Medi-Cal Home and Community
Based Services (HCBS) Waivers
Elissa Gershon, Senior Attorney
Disability Rights California
June 5, 2013
HCBS Waivers in California being
discussed today:
• Medi-Cal Home and Community Based
Services Developmental Disabilities Waiver
(DD Waiver)
• Medi-Cal Nursing Facility/Acute Hospital
Home and Community Based Services Waiver
(NF/AH Waiver)
What is “Institutional Deeming”?
• Medi-Cal is allowed to determine your eligibility
using “institutional deeming.” This means Medi-Cal
will evaluate you for eligibility as if you lived in an
institution, and not with your parents or spouse.
• Why? Because without the Waiver, people whose
incomes are otherwise too high to qualify for MediCal would be eligible to receive Medi-Cal funded
care in an institution (ICF/DD, nursing facility,
subacute facility, etc.)
What is the DD Waiver?
• Medi-Cal program that pays for many home and
community based services provided by regional
centers. Often considered a funding stream, not
a separate program.
• DD Waiver services will be listed in the
consumer’s Individual Program Plan (IPP) or
IFSP (Individual Family Service Plan)
Who is eligible for the DD
Waiver?
You are eligible for DD Waiver services if you:
• Meet California’s definition of developmental disability,
• Are a regional center consumer,
• Get Medi-Cal or would be eligible for Medi-Cal if your
spouse’s or parents’ (if you are under age 18) income or
resources were not counted, and
• Qualify for care in a Medi-Cal funded intermediate care
facility (ICF)
▫ You do not have to be in an ICF to be eligible for the
DD Waiver — you just have to need the care and
have needs that qualify you for services in an ICF.
Do all regional center consumers
qualify for DD Waiver services?
No. Some regional center consumers do not
qualify for DD Waiver services because:
• Their needs do not match those required to
qualify for ICF services– such as having
significant medical needs
Remember: Even if you are not eligible for DD
Waiver services, you can still receive the services
listed in your IPP or IFSP
How Do I Apply for the DD Waiver?
• You may not need to apply. The regional center usually
identifies people who are eligible.
• But, if your regional center does not identify you for DD
Waiver services, you have the right to apply on your own.
Make certain there is a service covered under the DD waiver
in your IPP or IFSP.
• Send a letter to your regional center asking to be identified as
eligible for the DD Waiver for the services you need. And,
make sure that the DD Waiver services you need are included
in your IPP or IFSP.
• The regional center will send you a letter to let you know if
you are eligible for DD Waiver services.
Why is it a good idea to get DD Waiver
services if I am eligible?
• The DD Waiver services you receive cannot be limited by where you live in
the state.
• Regional centers cannot use Purchase of Service (POS) guidelines to limit
the amount or kind of services you receive under the DD waiver.
• Consumers who receive DD Waiver services get their IPP or IFSP reviewed
every year (instead of every three years).
• Children who get Medi-Cal under the DD Waiver have extra protections.
▫ Redetermination before ending the child’s Medi-Cal eligibility.
▫ Continuing Eligibility for Children provisions (no-cost MediCal coverage for up to 12 months after the child is found to be
no longer eligible for any coverage under Medi-Cal).
• Consumers who are eligible for DD Waiver services have an extra vehicle
exemption.
What are DD Waiver Services?
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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
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
For more information:
• Look for the DD Waiver at the Department of
Health Services web site:
http://www.dhcs.ca.gov/services/medical/Pages/HCBSDDMediCalWaiver.aspx
• Read more about the DD Waiver in DRC’s
Rights Under the Lanterman Act at:
http://www.disabilityrightsca.org/pubs/5
06301Ch13.pdf
What is the NF/AH Waiver?
• Medi-Cal program that pays for home and
community based services for people who would
otherwise qualify for care in a nursing facility.
• Pays for services beyond what is available in the
Medi-Cal State Plan (regular Medi-Cal).
Who is eligible for the NF/AH Waiver?
Eligibility Requirements:
• Must have full scope Medi-Cal Eligibility
• Physically Disabled (no age limit)
• Must meet one of the following levels of care:
▫ acute hospital,
▫ adult or pediatric subacute nursing facility,
▫ distinct-part nursing facility,
▫ adult or pediatric Level B (skilled) nursing facility,
or
▫ Level A (intermediate) nursing facility (NF)
• Must meet other criteria and requirements listed in the waiver
How Do I Apply for the NF/AH
Waiver?
Complete the HCBS Waiver Application and send to
DHCS In-Home Operations. The application is at:
http://www.dhcs.ca.gov/formsandpubs/p
ublications/Documents/HCBS%20Waiver
%20App.pdf
Note: There is a waitlist for individuals at the NFA/B level of care unless:
• The application is turning 21 and aging out of
EPSDT or
• The applicant resides in a nursing facility
What are NF/AH Waiver Services?
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Private Duty Nursing, including Shared Nursing
Home Health Aide Services
Case Management
Transitional Case Management
Environmental Accessibility Adaptations
Personal Emergency Response Systems (PERS)
PERS Installation and Training
Medical Equipment Operating Expenses
Waiver Personal Care Services
Community Transition
Habilitation Services
Respite Care (home and facility)
Developmentally Disabled/Continuous Nursing Care NonVentilator Dependent Services
• Developmentally Disabled/Continuous Nursing Care
Ventilator Dependent Services
How to Get NF/AH Waiver Services:
• You can choose from the menu of NF/AH
Waiver services up to a cost-cap for your level of
care
• Your doctor must include the services you need
in a Plan of Treatment
• Cost-cap includes most other Medi-Cal services:
IHSS, and unless enrolled in managed care,
CBAS, medical supplies and equipment
Institutional
Level of Care
Annual
Institutional
Rate
Annual Waiver
Cost-Cap
Nursing Facility
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(NF)-A
Nursing Facility
(NF)-B
NF-B Pediatric
NF-Distinct Part
NF-Subacute,
Adult
NF-Subacute,
Pediatric
Acute Hospital
$34,388
$29,548
$56,074
$48,180
$110,280
$124,342
$271,697
$101,882
$77,600
$180,219
$282,574
$240,211
$437,757
$305,283
For more information:
The Nursing Facility/Acute Hospital Waiver is
available at:
http://www.dhcs.ca.gov/services/medical/Pages/NFAHMedi-CalWaiver.aspx
DISABILITY RIGHTS CALIFORNIA
1-800-776-5746