Eligibility and Application

To qualify for a Medicaid waiver program, you must need a level of care normally provided by a hospital, nursing home, or other care facility. The waiver’s services must be necessary for you to live in the community, and it must be safe for you to do so.

Each waiver program is meant to help people with different conditions or situations. As such, each program has its own specific eligibility requirements. These requirements are explained more on the next page, where we discuss the four waiver programs.

Financial Eligibility

To qualify for a waiver program, you must have limited income and resources. If you have disability-based Medicaid coverage, like Medicaid through Supplemental Security Income (SSI) benefits, you automatically meet the financial eligibility rules.

If you do not already have disability-based Medicaid, you must:

• Have income that is $2,901 or less a month, and
• Have resources that are $2,000 or less if you are single ($3,000 or less for couples).

This income limit is higher than the regular Medicaid income limit. That means that you might qualify for a Medicaid waiver even if you wouldn’t otherwise qualify for Medicaid due to your income. And if you qualify for a waiver, you will get its services and also get the full range of other benefits offered by Medicaid.

Note: If your disability began before you turned 26, you can open an ABLE account where you can save up to $19,000 in resources each year (plus more if you have earned income) and not have it counted by Medicaid. Learn more about ABLE accounts.

How to Apply

Each waiver program has a different agency you must contact in order to apply for that waiver.

Regardless of the waiver program, the process of applying and getting services is basically the same:

1. You contact the agency for the waiver program you are applying for.
2. The agency sets up a screening call within seven business days. During the screening call, they ask you about your situation and your income to see if you might qualify.
3. If you might qualify, you may be put on a waiting list. Some waivers in some regions do not have waiting lists, but many do. How quickly you get off the waiting list and start getting services depends on your condition and the urgency of your need, which is determined on your screening call.
   1. If you are on a waiting list and your situation changes, like your condition or your finances, update your information with the agency you applied through. It could affect your placement on the list.
4. Once a spot opens up and you get off the waiting list, a nurse does an in-home assessment to confirm that you need waiver services. You should find out if you have been approved within 45 days.
5. Once approved, you get a case manager who works with you to decide which services you need to live in the community and which you can get based on your budget.

Appeals

If your application is denied, or you disagree with a decision about waiver services, you can appeal the decision. To appeal, contact your local Division of Family and Children Services (DFCS) office within 30 days after you get a notice about eligibility or services.