Overview of the Medi-Cal Assisted Living Waiver
The Medi-Cal Assisted Living Waiver (ALW) provides assisted living services for California residents who are elderly or disabled and require a Nursing Home Level of Care, but prefer to reside in an assisted living environment instead of a nursing home. The ALW provides personal care assistance, homemaker services, and home health aides in Adult Residential Facilities (ARFs), Residential Care Facilities for the Elderly (RCFE), and Public Subsidized Housing (PSH). While this Waiver is intended to delay / prevent nursing home placements, it also assists current nursing home residents in transitioning to assisted living. Some of the assisted living settings offer memory care, which is specialized care for persons with Alzheimer’s disease or related dementias.
Many Waiver programs offer a participant-directed option, allowing program beneficiaries to select their own caregivers, including friends and relatives. The ALW does not. Assisted Living Waiver services are provided by licensed home health agency providers or staff employed by the residential care facility.
The ALW is not available statewide, and currently, is available in 15 CA counties. However, persons can move to an assisted living setting within a county that offers the program.
The Assisted Living Waiver is not an entitlement program. Applicants who meet eligibility requirements are not guaranteed immediate receipt of assisted living services. There are a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms. Currently, there is a significant waiting list. However, the waiting list has decreased from 4,502 persons in 2019 to 2,986 in February of 2024.
The Assisted Living Waiver is a 1915(c) Medicaid Waiver. In California, the Medicaid program is called Medi-Cal.
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization, and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a Nursing Home Level of Care and are at risk of institutionalization, such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. Meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.
Benefits of the Medi-Cal Assisted Living Waiver
Follows is a list of the benefits available via the Assisted Living Medi-Cal Waiver. An individualized service plan determines which services a program participant will receive, and the frequency with which they are received.
– Activities – recreational, therapeutic, and social
– Care Coordination / Management
– Homemaker Services – housekeeping and laundry
– Medication Oversight
– Personal Care – non-medical assistance with daily living activities, such as bathing, dressing, toileting, and eating
– Prepared Meals and Snacks
– Residential Habilitation – one-on-one care assistance with a focus on improving socialization, self-help, and adaptive skills in regards to behavioral issues
– Skilled Nursing / Home Health Aides – on an as-needed basis
– Transitional Assistance – from nursing facility to assisted living
– Transportation / Coordination of Transportation
ALW services are offered in Adult Residential Facilities (ARFs), Residential Care Facilities for the Elderly (RCFE), and Public Subsidized Housing (PSH). The ALW does not cover the cost of room and board.
Eligibility Requirements for California’s Assisted Living Waiver
The ALW is for California residents who are elderly (65+) or between the ages of 21 and 64 if disabled. Applicants who are nursing home residents must have been there a minimum of 60 days. Applicants must be willing to reside in a CA county that has an assisted living residence that participates in the ALW program. Currently, ALW services are available in the following California counties:
Alameda
Contra Costa
Fresno
Kern
Los Angeles
Orange
Riverside
Sacramento
San Bernardino
San Diego
San Francisco
San Joaquin
San Mateo
Santa Clara
Sonoma
Financial Criteria: Income & Assets
Income
While the Assisted Living Waiver itself has no income limits, one must be eligible for full-scope Medi-Cal without a Share of Cost in order to be eligible for the ALW. This income limit is equivalent to 138% of the Federal Poverty Level (FPL). While this figure increases annually in January, Medi-Cal’s income limits increase each April. Effective 4/1/24 – 3/31/25, a single applicant can have a monthly income up to $1,732. When both spouses are applicants, the income limit for the couple is $2,352 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Only the applicant spouse’s income is considered, which is limited to $1,732 / month. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a Spousal Income Allowance, also called a Monthly Maintenance Needs Allowance. The maximum amount that can be transferred is $3,854 / month and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than $3,854 are not entitled to a Spousal Income Allowance.
ALW participants must contribute towards their room and board costs. The amount is based on their income. In CA, in 2024, state residents who receive SSI and live in an assisted living setting receive a monthly payment of $1,575.07. Of this amount, an individual can retain $177 / month as a Personal Needs Allowance, while the remaining $1,398.07 / month must be paid to the residence for room and board. If an applicant has income over $1,575.07 / month, $1,418.07 / month goes towards room and board and the individual can keep $177 / month.
Assets
There is no asset limit (effective 1/1/24). An applicant’s assets, regardless of value, are not considered in the eligibility process.
There is a Look-Back Period during which Medi-Cal scrutinizes past asset transfers of persons applying for nursing home care, but it is not applicable to persons applying for the Assisted Living Waiver. However, if one may require Nursing Home Medicaid in the near future, it may be applicable. With the elimination of the asset limit, assets transferred on or after 1/1/24 are not considered. Assets transferred prior to 1/1/24 are still being scrutinized. However, the 30-month “look back” is being phased out month-by-month and will no longer exist by July of 2026.
While all assets are disregarded when determining Medi-Cal eligibility, one’s assets are not necessarily safe from the Medicaid Estate Recovery Program (MERP). Following the death of a long-term care Medicaid beneficiary, the state attempts reimbursement of long-term care costs for which it paid for that individual via their remaining estate. This may include one’s home. With the utilization of proper planning strategies, one can protect their home and other assets from being used as reimbursement and instead go to loved ones as inheritance. Contact a Professional Medi-Cal Planner for assistance.
Medical Criteria: Functional Need
An applicant must require a Nursing Facility Level of Care (NFLOC). For the Assisted Living Waiver, a specialized, electronically scored assessment tool is administered by a registered nurse to determine if this level of care need is met. As part of the assessment, an applicant’s care needs are further determined on a tier level of one to five. Tier one indicates an applicant requires the minimal amount of support provided by the ALW, while a determination of tier five indicates one requires the highest level of support available. An applicant’s ability to independently complete Activities of Daily Living (i.e., transferring from the bed to a chair, mobility, eating, toileting) is one area that is considered during the assessment. Relevant to some persons with Alzheimer’s disease or a related dementia, behavioral problems, such as regular attempts to leave the facility or removal of one’s clothes, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
Having income over Medicaid’s limit does not necessarily mean an applicant cannot still qualify for Medicaid. While Medi-Cal has a Share of Cost program, the Assisted Living Waiver does not allow applicants to qualify via this program. With “Share of Cost”, an applicant with income over Medi-Cal’s income limit has a set amount of income, a “Share of Cost”, that must be spent on medical expenses and supplies before qualifying for program benefits. However, in some situations, it may be possible to eliminate one’s Share of Cost, allowing them to be eligible for the ALW. Find an Experienced Medicaid Planner that can assist.
How to Apply for the Medi-Cal Assisted Living Waiver
Before You Apply
Prior to submitting an application for the Assisted Living Waiver, applicants need to ensure they meet the eligibility criteria (take a test here). Applying when over the income limit may be cause for denial of benefits.
As part of the application process, applicants will need to gather documentation for submission. Examples include proof of income and copies of Social Security and Medicare cards. A common reason applications are held up is required documentation is missing or not submitted in a timely manner.
The Assisted Living Waiver currently has a statewide waitlist for program participation. The ALW is approved for a maximum of approximately 14,544 beneficiaries each year. In some cases, an applicant’s access to a participant slot is based on the immediate need for program services. Persons can contact an Assisted Living Waiver Care Coordination Agency to inquire as to the current average waiting period.
Application Process
In order to be eligible for the Assisted Living Waiver, an applicant must be a Medi-Cal recipient with zero Share of Cost. To apply for Medi-Cal, one must complete an Application for Health Insurance. Persons can also apply online at Covered California or over the phone / in person at one’s Department of Health Care Services county office.
To apply for the ALW, applicants must contact a participating Care Coordination Agency in their county, or the county to which they would like to relocate, to fill out and submit a program application to CA’s Department of Health Care Services. Persons can see a list of participating RCFE’s and ARF’s by city and county here and a list of participating PSH facilities by city here. As part of the application process, a care needs assessment is completed by a registered nurse hired by the Care Coordination Agency. An over-the-phone prescreening is completed first to determine if the individual qualifies for the actual assessment.
There are currently no available assisted living beds via the Assisted Living Waiver. Applicants should complete a Waitlist Request Form to be put on a statewide waitlist. The Care Coordination Agency will be contacted by CA’s Department of Health Care Services (DCHS) when a participant slot becomes available. The applicant will have 60 days to submit a completed application to DHCS. It is possible that an applicant who currently receives Medi-Cal benefits, but who does not yet meet the functional need for care, be placed on the waiting list for the ALW.
Learn more about the Assisted Living Waiver. Alternatively, persons can contact their local DHCS county office.
The Assisted Living Waiver is administered by the California Department of Health Care Services (DHCS).
Approval Process & Timing
The Medi-Cal application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as a waitlist currently exists for the Assisted Living Waiver, approved applicants may spend years waiting to receive benefits.