Senior Care Solutions: What is Medicaid Waiver?
Generous benefits are available to help pay for assisted living, in-home care, and nursing home care.
- You may be surprised to find out you can qualify for Medicaid.
- Home and Community-Based Services help keep seniors at home instead of being placed in nursing homes.
- A Medicaid Aged and Disabled Waiver (A&D Waiver) through the Indiana Division of Aging can help pay for in-home services or assisted living services.
- PACE (Program of All-Inclusive Care for the Elderly) is another program option available through the A&D Waiver.
Indiana Medicaid Home and Community-Based Services
Indiana Division of Aging and Medicaid Waivers
- Must be aged, blind, or otherwise disabled.
- Must reside in or transition into an HCBS-compliant setting (non-institutionalized).
- Must have income no higher than 300% of maximum Supplemental Security Income (SSI) amount (parental income for children under 18 years of age is disregarded).
- Meet “nursing facility level of care.”
- A complex medical condition requires direct assistance from others, such as decubitus ulcers, comatose condition, or management of severe pain.
- Need for direct assistance with medical equipment, such as a ventilator, suctioning, tube feeding, central intravenous access (I.V.), and so on.
- Direct assistance is required for special routines or prescribed treatments, such as tracheotomy, acute rehabilitation conditions, administration of continuous oxygen, and so on.
- Medical observation and physician assessment are required due to a changing, unstable physical condition.
- Other substantial chronic conditions.
Service Options with a Medicaid Waiver
- Adult Day Service
- Adult Family Care
- Assisted Living
- Attendant Care
- Self-Directed Attendant Care
- Case Management
- Community Transition
- Environmental Modifications
- Environmental Modification Assessments
- Health Care Coordination
- Home Delivered Meals
- Nutritional Supplements
- Personal Emergency Response System
- Pest Control
- Specialized Medical Equipment and Supplies
- Structured Family Caregiving
- Vehicle Modifications
Program of All-Inclusive Care for the Elderly (PACE®)
The eligibility criteria for a PACE program includes being 55 years of age or older, certified by their state to need nursing home level of care, able to live safely in the community at the time of enrollment and live within the above-mentioned PACE service area. If a PACE enrollee does need nursing home level of care, the PACE program will cover the majority of the costs in coordination with the state Medicaid program. PACE would continue to coordinate the enrollee’s care while in the program.
The PACE program is able to provide the entire continuum of care and services to seniors with chronic conditions and care needs while maintaining their independence in their home for as long as possible.
- Adult daycare that offers nursing, physical therapy, occupational therapy, recreational therapy, meals, nutritional counseling, social work, and personal care..
- Medical care is provided by a PACE physician who knows the history, needs, and preferences of the patient..
- Home health care and personal care..
- All needed prescription drugs..
- Social services..
- Medical specialties such as audiology, dentistry, optometry, podiatry, and speech therapy..
- Respite care..
- Hospital and nursing home care when needed.
Like most healthcare programs, PACE services may or may not be entirely free. If you already qualify for Medicaid, there is no monthly premium for the long-term care part of PACE benefits. If you have not yet qualified for Medicaid, but you do have Medicare, you will pay a monthly premium for the long-term care portion of PACE, as well as a monthly premium for Medicare Part D drugs and medications. There are no deductibles or copays for any of the PACE services, drugs, or approved care. If you do not have Medicaid or Medicare services, a person can pay privately for PACE services and care.
To understand how PACE fits into Indiana’s healthcare system, here’s how Indiana Medicaid explains it:
The PACE program is operated within the risk-based managed care (RBMC) delivery system, and PACE organizations are considered managed care entities (MCEs). In this delivery system, contracted MCEs are paid a capitated monthly premium for each IHCP member enrolled with the MCEs. The capitated premium covers the cost of the services covered under the program and incurred by IHCP members enrolled with the MCE. The MCE assumes the financial risk for services rendered to its members. The Indiana Family and Social Services Administration (FSSA) currently partners with Franciscan Alliance in Indianapolis and Dyer, Indiana, and Trinity Health in Mishawaka, Indiana, to serve Indiana’s PACE participants.
PACE participants are required to sign an enrollment agreement indicating they understand the PACE organization must be their sole service provider. Services must be preapproved or obtained from specified doctors, hospitals, pharmacies, and other healthcare providers that contract with the PACE organization. Before providing services to a member, IHCP providers should always check the member’s Medicare and IHCP card for a sticker indicating that the member is a PACE participant. The IHCP will deny payment of fee-for-service claims submitted by non-PACE providers for PACE members.
Senior Solutions Consulting: Helping to Navigate Complex Long-Term Care
When you have questions about benefits for long-term care, SSC has answers!