Overview of Medi-Cal’s Home and Community Based Alternatives Waiver
California’s Home and Community Based Alternatives Waiver, or HCBA Waiver, is for state residents who are aged or disabled and medically fragile and / or technology dependent. “Medically fragile” is used to describe persons who would require nursing home or hospital admission without the long-term services and supports provided via this program. “Technology dependent” describes persons who are dependent on a mechanical ventilator, continuous or bi-level positive airway pressure support, tracheostomy based respiratory support, and / or intravenous administration of medications or nutritional substances through a central line.
HCBA Waiver services are intended to allow these persons to continue to live independently in their homes (or return home). Available services include in-home skilled nursing care, home modifications for safety and accessibility, personal emergency response systems, assistive technology, and respite care.
Program participants can reside in their own home, the home of a loved one, or a congregate living health facility (CLHF). They cannot live in an assisted living residence or an adult foster care home.
HCBA Waiver services may be provided by licensed care workers, or alternatively, program participants have the option to self-direct some of their services. This participant-directed option allows the hiring of a relative or friend to provide personal care services. While one’s adult child can be hired, a spouse or other legally responsible person can only be hired under very limited circumstances. Caregiver payments are provided by California’s Department of Social Services (DSS).
California’s Medicaid program is called Medi-Cal. The Home and Community Based Alternatives Waiver, which was previously called the Nursing Facility/Acute Hospital (NF/AH) Waiver, is a 1915(c) Medicaid Waiver. It is not an entitlement program. This means applicants who meet eligibility requirements are not guaranteed immediate receipt of program benefits. There are a limited number of participant enrollment slots, and when these slots are full, a waitlist forms.
Benefits of the Home and Community Based Alternatives Waiver
Follows is a list of potential benefits available via the HCBA Waiver. An individualized service plan determines which services a program participant receives, and the frequency with which they are received.
– Assistive Technology – to maintain or improve one’s ability to function
– Case Management / Comprehensive Case Management / Transitional Case Management
– Continuous Nursing and Supportive Services – for persons residing in congregate living health facilities
– Habilitation Services – assistance in learning, maintaining, and improving socialization, self-help, and adaptive skills
– Home Modifications – i.e., addition of wheelchair ramps & grab bars and modifying a bathroom for wheelchair access
– Medical Equipment Operating Expense
– Paramedical Services – i.e., medication administration and activities that require sterile procedures
– Personal Emergency Response Systems
– Private Duty Nursing – includes home health aides
– Respite Care – in-home and facility
– Training – family and caregiver
– Transitional Services – payment of security deposits, utility set-up fees, and moving services for persons moving from a nursing home back home
– Waiver Personal Care Services (WPCS) – meant to supplement personal care services already being provided through In-Home Supportive Services (IHSS). Adult companions (supervision, non-medical care, and socialization) are not available via IHSS personal care services, but are available via WPCS.
While program participants can live in congregate living health facilities, the HCBA Waiver does not cover the cost of room and board.
Eligibility Requirements for Medi-Cal’s Home and Community Based Alternatives Waiver
The HCBA Waiver is for California residents of any age who are medically fragile and / or technology dependent. Additional eligibility criteria are as follows and is relevant for seniors (65+ years old).
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 138% of the Federal Poverty Level (FPL). While the FPLs increase each January, the HCBA Waiver income limits increase in April. Effective April 2023, a single applicant can have a monthly income up to $1,677. When both spouses are applicants, the income limit is $2,269 / 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 $1,677 / 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.
In 2023, the maximum amount of income that can be transferred to the non-applicant spouse is $3,715.50 / month. This 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 this amount are not entitled to a Spousal Income Allowance.
In 2023, the asset limit is $130,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $195,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can have up to $130,000 in assets, while the non-applicant spouse is allocated a larger portion of the couple’s assets as a Community Spouse Resource Allowance (CSRA) to prevent spousal impoverishment. In 2023, the CRSA allows the non-applicant spouse to keep up to $148,620 in assets.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
While there is a 30-month Look-Back Period during which Medi-Cal scrutinizes past asset transfers of persons applying for Nursing Home Medicaid, the Look-Back Rule is not applicable to persons applying for the Home and Community Based Alternatives Waiver. However, if it is thought that one may require Medi-Cal funded nursing home care in the near future, it is vital that assets not be gifted or sold under fair market value. Violating Medicaid’s Look-Back Period results in a Penalty Period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. Fortunately, for Medi-Cal eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or indicates in writing they have an Intent to Return home. California is unique from other states in that there is no home equity interest limit.
– A non-applicant spouse lives in the home.
– The applicant has a dependent relative, such as a disabled child, living in the home.
– The applicant has a child under 21 years of age living in the home.
While the home is likely exempt while one is receiving Medi-Cal benefits, it may not be safe from Medicaid’s Estate Recovery Program. Learn more about when Medicaid can and cannot take one’s home here.
Medical Criteria: Functional Need
An applicant must require a Nursing Facility Level of Care (NFLOC). For the Home and Community Based Alternatives Waiver, a level of care (LOC) evaluation is completed to determine if this level of care need is met. This waiver has three subsets of NFLOC. The least restrictive subset requires that medically necessary care in a nursing facility providing skilled nursing services or intermediate care services be required for 60+ days if HCBA services are not provided. While an applicant’s need for assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) is evaluated as part of the LOC assessment, one of the NFLOC subsets must be met. ADLs and IADLs include personal hygiene, mobility, dressing, meal preparation, and housework. Persons with Alzheimer’s disease or a related dementia can functionally qualify for the HCBA Waiver if they meet the level of care need.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for the Home and Community Based Alternatives Waiver. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
Medi-Cal has a Share of Cost Program, which may also be called a Medically Needy Program. With this program, an applicant with income over Medi-Cal’s income limit has to pay towards the cost of their care services / medical expenses, which is their “share of cost”. This can be thought of as a deductible and is based on one’s monthly income. Once one has paid their share of cost for the month, the HCBA Waiver will pay for services and supports. More about the Medically Needy pathway to eligibility.
When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Medicaid Asset Protection Trusts, although they violate Medicaid’s Look Back Rule, are another option that protects assets and is a good option if created well in advance of the need for long-term care. Medicaid-Compliant Annuities, in which a lump sum of cash is turned into an income stream, is another option. There are many other options when the applicant has assets exceeding the limit.
While these strategies often violate Medi-Cal’s 30-month Look-Back Period, the Look-Back Rule does not apply to the Home and Community Based Alternatives Waiver. However, some persons will go on to require Nursing Home Medicaid, and if this is the case, the Look-Back Period might be relevant. Due to this, it is best to implement Medicaid planning strategies with careful planning and well in the advance of the need for nursing home care. There are, however, some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.
How to Apply for Medi-Cal’s Home and Community Based Alternatives Waiver
Before You Apply
Prior to submitting an application for the HCBA Waiver, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Since the Home and Community Based Alternatives Waiver is not an entitlement program, there may be a waitlist for program participation. The HCBA Waiver is approved for a maximum of approximately 9,871 beneficiaries each year. In the case of a waitlist, priority is given in the following order:
1) Persons transitioning to the waiver from a similar home and community based services program
2) Persons who are under 21 years old
3) Persons living in a health care facility for 60+ days at the time the HCBA Waiver application is submitted
4) Persons living in the community when the HCBA Waiver application is submitted.
Of the 9,871 participant slots, 2,484 are reserved for persons in the first three groups.
To apply for the HCBA Waiver, one must contact the HCBA Waiver Agency serving their county and request an application. Completed applications should be submitted to the Waiver Agency.
Persons who live in Alpine, Imperial, Inyo, Marin, Mendocino, Mono, and Napa do not have a Waiver Agency serving their area. These persons should submit their completed HCBA Waiver Participant Application to the Integrated Systems of Care Division. The address is on the application.
The HCBA Waiver is administered by California’s Department of Health Care Services (DHCS) and is operated by the Integrated Systems of Care Division (ISCD). HCBS Waiver services are provided by local agencies that contract with DHCS.
Approval Process & Timing
The California Medicaid / 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 even further. 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 may exist, approved applicants may spend many months waiting to receive benefits.
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. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.