Am I Eligible for an Innovations Waiver?
The Innovations Waiver is a Home and Community-Based Service Waiver under the Medicaid program that provides services to people with intellectual and/or developmental disabilities (like Autism, Cerebral Palsy, Down Syndrome, etc.). The purpose of the Waiver is to provide services in the community rather than providing services in an institution.
Neither you nor your family member need to be on Medicaid before you can apply for this program. The best way to see if you are eligible is to contact your Local Management Entity/Managed Care Organization (LME/MCO).
This Medicaid Waiver serves children and adults who might not otherwise qualify for Medicaid because their family income is too high. The family’s income is “waived” and only the income of the person with the disability is counted. There is a wait list for this program. The wait list is also sometimes referred to as the Registry of Unmet Needs or “RUN”.
What are the eligibility requirements?
Criteria #1 – The individual must require active treatment in, or the level of support provided by an intermediate care facility for intellectual disabilities (ICF-I/DD), but doesn’t need to be living in an ICF. An individual might be eligible if their disability is severe enough that they need services to address issues like:
- Inability to take care of most personal needs
- Inability to understand simple commands
- Inability to communicate basic needs and wants
- Inability to be employed at a productive wage level without systematic long-term supervision or support
- Inability to learn new skills or apply those skills without aggressive and consistent training
- Inability to demonstrate behavior appropriate to the time, situation or place without direct supervision
- Severe maladaptive behaviors that impact the health and safety of the person or others
- Inability or extreme difficulty in making decisions requiring informed consent
- Presence of other skill deficits or specialized training needs that necessitates the availability of trained personnel to teach the individual to learn functional skills
Criteria #2 – The individual must have a diagnosis of intellectual disability (formerly known as mental retardation) or a closely related condition other than mental illness that results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disabilities. Autism and Cerebral Palsy are examples of closely related conditions that might negatively impact adaptive behavior or functioning, regardless of the individual’s IQ or cognitive ability.
Criteria #3 – The condition must have manifested before the individual turned age 22.
Criteria #4 – The condition is likely to continue indefinitely.
Criteria #5 – The condition must result in “substantial functional limitations” in three or more areas of major life activity in these six categories:
- Receptive and expressive language
- Capacity for independent living
You can read more about how someone would qualify as having a “substantial functional limitation” in these categories here: NCMedicaid: Intermediate Care Facilities for Individuals with Intellectual Disabilities, 8E. Generally, a psychologist or physician determines whether an individual has a substantial functional limitation in a major life activity.
What services are provided with the Innovations Waiver?
Some of the supports available to individuals who are on the Innovations Waiver include:
- Community Living and Support –assistance with daily living/self-care tasks, usually provided in family home
- Supported Living-provides support in the waiver recipient’s own home (not family home)
- Residential Supports –such as waiver group home services
- Supported Employment
- Day Supports-usually provided in a group setting
- Assistive technology, home modifications, and vehicle modifications
- Community transition services–to help pay for expenses to set up a new home
- Community navigator/community networking-to help the individual integrate into the community
- And other services.
Please be aware that some of these services (or others) may be available to you while you wait for a waiver slot to become available. You will need to check with your LME/MCO about services that might be available while you are on the wait list.
How long does it take to get Innovations Waiver Services?
Unfortunately, there are not enough Waiver “slots” for everyone who needs one in NC. Each of the state’s six Local Management Entities/Managed Care Organizations (LME/MCO) keeps a wait list of people who have requested the Waiver. The wait list can be ten years long or longer. Waiver slots are awarded on a first come-first served basis, so the sooner you get on the list the better.
Although you will not receive Waiver services while on the wait list, your LME/MCO may refer you to other resources that can help while you are waiting for a slot.
How do I apply for the Innovations Waiver?
You must contact the LME/MCO that provides behavioral health services for your county to request that you (or your child or ward) receive services under the Waiver. If you are eligible, the LME/MCO will add your name to its wait list. You should ask that they confirm the date of placement on the wait list in writing.
Other ways to get an Innovations Waiver
The state determines specific and very limited circumstances where a person can sometimes jump to the head of the Waiver wait list line. Here are some examples:
- Children on the CAP/C waiver who age out of that waiver at 21.
- People in institutions can sometimes receive a slot through Money Follows the Person funding so that they can leave the institution.
- There are slots for families transferred by the military.
- There are also a very limited number of emergency slots available through the LME/ MCOs.
Learn more about the Innovations Waiver, including your right to appeal if the LME/MCO refuses to add you to its wait list.