Wisconsin Assisted Living and In Home Care Medicaid Waiver Information and Rules for 2017

Introduction

Wisconsin provides long-term care resources to seniors through its Department of Health Services, Long Term Services and Supports (DHS, LTSS). This office provides information and access to resources for long term care services, both state-funded and through Medicaid waiver programs. On a state basis, the DHS LTSS division oversees the Aging and Disability Resource Consumer Page, which is the first stop for aging and seniors services in the state.

Additional resources for seniors over 60 are administered by the state’s regionalArea Agencies on Aging. Established under the Older Americans Act (OAA) in 1973, Area Agencies on Aging (AAAs) respond to the needs of Americans aged 60 and over in every local community. Wisconsin hasthree of these agencies. Milwaukee and Dane are single county agencies that also serve as county aging units. The other 70 counties and 11 federally recognized Indian Tribes are served by the Greater Wisconsin Agency on Aging Resourcesas the contract and oversight agency. TheAAAs assess current needs of older people in their planning and service area and assess available services, programs, and institutions; develop plans to help address service gap. In addition, they help assure access to services, programs, and institutions; advocate for the needs of older people; and, serve as a focal point for evidence based health promotion and disease prevention activities.

Wisconsin’s Department of Health Services also offers two Medicaid long term care programs (also known as Medicaid waivers) that assist seniors who are typically eligible for Medicaid long-term care benefits for nursing homes to remain in their community or even in their own home. The programs are called: 1) Family Care and 2) IRIS (Include, Respect, I Self-Direct).

Medicaid Waiver Programs for Assisted Living and In Home Care

Wisconsin Family Care Medicaid Waiver (HCBS Family Care Waiver)

Family Care is a long-term care program which helps frail elders and adults with disabilities get the services they need to remain in their homes. This comprehensive and flexible program offers services to foster independence and quality of life for members, while recognizing the need for interdependence and support. As of January 2017, the program served 19,062 seniors over 65 years old. The goal of Family Care is to: 1) Give people better choices about the services and supports available to meet their needs; 2) Improve people's access to services; 3) Improve the overall quality of the long-term care system by focusing on achieving people's health and social outcomes; 4) Create a cost-effective long-term care system for the future.

In addition, Wisconsin operates the Family Care Partnership Program, which uses Managed Care Organizations to administer services more effectively by facilitating member choice. A key component of the Partnership Program is team-based care management. Under this arrangement, the participant, his or her physician, and a team of nurses and social workers develop a care plan together. The team coordinates all service delivery. Participants often keep their own physician who, in most cases, is added to the Partnership provider network. The eligibility requirements under Medicaid are the same. There were 1,339 seniors enrolled in the Family Care Partnership Program.

Services

Services include: Adaptive aids, adult day care, case management, communication aids/interpreter services, consumer education and training, counseling and therapeutic resources, customized goods and services, daily living skills training, day services/treatment, financial management services, home modifications, housing counseling, home-delivered meals, Personal Emergency Response Services, Prevocational Services, Relocation Services, Residential Services (Adult Family Home, Community-Based Residential Facility, Certified Residential Care Apartment Complex), respite care, self-directed personal care, skilled nursing, specialized medical equipment and supplies, specialized transportation, support broker, supported employment, supportive home care, training services for unpaid caregivers, and vocational futures planning.

Eligibility

  1. Health: Applicants must require a Nursing Home Level of Care orIntermediate Level of Care.
  2. Financial: This waiver has a special income limit equal to 300% of the Federal Benefit Rate, meaning that an individual can only receive $2,205 per month in income to qualify for the benefit. In addition, the individual cannot have assets that exceed $2,000 (or $3,000 for a couple) to qualify. The use of a Miller Trust, or Qualified Income Trust, is not allowed for the use of funneling income into the trust for purposes of care in order to access the benefit. Further, the Family Care waiver does notallow a “medically-needy” spend down category for eligibility unless you are physically disabled. The non-applicant spouse is allowed to keep $120,900 in assets and can receive a monthly allowance of up to $3,022.50 for other expenses without affecting the applicant’s financial eligibility.

Practical Considerations

There are financial caps on the amount of the benefit that can be disbursed through the program, which differs based on the region in the state, but averages around $450 a month for non-nursing home benefits. The Family Care waiver not only serve the senior population (aged 65+) but also the physically and intellectually disabled. As of January 2017, the senior population served totalled around 20,000 of the over 55,000 available slots in the waiver, meaning the majority of the Family Care waiver participants are not seniors over 65.

Wisconsin Self Directed Supports- Elderly and PD Medicaid Waiver (HCBS IRIS Waiver)

TheIRIS Program is a Medicaid Home and Community-Based Services (HCBS) waiver for self-directed long-term supports. The program is an option for adults with long-term care needs. The Wisconsin Department of Health Services, Division of Medicaid Services (DMS) oversees the program. IRIS is available to Wisconsin residents determined financially eligible for Medicaid, functionally in need of nursing home or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) level of care; and living in a county where managed long-term care and IRIS are available. People who are eligible have the choice of IRIS or managed care through their local Aging and Disability Resource Center (ADRC).

Services

Services include: Adaptive aids, adult day care, communication aids/interpreter services, consumer education and training, counseling and therapeutic resources, customized goods and services, daily living skills training, day services/treatment, fiscal employer agent, home modifications, housing counseling, IRIS Consultant Agency Provider, Live-in Caregiver, home-delivered meals, Personal Emergency Response Services, Prevocational Services, Relocation Services, Residential Services (Adult Family Home, Certified Residential Care Apartment Complex), respite care, self-directed personal care, skilled nursing, specialized medical equipment and supplies, specialized transportation, support broker, supported employment, supportive home care, and vocational futures planning.

Eligibility

  1. Health: An applicant must require a Nursing Home Level of Care.
  2. Financial: This waiver has a special income limit equal to 300% of the Federal Benefit Rate, meaning that an individual can only receive $2,205 per month in income to qualify for the benefit. In addition, the individual cannot have assets that exceed $2,000 (or $3,000 for a couple) to qualify. The use of a Miller Trust, or Qualified Income Trust, is allowed for the use of funneling income into the trust for purposes of care in order to access the benefit. Further, the IRIS waiver allows a “medically-needy” spend down category for eligibility, meaning you can spend your income on medical and other remedial care and have that amount deducted from your countable income. The non-applicant spouse is allowed to keep $120,900 in assets and can receive a monthly allowance of up to $3,022.50 for other expenses without affecting the applicant’s financial eligibility.

Practical Considerations

Medically needy spend down category is available to participants in the IRIS waiver. This waiver is for seniors who wish to have more self-direction in their long-term care planning. It is a significantly smaller program than the Family Care waiver, however, and does not offer case management services or the ability to live in a community-based residential facility. IRIS Self-Directed Personal Care (SDPC) is a self-directed option that is available only to participants in the IRIS program and is another unique aspect of the IRIS waiver. IRIS SDPC can be used at work or in other community settings outside of the home. Participants may also hire family members to provide personal care. Participants are not eligible for IRIS SDPC if they live in a group residential setting such as an adult family home or residential care apartment complex, unless the residential provider is a relative.

Wisconsin Community Options Program Medicaid Waiver (HCBS COP Waiver)

Community Options is a program available in a limited number of counties that helps people who need long term care to stay in their own homes and communities. Its purpose is to provide cost-effective alternatives to expensive care in institutions and nursing homes. Elderly people and people with serious long-term disabilities receive funds and assistance to find services they are not able to get through other programs.

Services

Services include: home modification, respite care, adaptive equipment, financial counseling, care management, communication aids, home health care, residential services, personal care, and housekeeping.

Eligibility

  1. Health: An applicant must require a Nursing Home Level of Care.
  2. Financial: This waiver has a special income limit equal to 300% of the Federal Benefit Rate, meaning that an individual can only receive $2,205 per month in income to qualify for the benefit. In addition, the individual cannot have assets that exceed $2,000 (or $3,000 for a couple) to qualify. The use of aMiller Trust, or Qualified Income Trust, is allowedfor the use of funneling income into the trust for purposes of care in order to access the benefit. Further, theCOP waiver allows a “medically-needy” spend down category for eligibility, meaning you can spend your income on medical and other remedial care and have that amount deducted from your countable income. The non-applicant spouse is allowed to keep $120,900 in assets and can receive a monthly allowance of up to $3,022.50 for other expenses without affecting the applicant’s financial eligibility.

Practical Considerations

The COP waiver is the smallest of Wisconsin’s Medicaid long term care waiver programs, and is limited geographically. Further, the target population of this waiver (although it is available to seniors over 65 years old) is really the elderly population with severe long-term disabilities, and the care provided is tailored for that population.

Conclusion

For the HCBS Medicaid waivers, the wait lists are administered by county and the Department of Human Services Medicaid Waiver Manualsets forth how the county prioritizes eligible beneficiaries in the wait list. Generally, the wait list is administered on a first-come, first-serve basis; however, there are exceptions based on the needs of the waiver participant. The Family Care program is now available statewide, and is not at capacity, however this does not mean there is still not a wait list in the specific county as applications are processed.