The Home and Community Based Alternatives (HCB Alternatives) Waiver
The Home and Community Based Alternatives (HCB Alternatives) Waiver
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 Program is currently up for renewal. The existing 2017-2021 HCBA Waiver1 is still in place until March 31, 2022, because the Centers for Medicare and Medicaid Services (CMS) is reviewing the 2022-2026 HCBA Waiver Renewal.2
California has 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 Waivers provide an alternative to institutional care for people who qualify for placement in a Medicaid-funded facility. Section 1915(c) of the Social Security Act (42 U.S.C. § 1396n(c)) allows the federal government to waive certain provisions of Federal Medicaid law in order to allow states to provide home and community-based services in lieu of institutional care to qualifying individuals.3 With a 1915 (c) Waiver, states can waive three Medicaid requirements for Medicaid State Plan services:
- Comparability (42 U.S.C. § 1396a(a)(10)(B))
- Statewideness (42 U.S.C. § 1396a(a)(1)) (States can limit availability to certain areas of the state)
- Income and resources for the medically needy (42 U.S.C.§ 1396a(a)(10)(C)(i)(III))
What this means in practice is that States can offer an HCBS waiver to a limited number of people; can limit where in the state waiver services are available; and can target certain types of populations (for example seniors, people with disabilities, mental illness, or Intellectual or Developmental Disabilities (I/DD) and people with certain illnesses or conditions (such as people with AIDS or technology-dependent children)). It also means that income protections like institutional deeming and spousal impoverishment protections apply to Waiver recipients.4 A 1915(c) waiver thus allows states to cover services beyond the scope of traditional Medicaid benefits. Not all states offer services through 1915 (c) Waivers.
In California, the Department of Health Care Services (DHCS, California’s Medicaid program) has been mandated by the California Legislature to “seek all necessary waivers... in order to provide in-home and community-based care.” Welf. & Inst. Code §§ 14132(t), 14137. California currently has six Home and Community-Based Services (HCBS) waivers, including the Home & Community-Based Alternatives (HCBA) Waiver. These 1915(c) Waivers are funded with both state and federal dollars.
California’s six 1915(c) Waivers are:
|Waiver Name||Target Population||Service Area|
|AIDS Medi-Cal Waiver Program||Individuals with HIV/AIDS||Statewide|
|Assisted Living Waiver (ALW)||Aged, Disabled, 21 & Over||15 Counties; Waiting list|
|Home and Community-Based Alternatives (HCBA) Waiver (formerly NF/AH Waiver)||Aged, Disabled, All Ages||Statewide; Waiting list|
|Home and Community-Based Services Waiver for the Developmentally Disabled (HCBS-DD) Waiver||Individuals with Intellectual or Developmental Disabilities, All Ages||Statewide|
|Multipurpose Senior Services Program (MSSP)||Aged, 65 and older||46 Counties; Waiting list|
|Self-Determination Program||Has a developmental disability and receives services from a Regional Center||Statewide; 2500 statewide 2018-2021|
2. What is the Home and Community Based Alternatives (HCBA) Waiver?
The HCBA Waiver provides care management services to Nursing Facility eligible individuals of any age.5 The Integrated Systems of Care Division (ISCD) is the unit within DHCS responsible for overseeing administering the HCBA Waiver. This unit was previously known as In Home Operations (IHO) and IHO staff previously administered the HCBA Waiver (previously called the Nursing Facility/Acute Hospital, NF/AH Waiver) directly.
In 2018, DHCS shifted responsibility for direct administration of the Waiver to what are known as HCBA Waiver Agencies. There are Nine Waiver Agencies for the state, serving different geographic locations. There are no Waiver Agencies for Alpine, Imperial, Inyo, Marin, Mendocino, Mono, Napa, and in those counties DHCS manages waiver services for recipients. Applicants for the Waiver submit their applications to the Waiver Agency which serves their location. Waiver Agencies process applications for Waiver services, assess applicants, develop a Plan of Treatment, and submit that Plan of Treatment to DHCS for approval. Once a person is approved for HCBA Waiver services, the Waiver Agency provides monthly comprehensive care management to ensure all of the services on the Plan of Treatment are being delivered.
The list of Waiver Agencies is below, and available here: https://www.dhcs.ca.gov/services/ltc/Pages/Home-and-Community-Based-(HCB)-Alternatives-Waiver.aspx
|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|
Services available under the Waiver include:
- Facility respite, family/caregiver training
- Medical equipment operating expense
- Personal Emergency Response System (PERS)—installation and testing
- Private duty nursing including home health and shared services
- Transitional case management for medically fragile and technology dependent individuals of any age
- Case management/coordination
- Home respite
- Waiver Personal Care Services (WPCS)
- Community transition
- Continuous nursing and supportive services
- Environmental accessibility adaptations
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.”
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: https://www.dhcs.ca.gov/services/ltc/Documents/2019HCBAApp.pdf
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 for the HCBA Waiver?
There used to be a waitlist for the HCBA Waiver, however, currently, there are open slots on the waiver. In 2021, the maximum number of participants who can be served is 8,974. The order of priority for enrollment is:
- Individuals transitioning to the Waiver from similar HCBS programs.
- Individuals under 21 years of age
- Individuals who have been residing in a health care facility for at least 60 days at the time the HCBA Waiver application is submitted to a Waiver Agency or DHCS in areas there is no Waiver Agency
- Individuals residing in the community at the time of submission of the HCBA Waiver application.
DHCS reserves 60% of the Waiver capacity for the first three categories. Once an application is submitted, if a waiver slot is available, the Waiver Agency must meet in person with the applicant within 60 days. Within 90 days of determining eligibility (not 90 days from the application date) the Waiver Agency has to identify a service provider, and submit a Plan of Treatment (POT), which sets forth all waiver and state plan services to DHCS.
Consumers can only be on one HCBS Waiver at a time. For more information about the HCBS Waivers administered by DHCS, go to: https://www.dhcs.ca.gov/services/ltc/Pages/Home-and-Community-Based-(HC…
Disability Rights California has heard reports of long delays in processing of applications, and we are currently addressing these delays with DHCS.
6. As a HCBA Waiver participant, how can I be sure to receive all of the services I need?
Under the Waiver, there should not be an individual cost limit and you should be able to get all “medically necessary” services that your doctor authorizes in a Plan of Treatment.
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. You will only be able to get the services in your Plan of Treatment. If you are not approved for the requested services, make sure you get a written notice so that you can appeal and have a Medi-Cal Fair Hearing. Here is where you can find more information about your right to a hearing: https://www.cdss.ca.gov/hearing-requests. You can also call Disability Rights California at 1-800-776-5746 for assistance.
7. What are Waiver Personal Care Services (WPCS)?
“Waiver personal care services” are personal care services which can be combined with In-Home Supportive Services (IHSS). In order to receive WPCS, you must be on the HCBA Waiver. You must also already receive IHSS. Your WPCS will be determined after your IHSS hours are determined. WPCS is not meant to replace IHSS, but it is also more flexible than IHSS. WPCS includes an Adult Companionship component. These are services that include non-medical care, supervision, and socialization provided to a waiver participant. To help maintain a waiver participant’s psychological wellbeing, adult companions may assist waiver participants in accessing self-interest activities or accessing activities in the local community for socialization and recreational purposes, and/or providing or supporting an environment conducive to interpersonal interactions. IHSS overtime rules apply to WPCS as well. See: https://www.disabilityrightsca.org/publications/new-rules-for-ihss-over….
8. Can I get 24-hour Care from the HCBA Waiver?
Yes, you can if your doctor authorizes that in your Plan of Treatment. If you need 24 hour a day care, you should make sure that your Plan of Treatment states that.6 The current waiver says that you can only have a maximum of 24 hours per day of direct care services. Direct care services are services that require hands-on interaction between the care provider and the participant. You can review your Menu of Health Services (MOHS) for a breakdown of how many hours per day you receive in direct care services. The HCBA waiver requires that waiver agencies provide recipients with a copy of their Plan of Treatment and MOHS. You should make sure that your Plan of Treatment states that you need 24 hour a day care.
9. What if I get More than 24-hour Care—How Do I Decide What Services to Use?
Sometimes people who have hours authorized above 24 hours (through a combination of IHSS, Respite, Nursing, and WPCS) have to decide how to cover the 24 hours and which hours they need to reduce. The current version of the waiver states that recipients cannot receive:
“direct care services or any combination of direct care and protective supervision services exceeding 24 hours of care per day...Direct care services include State Plan services, such as personal care services, adult or pediatric day health care, In-Home Supportive Services (IHSS), PDN, shared PDN, and/or direct care authorized by the participant's private insurance. Direct care is hands on care to support the care needs of the waiver participant.”
The new Waiver has more flexibility about direct vs. indirect care (see Question 11 below) but for now, if a recipient has a total of hours of service per month which exceed 24 hours per day they should work with their Waiver Agency (and other agencies authorizing hours) to determine which services they want to use. For instance, a family where the parent is authorized to be paid to provide IHSS services may want to reduce non-IHSS hours in order to preserve their income.
10. Who Can Help Me Enroll in 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 first step is to put in an application for the HCBA Waiver. You should also apply for California Community Transition Services (CCT). The Waiver Agency works with a California Community Transitions Agency (CCT) to help people leave nursing facilities. Assistance can include helping you to find housing and paying for things like security deposits and utility setup, and helping you find caregivers. For more information about CCT services see: https://www.disabilityrightsca.org/publications/the-california-communit…
11. What Changes Can I Expect in the 2022-2026 Waiver Renewal?
Right now, DHCS is still waiting for approval from CMS, so the 2022-2026 Waiver is not yet in effect. However, the major changes proposed in the HCBA Waiver Renewal are set forth below:
- Increased overall waiver capacity7
- Allows legally responsible relatives (spouses, parents of minor children) to provide WPCS to family members
- Eliminated the age restriction for Respite (provided at home or in a facility) and Habilitation services, which are not available to youth as an Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit – to make the services available to all participants enrolled in the Home and Community-Based Alternatives (HCBA) Waiver base on based on medical necessity
- Included Pediatric Day Health Care (PDHC) centers licensed to operate a Transitional Health Care Needs Optional Service Unit (TCU), as a provider type for private duty nursing (PDN) for eligible participants who have turned 21 years of age
- Included Pediatric Day Health Care (PDHC) centers as a provider type for Facility-based Respite Services
- Removed Transition Coordination from the Comprehensive Care Management per member per month (PMPM) payment
- Defined the role of the Circle of Support within the Waiver, and HCBA Waiver Agency requirements when a participant does not have a Circle of Support
- Included telehealth as an alternative to the in-person requirement for a Physical or Occupational Therapist (PT or OT) to evaluate the need for, and appropriateness of, home modifications when a provider is not available within the service area
- Included additional requirements for HCBA Waiver Agencies to collaborate with Managed Care Plans (MCPs) for coordination of care, including entering into Memoranda of Understanding (MOU)
- Added Assistive Technology as a Waiver service, to maintain the participant's health and safety when medically necessary Assistive Technology is not available through the state plan nor other payment
- Added a paramedical service for participants who have maximized the amount of in-home supportive services (IHSS) available through the state plan
- Allowed annual re-assessments to be completed virtually after the end of the public health emergency, with prior approval
- Added definition of indirect care:
- Indirect care services do not require hands-on interaction between the care provider and the participant.
- Examples include, but are not limited to:
- Comprehensive Care Management
- Case Management
- Consultation between care providers
- IHSS that does not involve hands-on care, such as meal prep and cleanup, shopping/errands, laundry, domestic care, yard hazard abatement, heavy cleaning, etc.
- Community Transition Services
- Environmental Accessibility Adaptations
- Family/Caregiver Training
- Medical Equipment Operating Expense
- Personal Emergency Response (PERS) Installation and Testing
- PERS Monthly Service
- Professional services that do not include the provision of hands-on personal or custodial care.
- 1. https://www.dhcs.ca.gov/services/ltc/Documents/HCBA-Waiver-Amendment-12…
- 2. https://www.dhcs.ca.gov/services/ltc/Documents/2022-HCBA-Renewal-access…
- 3. The opportunity for states to apply for HCBS waivers was created in 1981 under the federal Omnibus Budget Reconciliation Act (OBRA). OBRA created Section 1915(c) of the Social Security Act to allow states to develop specific Medicaid program waivers for individuals who would be Medicaid-eligible if they were in a long-term care facility, typically a nursing home or institutional care facility.
- 4. Children can be eligible for Medicaid through a 1915 (c) Waiver, because their parents’ income is not deemed to them. Likewise, the community spouse’s income is not deemed to the Waiver spouse recipient.
- 5. Technically, the Waiver serves people at Nursing Facility, Subacute Facility, and Acute Hospital levels of care. The Waiver also funds services for people with I/DD living in Intermediate Care Facilities’-Continuous Nursing (ICF-DD-CN) and people in Congregate Living Health Facilities (CLHFs)
- 6. We recommend that you ask that your POT include a sentence saying that you require 24 hour a day care, including months with 31 days.
- 7. Year 1 (2022): 8,974 Maximum number of participants served at any point during the year Year 2: 8,974 Maximum number of participants served at any point during the year Year 3: 10,081 Maximum number of participants served at any point during the year Year 4: 11,215 Maximum number of participants served at any point during the year Year 5: 12,349 Maximum number of participants served at any point during the year