When families hear the word Medicaid, they may assume it is one single program with the same eligibility rules and benefits for everyone.
It isn’t.
Louisiana Medicaid includes different eligibility categories and programs that serve different populations and needs. The rules can also differ depending on whether someone needs routine medical coverage, long-term care services, or specialized home and community-based supports.
Three terms families commonly encounter are:
- Regular or traditional Medicaid
- Long-term care Medicaid
- Medicaid waivers
These terms are useful for understanding the general landscape, but they are not always separate Medicaid programs in a strict administrative sense. A person’s actual Medicaid eligibility category and the particular services they receive determine which rules apply.
This article provides a high-level overview to help Louisiana families understand the differences.
Important: This article is for general educational purposes only. It does not determine whether an individual qualifies for Medicaid, long-term care, a Medicaid waiver, or any particular service. Eligibility and service decisions are made by Louisiana Medicaid and the applicable state agencies based on the individual’s circumstances and program requirements.
What Is “Regular” or Traditional Medicaid?
When people say “regular Medicaid,” they often mean Medicaid coverage that primarily provides access to health care and medical services.
Depending on the person’s eligibility category, Medicaid may help cover services such as:
- Doctor visits
- Hospital care
- Prescription medications
- Preventive care
- Laboratory services
- Behavioral health services
- Certain therapies
- Medical equipment and supplies
- Other covered health care services
The specific benefits available depend on the individual’s Medicaid eligibility category and applicable program rules.
Many people qualify for Medicaid through income-based eligibility categories, while others qualify through disability, age, pregnancy, Medicare-related or other pathways.
Some of these categories use different financial and eligibility rules.
The important point:
Regular Medicaid primarily provides health coverage.
It does not automatically mean that a person qualifies for long-term care or home and community-based waiver services.
What Is Long-Term Care Medicaid?
Long-term care Medicaid generally refers to Medicaid coverage associated with an individual’s need for ongoing assistance because of significant functional or medical needs.
Long-term care can be provided in different settings.
For example, a person may receive Medicaid-supported long-term care:
- In a nursing facility
- At home
- In another community setting
- Through certain home and community-based programs
Depending on the program, long-term care may involve assistance with activities such as:
- Bathing
- Dressing
- Toileting
- Eating
- Mobility
- Transfers
- Personal care
- Nursing needs
- Other ongoing support needs
Long-term care Medicaid has different eligibility considerations from many ordinary health coverage categories.
For certain long-term care programs, an individual may need to meet a specified level of care, along with applicable Medicaid financial and other eligibility requirements.
This is one reason families should not assume that having regular Medicaid automatically means a person has long-term care coverage.
What Is a Medicaid Waiver?
A Medicaid waiver is a program that allows Medicaid to provide certain services in the community that may otherwise be unavailable through the standard Medicaid State Plan.
In Louisiana, waivers are particularly important for people who need ongoing support but may be able to live in their homes or other community settings rather than receiving care in an institution.
Louisiana has different waiver programs serving different populations.
For example, programs administered through the Office of Aging and Adult Services (OAAS) may serve older adults and adults with certain disabilities.
The Office of Intellectual and Developmental Disability (OIDD) administers developmental-disability waiver programs.
Waiver services can include things such as:
- Personal assistance
- Support coordination
- Respite
- Assistive technology
- Specialized medical equipment
- Home modifications
- Adult day services
- Employment or community supports
- Other services depending on the particular waiver
Not every waiver provides the same services.
Each waiver has its own eligibility requirements, service definitions, limitations and authorization processes.
What Is the Difference Between Medicaid and a Medicaid Waiver?
A simple way to think about the distinction is:
|
Regular Medicaid |
Long-Term Care Medicaid |
Medicaid Waiver |
|
|
Primary purpose |
Health coverage |
Ongoing long-term care |
Community-based long-term supports |
|
Who it may serve |
Various eligible populations |
People with qualifying long-term care needs |
Specific populations meeting waiver requirements |
|
Medical coverage |
Yes |
Yes, depending on eligibility |
Medicaid coverage may exist alongside waiver services |
|
Personal support services |
Limited depending on program |
May be available |
Often a major part of the waiver |
|
Home/community services |
Some may be available |
May be available |
Often specifically designed for community living |
|
Nursing facility services |
Not the primary purpose |
May cover qualifying nursing facility care |
Generally designed as an alternative to institutional care |
|
Waiting list/registry |
Generally not a waiver-style registry |
Depends on the program |
Some waivers have registries or limited availability |
|
Program-specific requirements |
Yes |
Yes |
Yes |
This table is intentionally simplified.
The actual relationship between Medicaid eligibility, long-term care and waiver services can be more complicated depending on the individual’s circumstances.
Can Someone Have Medicaid and Still Need a Waiver?
Yes.
Having Medicaid does not automatically mean that a person has access to every Medicaid service.
For example, someone may have Medicaid that covers their regular medical care but still need a separate determination for a home and community-based waiver.
A waiver may have additional requirements involving:
- Disability or age
- Functional needs
- Level of care
- Financial eligibility
- Program-specific criteria
- Available waiver capacity
- Service authorization
This is why families sometimes hear:
“You have Medicaid, but you still need to apply for the waiver.”
Those statements are not necessarily contradictory.
The person may already have Medicaid health coverage while separately seeking eligibility for a waiver program.
Does a Medicaid Waiver Replace Medicaid?
Generally, no.
A Medicaid waiver is better understood as an additional Medicaid pathway for specific services and populations rather than a completely separate health insurance program.
A person may have ordinary Medicaid health coverage while also receiving waiver services.
For example, a person may receive regular Medicaid-covered medical care while a waiver provides certain long-term supports that help the person remain in the community.
The exact arrangement depends on the individual’s Medicaid eligibility and the waiver involved.
Why Are There Different Medicaid Waivers in Louisiana?
Different people have different needs.
A young person with an intellectual or developmental disability may need a very different set of services from an older adult who needs assistance with daily activities.
Louisiana therefore has different waiver programs designed for different populations.
Examples include:
Developmental Disability Waivers
Louisiana’s OIDD system includes programs such as:
- New Opportunities Waiver (NOW)
- Residential Options Waiver (ROW)
- Supports Waiver
- Children’s Choice Waiver
These programs are designed for qualifying individuals with intellectual and/or developmental disabilities.
Aging and Adult Services Programs
Louisiana’s OAAS system includes programs such as:
- Community Choices Waiver
- Adult Day Health Care Waiver
- Long-Term Personal Care Services
- PACE
The eligibility requirements and services differ among these programs.
What Is the Difference Between a Waiver and Long-Term Care?
This is one of the areas that causes the most confusion.
Long-term care is a broad concept.
It refers to ongoing assistance someone may need because of disability, illness, aging or functional limitations.
A Medicaid waiver is one possible way Medicaid can provide certain long-term supports, particularly in community settings.
Long-term care can also be provided through other Medicaid pathways.
For example, qualifying long-term care may be provided in:
- A nursing facility
- A person’s home
- An adult day setting
- Another qualifying community setting
Therefore:
Long-term care ≠ nursing home.
And:
Medicaid waiver ≠ the only form of long-term care.
Does Having a Waiver Mean Medicaid Pays for Everything?
No.
A waiver does not provide unlimited coverage for every service a person may need.
Each waiver has its own:
- Covered services
- Eligibility requirements
- Service limits
- Authorization requirements
- Provider requirements
- Plan of Care requirements
- Funding or availability rules
Even when a service is listed as a waiver benefit, the individual generally must meet the applicable requirements for that service.
A waiver also does not necessarily replace other sources of care, such as Medicare, private insurance, family support or community resources.
What About Medicare?
Medicare and Medicaid are different programs.
Some Louisiana residents qualify for both Medicare and Medicaid.
When someone has both, the programs can work together, but they do not provide identical benefits.
Generally speaking:
- Medicare is primarily health insurance for people who qualify based on age or certain disabilities.
- Medicaid provides health coverage and, for qualifying individuals, may also provide certain long-term care and community-based services.
A person who has Medicare should not assume that Medicare will provide all of the long-term supports they may need.
Likewise, having Medicaid does not automatically mean the person qualifies for every Medicaid long-term-care program.
Why Does It Matter Which Program Someone Has?
It matters because the program can affect:
- Eligibility requirements
- Financial rules
- Medical or functional requirements
- Covered services
- Service limits
- Provider requirements
- Prior authorization
- Waiting lists or registries
- Plan of Care requirements
- Who administers the program
Two people can both have a Louisiana Medicaid card while receiving very different services under different eligibility categories.
That is why families should avoid relying on general statements such as:
“Medicaid covers that.”
The better question is:
“Which Medicaid program or eligibility category covers that service?”
What If Someone Needs More Help Than Their Current Medicaid Provides?
A change in someone’s needs does not automatically mean that they qualify for a waiver.
However, a significant change in circumstances may be a reason to ask whether another Medicaid program or service should be evaluated.
For example, a person may experience:
- Increased difficulty with daily activities
- A change in caregiver availability
- Increased supervision needs
- New mobility limitations
- A change in living arrangements
- Increased risk of institutional placement
The appropriate next step depends on the person’s circumstances and existing Medicaid program.
Families can contact the appropriate Louisiana agency or their Support Coordinator, when applicable, to discuss available options.
The Bottom Line
Regular Medicaid, long-term care Medicaid and Medicaid waivers are related—but they are not the same thing.
Regular Medicaid generally refers to Medicaid health coverage available through various eligibility categories.
Long-term care Medicaid refers more broadly to Medicaid coverage and services associated with ongoing long-term care needs, including qualifying care in institutional and community settings.
Medicaid waivers are specialized programs that provide certain additional services to qualifying populations, often to help individuals receive long-term supports in their homes or communities.
The most important thing for families to remember is:
Having Medicaid does not automatically mean a person qualifies for every Medicaid service.
The applicable Medicaid eligibility category, program, waiver, level of need and other requirements determine what services may be available.
If you’re unsure where someone fits, the best starting point is to identify what Medicaid coverage the person currently has and what type of assistance they need. From there, the appropriate Louisiana Medicaid or state agency can determine which programs may apply.
Program rules and available services can change. Always refer to current Louisiana Medicaid and Louisiana Department of Health information for the most current requirements.
Important: This article is provided solely for general educational and informational purposes. It is not legal, financial, medical, Medicaid eligibility, long-term-care, or benefits-planning advice.
Nothing in this article guarantees that an individual will qualify for Medicaid, a Medicaid waiver, long-term-care services, a particular service, or a specific amount of assistance. Medicaid eligibility, waiver eligibility, level-of-care determinations, service authorizations and program availability are determined by the applicable Louisiana agencies under current program rules.
Our agency is an independent Louisiana Support Coordination Agency and is not the Louisiana Department of Health, Louisiana Medicaid, OAAS, OIDD, Medicare, or another government agency. References to government programs are provided for informational purposes only.
