Waiver Program Explained
What is Pennsylvania’s Waiver Program?
Home and Community-Based Services (HCBS) Waiver Programs are available in Pennsylvania to provide supportive services to qualified individuals who wish to remain in their home and/or community rather than enter an institution (such as a nursing home or intermediate care facility). There are currently 10 programs available to adults in Pennsylvania. Some of these Waiver programs are currently closed to new applicants.
The HCBS Waiver programs differ in terms of the population they serve, the number of people they can serve, the application process, the criteria that must be met in order to qualify, and the services provided. Because of all these differences, figuring out which program you qualify for, and which program may best meet your needs, can be overwhelming.
What are HCBS Waiver Programs?
These are programs that provide long-term care services and supports to individuals at risk for institutionalization but who want to remain living in their home and/or community. Waiver programs provide certain medical and non-medical services to individuals in their home or in another community-based setting in order to help them remain living independently in the community (which is the preference of most individuals). The services provided under the various programs are not typically covered under Medicare and/or Medical Assistance, especially on a long-term basis. Examples of Waiver services include: skilled nursing coverage, personal care assistance services, and home modifications. The services available differ depending on the Waiver program the person qualifies for and the service plan that is developed to address the individual’s needs.
Examples of Waiver services include: skilled nursing coverage, personal care assistance services, and home modifications. The services available differ depending on the Waiver program the person qualifies for and the service plan that is developed to address the individual’s needs.
Why are these programs called “Waivers”?
The state Medical Assistance program must follow certain federal requirements. Waivers allow states to ask the Federal Government to waive (not apply) certain requirements that otherwise apply to the MA program. Under Federal rules, MA Programs must: Make Medical Assistance coverage available throughout the state; Follow the same eligibility rules and criteria statewide; and Offer certain benefit packages based on category of eligibility (benefit packages are the same across the state).
When states apply for Waiver programs, they ask the Federal Government to waive these requirements so that they can:
- Target a Waiver program to a particular area of the state where the need is greatest or to a certain group of people. Most of the Waivers currently available in PA are statewide, however, the LIFE program is only available in areas where there is a certified LIFE provider that covers a certain geographical area (see page 16 for more info). Waiver programs also target certain groups of people (such as people age 60 and older or people with certain diseases such as HIV/AIDS).
- Offer services through the Waiver programs that are not otherwise covered by MA. Waiver programs provide services such as personal assistance services (help with bathing, dressing, etc), skilled nursing services for adults, and home/environmental modifications. These services are not available to adult Medical Assistance recipients who do not qualify for a Waiver. Furthermore, not all Waiver recipients get the same services-an individualized plan is developed depending on the individual’s needs and informal supports available.
- Offer certain services that are targeted to the population being served by that particular Waiver program. The different Waiver programs offer a distinct set of services designed to meet the needs of the population being served. For example, skilled nursing services are covered by some Waivers but not others.
The following Waiver programs are available in Southwestern PA for adults with physical and developmental disabilities.
- Aging Waiver (PDA Waiver)
- AIDS Waiver
- Attendant Care Waiver
- Autism Waiver
- COMMCARE Waiver
- Independence Waiver
- OBRA Waiver
- LIFE Program
Other Waivers that are available to adults in PA include two Waivers for adults with Intellectual Disabilities. This Post includes some basic information about these programs:
- Consolidated Waiver
- Person/Family Directed Support Waiver
Who can get a Waiver?
As discussed in the above pages, there is general information that applies to all the Waiver Programs; however, each of the Waiver programs serves a different population and each program offers a different set of services. Some Waivers offer a limited set of services while others include a broad range of services. All of the Waivers have specific criteria individuals must meet in order to qualify.
Important! Waiver services are NOT an entitlement. All programs have limited capacity and limited funding. There is no guaranteed entrance into a Waiver, even if someone meets all the eligibility criteria for a particular Waiver. Some programs have waiting lists.
When Might Someone Need a Waiver?
There are a number of circumstances under which someone may want to apply for a Waiver program. Here are just some examples:
- When someone turns 21 years old and no longer qualifies for coverage of skilled nursing services under Medical Assistance but still requires that level of care to remain living independently in the community.
- When someone’s caregiver gets sick and is no longer able to provide all the care that person needs.
- When someone’s health declines and they are no longer able to live independently without some supportive services.