.
The MyCare Ohio Plan (MCOP), also called the Integrated Care Delivery System and commonly abbreviated as ICDS, has mandatory enrollment for “dual eligible” persons. (The term, dual eligible, is referring to persons who are eligible for both Medicaid and Medicare.) MCOP is a managed care program that is currently only available in 29 Ohio counties. Persons currently receiving services via Ohio’s Assisted Living Waiver (discussed above) who are dual eligible, including those with dementia, will automatically be enrolled in MCOP and continue to receive the same assisted living services.
The ADvantage Waiver offers a variety of home and community based services to prevent the premature institutionalization of the disabled and frail elderly. One such benefit is assisted living services, which offers personal care assistance, intermittent nursing services, medication assistance, and housekeeping in assisted living facilities. While persons with Alzheimer’s disease and related dementias are eligible to receive assisted living services, specific memory care services are not provided.
Oregon’s K Plan, also called Community First Choice (CFC) State Plan Option, provides home and community based services to promote independent living and prevent unnecessary nursing home admissions for persons who require a nursing home level of care. While not technically a waiver program, CFC will pay for services provided in assisted living facilities. Persons with dementia, such as Alzheimer’s disease, who meet the eligibility criteria are able to receive these benefits.
|Rhode Island||Medicaid Section 1115 Comprehensive Demonstration Waiver
RI operates its whole Medicaid program, including home and community based long-term services and supports, under the Rhode Island Medicaid Section 1115 Comprehensive Demonstration Waiver. That said, this waiver was originally called the Global Consumer Choice Compact Waiver, or simply, the Global Waiver. Assisted living services (personal care assistance, chore and homemaker services, companionship, and medication management) is an available benefit for persons, including those with dementia, under this waiver.
Unfortunately, the assisted living waiver application process is not the same in all states. However, the first step towards applying for is to determine if you (or your loved one) is eligible for Medicaid. A non-binding Medicaid eligibility test is available here.
If determined eligible, the next step is to apply for Medicaid. Since the application process varies based on the state in which one resides, it is vital one contact the Medicaid agency in their state to enquire about the application process. To locate your state Medicaid agency, click here.
If determined ineligible, the candidate should consider contacting a Medicaid planning professional to assist them in becoming eligible.