Medicaid Waiver Eligibility

Qualifying for a Medicaid waiver involves two separate determinations: financial eligibility and functional eligibility. Both must be met.

Financial Eligibility Waiver participants must qualify for Medicaid, which involves meeting income and asset requirements. These thresholds vary by state and waiver type. In Pennsylvania, for example, individuals receiving SSI are generally automatically eligible for Medicaid, which is also the primary gateway to waiver enrollment.

Functional Eligibility Waiver programs require documented evidence that an individual needs a level of care consistent with the waiver’s design. This is typically determined through a formal assessment of daily living skills, behavioral support needs, and community participation abilities. Diagnosis alone does not establish functional eligibility — the assessment must reflect real-world support needs.

Leahy Life Plan helps families understand both eligibility tracks, identify documentation that supports functional need, and prepare for the assessment process with a clear and accurate picture of the individual’s support requirements.