Maximizing Benefits for Special Needs – Medicaid Waiver Services

Do you need specialized support services for an individual with special needs?

Medicaid Waiver Programs offer a unique opportunity for individuals with special needs to take advantage of Federal and State government funds to support medical and non-medical custodial care services. In many cases, the “waiver” program will “waive” some of the Medicaid household financial eligibility criteria and also may provide expanded services beyond the usual state Medicaid program.

Individuals who currently utilize Medicaid or receive SSI can qualify by applying for a service waiver with their local disability services office. Also, in many states, an individual who has too much income to qualify for Medicaid or SSI, can pay a “share of cost” and receive waiver benefits.

All 50 states and the District of Columbia offer home and community-based services waiver programs to help meet the needs of individuals with special needs. These waivers can cover many services, including case management, home health aides, personal care, adult day health services, habilitation, and respite care. Waiver services also can provide funding for home modifications, specialized equipment and vehicle modifications. Many states also offer specialized waivers for specific categories of individuals requiring special needs care – Autism, Eldercare, Developmental Disability, Spinal Cord Injury, Traumatic Brain Injury and complex medical issues.

Unfortunately, currently, very few regions of the country have similar waiver programs for individuals challenged by mental illness, primarily because of lack of Federal funding.

There are several challenges with waiver programs. The first is the vast differences in programs and funding available across the country. Medicaid Waiver programs are mandated by the Federal government, but they are administered by each individual state. There are broad variations in waiver services from state to state – and each state can label their waiver programs individually and develop their own parameters for administration.

Each state is also able to design programs that specifically target populations within their state. That means programs and funding can be limited even further by location within a state and the individual’s unique condition. While Federal funding is provided to each state for these waiver programs, each individual state also provides funding and is allowed to define their own programs – within certain broad Federal guidelines.

Even states that offer similar programs face challenges. States independently design and fund their unique program, creating inequality in funds available across the country. Depending on the program design, initial funding and current state budget situation, services may be offered but not available. Wait lists are very common and some programs are so under-funded that they are largely unavailable.

There are also authorization guidelines and specific eligibility criteria that are required to determine the scope of benefits that are authorized for a specific individual. Documentation from the client’s physician is required as well as other supporting documentation from individual state assessment tools. In general, there are priority and urgency of service requirements that determine the specific benefits an eligible individual will receive.

Navigating Medicaid Waiver Services can be time consuming and complex. Understanding what services are available often depend on an individual’s unique medical condition, personal financial circumstances and specific community location. Information provided on the application and wording of the medical documentation can make a significant difference in eligibility and level of benefits.

Finding answers to your many questions is not always easy, as case managers and social workers working for these government programs often have very large caseloads.

National Care Advisors consultants are uniquely skilled at identifying, advocating for and securing waiver services. We have helped clients in all 50 states maximize the benefits available to them, taking into consideration their unique medical, financial and family circumstances. By advocating for benefits, we give our clients the best possible opportunity to qualify for services that they are entitled to receive.

Questions about Medicaid Waiver Services? Having trouble understanding what services are available for your client or loved one? NCA can help! Reach out today to schedule a Third Party Benefits Analysis to help you better understand all that is available. Schedule an appointment today with Care Advisors Online or call us to discuss other service options.