Navigating the landscape of long-term care can be overwhelming, especially when considering the financial aspects. For Oklahoma residents seeking alternatives to nursing homes, the Oklahoma Department of Human Services (DHS) ADvantage Waiver Program offers vital support. A key question for many families is: “How much does the Oklahoma DHS ADvantage Program pay for care?” This article provides a detailed overview of the ADvantage Waiver Program, explaining the services it covers and how it can help fund care for eligible individuals in their homes and communities.
Understanding the Oklahoma ADvantage Waiver Program
The Oklahoma ADvantage Waiver Program is a Home and Community Based Services (HCBS) Medicaid waiver designed to support elderly and disabled Oklahoma residents who are at risk of needing nursing home care. Instead of institutionalization, this program enables individuals to receive necessary long-term services and supports in more comfortable and familiar settings, such as their own homes, the homes of family members, or assisted living facilities. Funded by Medicaid (known as SoonerCare in Oklahoma), the ADvantage Waiver aims to provide a person-centered approach to care, tailoring services to meet individual needs.
One of the important features of the ADvantage Waiver is the option for Consumer Directed Personal Assistance Services and Supports (CD-PASS). This option empowers program participants to take control over their personal care by allowing them to choose, hire, and manage their own caregivers. This can include family members like adult children, siblings, or other relatives (excluding spouses in most cases), offering greater flexibility and personalized care arrangements. A financial services agency manages the employment aspects, handling payments and tax withholdings for hired caregivers.
It’s important to note that the ADvantage Waiver is not an entitlement program. Enrollment is limited, and a waitlist may exist when the program reaches its capacity. Therefore, understanding the eligibility criteria and application process is crucial for those interested in accessing these valuable services.
What Services Does the ADvantage Waiver Cover?
The ADvantage Waiver Program offers a comprehensive range of services aimed at supporting individuals in their daily living and health needs. The specific services a participant receives are determined by an individualized care plan developed based on their unique requirements. These services can significantly reduce the out-of-pocket costs for care that families would otherwise face. Here are some key benefits provided under the ADvantage Waiver:
-
Personal Care Assistance: Help with activities of daily living (ADLs) such as bathing, dressing, and mobility. This is a core service addressing the direct “care” aspect of the keyword.
-
Consumer-Directed Personal Assistance Services and Supports (CD-PASS): As mentioned, this allows participants to self-direct their personal care and choose their caregivers, influencing how “care” is delivered and potentially “paid” if hiring family.
-
Adult Day Health Care: Supervised care in a community setting during daytime hours, offering social interaction and health services.
-
Assisted Living Services: Support services within a Medicaid-approved assisted living facility, including personal care, housekeeping, and intermittent nursing care. Note that room and board are not covered.
-
Home Modifications: Changes to the home environment to improve accessibility and safety, such as grab bars and ramps.
-
Assistive Technology: Devices and equipment to aid with daily tasks and improve independence.
-
Personal Emergency Response Systems (PERS): Devices that allow individuals to call for help in case of emergencies.
-
Home Delivered Meals: Nutritious meals brought to the home, ensuring proper nutrition.
-
Respite Care: Temporary care to relieve primary caregivers, whether in-home or in a facility.
-
Skilled Nursing: Nursing services provided in the home, as needed.
-
Therapy Services: Physical, speech, respiratory, and occupational therapy to improve function and health.
-
Specialized Medical Equipment / Supplies: Necessary medical equipment and supplies beyond standard coverage.
-
Hospice Care: Support and care for individuals with a terminal illness.
-
Transitional Case Management: Assistance for individuals moving from an institution back home or into the community.
-
Advanced Supportive / Restorative Care: Specialized care to promote recovery and independence.
-
Case Management: Ongoing support and coordination of services by a case manager.
-
Prescription Medications: Coverage for necessary prescription medications.
-
Remote Supports: Technology-based support and monitoring services.
While the ADvantage Waiver Program funds a wide array of care services, it’s crucial to understand that it does not cover the cost of room and board in assisted living facilities. The program focuses on providing the necessary care and support services to allow individuals to live safely and comfortably in their chosen community setting.
Eligibility for ADvantage Waiver: Key Requirements
To be eligible for the Oklahoma ADvantage Waiver Program, individuals must meet specific criteria related to age or disability, residency, functional need, and financial status. These requirements ensure that the program serves those who genuinely need its support to avoid institutionalization.
Financial Eligibility: Income and Asset Limits
Financial eligibility is a key aspect of qualifying for the ADvantage Waiver. There are limits on both monthly income and countable assets. These limits are set to ensure that the program benefits those with limited financial resources.
In 2024, the income limit for ADvantage Waiver applicants is capped at 300% of the Federal Benefit Rate (FBR). This translates to a monthly income limit of $2,829 for a single applicant, regardless of marital status. If both spouses are applying, each spouse is assessed individually and can have income up to this limit. Importantly, when only one spouse applies, the income of the non-applicant spouse is not counted towards the applicant’s income eligibility.
Furthermore, Oklahoma has provisions to prevent spousal impoverishment. 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). In 2024, the maximum MMNA is $3,854. This ensures that the non-applicant spouse has sufficient income to maintain their own living needs.
In addition to income limits, there are also asset limits. In 2024, the asset limit for a single applicant is $2,000. For married couples with both spouses applying, each spouse can have up to $2,000 in countable assets. When only one spouse is applying, Medicaid considers the couple’s assets jointly owned. In this case, the applicant spouse is limited to $2,000 in assets, while the non-applicant spouse is protected by the Community Spouse Resource Allowance (CSRA).
:max_bytes(150000):strip_icc():format(webp)/GettyImages-922847682-59624517519de2000e0e2b65.jpg)
In Oklahoma, the CSRA allows the non-applicant spouse to retain 50% of the couple’s countable assets, up to a maximum of $154,140. If 50% of the assets is less than $30,828, the non-applicant spouse can keep the entire amount up to $30,828. Certain assets are considered non-countable and are exempt from these limits. These typically include the applicant’s primary home (under specific equity limits), household furnishings, personal effects, and a vehicle.
It is critical to be aware of Medicaid’s Look-Back Rule, which involves reviewing financial transactions for the 60 months prior to application. Gifting assets or selling them below fair market value during this period can result in a Penalty Period of Medicaid ineligibility.
Medical Eligibility: Nursing Facility Level of Care
In addition to financial criteria, applicants must also demonstrate a medical need for care at the Nursing Facility Level of Care (NFLOC). This means the individual’s health condition and functional limitations are such that they would require the level of care typically provided in a nursing home setting.
The Oklahoma DHS utilizes the Uniform Comprehensive Assessment Tool (UCAT) III to evaluate an applicant’s functional abilities and determine if they meet the NFLOC requirement. This assessment heavily considers the individual’s ability to perform Activities of Daily Living (ADLs), such as bathing, dressing, eating, toileting, transferring, and continence, and Instrumental Activities of Daily Living (IADLs), such as meal preparation, managing medications, and transportation.
Conditions like Alzheimer’s disease and related dementias can contribute to meeting the NFLOC, but a diagnosis alone is not sufficient. The assessment focuses on the level of care required due to the functional impairments resulting from the condition.
Navigating Income and Asset Limits: Options if You Exceed Them
Exceeding the income or asset limits for Medicaid does not automatically disqualify an individual from receiving ADvantage Waiver benefits. Oklahoma Medicaid offers several strategies to help individuals who are over these limits to still qualify for needed care.
For applicants with income exceeding the limit, Miller Trusts, also known as Qualified Income Trusts, can be a valuable tool. These trusts allow “excess” income to be deposited into the trust account, where it is no longer counted towards the income limit for Medicaid eligibility purposes.
For those with assets above the allowable limit, options like Irrevocable Funeral Trusts (IFTs) and Medicaid-Compliant Annuities can be considered. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid annuities convert countable assets into an income stream, which can help in meeting asset limits while providing income for care needs. Other Medicaid planning techniques may also be available depending on individual circumstances.
Navigating these financial rules and planning strategies can be complex. Seeking guidance from a professional Medicaid Planner is highly recommended. These experts are knowledgeable about Oklahoma Medicaid rules and can provide personalized advice to help individuals qualify for the ADvantage Waiver while protecting their financial well-being to the greatest extent possible.
Applying for the Oklahoma ADvantage Waiver Program
The application process for the ADvantage Waiver involves several steps, from preparing documentation to submitting the application and awaiting a decision.
Before You Apply: Preparation
Prior to applying, it is essential to ensure that you or your loved one likely meet the eligibility criteria. Utilizing a Medicaid Eligibility Test can be a helpful first step to assess potential eligibility. Gathering necessary documentation in advance can also streamline the application process. This documentation may include:
- Social Security cards
- Medicare cards
- Life insurance policies
- Property deeds
- Pre-need burial contracts
- Bank statements (for up to 60 months prior to application)
- Proof of income
Understanding that a waitlist may exist for the ADvantage Waiver is also important. Planning ahead and applying as early as possible can be beneficial.
The Application Process: Step-by-Step
To apply for the Oklahoma ADvantage Waiver Program, you can utilize the online application portal for in-home and assisted living services. Alternatively, you can contact the Medicaid Services Unit at 1-800-435-4711 or visit your local county Oklahoma Department of Human Services (OKDHS) office.
For further information about the ADvantage Waiver Program, you can visit the official OKDHS website or contact the OKDHS Aging Services Division (ASD) directly at 405-521-2281.
Approval Timeline and What to Expect
The Medicaid application process can take time. It typically takes up to 3 months from the initial application submission to receive an official determination letter. Completing the application accurately and providing all required documentation promptly can help avoid delays. While federal regulations mandate application review within 45 days (or 90 days for disability-based applications), processing times can sometimes exceed these guidelines. Furthermore, even after approval, individuals may need to wait for program enrollment due to potential waitlists.
Understanding HCBS Medicaid Waivers: A Broader Perspective
The Oklahoma ADvantage Waiver Program is part of a larger nationwide effort to rebalance long-term care systems, moving away from primarily institutional care towards Home and Community Based Services (HCBS). These 1915(c) Medicaid waivers represent a significant shift in how long-term care is funded and delivered.
Historically, Medicaid primarily covered long-term care within nursing homes. HCBS waivers were created to provide states with the flexibility to use Medicaid funds to offer services in community settings. The goal of HCBS is to empower individuals to receive care in the least restrictive and most integrated settings possible, delaying or preventing the need for institutionalization. These waivers often target specific populations with NFLOC needs, such as the elderly, individuals with disabilities, and those with Alzheimer’s disease or related dementias.
It is important to remember that HCBS waivers like the ADvantage Waiver are not entitlement programs. Meeting the eligibility criteria does not guarantee immediate program enrollment due to funding limits and potential enrollment caps. However, they offer a crucial pathway for many Oklahoma residents to receive the care they need in their homes and communities, enhancing their quality of life and independence.
Conclusion
The Oklahoma DHS ADvantage Waiver Program is a vital resource for elderly and disabled Oklahomans seeking alternatives to nursing home care. While the program does not directly “pay” a fixed amount to participants for “care” in a cash benefit sense, it funds a comprehensive suite of services designed to support individuals in their homes and communities. These services, ranging from personal care assistance to home modifications, effectively cover significant costs associated with long-term care, making care more accessible and affordable for eligible individuals. By understanding the program’s benefits, eligibility requirements, and application process, Oklahoma residents can explore this valuable option to receive the care they need while remaining in their preferred living environment. For those seeking to understand how to access these services or navigate the complexities of Medicaid eligibility, consulting with a Medicaid planner or contacting the Oklahoma Department of Human Services is a recommended next step.
