California Medicaid / Medi-Cal Home and Community Based Alternatives Medicaid Waiver (HCBA)

Last updated: March 25, 2024


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).

The HCBA Waiver is not an entitlement program. 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. There is currently a waiting list that began in July 2023. See the enrollment dashboard for current waitlist totals. Steps are being taken by California’s Department of Health Care Services (DHCS) to increase the number of participant slots.

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Wait List Alternatives: Are you interested in connecting with a Medicaid Planning Professional to discuss alternatives to Medi-Cal’s Home and Community Based Alternatives Waiver? Wait-lists can last from months to years, but there are other Medicaid programs that offer immediate care outside of nursing homes.
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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.


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
– Telehealth
– 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).

 The American Council on Aging provides a free, quick and easy Medi-Cal Eligibility Test for seniors
Financial Criteria: Income & Assets

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 4/1/24, a single applicant can have a monthly income up to $1,732. When both spouses are applicants, the income limit 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. In 2024, the maximum amount of income that can be transferred to the non-applicant spouse is $3,854 / 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.

There is no asset limit. Effective 1/1/24, the asset limit for Medi-Cal was eliminated.

There is a Look-Back Period during which Medi-Cal scrutinizes past asset transfers of persons applying for Nursing Home Medicaid, but it is not applicable to persons applying for the Home and Community Based Alternatives Waiver. However, if one may require Medi-Cal funded nursing home care 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. The 30-month “look back” is being phased out month-by-month and will no longer exist by July 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 an Experienced Medi-Cal Planner for assistance.


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.

 Learn more about long-term care Medicaid in California.


Qualifying When Over the Income Limits

Having income over Medicaid’s limit does not mean an applicant cannot still qualify for the Home and Community Based Alternatives Waiver. Medi-Cal has a Share of Cost Program, also 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. This is their “share of cost”. It 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, MSSP will pay for services and supports the remainder of the month. Professional Medicaid Planners can assist persons in lowering their “share of cost”. 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 limit can 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 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 Home and Community Based Alternatives Waiver is not an entitlement program. Despite being approved for a maximum of approximately 10,774 beneficiaries each year, there is currently a waitlist for program participation. Persons who meet “Reserve Capacity” are given priority. This includes:

1) Persons transitioning to the waiver from a similar home and community based services program due to unmet needs
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

Of the 10,774 participant slots, 6,464 are reserved for persons in these groups.


Application Process

To receive services via the HCBA Waiver, one must apply for Medi-Cal. To apply, one can complete and submit an Application for Health Insurance. The box, “Do you need help with long-term care or home and community-based services?” should be marked yes. Persons who require assistance with completing the application can call Covered California’s Customer Service Center at 1-800-300-1506. Persons can also apply online at Covered California or over the phone / in-person at their County Social Services Office.

Persons can apply for the HCBA Waiver before or after applying for Medi-Cal. To apply for the HCBA Waiver and be put on the waiting list, 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.

Learn more about the Home and Community Based Alternatives Waiver. Persons can also contact their local DHCS county office.

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 exists, approved applicants may spend many months waiting to receive benefits.

 What are 1915(c) HCBS Medicaid Waivers?
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 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 participant slots.

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