Medicaid Waiver

A Medicaid waiver can help a person live in the community in the least restrictive setting, rather than live in a nursing home or institution. Services may include case management, personal care or adult daycare, financial management, job coaching, assistive technology, personal support services, nursing care, and more.

However, because Medicaid is run by individual states, Medicaid waivers vary across the country. States are also able to opt out of new Medicaid funding and requirements. There are also different types of Medicaid waivers, each of which serves a different purpose.

In this article, we’ll define what a Medicaid waiver is, look at several different types of waivers, and show you how to check if you are eligible for a waiver.

Key Takeaways

  • Through a Medicaid waiver, the federal government can waive rules that normally apply to the Medicaid program.
  • States choose groups of people with particular needs and health conditions and use a waiver to make them eligible for Medicaid.
  • There are hundreds of Medicaid waivers in force across the country and Medicaid provides a full list of them.
  • For most people, the most relevant type of waiver will be the Home and Community-Based Services (HCBS) waiver which lets states provide care to certain individuals in the community, rather than putting them into institutional care.

What Is a Medicaid Waiver?

In order to understand Medicaid waivers, we first need to define Medicaid. Medicaid is often confused with Medicare, but the programs are very different.

Medicare is a U.S. federal government health insurance program that subsidizes healthcare services. The plan covers people age 65 or older, younger people who meet specific eligibility criteria, and individuals with certain diseases.

Medicaid, on the other hand, is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. The program is jointly funded by the federal government and individual states. It is operated at the state level, which means that coverage and administration vary greatly from state to state. It is available only to individuals and families who meet specific income-based criteria.

The Medicaid waiver program is a way for the federal government or states to change the rules about who can access Medicaid and the healthcare that is available through this program. In general, states choose groups of people with particular needs and health conditions and use a waiver to make them eligible for Medicaid. For example, some states provide waivers for care relating to developmental disabilities, traumatic brain injuries, AIDS, and substance use disorders.

Important

Medicaid waivers vary by state, but you can check your eligibility for a waiver online or by contacting Medicaid. Many states allow people to apply online.

Types of Medicaid Waiver

There are hundreds of Medicaid waivers in force across the country and Medicaid provides a full list of them.

However, most waivers can be broken down into just a few types:

  • Section 1115 waivers: These waivers are used by states to research and test new ways of delivering Medicaid care, or new ways of funding this.
  • Section 1915(c) waivers: These are known as Home and Community-Based Services (HCBS) waivers and are designed to allow states to provide home and community-based services to people in need of long-term care. This means they can stay in their own home or a community setting (such as a relative’s home or a supported living community) instead of going into a nursing facility.
  • Section 1915(b) waivers: These waivers allow states to provide care with managed care delivery organizations.

For most people, the most relevant type of waiver will be the HCBS waiver. Its purpose is to let states provide care to certain individuals in the community, rather than putting them into institutional care. This includes elderly people, and those with disabilities.

What Care Is Provided Under an HCBS Waiver?

If you or a family member qualify for an HCBS waiver, you may gain access to a wide range of healthcare services. Beneficiaries of this waiver may live in their own home, at a relative’s home, or in a senior living community that isn’t a nursing home.

Those who are accepted into their state’s HCBS waiver program will receive a range of medical and non-medical care, which can vary depending on the individual’s needs and situation, as well as state guidelines.

This may include:

  • Personal care services and supervision, at home or in an assisted living facility
  • Home health aides
  • Nursing
  • Medical supplies and medical equipment
  • Chore and homemaking services, such as shopping, laundry, and cleaning
  • Hot meal delivery services
  • Respite care to relieve a primary caregiver
  • Counseling services
  • Home and/or vehicle modifications, such as ramps and safety rails, to increase independence
  • Support and case management
  • Assistance transitioning from a nursing home into the community
  • Access to senior centers or adult group day care
  • Transport to and from non-emergency medical appointments
  • Non-medical transportation services
  • Personal emergency response systems

In addition, states can also offer a variety of non-medical services, including:

  • Case management
  • Homemaker services
  • Home health aides
  • Respite care
  • Personal care
  • Adult daycare

States may also include any other services that help individuals maintain as much independence as possible. Your eligibility for a Medicaid waiver, as well as the waivers available to you, will vary by state. You can check medicaidwaiver.org for a list of waivers in your state.

Who Qualifies for a Medicaid Waiver?

It varies a lot by state. But generally, states offer HCBS waivers to elderly people (aged 65 or over), physically disabled people, adults and children with developmental disabilities, and medically fragile people (who require life support or other extensive medical equipment).

Can I Use My Medicaid Coverage in Any State?

No. Because each state has its own Medicaid eligibility requirements, you can't just transfer coverage from one state to another, nor can you use your coverage when you're temporarily visiting another state unless you need emergency health care.

How Do I Apply for a Medicaid Waiver?

To begin the application process for a Medicaid HCBS waiver program, contact your state Medicaid office. You'll then be given information on how to submit an official application.

The Bottom Line

Medicaid waivers can be used to extend the eligibility of Medicaid to those with long-term healthcare needs. If you or a family member requires significant levels of healthcare support, check if you can apply for a Medicaid waiver to access these services.

Article Sources
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  2. U.S. Centers for Medicare and Medicaid Services. "What's Medicare?"

  3. U.S. Centers for Medicare and Medicaid Services. “January 2022 Medicaid & CHIP Enrollment Data Highlights

  4. U.S. Centers for Medicare & Medicaid Services. “State Medicaid Plans and Waivers.”

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  6. Medicaid.gov. "Managed Care Authorities."

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  8. U.S. Centers for Medicare and Medicaid Services. “Beneficiary Resources.”