DPSS ePolicy

To convert existing policy to new webpage – No content changes.

Revision of existing policy and/or form(s).

What changed?

1. The name for the In-Home Operations (IHO) Waiver was changed to the Home and Community-Based Alternatives (HCBA) Waiver; and
2. The referral form used for the HCBA Waiver was changed to Medi-Cal HCBS Eligibility Notice.

The Home and Community-Based Services (HCBS) waiver programs are designed to serve persons with developmental disabilities who live at home or in the community rather than in an institutional setting.

The HCBS waivers use special Medi-Cal eligibility rules (waiver rules) that allow the income and property belonging to a spouse or parent to be “waived” even though the individual lives at home or in a community-based non-medical facility (i.e., not institutionalized).  Waiving of spousal/parental income and property allows the waiver individual to become or continue to be eligible to Medi-Cal.

This policy document covers the following HCBS waivers:

Department of Developmental Services (DDS) Waiver

Provides services to individuals with developmental disabilities who live at home and meet the level of care criteria for admission into an Intermediate Care Facility.

Home and Community-Based Alternatives (HCBA) Waiver

• Formerly known as the Nursing Facility/Acute Hospital (NF/AH) or Medi-Cal In-Home Operations (IHO) waivers.
  
• Designed for individuals who in the absence of the waiver program would require the level of care provided at Nursing Facilities, Sub-Acute Facilities or Acute Hospitals.

Multipurpose Senior Services Program (MSSP) Waiver

Provides services to certain persons over 65 years of age who live at home and meet the level of care criteria for placement in a Nursing Facility.

The HCBS waiver programs are administered by the Department of Health Care Services (DHCS).  Waiver services are provided through local Care Coordinating Agencies (CCAs) who are responsible for determining if an individual meets the level of care criteria for the waivers.

Waiver eligibility depends on Medi-Cal eligibility.  The waiver individual must be eligible to full-scope Medi-Cal benefits in order to receive waiver services.

Once the CCA determines that the individual meets the level of care criteria, they will then refer the individual to the Department of Public Social Services (DPSS) to conduct a full Medi-Cal evaluation.

Applicants to the HCBS waivers must first be evaluated for all Medi-Cal programs before waiver rules can be applied.  Individuals who are determined eligible to MAGI/Non-MAGI with No Share-of-Cost (SOC) Medi-Cal must be placed in the appropriate aid code without the special waiver rules.

The special waiver rules apply only to individuals who:

1. Do not qualify for MAGI Medi-Cal due to excess income;
2. Do not qualify for Non-MAGI Medi-Cal due to excess property; or
3. Qualify for Non-MAGI Medi-Cal with a SOC.

The HCBS Waiver programs were originally implemented in 1982 and are designed to serve persons with developmental disabilities who live at home or in the community as an alternative to more costly institutional care.

Terms and Descriptions

Community-Based Non-Medical Facility

Private or public homes or institutions that provide assistance with personal care needs, but do not offer nursing or medical care.

HCBS Waiver Administrators

State agency/department that administers an HCBS waiver program.

Care Coordinating Agencies (CCAs)

Contracted public entities, private nonprofit agencies, that coordinate the delivery of services prescribed for the different waiver programs.

Regional Centers (RC)

Non-profit private corporations that contract with DDS to provide support or coordinate services for individuals with developmental disabilities.

Institutional Deeming

Special Medi-Cal eligibility rules that look at the individual as if they were “institutionalized” (i.e., the individual is in their own Medi-Cal Family Budget Unit and only their own income and resources are counted).

Medi-Cal Family Budget Unit (MFBU)

Number of persons included in the family group for a Medi-Cal evaluation.

Spousal Impoverishment (SI) Provisions

Federal requirements designed to prevent the spouse of an institutionalized/HCBS person, from becoming impoverished due to the high cost of institutionalization.

Referral Process

The referring agency is responsible for determining if the applicant is medically eligible (i.e., meets the Level of Care criteria) to participate in the waiver program.

Waiver:  DDS Waiver

Referring Agency:  DDS Regional Centers

Level of Care Criteria:  Intermediate Care Facility for the developmentally disable

Waiver: HCBA Waiver (Formerly the NF/AH and IHO Waivers)

Referring Agency:  DHCS In-Home Operations (IHO) Branch

Level of Care Criteria:  

1. Nursing Facility Level A or B – for at least 365 consecutive days; 
2. Sub-Acute Facility – for at least 180 consecutive days; 
3. Acute Hospital – for at least 90 consecutive days

Waiver:  MSSP Waiver

Referring Agency:  Department of Aging and Adult Services (DAAS)

Level of Care Criteria:  Certifiable for placement in a Nursing Facility.

Once waiver eligibility is determined by the designated agency, the appropriate referral form must be sent to DPSS for a Medi-Cal evaluation.

Eligibility Determination

Medi-Cal applicants/beneficiaries who are participating or requesting to participate in the HCBS waiver programs must meet the following requirements:

1. Be eligible to full-scope Medi-Cal benefits;
2. Comply with all Medi-Cal eligibility requirements.

Individuals eligible to restricted-scope Medi-Cal benefits, those without Satisfactory Immigration Status, and those in restricted-scope benefits due to failure to comply with the requirements of the Deficit Reduction Act are not eligible to participate in the waiver programs.

Full Medi-Cal Evaluation

Waiver applicants must first be evaluated under regular Medi-Cal rules, following the full hierarchy of Medi-Cal programs.  If the individual is a member of a family unit, the evaluation must include all household members.

If the waiver individual is not eligible to Medi-Cal (i.e., MAGI/Non-MAGI) in the family unit’s evaluation or is eligible to Non-MAGI Medi-Cal with a SOC; the special waiver rules apply.

Spousal Impoverishment Provisions

As of January 1, 2014, Spousal Impoverishment provisions must be applied as part of the Medi-Cal eligibility determination process for married individuals who:

1. Are participating or requesting to participate in HCBS waiver programs; or
2. Are receiving, or pass the Needs Assessment for the In-Home Supportive Services/Community First Choice Options (IHSS/CFCO).

Institutional Deeming

Individuals being evaluated under the special waiver rules must be treated as if they are “institutionalized” for purposes of treatment of income and resources.

• If the individual is an adult, then institutional deeming rules apply. 
  • If the individual is married, Spousal Impoverishment provisions apply even though the individual lives at home with his/her spouse.
• If the individual is a child, then parental income and resources are not considered in the child’s Medi-Cal evaluation.

Household Composition

Institutionally deemed individuals are in their own MFBU and therefore only their own income and property is counted (i.e., the income and property of the spouse or parents are excluded).

• If the individual is a married adult, then the individual must be excluded from the MFBU of his/her spouse.
• If the individual is a child in his/her parent's SOC case, then the child will be excluded from his/her parent’s MFBU. 

Note:  The waiver child may provide linkage to his/her parents/caretaker relative.

The following section shows a list of acceptable referral forms for each of the waivers:

DDS Waiver

DHS 7096 - Department of Developmental Services (DDS) Waiver Application Form

HCBA Waiver 

Medi-Cal HCBS Waiver Eligibility Notice

MSSP Waiver

MC 364 - California Department of Aging (CDA) Waiver Referral

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