Medicaid Waivers

Unlike Medicare–which is run entirely by the federal government to cover people aged 65 or older and some people under age 65 who may qualify due to a disability or another special situation–Medicaid is a state and federal partnership that is needs-based and managed by each state. Because both the state and federal government put in money for the Medicaid program, services available in Medicaid vary from state to state as well as eligibility requirements to receive them.

Medicaid offers two types of care coverage for people with disabilities: acute care services and long-term services and supports:

Acute care services are health services provided over a short-term for the prevention, diagnosis, or treatment of a medical condition. Acute care covers the type of things normally covered by private insurance such as doctor’s visits, prescriptions, inpatient care, and emergency services. Traditional Medicaid includes acute care services.

Long-term services and supports involves a broad range of health and health-related assistance provided over an extended period of time. Long-term services and supports are not intended to treat or cure a medical condition and help in maintaining or improving an optimal level of functioning and quality of life. Long-term services and supports are almost NEVER included in private insurance policies and includes things like a personal care attendant to help with dressing, employment supports, and/or an adult day program to provide social and other related support services. Because intellectual and developmental disabilities are by definition severe, chronic disabilities that are likely to continue indefinitely, resulting in substantial functional limitations in major life activities, long-term services and supports are almost always essential.

A waiver can cover things almost NEVER covered by private insurance, like an attendant that helps someone get out of bed and get dressed. HCBS waiver services can include, but are not limited to: personal assistant services; in-home or out-of-home respite care; home nursing services; medical equipment and supplies; assisted living; employment supports; cognitive rehabilitation; occupational, physical and speech therapies; and more.

Medicaid can pay for long-term services and supports provision either in an institutional setting (e.g., nursing facility, intermediate care facility, state supported living center) or in a community setting in someone’s home. Long-term services and supports provided in the community are available through Home & Community-based Services (HCBS) waivers and Community First Choice (CFC).

Texas has six Medicaid Home & Community-based Services waivers that help people with disabilities live and work in their community, instead of being institutionalized (see the overview of each on this page). Waivers “waive off” Medicaid requirements for institutional settings required by the federal government. Here is an overview of Medicaid Waivers, and here are comprehensive details about each type of waiver for comparison.

The wait can be long. Since funding from the Texas Legislature determines the availability of waiver services, there are waitlists (also called “interest lists”). Texas does not rank high for services compared to most other states, and some Medicaid waivers have long waiting lists (as much as 16 years for some waivers). Even if you are eligible, you may not be able to get services right away.

Join all waiver waitlists as early in life as possible. You do not have to prove eligibility to be added to the waiver waitlists. You will go through the eligibility process once you reach the top of the list. Only then is your eligibility information reviewed and used to decide if you can enroll.

Accept what you can while you wait for other waivers. Many people accept whatever waiver becomes available first, while waiting for a waiver that better meets their needs.

The following eligibility criteria is specific to Home & Community-based Services (HCBS) waivers and NOT general Medicaid. In order to qualify for a HCBS waiver, you must meet both financial and functional eligibility. It is important to note that eligibility is not determined until an individual is offered a HCBS waiver (e.g., their name comes to the top of the interest/waiting list).

All six HCBS waivers specific to people with disabilities listed above – except MDCP and STAR PLUS – provide long-term services and supports for Texans of all ages. MDCP is for Texans aged 0-20 and STAR PLUS is for Texans 21 and older.

Financial Eligibility:

For all waivers — except TxHmL:

• Income must be within 300% of Social Security Income (SSI)
• Does not look at parental income

For TxHmL waiver:

• Income must be within 100% of SSI
• Does look at parental income

Functional Eligibility:

Individuals must meet the functional eligibility criteria for the specific waiver. Refer to page 3 of the Texas Long-Term Services and Supports Waiver Programs document for functional eligibility criteria specifics.

Yes. Check out Navigate Life Texas’ explanation on Texas Medicaid Waiver Programs for Children with Disabilities.

Watch this video by The Arc of Texas and The Texas Council for Community Centers about how to access a crisis diversion waiver.

About Crisis Diversion

Crisis Diversion waivers are HCS waivers, historically funded separately from the first come, first serve waitlist (currently they are funding these waivers with attrition) to prevent Texans with disabilities from being institutionalized due to a lack of supports and services. The phrase many people know in relation to qualifying for a crisis diversion waiver is “imminent risk of institutionalization.” This term means different things to each person or family and is not a black and white definition.

Contact your LIDDA and tell them you or your loved one needs an HCS crisis diversion waiver. The LIDDA should help you through the process. It is very important for you and/or your loved to be involved in the process and ensure the LIDDA paints an adequate picture of the situation – the support needed to prevent institutionalization.

The LIDDA, with you or your loved one’s input, will fill out form 1058 and the LIDDA will submit a copy of the Determination of Intellectual Disability (DID), the person’s Inventory for Client and Agency Planning (ICAP) booklet/scoring sheet, and other needed documentation to HHSC. You can learn more about the full process here.

Do I need to enter an Intermediate Care Facility (ICF) to receive a diversion waiver?

No! If an ICF or other services are not “adequate and appropriate” for you or your loved one’s needs, which can be true for many reasons, including location or the institutional model (for example, living with lots of other people or not with parents), then you meet the requirements for “imminent risk” of institutionalization and can request a diversion waiver.

Learn more and see a detailed chart of Texas Medicaid programs available depending on your assets and income on the Texas Medicaid Waivers webpage.

Community First Choice (CFC) provides home and community-based attendant services and supports to Medicaid recipients with disabilities. CFC enables Texas Medicaid to provide the most cost-effective approach to basic attendant and habilitation service delivery. To be eligible for CFC, an individual must be eligible for Medicaid, need help with activities of daily living, such as dressing, bathing and eating, and need an institutional level of care. This option allows Texans with Medicaid who need basic long-term services to remain in their community, to receive them without a wait.

The Arc of Texas advocated during the 83rd Legislative session to provide this critical option to Texans.