Elderly Waiver Program Keeps People Out of Nursing Homes

Iowa has a Medicaid program for helping people who need extra care to stay out of nursing homes and continue to live at home.  For people over 65 the program is called the Elderly Waiver program.  The program provides funding for services and personal care support in your home or an assisted living facility.  The program is for people who would need to go to a nursing home or other medical institution if they did not get this in-home care.  With the desire to stay in your home and the high cost of nursing home care, this is an important program for elderly Iowans.

What are the requirements for eligibility for the Elderly Waiver program?

For a single person in 2024:  if your monthly income is $2,829 or less and your assets are $2000 or less and you need in-home care, you may be eligible for Elderly Waiver Program.  You do not count your home, car, household goods, and certain burial/funeral funds or contracts.  If your monthly income is over $2,829 you may still be eligible under certain conditions. 

If you are married and only one of you needs help, the asset limits are more complicated. The spouse not applying for help may be able to keep assets up to $154,140 (in 2024) and possibly more.  

• You must be an Iowa resident and a U.S. citizen or person with legal entry into the U.S.
• You must be 65 years of age or older.
• You must meet the income and assets requirements for Medicaid assistance for living in a nursing home facility. 
• You must need nursing or skilled “level of care”.

You apply for the Elderly Waiver program through Iowa Department of Health and Human Services.  Iowa Medicaid Enterprises is responsible for determining if you need the “level of care” required for Elderly Waiver services.

How do I know if I need the “level of care” required for Elderly Waiver?

To be eligible for the Elderly Waiver program, you must need care that is considered nursing or skilled level of care.  This means the care is necessary for you to stay in your home safely.   In other words, without Elderly Waiver services you would need this care in a medical institution such as a nursing home.

A person completes the interRAI - Home Care (HC) form with input from you.  The form asks if you need assistance or if you have problems in the following areas:

1. Cognitive – such as memory issues
2. Ambulation – such as using a wheelchair
3. Bathing/Grooming – such as risk of falling
4. Dressing
5. Therapy
6. Behaviors
7. Elimination – toilet issues such as incontinence
8. Living Arrangement – including if dangerous to live alone
9. Respiratory – such as use of oxygen
10. Tube Feeding
11. Medications – such as help for set-up
12. Eating
13. Skin – such as bed sore treatment

Based on this medical evaluation Iowa Department of Health and Human Services (HHS) decides if you are eligible for Elderly Waiver services.  If the answers on the form indicate that you have no problems or need for care, you will not be eligible for the Elderly Waiver program.  The form is a tool for indicating whether you need nursing home level of care services. 

The bottom line to qualify for Elderly Waiver is that you need care services to safely stay in your home and without the Elderly Waiver you would have to get the care in a nursing home.  

If denied Elderly Waiver services you can appeal the decision, or re-apply in the future if your need for care increases.

What if my Elderly Waiver benefits are cancelled? 

You can lose your Elderly Waiver services if you get new income or assets that put you over eligibility limits.  You can also lose your Elderly Waiver services if you no longer need the level of care provided by the program.

Annually, the Iowa Department of Health and Human Services (HHS) through Iowa Medicaid Enterprise (IME) reviews people getting help through the Elderly Waiver program.  The evaluation is to see whether you still need the care services provided by the program.  Your doctor, nurse, or physician assistant will need to submit current medical information regarding diagnoses and medications. It is important that you, your doctor and other care providers understand this review and the level of care required for Elderly Waiver services. 

Loss of Elderly Wavier services can occur after the annual review of your level of care. HHS or your MCO will have someone go through the interRAI - Home Care (HC) form with you. The questions are meant to assess your level of independence. 

The loss of Elderly Waiver services which keep you in your home may be catastrophic. Elderly Waiver services allow people to remain in their homes instead of moving into an assisted living facilty or nursing home.  

What if HHS notifies me that I am not eligible for Elderly Waiver services?

• You need to file an appeal with the Department of Health and Human Services within the deadline listed on the notice.  A hearing will be scheduled with an Administrative Law Judge to decide if you qualify for Elderly Waiver services.  If you are curerntly receiving Elderly Waiver services, you can file an appeal within 10 days of the notice and also request that your Elderly Waiver services continue during your appeal.  If you lose the appeal, you may have to repay the state for the continued care services. 
• You should review the canceling of your Elderly Waiver with your doctor and other care providers.  Ask them if they can provide medical support to show your need for Elderly Waiver services. At the hearing, you can testify and provide additional evidence to the judge.
• You should call Iowa Legal Aid for advice and possible help representing you at the hearing.

Sometimes the completed interRAI - Home Care (HC) form does not tell the whole story of your need for Elderly Waiver services.  It may be that you have told your doctor that you don’t need help when you do need help.  You may feel uncomfortable talking about your personal care needs.  However, it is very important to be honest in the evaluation of your care needs.  Trying to do things that put you at risk of falling or that risk your health in other ways is foolish.  This can also lead to having to go into a nursing home.  Sometimes even though you are able to do some things on your own there may be a combination of medical care and personal care needs that would prevent you from staying at home without Elderly Waiver services. 

Review the completed interRAI - Home Care (HC) form with your doctor. 

• Be honest about your need for help and care. 
• Make sure your doctor understands your limitations and needs. 
• Ask your doctor to submit a letter or updated medical record to Iowa Medicaid Enterprises (IME) and to the Administrative Law Judge, explaining why you need the Elderly Waiver program to safely stay in your home. 

A clear statement from your doctor stating that you would need to go to a nursing home if your Elderly Waiver care is canceled is very helpful for persuading IME and the Administrative Law Judge. 

If it becomes clear from your medical support that you need the Elderly Waiver services, the Department of Health and Human Services may re-instate you in the program before the hearing.  Otherwise the Administrative Law Judge will decide if your Elderly Waiver program should continue or not. 

Even if you lose the appeal and your Elderly Waiver services are canceled, you can re-apply for the program should your need for in-home assistance increase. 

If you are having problems, you may wish to call Iowa Legal Aid.