The Home and Community Based Alternatives (HCB Alternatives) Waiver

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#5591.01

California has programs called “home and community-based services waivers.” They help people get Medi-Cal services at home. This pub tells you about one of the programs. It is the Home and Community-Based Alternatives (HCBA) Waiver. The pub tells you how to get one. It tells you who can help you get one.

PLEASE NOTE THAT THE HCBA WAIVER IS AN EVOLVING PROGRAM AND AS WE GET NEW INFORMATION, WE WILL UPDATE THIS FACT SHEET. CALL DRC IF YOU HAVE QUESTIONS ABOUT WHETHER ANY INFORMATION IN THIS FACT SHEET IS CURRENT.

California has a few programs called “home and community-based services waivers” that help people get Medi-Cal services at home. This publication is about a program called the Home and Community-Based Alternatives (HCBA) Waiver.

1. What are Home and Community-Based (HCBS) Waivers?

Home and Community-Based Services (HCBS) Waivers are programs that offer Medi-Cal services to a limited number of people with disabilities to help them live at home instead of in a nursing facility or other Medi-Cal funded institution. People with all types of disabilities are eligible as long as they would qualify for admission to a nursing facility (including an intermediate care facility), subacute facility, or acute hospital. These programs are called “Waivers” because states implement programs that “waive” certain federal Medicaid rules in order to provide different or more services than the state offers to other Medicaid (Medi-Cal) eligible people.

Waivers allow the state to:

  • Provide home and community-based services to a limited number of people, rather than all eligible Medi-Cal recipients in the State (waiver of “statewideness”;
  • Offer home and community-based services that are not offered under regular Medi-Cal (Medi-Cal State Plan) (waiver of “comparability”); and
  • Provide Medi-Cal HCB services to people who otherwise would not be eligible because their family or spouse’s income is too high (institutional and spousal deeming).

There are several different kinds of HCBS Waiver programs offered by the State of California.  These Waivers include:

  • Developmental Disabilities (DD) Waiver
  • Home and Community Based Alternatives (HCBA) (formerly called the Nursing Facility/Acute Hospital (NF/AH)) Waiver
  • In-Home Operations (IHO) Waiver
  • Assisted Living (ALW) Waiver
  • Multi-Purpose Senior Services Program (MSSP)
  • AIDS Waiver

Consumers can only be on one HCBS Waiver at a time. For more information about the HCBS Waivers administered by DHCS, go to: click here for the 'Medi-Cal Waivers' page on DHCS' website.

2. What is the Home and Community Based Alternatives (HCBA) Waiver?

The Home and Community Based Alternatives (HCBA) Waiver used to be called the Nursing Facility/Acute Hospital (NF/AH) Waiver. The purpose of the HCBA Waiver is to provide Medi-Cal beneficiaries with long-term medical conditions who meet one of the designated "levels of care" (i.e., nursing facility (including intermediate care facility), subacute, acute hospital), described below, the option of returning to and/or remaining in their homes or home-like community settings in lieu of institutionalization.

The Waiver was renewed in 2017 and the state made some changes to the way Waiver is administered in August 2018. Most importantly, the Department of Health Care Services (DHCS) has contracted with “Waiver Agencies” to administer the Waiver in most counties. Waiver Agencies provide case management and do assessments for Waiver services, which means that after being admitted to the Waiver most participants will work with a community-based case manager from their assigned Waiver Agency to help develop a Plan of Treatment (POT) and secure needed services.  Another important change is the elimination of individual cost limits for Waiver services. In earlier versions of the Waiver, applicants and participants were given a budget for home care services based on their “level of care.” Now, services must be authorized based on the individual’s need and as approved by his/her doctor. Finally, the new Waiver added several thousand more slots over the five years of the Waiver so that more people may be served.

3. What services are covered under the HCBA Waiver?

The HCBA Waiver covers a wide range of home care services which include the following:

  • Private duty nursing including home health and shared services
  • Waiver Personal Care Services (WPCS)
  • Case management/coordination
  • Habilitation
  • Home respite
  • Community transition
  • Continuous nursing and supportive services
  • Environmental accessibility adaptations
  • Facility respite, family/caregiver training
  • Medical equipment operating expense
  • Personal Emergency Response System (PERS) -installation and testing
  • Transitional case management for medically fragile and technology dependent individuals of any age

For more information on the HCBA Waiver program and services, please visit this link for the 'Home and Community-Based Alternatives (HCBA) Waiver' page on DHCS' website and this link for the 'In-Home Operations (IHO) Waiver' page on DHCS' website.

4. How do I qualify to be on the HCBA Waiver?

In order to qualify for the HCBA Waiver, you must be eligible for admission to, or be residing in, a Medi-Cal funded nursing facility, subacute facility, Intermediate Care Facility-Developmental Disabilities/Continuous Nursing (ICF-DD/CN) or acute hospital. These designations are “levels of care.” The HCBA Waiver uses spousal impoverishment rules to determine the eligibility of waiver participants with a community spouse, just as a nursing facility does under federal law. See 42 U.S. Code § 1396r–5. If the Waiver applicant is a child, parental income and resources are not considered even though the child lives in the home.

In order to apply to be on the Waiver, you should contact the Waiver Agency assigned to your county (or zip code). If you reside in a county that does not have an assigned Waiver Agency, you should contact DHCS directly to apply by complete the form found online at: this link for the form.  

If you need an application in Spanish, please call (916) 552-9105.  Completed applications should be sent to:  Integrated Systems of Care Division, HCBS Programs Eligibility/Intake Unit, 311 South Spring Street, Ste 800, Los Angeles, CA 90013.

5.  Is there a waitlist to be on the HCBA Waiver?

There is a waitlist for the HCBA Waiver, and applicants who potentially meet the waiver level of care criteria are placed on a waitlist.  Even though the new Waiver has more slots, the state is reserving 60 percent of slots for people living in institutions over 90 days and for individuals turning 21 and aging out of the EPSDT program.  In addition, children who need to be placed on the Waiver to become eligible for Medi-Cal (called “institutional deeming”) will get “priority review” and should not be placed on a waitlist. 

According to the Waiver, slots will be filled on a rotating basis, alternating between individuals residing in facilities and in the community. This means that you may be on a waitlist for many months or even longer, so you should apply as soon as possible.  It is not yet clear what, if any, steps DHCS will take to clear the current waitlist, but we understand that Waiver Agencies (see Question 7 below) will be responsible for the people on the waitlist in their geographic areas. After you apply, DHCS will send a letter confirming receipt of the completed HCBS Waiver Application which will include the effective date of placement on the HCBA Waiver waitlist.

The waiver reserves slots for individuals who have been residing in a health care facility for at least 90 days at the time of submission of their application to DHCS.  Therefore, it is critical that you apply for the HCBA Waiver before you are discharged from the hospital.

6. As a HCBA Waiver participant, how can I be sure to receive coverage for all of the services I need?

Until recently, there were individual cost limits for Waiver services.  Depending on the level of care that a participant is assigned, the participant would have a budget for services that included Waiver services and some other Medi-Cal services such as In-Home Supportive Services (IHSS).  These cost limits frequently prevented Waiver participants from being able to receive all of the services their doctor believes are medically necessary.  Also, until recently, if IHSS wages went up, then DHCS would reduce the amount of Waiver services a participant could receive, to stay under the cost limit.  Under the new Waiver, there should not be an individual cost limit and participants should be able to get all “medically necessary” services that their doctors request in a Plan of Treatment.

We recommend that current Waiver participants who do not think they have enough services (especially if you know that you are only getting services up the cost limit for your level of care), should get a new Plan of Treatment completed and signed by your doctor.  Here is the Plan of Treatment form:  click here for the link.  Make sure the Plan of Treatment includes all services your doctor agrees are medically necessary, including the number of in-home nursing and/or Waiver Personal Care Services that are needed per month.1 Submit the new, signed Plan of Treatment to your assigned Waiver Agency and ask for a reassessment. If you are not approved for the requested services, make sure you get a written notice so that you can appeal.  You can call Disability Rights California at 1-800-776-5746 for assistance.

7.  What are Waiver Agencies?

Waiver Agencies are local, non-governmental organizations that have contracted with the state to provide case management, purchase Waiver services through local vendors, enroll Waiver participants, perform level of care evaluations, and develop and review participant service plans.  DHCS will continue to administer the Waiver program directly in geographic areas where there are not any waiver agencies.

Waiver agencies are new in the Waiver and below is a chart of the available waiver agencies and the counties they serve.  Most Waiver Agencies began serving Waiver consumers and applicants on August 2, 2018.  You can also find this list of agencies and their services areas online here: click this link for the 'Home and Community-Based Alternatives (HCBA) Waiver' page on DHCS' website.  A list of contact information is here: click this link for Waiver Agency contact information sheet from DHCS' website.

Waiver Agency Service Area
Access TLC Santa Barbara County, and sections of Los Angeles and Orange Counties
(click here for service area defined by zip codes list)
Centers for Elders’ Independence Alameda and Contra Costa Counties
Home Health Care Management Butte, Glenn, Sacramento, San Joaquin, Shasta, Solano, Sutter, Tehama, Yolo, Yuba, Colusa, Del Norte, El Dorado, Humboldt, Lake, Lassen, Modoc, Nevada, Placer, Plumas, Sierra, Siskiyou, and Trinity Counties
Institute on Aging San Francisco, San Mateo, San Bernardino, and Riverside Counties
Libertana Home Health Kern, Fresno, Kings, Tulare, Madera, Mariposa, Merced, Stanislaus, Tuolumne, San Luis Obispo, Amador, Calaveras, Santa Clara, Santa Cruz, San Benito, Monterey, and sections of Los Angeles and Orange Counties
(click here for service area defined by zip codes list)
Partners in Care Sections of Los Angeles County
(click here for service area defined by zip codes list)
San Ysidro Health San Diego County
Sonoma County Human Services Department Sonoma County
Ventura County Agency on Aging Ventura County

8.  Who Can Help Me Get On To the Waiver So I Can Leave a Nursing Facility?

If you need help to get out of a medical facility, the Waiver Agency assigned to your geographic area is responsible for helping you get out and move home.

The HCBA Waiver also can provide Transitional Case Management and Community Transition services to help you find housing and pay for things like security deposits and utility setup.

 

1 See, 42 C.F.R. § 441.301(c)(2). “The service plan must be inclusive of all the services and supports that are furnished to meet the assessed needs of a participant, including services that are funded from sources other than the waiver (e.g., services that are obtained through the State Medicaid plan, from other public programs and/or through the provision of informal supports.”  CMS, Home & Community-Based Services 1915(c) Technical Guide, at 46, available at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/downloads/technical-guidance.pdf. – (Return to main document)

 

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For legal assistance call 800-776-5746 or complete a request for assistance form. For all other purposes call 916-504-5800 (Northern CA); 213-213-8000 (Southern CA).

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