Understanding the financial aspects of caregiving is crucial, especially when navigating programs like Oklahoma’s ADvantage Waiver. If you’re exploring options for yourself or a loved one needing in-home or community-based care in Oklahoma, you’re likely wondering about the costs and how caregiver compensation works, particularly within the ADvantage Program. This guide breaks down the key aspects of the Oklahoma Department of Human Services (DHS) ADvantage Program and sheds light on how caregiver payment is structured.
Overview of Oklahoma’s ADvantage Waiver Program
Oklahoma’s ADvantage Waiver Program is a lifeline for elderly and disabled Oklahoma residents who require a nursing facility level of care but wish to remain living in their homes or communities. This Medicaid waiver program provides vital home and community-based services (HCBS) as an alternative to institutionalization in a nursing home. The program is designed to offer long-term services and supports tailored to the unique needs of each participant. These services can range from in-home personal care assistance to adult day health care, assistive technology, and even home modifications for accessibility and safety. Importantly, the ADvantage Program also extends its support to individuals currently residing in nursing facilities who are capable of returning home with the right care and assistance.
A significant benefit of the ADvantage Waiver Program is the flexibility it offers in personal care assistance. Participants can receive care from licensed professionals, or they have the option to manage their own care through Consumer Directed Personal Assistance Services and Supports (CD-PASS). This consumer-directed approach empowers participants to take control of their care by hiring, managing, and even dismissing their chosen caregivers. Under CD-PASS, a program participant can select a “personal services assistant,” which can be a friend or family member, such as an adult child, grandchild, niece, nephew, or sibling. It’s important to note that spouses are generally not eligible to be hired as paid caregivers, with very few exceptions. To further support participants in their employer responsibilities, the program allows for the designation of an “authorized representative” to assist with employer-related tasks. However, the authorized representative cannot be the paid caregiver. A financial management services agency is in place to handle the financial administration of CD-PASS, including tax withholdings and caregiver payments, ensuring a smooth and compliant process.
It’s also worth mentioning that Medicaid-funded personal care assistance is available through Oklahoma’s State Plan Personal Care, which differs from the ADvantage Waiver by not requiring a Nursing Facility Level of Care.
Participants in the ADvantage Waiver Program have the flexibility to live in their own homes, the home of a friend or family member, or in a Medicaid-approved assisted living facility. However, adult foster care homes are generally not considered eligible residences.
Keep in mind that the ADvantage Waiver Program is not an entitlement program. Meeting the eligibility criteria does not guarantee immediate enrollment due to a limited number of participant slots. When the program reaches its capacity, a waitlist is established for individuals seeking to participate.
Wait List Alternatives: If you are facing a waitlist for the ADvantage Waiver Program, exploring alternative Medicaid options for immediate care outside of nursing homes can be beneficial. Consulting with a Medicaid Planning Professional can provide valuable insights and guidance in navigating these alternatives.
The ADvantage Waiver Program operates under a 1915(c) Home and Community Based Services (HCBS) Medicaid Waiver, within Oklahoma’s Medicaid system known as SoonerCare.
Benefits of the ADvantage Waiver Program
The ADvantage Waiver Program offers a comprehensive suite of benefits designed to support individuals in their home and community settings. The specific services and supports a participant receives are determined by an individualized care plan. Here are some of the key benefits available:
- Adult Day Health Care
- Advanced Supportive / Restorative Care
- Assisted Living Services (including personal care, housekeeping, laundry, intermittent nursing care)
- Assistive Technology
- Case Management
- Consumer-Directed Personal Assistance Services and Supports (CD-PASS)
- Home Delivered Meals
- Home Modifications (such as grab bars, ramps, doorway widening)
- Hospice Care
- Personal Care Assistance
- Personal Emergency Response Systems
- Prescription Medications
- Remote Supports
- Respite Care (short-term care in-home or in a nursing facility to provide relief for primary caregivers)
- Skilled Nursing
- Specialized Medical Equipment / Supplies
- Therapy Services (physical, speech, respiratory, and occupational)
- Transitional Case Management (to assist individuals moving from institutions back home or into the community)
While the ADvantage Waiver Program can cover services provided in assisted living facilities, it’s important to note that the program does not cover the cost of room and board in these settings.
Eligibility Requirements for the ADvantage Waiver Program
To be eligible for the ADvantage Waiver Program, applicants must be Oklahoma residents at risk of nursing home placement and be either elderly (age 65 or older) or disabled (ages 21 to 64). For disabled adults, it’s important to note that cognitive impairments related to developmental disabilities or intellectual disabilities may affect eligibility. However, disabled participants already in the program can continue receiving services after turning 65. Here’s a closer look at the eligibility criteria:
Financial Criteria: Income, Assets & Home Ownership
Income: The income limit for ADvantage Waiver applicants is set at 300% of the Federal Benefit Rate (FBR), which is adjusted annually in January. For 2024, this translates to a monthly income limit of $2,829 for a single applicant, regardless of marital status. When both spouses are applying for the program, each spouse is assessed individually and can have a monthly income up to $2,829. If only one spouse is applying, the income of the non-applicant spouse is not considered when determining the applicant spouse’s income eligibility. Furthermore, a portion of the applicant spouse’s income can be transferred to the non-applicant spouse as a Spousal Income Allowance, also known as the Monthly Maintenance Needs Allowance (MMNA), to prevent spousal impoverishment.
In 2024, the maximum MMNA is $3,854. This figure represents the maximum amount of monthly income that can be transferred to the non-applicant spouse to raise their income to this level. Non-applicant spouses with an income at or above $3,854 per month are not eligible for a Spousal Income Allowance.
Assets: In 2024, the asset limit for a single ADvantage Waiver applicant is $2,000. For married couples where both spouses are applicants, each spouse can have up to $2,000 in assets. When only one spouse is applying, Medicaid still considers the assets of both spouses jointly owned. In such cases, the applicant spouse can retain up to $2,000 in assets, while the non-applicant spouse is protected by the Community Spouse Resource Allowance (CSRA), which allows them to keep a larger share of the couple’s assets.
In Oklahoma, the CSRA allows the non-applicant spouse to keep 50% of the couple’s countable assets, up to a maximum of $154,140. If 50% of the couple’s assets is less than $30,828, the non-applicant spouse can retain all of the couple’s assets, up to $30,828.
Certain assets are considered exempt and are not counted towards Medicaid’s asset limit. These typically include the applicant’s primary home, reasonable household furnishings and appliances, personal effects, and one vehicle.
It’s crucial to be aware of Medicaid’s Look-Back Rule. Giving away assets or selling them for less than fair market value within 60 months of applying for long-term care Medicaid can lead to a Penalty Period of Medicaid ineligibility.
To estimate potential asset overage and explore spend-down strategies, you can use a Medicaid Spend Down Calculator.
Home Ownership: For many, the home is their most valuable asset, and concerns about Medicaid taking the home are common. Oklahoma Medicaid provides exemptions for the home under certain conditions:
- If the applicant lives in the home or has “Intent” to Return, and in 2024, their home equity interest is $713,000 or less. Home equity is the home’s current market value minus any outstanding mortgage. Equity interest is the applicant’s ownership portion of the home’s equity.
- If the applicant’s spouse resides in the home.
- If the applicant has a child who is permanently disabled or blind (regardless of age) living in the home.
- If the applicant has a minor child (under 21 years old) living in the home.
While the home may be exempt during Medicaid benefits, it may still be subject to Medicaid’s Estate Recovery Program after the recipient’s death. Understanding the potential of Medicaid taking the home is important for long-term planning.
Medical Criteria: Functional Need
To qualify for the ADvantage Waiver Program, applicants must demonstrate a need for care at the Nursing Facility Level of Care (NFLOC). The OHS Uniform Comprehensive Assessment Tool (UCAT) III is used to evaluate whether this level of care is required. A significant factor in this assessment is the applicant’s ability to perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). ADLs and IADLs include essential tasks such as bathing, personal hygiene, mobility, dressing, toileting, meal preparation, shopping, and housework. Individuals with Alzheimer’s disease or related dementias may be eligible if they meet the NFLOC, but a dementia diagnosis alone does not automatically qualify an individual for this level of care.
For a deeper understanding of long-term care Medicaid in Oklahoma, you can learn more here.
Qualifying When Over the Limits
Exceeding Medicaid’s income and/or asset limits doesn’t automatically disqualify an applicant from Oklahoma Medicaid or SoonerCare. Several Medicaid planning strategies can help individuals who would otherwise be ineligible to qualify for benefits. Some strategies are straightforward, while others are more complex and require expert guidance.
For applicants with income above the limit, Miller Trusts, also known as Qualified Income Trusts, can be utilized. Excess income is deposited into the trust, effectively removing it from countable income for Medicaid eligibility purposes.
For those with excess assets, Irrevocable Funeral Trusts (IFTs) are a potential solution. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option is Medicaid-Compliant Annuities, which convert countable assets into an income stream. Numerous alternative options exist for individuals with assets exceeding Medicaid limits.
Improper Medicaid planning or incorrect implementation of strategies can lead to application denials or benefit delays. Consulting with professional Medicaid Planners who specialize in Oklahoma Medicaid can be invaluable. These experts are knowledgeable in the available planning strategies to meet Medicaid’s financial eligibility criteria while safeguarding Medicaid eligibility. Furthermore, advanced planning strategies can also protect assets from Medicaid’s Estate Recovery Program and preserve them for family inheritance. These more complex strategies often involve Medicaid’s 60-month Look-Back Rule and require careful planning well in advance of needing long-term care. However, Medicaid planners are aware of potential workarounds and can provide tailored guidance. Therefore, seeking advice from a Medicaid Planner is highly recommended for navigating Medicaid eligibility when income and/or assets exceed the limits. You can find a Medicaid Planner here.
How to Apply for Oklahoma’s ADvantage Waiver Program
Before You Apply
Before applying for the Oklahoma ADvantage Waiver Program, it’s essential to ensure that you meet the eligibility criteria. Applying when over the income and/or asset limits will likely result in denial of benefits unless proper Medicaid planning strategies are in place. The American Council on Aging provides a Medicaid Eligibility Test to help determine if you might meet Medicaid’s eligibility requirements.
Gathering necessary documentation is a crucial step in the application process. This may include copies of Social Security cards, Medicare cards, life insurance policies, property deeds, pre-need burial contracts, bank statements for the 60 months prior to application, and proof of income. Incomplete documentation or delays in submission are common reasons for application delays.
As the ADvantage Waiver is not an entitlement program and has a limited number of participant slots (approximately 25,472 annually), a waitlist may exist for program participation. In the event of a waitlist, access to a participant slot is determined by the date of Medicaid waiver application.
Application Process
To apply for the ADvantage Waiver Program, you can complete an online application for in-home/assisted living services. Alternatively, you can contact the Medicaid Services Unit at 1-800-435-4711 or your local county Oklahoma Department of Human Services (OKDHS) office.
For further information about the ADvantage Waiver Program, you can visit this page or contact the OKDHS Aging Services Division (ASD) at 405-521-2281. The Oklahoma Department of Human Services’ (OKDHS) Division of Aging Services is responsible for administering the ADvantage Waiver Program.
Approval Process & Timing
The Medicaid application process can take up to 3 months or longer from the initial application to receiving a determination letter of approval or denial. Completing the application and gathering all required documentation typically takes several weeks. Incomplete applications or missing documents will cause delays. Federal law mandates that Medicaid offices have up to 45 days to review applications (up to 90 days for disability applications) and issue a decision. However, delays beyond these timeframes can occur. Furthermore, if a waitlist is in place, even approved applicants may have to wait several months to begin receiving benefits.
Understanding 1915(c) HCBS Medicaid Waivers: Historically, Medicaid primarily covered long-term care within nursing homes. 1915(c) HCBS Medicaid Waivers were created to enable states to offer benefits in home and community settings. “HCBS” stands for Home and Community Based Services. The aim of HCBS waivers is to prevent or delay institutionalization by providing care in various settings, including the individual’s home, a relative’s home, assisted living facilities, or adult foster care/adult family living. These waivers often target specific populations needing a Nursing Home Level of Care and at risk of institutionalization, such as the elderly, disabled, or those with Alzheimer’s. It’s important to remember that waivers are not entitlements. Meeting eligibility requirements does not guarantee immediate receipt of benefits due to the limited number of program participant slots.
