What is a Medicaid waiver, in plain English?

What is being waived, and why?

Start with the rule that gets set aside.

Medicaid has always paid for long-term care in an institution – a nursing home, or an intermediate care facility. For decades that was more or less the only place the long-term care money existed. If you needed that level of care and you were on Medicaid, the funding was available in a building, and not in your house.

A waiver is federal permission to set that rule aside. Under section 1915(c) of the Social Security Act, a state can ask the federal government to waive the requirement that this care be delivered in an institution, so the same Medicaid funding can pay for services in a person’s own home and community instead.

That is the whole idea, and it is worth stating plainly: the money follows the person home.

What that means in practice

Because the funding is standing in for institutional care, a waiver comes with a matching test. The person has to need the level of care the institution would have provided. For an older adult in Georgia, that means nursing-home level of care, assessed with a standard tool called the DON-R, with a medical form called the DMA-6 alongside it.

That test is why waiver eligibility is stricter than plain Medicaid eligibility. It is also why someone can be on Medicaid for years and still not be on a waiver: Medicaid covers their doctor and their prescriptions, but they have never needed institutional-level care.

Once a person is on a waiver, they receive a defined package of services written into a care plan. For Georgia’s elderly and disabled waiver that can include a personal support helper, home-delivered meals, adult day health, respite, skilled nursing visits, an emergency response button, home modifications and Structured Family Caregiving. A case manager coordinates it. Medicaid pays the case management agency directly, and no bill for case management ever goes to the member or the family.

Georgia’s waivers, briefly

Georgia runs several §1915(c) waivers, each for a different group:

• EDWP – the Elderly and Disabled Waiver Program. For older adults and adults with disabilities who meet nursing-home level of care. Delivered two ways: CCSP, where home and community services are coordinated on their own and the member keeps their own physician, and SOURCE, where medical care is integrated with those services, under tighter SSI-level income rules and without spousal protections. See CCSP versus SOURCE.
• ICWP – the Independent Care Waiver Program. For adults with severe physical disabilities, and in some cases traumatic brain injury, who would otherwise need hospital or nursing facility care.
• NOW and COMP – the New Options Waiver and the Comprehensive Supports Waiver. For people with intellectual and developmental disabilities. NOW provides a lower level of support, COMP a more intensive one.
• GAPP – the Georgia Pediatric Program. For medically fragile children who need skilled nursing care at home.

Which one applies is not a choice a family makes freely; it follows from age, disability and the kind of care needed. The comparison page, which Georgia waiver applies, sets them side by side.

Slots and waiting lists, honestly

This is the part that surprises people, so here it is directly.

A waiver is approved for a limited number of funded slots, not for everyone who meets the criteria. That is a condition of how waivers are authorized: the state commits to serving a set number of people, and the federal approval is granted on that basis.

The consequence is that meeting the criteria does not entitle a person to immediate services. When the slots are full, people who qualify wait. That is normal, it is not a sign that something has gone wrong with an application, and it is not something an agency can shorten by trying harder.

A few things worth understanding about the wait:

• A waiting list place is not an approval. They are separate. You can be waiting for an assessment, waiting for a financial determination, or waiting for a slot after being found eligible, and those are different positions.
• Circumstances can change priority. How a state prioritizes within a waiting list depends on program rules and can change; ask where you actually stand rather than assuming.
• Keep your details current. Lists move slowly and contact details go stale. A missed letter or an unreturned call can cost a place.
• Start early. Realistic time from first contact to services starting is two to six months, before any wait for a slot. If someone is heading in this direction, opening the file early costs little.

The waiting list page goes into how this works in Georgia.

What a waiver is not

• It is not a grant or a check. Services are authorized in a care plan and paid to providers, not paid to the member.
• It is not insurance you can buy. There is no premium and no purchasing your way in.
• It is not around-the-clock care. Waivers fund scheduled services, not continuous coverage.
• It is not automatic once you have Medicaid. Waiver eligibility is a separate test on top.
• It is not permanent regardless of circumstances. Eligibility is reviewed, and a person can come off a waiver if their level of care or financial situation changes.

Where to go next

If the person you are asking about is an older adult or an adult with a disability in Georgia, Understanding EDWP is the next page. If you want to know what the services actually look like week to week, read what Georgia Medicaid covers at home.

The state’s front door is the Area Agency on Aging, which in metro Atlanta is the Atlanta Regional Commission, through its Empowerline service. A case management agency can also explain what the assessment involves.

Nothing on this page is a determination of eligibility for any waiver.