Have you ever heard of the waiver tiered structure? It’s how Medicaid determines which waiver a beneficiary qualifies for and when. If you’re new to learning about this structure, we’re sure you’ve got many questions – how does it work? How often will your needs be assessed? What role does a waitlist play in all of this? We’ll answer all of these questions in this article, focusing on the waiver tiered structure as it applies to LA Medicaid.

What is the Waiver Tiered Structure?

For a long time, Medicaid-eligible folks were assigned waiver and community benefits based on a first-come-first-served basis and were put on a waitlist. For 20 years, this waitlist stood, and many people with emergent care needs were made to wait long periods or never received the benefits they needed. This was a huge issue that desperately needed fixing.

To solve this problem and help to ensure that everyone was getting the care they needed in a timely manner, the waiver tiered structure came to be. According to LA Medicaid, here are the tiers put in place:

• Tier 1 – Supports Waiver
• Tier 2 – Residential Options Waiver
• Tier 3 – New Opportunities Waiver

*Note: Children get the Children’s Choice Waiver. Beneficiaries are considered children until they reach the age of 21 (more on this later).

How Medicaid Waiver Tiers Are Chosen for Beneficiaries

At this point, you might be wondering how waiver tiers are chosen for LA Medicaid beneficiaries. Here’s the criteria that Medicaid uses to place people in tiers:

• If you’re under the age of 21, you’ll receive an offer for the Children’s Choice Waiver. That is unless you are 18 and not currently attending school. In this case, you’ll get to choose either the Children’s Choice Waiver or to be placed in tier 1 and receive an offer for the Supports Waiver.
• If you’re over 21, you’ll automatically be placed in tier 1. Then, you will complete a needs-based assessment along with person-centered planning. If it’s determined that you need more support than tier 1, you’ll receive an offer for a higher-tiered waiver.

How Tier Bumping Works

Just because you were put in one tier doesn’t mean you’ll stay there permanently. There may be a time, or multiple times, when you realize that you need more support than your current waiver provides. At that time, you and your support coordinator will work together to complete a request to be moved to a more appropriate tier.

This procedure only applies if it’s been determined that your current waiver cannot meet your needs AND another waiver can appropriately do so. Just know that certain documentation and justification will be needed to prompt Medicaid to approve bumping you up to another tier.

Periodic Waiver Assessments

Now and again, you’ll go through a needs-based assessment to determine whether your current tier is still appropriate for your level of need. You’ll need to do additional assessments based on your Screen for Urgency of Needs (SUN) score, a measure of how urgent your needs are. Here are the SUN levels you could be placed in:

• 4 – Emergent – Supports needed within 90 days.
• 3 – Urgent – Supports needed within 3 to 12 months.
• 2 – Critical – Supports needed within 1 to 2 years.
• 1 – Planning – Supports needed within 3 to 5 years.
• 0 – No supports needed.

Your SUN level determines how often you’ll need to be re-evaluated for your waiver. Members at SUN score 3 need re-evaluation yearly, SUN score 2 every 2 years, SUN score 1 every 3 years, and SUN score 0 every 5 years. Outside of mandatory re-evaluations, you can speak with your support coordinator about re-evaluation.

So, there you have it – a comprehensive guide to the intricate tiered structure of LA Medicaid waivers. Equipping yourself with this knowledge about the inner workings of Medicaid empowers you to make informed decisions that align with your needs and goals.