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Eligibility

To meet EDCD Waiver eligibility requirements, the individual must need the level of care typically provided in a nursing facility. The individual does not need to agree to be placed in a nursing facility, but must meet the same criteria for admission into one—functional capacity requirements and on-going medical or nursing management. The individual must also be at-risk for nursing facility placement and meet the financial requirements for Long-Term Care Medicaid.
 
To qualify for the EDCD Waiver, the individual must meet the criteria in the following categories:
 
·         Functional capacity
·         On-going medical or nursing needs
·         Imminent risk
·         Financial eligibility
 

 

Functional Capacity

Functional capacity refers to the degree of assistance an individual requires to complete activities of daily living (ADLs)—bathing, dressing, toileting, transferring, eating, ambulating, positioning, and grooming.
 
Individuals may be considered to meet the functional capacity requirements for nursing facility level of care when they meet one of the following criteria:
 
1.      Dependent in 2-4 of the ADLs, semi-dependent/dependent in behavior pattern and orientation, as well as semi-dependent in joint motion or semi-dependent in medication administration;
2.      Dependent in 5-7 of the ADLs as well as dependent in mobility; or
3.      Semi-dependent in 2-7 of the ADLs as well as dependent in mobility and dependent in behavior pattern and orientation.

 

 

Medical and Nursing Needs

Individuals may be considered to meet the medical and nursing needs requirement for nursing facility level of care when his/her health needs require medical or nursing supervision or beyond custodial care. These medical and nursing needs include the following:
 
1. Due to a medical condition, the individual requires observation and assessment to evaluate the need for changes in treatment or procedures to prevent destabilization AND the person has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals; or
 
2. Due to the multiple, inter-related medical conditions, the potential for medical instability is high or medical instability exists; or
 
3. The individual requires at least one ongoing medical or nursing service. The following is a non-exclusive list of medical or nursing services:
 
(a) Application of aseptic dressings;
(b) Routine catheter care;
(c) Respiratory therapy;
(d) Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration;
(e) Therapeutic exercise and positioning;
(f) Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder;
(g) Use of physical (e.g., side rails, poseys, locked wards) or chemical restraints;
(h) Routine skin care to prevent pressure ulcers for individuals who are immobile;
(i) Care of small uncomplicated pressure ulcers and local skin rashes;
(j) Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability;
(k) Chemotherapy;
(l) Radiation;
(m) Dialysis;
(n) Suctioning;
(o) Tracheostomy care;
(p) Infusion therapy; and
(q) Oxygen.
 
Even when an individual meets nursing facility criteria, provision of services in a non-institutional setting shall be considered before nursing facility placement is sought.
 

 

Imminent Risk

The individual must be at-risk of nursing facility placement in the absence of Community-Based Waiver services.
 

Financial Eligibility

In order to qualify for Long-Term Care Medicaid (Medicaid Waivers or institutional care), you must need long-term care services either in an institution or in the community.
                                   
Financial eligibility includes both income and resources:
 
(1)   Income
 
Under Long-Term Care Medicaid, eligibility is based SOLELY on the income of the person who will be receiving long-term care services (at home using a Medicaid Waiver or in an institution such as a nursing facility).  Parents’ income is NOT included.  Community spouse’s income is NOT included UNLESS the community spouse is seeking community spouse allowance.

Special Medicaid Rules for Married Couples When One Spouse Receives LTC Services

Income eligibility allows for up to 300% of SSI, which is $2,163/month.

Virginia Department of Social Services Medicaid Fact Sheet #41 SPENDDOWN

Prenuptial agreements are not considered when determining financial eligibility.
 
(2)   Resources and Assets
 
Resources are cash and any other personal or real property that an individual owns, has the right/authority/power to convert to cash, and is NOT legally restricted from using for his/her support and maintenance.  Resources include: cash, bank accounts and CDs, stocks, bonds, trust funds, life insurance w/cash value, equity value of all nonexempt real property, and vehicles.
 
The resource limit for adults is $2,000.  The resource limit for children is $1,000.  Parents’ resources and assets are NOT included.

Financial Eligibility for Children Using Medicaid Long-Term Care

However, for married couples, the community spouse’s resources ARE counted when the spouse applies for Long-Term Care services.
           
A resource assessment is done by the DMAS or DSS that is based on both spouses’ resources.  The following are not counted as resources:
 
·         The home they live in
·         One car (if the couple have more than one car, they can exclude the car with the highest monetary value)
·         Burial costs up to $1,500 for each spouse