Issue
Another explanation of this issue and proposal is a DignityMA Interview with Pete Tiernan: Unlocking Federal Funding to Eliminate Home Care Waitlists.
In February 2025, the Healey-Driscoll Administration critically impacted a vital program that provides home care services to low-income seniors with complex care needs. The Executive Office of Aging & Independence (AGE) imposed an enrollment limitation on the Enhanced Community Options Program. This action had the effect of reducing program census from 8,735 active consumers in December 2024 to 5,037 active consumers in December 2025, a 42% reduction in consumers supported.
The action also resulted in AGE denying access to the ECOP program and placing consumers on a waiting list. The results from a recent public records request indicate that as of 3/30/26, there are 873 clinically eligible consumers who have been placed on a waitlist.
Background
AGE operates the State Home Care Program, which primarily serves low-income older adults with needs for long-term services and supports. An important sub-program, ECOP offers a higher level of services than the BASIC program. ECOP is reserved for individuals with more complex service needs; in order to qualify for ECOP, an individual needs to clinically qualify by a nurse certifying that their need for supports is equivalent to an individual who would qualify for a MassHealth-funded nursing home placement.
To offer context to the therapeutic benefits of the program, ECOP promotes diversion from a nursing home placement by offering assistance with daily activities such as bathing, shopping, or cleaning. Seniors participating in the BASIC program utilize about $421 per month in services while consumers in the ECOP program utilize about $1,145 per month. The enhanced service plans that ECOP consumers are able to access are instrumental towards supporting successful at-home living.
It is important to emphasize that the ECOP program is serving low-income seniors. Some misleading media statements issued when the Healey-Driscoll Administration first implemented waitlists suggested that the ECOP program primarily “functions as a middle-income home care program”. A common public policy measure is to recognize 200% of the Federal Poverty Level (FPL) as indicator of a “low-income” household. In 2025, 200% FPL was defined as up to $31,300 in annual income for a single individual and $42,300 for a household of two. A September 2025 snapshot of the ECOP program demonstrates that 93% of participants were below the 200% FPL standard. Furthermore, it is indicated that 85% of ECOP participants are living alone.
9110-0650 (new line item)—Limited Frail Elder Waiver
Explanation of Amendment
In response to the conditions noted above, Dignity Alliance has taken notice of relatively recent federal policy tools made available by the Centers for Medicare & Medicaid Services (“CMS”) that create an opportunity to convert most traditional ECOP utilization into Medicaid-reimbursable activity. Prudent application of these policy tools will result in qualifying health care expenditures generating Federal Financial Participation (FFP) revenue with a federal match rate of 50%.
Dignity Alliance asserts that maximizing on the ECOP program will allow AGE to eliminate the ECOP waitlist and offer all clinically qualifying seniors the opportunity to access enhanced service plans typical of the ECOP program. Furthermore, even after factoring for the costs of releasing the waitlist and fully serving home care program consumers, the new FFP revenue will yield a +$38.5M net positive increase to the General Fund.
This initiative is serving the same consumers that are assumed in the Governor’s FY27 Recommendation, while at the same time providing all qualifying consumers with access to appropriate service plans.
Dignity Alliance further advocates for the net savings to be re-invested into the elder care services portfolio to cure the waitlist of the Basic State Home Care program.
Interested readers are encouraged to review the Dignity Alliance Policy Memo prepared by Peter Tiernan titled “Policy Memo on How to Eliminate ECOP Waitlists” (docx).
The amendment language is admittedly complex, but it does prescribe how to successfully apply the CMS policy tools in a manner to generate an estimated $54.6M per year in new FFP revenue; yielding an estimated net savings to the General Fund of $38.5M per year.
Highlighted Control: It is emphasized that inside section language places substantial restrictions on the ability to unlock expenditure authority. No expenditure can be made until after a new 1915(c) waiver is approved. Furthermore, as guardrail to further ensure the positive financial benefits of this item, dollars follow the ECOP consumers who transfer from 9110-1630. As spending on transferred consumers occurs in the new line item, expenditure authority in 9110-1630 is reduced accordingly.
Line Amount: $122,000,000 (note this is a maximization initiative. As a result of increased FFP Revenue, the new line item will yield a net gain of at least $38,000,000 to the General Fund)
Amendment Language
For health care services provided to MassHealth members who are older adults eligible for community-based waiver services; provided, that such services shall be provided to members participating in a new MassHealth waiver established during calendar year 2026 and titled “Limited Frail Elder Waiver” and approved under 1915(c) of the Social Security Act; provided that the waiver shall serve as a pathway to, and operated in coordination with, the Frail Elder Waiver that is enabled in item 9110-0600; provided that no expenditures from this item shall be authorized until after a Frail Elder Waiver Limited program is approved; provided further that funds may be expended from this item for health care services provided to recipients in prior fiscal years; provided further, that the financial eligibility requirements shall be less restrictive than the Frail Elder Waiver and shall leverage state policy flexibilities clarified by CMS State Medicaid Director Letter SMD #21 004 which permit states to tailor financial eligibility rules for HCBS populations without altering institutional eligibility standards; provided further that the resource limit for the Frail Elder Waiver Limited program shall be no less than $130,000; provided further, that the Frail Elder Waiver Limited program shall elect to implement an individual cost limit on combined waiver and state plan services; provided further, that for “waiver year one” of the Frail Elder Waiver Limited program the individual cost limit shall be established at no less than $1,300 per month; provided further, that the target population of the Frail Elder Waiver limited program shall reserve capacity to first enroll individuals in the state home care program who are either participating in or waitlisted for the ECOP program; provided further, that in addition to the Frail Elder Waiver Limited program being constrained by a maximum number of unduplicated participants served throughout a waiver year, there shall be a point-in-time limitation of participants who may be served in a month; provided further, that the Secretary of Aging and Independence shall be granted substantial deference for establishing point-in-time participant limitations to ensure the limitation level allows for both the maximum transition of ECOP-eligible consumers and the reasonably expected demand for the waiver outyears; provided further, that the secretary of administration and finance shall reduce the amount available in item 9110-1630 by an amount equivalent to 75% of the net cost of services that are reimbursed from this item; provided further, that the secretary of administration and finance shall reduce the amount available in item 9110-1633 by an amount equivalent to 25% of the net cost of services that are reimbursed from this item.
Fiscal Note
Gross State Investment: Relative to the Governor’s FY27 Recommendation, it is estimated that 6,919 average monthly ECOP consumers will be associated to +$15.1M in additional outlay.
Of these 6,919 consumers, 6,227 are projected to qualify for a new 1915(c) Waiver, “Limited Frail Elder Waiver”. Eligible health care expenditures are estimated to generate $53.6M in new FFP Revenue.
Estimated Net State Cost: Due to the new FFP revenue, this initiative will have a net positive effect on the General Fund. When expressed in terms of new cost, it is estimated at -$38.5M. Alternatively stated, the item is a $38.5 cost savings initiative.
Cost Avoidance Impact: In addition to the $38.5M in cost savings, this initiative will generate cost avoidance in the form of both delayed nursing facility placement, and delayed enrollment in the traditional Frail Elder Waiver. Deference is given to AGE to suggest a cost avoidance estimate. Dignity Alliance does raise awareness of a 2/1/18 report from AGE to House & Senate Committees on Ways and Means that opines on most substantial cost avoidance attributable to the state home care program.
Why It Matters
Preserves Dignity and Independence
This initiative preserves the long-standing Massachusetts social contract as reflected in the ECOP program to offer low-income seniors with a nursing facility level-of-care need to be able to access service plans offering an appropriate level of service intensity. It cures the ECOP waitlist that has been steadily accruing ever since AGE announced it was waitlisting consumers in January 2025.
This initiative improves the proposition for low-income seniors to successfully age in place.
Reduces Institutional Pressure
Massachusetts nursing facilities are experiencing closures, staffing shortages, and financial instability. Preventing unnecessary admissions protects both residents and system capacity.
Aligns Fiscal Responsibility with Humane Policy
Community-based stabilization is significantly less expensive than hospital or long-term care placement.
This amendment reflects fiscally responsible Medicaid management while strengthening humane care policy.
Maximizes Federal Participation
Requiring EOHHS and AGE to maximize Medicaid reimbursement ensures that the Commonwealth draws down available federal dollars rather than relying solely on state funds.
Leveraging federal resources reduces net state exposure and increases return on investment.
Bottom Line
This amendment is both a sound Medicaid strategy and a reaffirmation of Massachusetts’ commitment to community-based aging.