Summary

The HCBA Waiver ("Waiver") enables Medi-Cal-eligible individuals with long-term medical conditions who meet designated levels of care to remain in or return to a home or home-like community setting instead of an institution.

The Waiver has three main goals:

1. Help eligible individuals safely transition from medical facilities to home settings using Waiver services;
2. Provide community-dwelling individuals at risk of institutionalization within 30 days the option to develop care plans that safely meet their medical needs at home; and
3. Maintain cost neutrality compared to institutional care. The HCBA Waiver serves as the payer of last resort unless otherwise specified by law. Waiver services are only authorized when not available through other sources, including private insurance.

The California Department of Health Care Services (DHCS), through its Integrated Systems of Care Division (ISCD), administers and monitors the Waiver statewide. DHCS reviews and approves initial eligibility, level of care determinations, and oversees Waiver Agencies and service providers. DHCS maintains sole responsibility for managing expenditures, setting rates, and developing program policies and procedures.

DHCS primarily operates the Waiver through contracted Waiver Agencies that handle local administration and provide Comprehensive Care Management through a Care Management Team (CMT). These agencies evaluate eligibility, process enrollments, conduct annual evaluations, review care plans, authorize services, manage utilization, maintain provider networks, ensure quality, and handle billing when authorized.

The CMT consists of a Registered Nurse (RN) and a Social Worker with at least a Bachelor's degree, or professionals with Bachelor's degrees in related fields (such as gerontology, marriage and family therapy, or psychology) supervised by a Master's-level Social Worker (MSW). Both team members must be employed or contracted by the Waiver Agency. The CMT coordinates State Plan and Waiver services to help participants transition to or remain in their homes. While only Waiver Agencies can provide Comprehensive Care Management in their service areas, other Waiver services come from qualified Medi-Cal providers.

In areas lacking qualified providers, Waiver Agencies may provide services with state pre-authorization after demonstrating compliance with federal requirements. These requirements include:

1. Being the only willing and qualified provider in the area;
2. Implementing conflict of interest protections;
3. Providing dispute resolution processes; and
4. Documenting ongoing provider recruitment efforts. Agencies cannot authorize direct care treatment authorization requests for their own staff or affiliates.

Waiver Agencies help participants develop person-centered care plans, secure necessary services, manage ongoing care, and coordinate with Medi-Cal managed care plans and community programs. This ensures participants can access community living benefits in their preferred settings.

In areas without a Waiver Agency, DHCS manages administration directly. Case management comes from qualified Medi-Cal-enrolled providers at standard fee schedule rates. All other services are delivered by qualified Medi-Cal providers approved for Waiver services, as detailed in Appendix C.

Eligibility Requirements