Example

Ernie’s Story

Ernie is 45 years old and was diagnosed with multiple sclerosis (MS) 15 years ago. He’s been living on his own for most of his adult life and has always valued his independence.

A few years after he was diagnosed, Ernie went from working full-time to part-time and started getting Social Security Disability Insurance (SSDI) benefits, through which he gets Medicare. He doesn’t qualify for Medicaid because his income is too high.

Over the years, his MS has progressed, and in the past few years he has been having a hard time with cooking, cleaning, and other daily tasks. The home health care he gets under Medicare just isn’t keeping up with his needs. He’s starting to think that he could use extra services but isn’t sure where to look.

A few friends tell Ernie he should think about moving into a nursing facility, but Ernie prefers to keep living at home. He starts looking online to see if he can find an alternative. That’s when he reads about Georgia’s Medicaid waiver programs, which give extra benefits and services to qualifying people with disabilities to help them live in the community rather than in an institution. That’s exactly what he needs.

Learning about Waivers

Ernie learns that waiver programs are for people who need long-term care services that are at the same level as those provided in a nursing facility. Ernie probably would not have qualified a few years ago, but because his MS has progressed, now he does need that level of care.

Also, his income and resources are under the waiver program limit. Even though he doesn’t qualify for regular disability-based Medicaid, he could qualify for a waiver program, because the income limit is higher than it is for regular Medicaid.

Excited, Ernie starts reading about each of the four waivers to see if one of the programs fits his needs. Two of the waivers don’t apply to him, because they are for people with intellectual or developmental disabilities. But the Independent Care Waiver Program (ICWP) seems perfect for his situation. The ICWP is for people who need help caring for themselves and doing activities of daily living because of physical impairments. It would provide the personal support services that he needs to keep living in his home, plus other benefits he might need, like home modifications and home delivered meals. This would be a huge help for Ernie.

Applying for the Waiver

Ernie calls Alliant Health Solutions to apply for the ICWP waiver. The staff then schedules a screening call for later that week to get more information about Ernie.

On the screening call, Ernie has to answer questions about his situation so that the staff member can see if he’s eligible and how urgently he needs waiver services, which would affect his placement on the waiting list. Based on Ernie’s answers, the staff member tells him that he is potentially eligible for the waiver, but a nurse would have to do an in-home assessment to make sure. Then, he puts Ernie’s name on the waitlist.

The ICWP waitlist in his region is short, so Ernie only has to wait a few weeks before the next step in the process: A nurse named Eve comes to his house for an assessment to make sure Ernie qualifies for waiver services. Eve and Ernie discuss his activities of daily living, like bathing, dressing, mobility, eating, cognition, and memory. It’s clear to Eve from their conversation that the level of care Ernie needs is equal to that provided in a nursing home.

Eve tells Ernie that she would move his application forward to be looked at by the health insurance company, which has to give the final approval. A week or so after Eve’s visit, Ernie is officially approved for the ICWP.

Ernie is ecstatic! He meets his new case manager, and they work together to decide which services Ernie should get and how to stay within his budget. Because his income is over the regular Medicaid limit, Ernie needs to pay for part of the cost of these services. But this is okay with Ernie, because he now gets full Medicaid coverage, can keep living in his home, and can continue working part-time. Ernie is thrilled that he can keep living and working in his community.