What is a Medicaid Waiver?
For persons with limited financial resources, Medicaid pays for nursing home care. For those who wish to live at home or in assisted living, sometimes Medicaid will pay for care in those locations if it can be obtained at a lower cost than in a nursing home. It does this through Medicaid Waivers, which are also called Home and Community Based Services (HCBS Waivers) or Waiver Funded Services.
Description
For Connecticut residents 18-64 years old who need help completing their activities of daily living, state Medicaid officials created the Personal Care Assistance (PCA) Program, which is also referred to as the PCA Waiver. This waiver program pays for the cost of an agency-based personal care attendant to assist the participant with their daily living activities, such as bathing, dressing / undressing, and mobility, as well as provides for adult day care. While this program is not relevant for persons over 64 years old, the Connecticut Home Care Program for the Elders (CHCPE) is intended for this aging population.
The PCA program was originally modeled on the national Cash and Counseling framework, allowing program participants to elect which personal caregivers to use. Though this program no longer allows for participant direction, program participants have the option to choose and hire their own personal caregivers through the Community First Choice (CFC) state plan option. One advantage of the CFC option is that it does not have waiting lists for services, as is common for the PCA waiver.
The Personal Care Assistance Program is administered by Connecticut’s Department of Human Services.
Did You Know? According to the Population Reference Bureau, there was approximately 56.5 million Americans aged 65+ in 2022. This number is expected to increase to approximately 95 million by the year 2060.
Eligibility Guidelines
General Requirements
The PCA program serves individuals age 18 – 64 who have a recognized disability. In addition to the age requirement, applicants must be residents of Connecticut who require nursing home level of care and need hands-on assistance with at least two of their activities of daily living, such as bathing, eating, meal preparation, and administration of prescription drugs.
Financial Requirements
Applicants also must be financially eligible for Connecticut Medicaid. While Connecticut allows state residents to become Medicaid eligible by meeting different sets of requirements (referred to as “pathways”), most commonly, they must meet the following financial criteria for the year 2024.
Income Limits
Single applicants are not permitted to have more than $2,829 in monthly income. For married couples, income of the non-applicant spouse is not counted toward the income eligibility of an applicant spouse. Furthermore, under this scenario, income up to $3,853.50 a month can be allocated to the non-applicant spouse from the applicant spouse. This is called a monthly maintenance needs allowance and is in place to ensure the non-applicant spouse has enough funds from which to live. If the non-applicant spouse already has monthly income equal to, or above, this figure, a transfer of income is not permitted from the applicant spouse.
Over the Income Limits?
Persons who cannot afford their cost of care but are over Medicaid’s income limit may still qualify through the Medically Needy pathway. The state has a program that evaluates the individual’s care costs and their income. If it is calculated they cannot meet their care costs, they can qualify for Medicaid provided they spend-down the income over the limit on their medically necessary care costs.
Asset Limits
Single applicants can have up to $1,600 in countable resources. An owner-occupied home (limited to $1,071,000 in equity interest), a primary vehicle, and some personal effects are not considered as countable assets. However, all savings, stocks, and additional property are counted as assets.
In the situation where a spouse is not applying for Medicaid, that spouse is permitted to keep 50% of the couple’s assets, up to $154,140 (as of 2024). If the couple’s assets are under $50,000, the non applicant spouse can keep all of the assets, up to this amount. (All assets of a married couple are considered jointly owned. Learn more here.)
This is called the community spouse resource allowance. As with the income allowance, the resource allowance is intended to prevent spousal impoverishment.
Over the Asset Limits?
Persons over the asset limit can “spend down” countable assets on ones that are not counted towards the asset limit. For instance, persons can pay off debt, make home modifications, or purchase an irrevocable funeral trust.
Please note that assets should not be gifted or sold for under fair market value within 5 years of applying for CT Medicaid. This is because there is a Medicaid look-back period in which the state scrutinizes past asset transfers to ensure this has not been done to meet the asset limit. Violating the look-back rule can result in a period of Medicaid ineligibility.
Please note: Financial eligibility for Medicaid is exceedingly complex. The above rules have been simplified to provide an easier understanding of the program. Married couples, persons exceeding these fixed limits and persons unsure of their eligibility should consult with a Medicaid planning professional familiar with CT Medicaid nuances.
Benefits and Services
Personal caregivers can aid participants with their activities of daily living. These activities can include bathing, dressing, and hygiene, among other routine tasks. In addition to personal care services, the PCA program pays for mental health counseling, adult day care / adult day health care, and adult family living, which we have written about extensively here.
How to Apply / Learn More
More information about the PCA program can be found here or by downloading the Waiver Application. Be aware that the latter is not intended for consumers, but does provide extensive details about the program.
Interested applicants can call the state Department of Social Services at 1-800-445-5394. Persons can also go the Department’s website to check their eligibility and apply via the online application tool. This program is available throughout Connecticut, but it is not considered an entitlement program. This means that enrollment slots are limited, and unfortunately, waiting lists of several months are common.
