In February 2024, Oregon received approval from the U.S. Centers for Medicare and Medicaid Services (CMS) to implement an innovative 1115 Medicaid demonstration waiver incorporating family caregiver supports and supports for older adults and adults with disabilities. The Oregon Project Independence Medicaid (OPI-M) waiver expands the state-funded Oregon Project Independence (OPI) program to allow more at-risk Medicaid-eligible older adults and people with disabilities to receive long-term services and supports (LTSS). The waiver also provides access to supports for their family caregivers.
OPI offers a pathway for qualified older adults and people with disabilities who need assistance with activities of daily living (ADLs) to receive LTSS at home and delay or avoid transitioning to traditional Medicaid. Because OPI is state-funded, however, the state’s ability to expand the program to reach larger numbers of people has been limited. The state designed the OPI-M 1115 demonstration waiver to increase access to supports for people who do not require Medicaid nursing facility level care and for their unpaid caregivers, making services available to more individuals.
“We rolled in the family caregiver assistance program services without caps [into the Medicaid waiver] to make existing [family caregiver] services available to a greater number of people”
— Jane-ellen Weidanz, Deputy Director of Policy, Oregon Department of Human Services, Office of Aging and Physical Disabilities
What is included in the OPI-M program?
Those eligible for OPI-M include adults aged 60 and over and people with physical disabilities aged 18 and over who are citizens and:
- Have an income of up to and including 400 percent of the federal poverty level (FPL)
- Are not receiving Medicaid LTSS or are already participating in the OPI program
- Have resources up to and including the equivalent of six months of Medicaid nursing facility costs
- Have ADL support needs included in the program’s eligibility criteria
OPI-M includes a set of extensive (up to 18) categories of ADL support needs that qualify for the program. OPI-M’s services were modeled on OPI and the state’s Family Caregiver Support Program. In OPI-M, participants can receive supports similar to those included in OPI, including adult day services, personal care services, specialized medical equipment and assistive technology, transportation support, home-delivered meals, and evidence-based health promotion programs. OPI-M also allows participants to receive up to 40 hours per pay period of in-home personal care. New services include home modifications, caregiver support, and training.
What makes Oregon’s OPI-M program unique?
Support for caregivers: OPI-M’s definition of a qualifying informal caregiver is flexible. The definition includes: those providing unpaid support for at least three months and who expect to continue providing care for at least three more months; caregivers of those who have a new diagnosis or other health needs requiring at least three months of I/ADL support; or caregivers of those receiving hospice. Caregivers are not required to be legally or biologically related to the care recipient, but they must be providing at least 10 hours a week of in-person care.
OPI-M provides access to caregiver education and training and community caregiver support services. OPI-M uses the Unpaid Caregiver Assessment Tool to assess caregivers’ need for services. The state plans to provide caregiver training access through Oregon Care Partners, a free resource for caregivers to improve care of older adults and people living with Alzheimer’s disease in Oregon. Oregon’s administrative rules for the OPI-M program (effective May 31, 2024) allow unpaid caregivers to receive education and training on topics including, but not limited to, stress reduction, addressing complex behaviors, and culturally specific caregiving. Caregivers are not charged for participating in training. Caregivers also have access to support services including, but not limited to, paid wellness services, group-based activities, peer supports, and facilitated support groups.
Expansion of care without the threat of estate recovery: State Medicaid agencies are required by federal law to seek repayment for long-term care services from participants’ estates after the participant passes away. Notably, OPI-M does not include estate recovery requirements for participants (includes those with income up to 400 percent of the FPL). This flexibility allows the program to reach more people with long-term care needs who would like to remain at home but are limited by financial requirements or those who are fearful of having their assets subject to estate recovery.
Washington State’s Medicaid Alternative Care and Tailored Supports for Older Adults programs within the state’s Medicaid 1115 waiver served as a model for Oregon’s waiver. Washington’s waiver also does not include estate recovery requirements and incorporates supports for unpaid family caregivers.
“We received approval to eliminate estate recovery, which was a significant barrier to participation; in the early 2000s, 80 percent of participants were not entering the Medicaid program because they didn’t want to face estate recovery.”
— Jane-ellen Weidanz, Deputy Director of Policy, Oregon Department of Human Services, Office of Aging and Physical Disabilities
What are the next steps, and what can states learn from Oregon’s waiver?
Oregon began a phased implementation of OPI-M on June 1, 2024, with full implementation scheduled for March 1, 2025. During this phase-in, individuals on the OPI waitlist and those already participating in OPI are eligible to participate in OPI-M. The next steps for the OPI-M program include building out training and support materials for Area Agencies on Aging (AAAs) and Medicaid-eligible providers to coordinate case management. Oregon has created a resource guide for staff on implementation, including 14 implementation plans at the local level and guidance on what assessments can be used to determine OPI-M eligibility during the initial implementation phase. Developed by the AAAs serving Oregon’s counties, plans include timelines for each phase of implementation, steps to address waitlists for services, eligibility requirements, and how potential barriers to implementation will be addressed.
This new waiver will allow Oregon to reach caregivers of Medicaid beneficiaries whose income does not qualify them for Medicaid but who cannot afford services and supports. It also has greater potential reach because estate recovery can prevent people from wanting to access state benefits. OPI-M can serve as an example for other states on how to use the flexibility of Medicaid 1115 waivers to incorporate services and supports for more adults with LTSS needs and for their caregivers.
Acknowledgement
The authors thank Oregon state officials for their input on this blog post, which is supported by The John A. Hartford Foundation. For more information about promising state practices in family caregiver policy, visit NASHP’s RAISE Act Family Caregiver Implementation and Technical Assistance Center.
