Medicaid Waiver: A Primer
Presentation by
Randy Laya, M.S.
Federal Programs, Manager
Regional Center of Orange County (RCOC)
and
Suzanne Butler
RCOC Insurance and Benefits Specialist
What are Home and CommunityBased Services (HCBS) Waivers?
Medi-Cal waivers are programs under Medi-Cal that:
 Provide additional services to specific groups of
individuals,
 Limit services to specific geographic areas of the
state, and
 Provide medical coverage to individuals who may
not otherwise be eligible under Medicaid rules.

Currently there are ten Waiver programs in
California.
A few of the HCBS Medi-Cal Waiver
programs currently authorized in CA
A. Home and Community Based Services Waiver for
Individuals with Developmental Disabilities AKA
the Medicaid Waiver or the DDS Waiver
B. In-Home Operations:
1. Nursing Facility/Acute Hospital (NF/AH) Waiver
2. In-Home Operations Waiver
C. Multipurpose Senior Service Program (MSSP) Waiver
D. Acquired Immune Deficiency Syndrome (AIDS) Waiver
Role and Responsibilities of the Regional Centers
The 21 regional centers are charged with the
responsibility to coordinate, provide, arrange or
purchase services and supports for persons with
developmental disabilities in California.
The regional centers were created under the
Lanterman Act and receive their funding through
contract with DDS.
DDS has delegated responsibility to the regional
centers for assuring that HCBS Waiver
requirements are met.
The Medicaid Waiver (MW)

Allows California to claim Medi-Cal
reimbursement for specific Regional Center
services

Regional centers must meet consumer’s needs
 The
major purpose of the Medicaid
Waiver program is to bring federal
dollars into the state of CA
What are the
Medicaid Waiver program
requirements?
1. Meet the Lanterman Act definition of developmental
disability
A “developmental disability” means:
 A disability which begins before age 18,
 Is expected to continue indefinitely,
 Presents a substantial disability for the individual, and
 Is due to mental retardation, cerebral palsy, epilepsy, autism or a
disabling condition closely related to mental retardation or requiring
treatment similar to that required for individuals with mental retardation.
The definition expressly excludes other handicapping conditions that are
solely learning disabilities, psychiatric disorders or physical in nature.
2. Be an active regional center consumer
Regional Centers administer three programs:
Prevention, Early Intervention, and On-Going (Active)
each with their own eligibility criteria
 To be active, the individual must have a developmental
disability and have an open case with regional center
3. Have full-scope Medi-Cal benefits,
Be eligible to access all services available
through Medi-Cal, or
Meet the requirements for institutional
deeming (we’ll discuss this later)
4. Have substantial limitations in adaptive functioning which
qualifies the consumer for the level of care provided in an ICFDD, intermediate care facility for the developmentally disabledHabilitation (ICF/DD-H), or intermediate care facility for the
developmentally disabled-Nursing (ICF/DD-N).
Evaluation of each consumer’s level of care needs is based on his/her
ability to perform activities of daily living and community participation.
Provides funding for services only to individuals who, but for the provision
of these services, would require the level of care provided in an ICF-DD;
This determination is typically made through two CDER (Client
Development and Evaluation Report) deficits or two medical deficits or one
of each
5. Not be concurrently enrolled in another
HCBS Waiver
 Individuals may occasionally qualify for two or
more Waiver programs, such as NF/AH Waiver (for
medical technology dependency) and the Medicaid
Waiver
Can only be enrolled in one Waiver program at a
time
6. Choose to participate and receive
services through the HCBS Waiver and to
reside in a community setting.
 Consumer needs to have a MW qualifying
service in place that directly addresses one of
the CDER deficits
 Must use a MW qualifying service at least
once every twelve month
 $1000 per month
Services that qualify for the DDS Waiver program:
Homemaker
Home Health Aide Services
 Respite Care
 Habilitation:
– Residential habilitation for children services
– Day habilitation
– Prevocational services
– Supported employment services
 Environmental Accessibility Adaptations
 Skilled Nursing
 Transportation
 Specialized Medical Equipment / Supplies
 Chore Services
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Services that qualify for the DDS Waiver program:

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Personal Emergency Response System (PERS)
Family Training
Adult Residential Care:
– Adult Foster Care
– Assisted Living
– Supported Living Services
Vehicle Adaptations
Communication Aides
Crisis Intervention:
– Crisis Intervention Facility Services
– Mobile Crisis Intervention
Nutritional Consultation
Behavior Intervention Services
Specialized Therapeutic Services
Transition / Set-Up Expenses
Habilitation

http://www.dhcs.ca.gov/services/ltc/Pages/DD.aspx
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Each regional center contracts directly
with DDS to provide services that meet
the needs of their DD population
 Not all MW qualifying services are offered
by all regional centers
 Each regional center develops their own
Purchase of Services guidelines
 These guidelines are:

– Approved by each regional center’s Board of
Directors, and
– Approved by DDS
Legislative changes
In 2009, the state legislature passed
Trailer Bill Language (TBL) mandating that
regional centers utilize generic resources
when available
 The TBL also mandated that regional
centers reduce their services, if a generic
resource is available, whether the
consumer chooses to use the generic
resource or not

HCBS Waiver Participation
Requirements
Applies to:
HCBS Waiver
Participants
Only
All
Regional
Center
Consumers
Meet the Lanterman Act definition of developmental
disability
x
x
Be an active regional center consumer
x
x
Have or be eligible for full scope Medi-Cal benefits or
meet the requirements for institutional deeming
x
Meet the level of care for ICF-DD services as
documented on Medicaid Waiver Eligibility Record (DS
3770)
x
Not be concurrently enrolled in another HCBS Waiver
(such as NF/AH Waiver)
x
HCBS Waiver initial eligibility determination and annual
recertification is reviewed by a Qualified Mental
Retardation Professional (QMRP)
x
Eligibility
HCBS Waiver Participation
Requirements
Applies to:
HCBS Waiver
participants only
All Regional
Center
Consumers
IPPs are responsive to consumer’s needs and
preferences
x
x
IPPs are developed by a planning team [as defined in
Welfare and Institutions Code § 4512, subd. (j)] that
includes the consumer, and where appropriate his/her
legal representative, using a person-centered approach
x
x
IPPs specify the type and amount and provider of
services and supports
x
x
IPPs must contain at least one HCBS Waiver
funded service
x
IPPs must be reviewed at least annually
x
Individual Program Plans (IPPs)
HCBS Waiver Participation
Requirements
Applies to:
HCBS Waiver
Participants
Only
All Regional
Center
Consumers
x
x
Services and supports are provided in accordance with
service definitions and provider qualifications specified
in Title 17
x
x
Consumers are given a choice of qualified providers
x
x
Quarterly or semiannual progress reports from CCFs
and day programs documenting progress toward
achieving IPP objectives
x
x
Fair Hearings
Have a right to a fair hearing when eligibility is denied
or terminated or when services are suspended,
reduced or terminated without the agreement of the
consumer
Qualified Providers
HCBS Waiver Participation
Requirements
Applies to:
HCBS Waiver
Participants
Only
All Regional
Center
Consumers
Service coordinators monitor implementation of IPPs to
assure that services and supports are delivered
x
x
Quarterly face-to-face meetings with consumers who
live in CCFs, FHA, independent and supported living
settings
x
x
Two unannounced visits to CCFs annually
x
x
x
x
x
x
x
x
Necessary Safeguards to Protect
Health and Welfare
Scheduled annual CCF facility visit
Quality assurance monitoring of CCFs every three years
Monthly face-to-face contact for the first 90 days after
moving from a developmental center to the community
HCBS Waiver Participation
Requirements
Applies to:
HCBS Waiver
Participants
Only
All Regional
Center
Consumers
Special incidents are reported in accordance
with Title 17
x
x
A review of the general health status of the
consumer including a medical, dental, and
mental health needs shall be conducted, as
agreed to by the consumer or the consumer’s
authorized representative.
x
x
Necessary Safeguards to Protect
Health and Welfare
Any questions about the MW
program?
Institutional Deeming
Medi-Cal
What is Institutional Deeming?

Institutional deeming means that "the individual
is assessed to be Medi-Cal eligible “as if” he/she
were in a long-term care facility".

If the family’s income/property/assets exceeds
regular Medi-Cal limits, then only the
income/property/assets of the child or the
disabled adult spouse is considered under
institutional deeming.
Who is eligible for ID Medi-Cal?
Consumers who meet the criteria of the HCBS Waiver
program
 Consumers who are citizens or in the US with satisfactory
immigration status
 Typically a consumer with an income of less than $620/mo
and with assets that total less than $2000.
 Consumer in the family home up to the age of 21 y.o. who
does not otherwise qualify for regular Medi-Cal; child’s
income is the only income counted

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However, if the consumer has income and resources of
his/her own such as a trust fund or court-appointed child
support, the consumer may be assessed with a share of
cost or may be denied eligibility
How does a consumer obtain ID Medi-Cal?
Service
Coordinator starts the process by confirming that the consumer
meets the eligibility criteria to be added to the MW program.
The Regional Center sends the DDS Waiver Referral form to the Medi-Cal
office.
The Medi-Cal office assigns a Medi-Cal worker to the child’s case.
The family is sent a Medi-Cal application to complete.
The family’s income/assets/property is disregarded in the eligibility
determination for the child if it exceeds Medi-Cal’s limits; BUT
The family must complete the Medi-Cal application and submit their
financial, property, and citizenship information or the child’s application will
be denied.
Once the application is completed an eligibility determination is made by
the Medi-Cal worker. If the family is eligible for regular Medi-Cal, the child
will be added to that program and not the ID Medi-Cal program.
What are the advantages of having ID Medi-Cal?

FCPP (Family Cost Participation Program) assessed for regional
center services is waived with Full Scope Medi-Cal

Medi-Cal offers services/supports that may not be covered by
private insurance:
 Diapers
 Dental

Shift nursing through EPSDT Durable Medical Equipment
Vision
IHSS
Mental Health
Medi-Cal serves as a secondary insurance for the consumer that has
private insurance.
– Medi-Cal will cover certain co-pays that are the family’s responsibility
once the private insurance has paid their portion
 Medications
Hospitals
DME
What causes the ID Medi-Cal case to be denied or
to close?
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The Medi-Cal application with the required documentation was not
submitted to the Medi-Cal office in a timely manner
The consumer has unsatisfactory immigration status
Excess income/assets/property
The annual redetermination paperwork was not received by the
Medi-Cal office
– Family moved and didn’t leave forwarding address
– Family didn’t realize that paperwork needed to be resubmitted
each year
The consumer is no longer residing in CA
The consumer becomes eligible for regular Medi-Cal
The consumer is no longer eligible for the MW program
Questions?