Problem
Last June, Governor Healey capped the ECOP ( Enhanced Community Options Program) at 7,322 from 9,000. Once the cap is reached, new enrollees are put on a waiting list. Requiring frail elders to wait months for home care will inevitably lead to many developing worse health problems and ending up in nursing homes, said Betsey Crimmins, executive director of Mass Aging Access. Peter Tiernan and Dignity Alliance have expressed concerns since this was announced over a year ago.
In January 2025, the ECOP program supported 9,283 active consumers; for January 2026 Executive Office of Aging & Independence (AGE) has capped the program at 5,374 active consumers. This 42% caseload reduction is highly concerning and should be more widely known by the general public. A recent public records request suggested that as of 9/26/25, there were 950 low-income elders who were clinically eligible but waitlisted for enrollment to the ECOP program. To be clear, a year ago these 950 consumers would have been enrolled in the ECOP program. This waitlist has been implemented with very little, some would say insufficient, public dialogue.
The main method to help people age in place is the state’s Enhanced Community Options Program (ECOP), which serves low-income older adults, if they clinically qualify for MassHealth–funded nursing-home care. These individuals are most often in the process of reducing their assets to become eligible for the Frail Elder Waiver program. In other words, they are eligible for nursing facilities but could stay in their own homes—where they prefer to be—if they could get some small amount of help for bathing, shopping, or cleaning. No one gets more than 7.5 hours per week of assistance.
The state has proudly recorded a long-standing commitment to funding ECOP. Nursing facilities—most of which are understaffed and many of which are closing—may prove unsafe. The state should examine its implicit bias toward institutionalization. Because keeping people out of nursing facilities is both cheaper and kinder. In this crisis, Massachusetts should want to maintain, and beef up, any programs that help people remain in their home communities.
Soon after Trump was inaugurated for the second time, however, long before anyone knew how his Medicaid cuts would affect any state, the first notice appeared of cuts to the ECOP home care program. Paul Lanzikos, cofounder of Dignity Alliance Massachusetts, wrote to Gov. Maura Healey (D-Mass.) and Secretary Robin Lipson, Executive Office of Aging & Independence (AGE), to suggest other ways to respond.
“we cannot understate our distress [that. . . ] in appearance, the first cost-containment measure being taken is the restriction of services to consumers. We offer that there are numerous program reforms, payment reforms, and revenue maximization initiatives that should be exhaustively explored prior to taking this most serious action of limiting the number of individuals to be served, or the volume of services that they may receive..”
The restriction of services was not just an appearance of excluding needy people. Over the course of 2025, the Executive Office of Aging & Independence (formerly Elder Affairs) went about lowering the number of eligible consumers entitled to services by about 2,000, to a monthly statewide average of 5,679.
At the same time, a surge in residents older than age 85 is widely anticipated. In this crisis, the Healey administration should recognize an “affirmative duty of care” as an obligation, whether the statute that created ECOP explicitly requires it or not.
Solution
Read Pete Tiernan’s Policy Brief to Cure the ECOP Waitlist(docx).
Excerpts are below.
Please note that the solution below saves the state money. In other words, we can afford to fully fund the ECOP!
AGE can and should act now to convert approximately 90% of ECOP-eligible program census (both active and waitlisted) into a special Medicaid-funded waiver program and thereby generate matching federal funds as new program revenue. This can be accomplished by MassHealth leveraging two policy tools that CMS makes available to state Medicaid programs, one of which is relatively new and not yet deployed in Massachusetts. (?What are the policy tools?)
Annualizing September 2025 ECOP program experience, a prudent transformation should generate $50-$55M per year in new FFP revenue. After assuming that the ECOP waitlist is eliminated and all eligible consumers have access to enhanced service plans, the net cost to the General Fund would still be approximately $38M less than the current program configuration. A portion of these additional savings should be committed towards eliminating the waitlist in the State Home Care Basic Program. The author also strongly recommends committing a portion of new funds towards supporting Public Guardianship services for individuals who are Nursing Home Residents or at risk of nursing home placement.
Converting ECOP to Medicaid-Reimbursable Activity: A New “Limited Frail Elder Waiver” Program Option
There are two policy options made available by CMS to states that can be applied to the ECOP program for the purpose of efficiently converting existing AGE service commitments into Medicaid-reimbursable activity. MassHealth has not deployed either of the policy options in the administration of any of their current 1915(c) waiver programs, including the Frail Elder Waiver. Furthermore, one of the policy options is relatively new and not yet in wide use by other states.
The concept is to establish a new 1915(c) waiver program that is placed on a continuum between the current ECOP Program and the well-known Frail Elder Waiver (“FEW”) program. This new 1915(c) program will provide a more limited service offering to participants in comparison to the FEW. The key distinction is the new program, tentatively titled “Limited Frail Elder Waiver”, will have a less restrictive financial eligibility criterion.
Key Design Elements to the Proposed “Limited Frail Elder Waiver” Program
In order to attain the redistribution of consumer census suggested by Figure 2, the key design elements to the Limited Frail Elder Waiver Program will need to include the following considerations:
- Same clinical eligibility as the Frail Elder Waiver.
- Same income eligibility standard as the Frail Elder Waiver.
- Less restrictive resource requirement, designed to facilitate enrollment by current ECOP membership. The ability to implement a resource eligibility criterion that differs from nursing home eligibility was recently clarified by CMS State Medicaid Director Letter (SMD) #21‑004. As such, there are few instances of other states making use of this important clarification (see below discussion “Targeted Resource Disregard for Applicants to Limited Frail Elder Waiver Program”). An open design question is whether there should be any asset/resource requirement whatsoever; or to adopt a high ceiling (for example $130,000) for the purpose of ensuring all Limited Frail Elder Waiver participants are subject to look-back eligibility determination procedures. The author’s current preference is to not utilize an asset test as it is thought that the overhead involved in administering such eligibility criteria is not cost-effective; but this is a matter that merits additional deliberation. This presentation assumes MassHealth will proceed with a ceiling of $130,000[1].
- Unlike the Frail Elder Waiver (and any other Massachusetts 1915(c) Waiver), to implement an individual cost limit on combined waiver and state plan services. The emphasis on including state plan services is to proactively address anticipated MassHealth concerns about creating an exposure to expanding AFC, PCA, or ADH services. The individual service cap applies to all MassHealth provided services (not just HCBS waiver services), and the cap would be set in a manner consistent with current ECOP cost obligations. The recommended cap is $1,275 per month (see below discussion “Leveraging 1915(c) Option for States to Adopt an Individual Cost Limit Inclusive of State Plan Service Costs”).
- For Limited Frail Elder Waiver participants who have service needs that exceed the service cap, the consumer can pursue eligibility in the traditional Frail Elder Waiver which does not have an individual service limit. Keep in mind that such consumers will need to satisfy the stricter asset/resource requirements of the traditional Frail Elder Waiver in order to access the more generous service plan.
- Unlike the Frail Elder Waiver, to implement a point-in-time enrollment limitation on the number of active monthly participants. This monthly enrollment limitation will essentially correspond with the number of ECOP-eligible participants. This feature will guard against likely “woodwork effect” concerns that will be initially raised by MassHealth management.
- Year One of the waiver to include target population criteria that reserves enrollment capacity to first enroll individuals in the state home care program who are participating in or waitlisted for the ECOP program.
Definitions
ECOP – serves low-income older adults, if they clinically qualify for MassHealth–funded nursing-home care. No one gets more than 7.5 hours per week of assistance.
Frail Elder Waiver