Waivers/Programs

The Social Security Act permits states to request waivers of otherwise applicable federal law in order to 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 traditional Medicaid (Medi-Cal) rules.

HCBS Waivers

Home and Community-Based Services (HCBS) Waivers (authorized under Section 1915(c) of the Social Security Act) allow the state to develop creative alternatives for individuals who would otherwise require care in a nursing facility or hospital. These waiver services can be offered in either a home or community setting and must cost no more than the alternative institutional level of care.

The Department of Health Care Services (DHCS) has several HCBS Waivers/Programs in effect. The complete list can be viewed on the DHCS Website. The following are the current waivers/programs that require a Medi-Cal (MC) eligibility determination to be completed at the county level:

  • Home and Community-Based Services for the Developmentally Disabled (HCBS-DD) Waiver (formerly DDS-HCBS)
  • Home and Community-Based Alternatives (HCBA) Waiver (formerly NF/AH, replaces MC IHO)
  • Multipurpose Senior Service Program (MSSP) Waiver

Recipients of HCBS Waivers/Programs must have full-scope Medi-Cal (MC) eligibility and must also be medically certified by the designated responsible agency. The responsible agency usually completes the medical certification prior to referring the individual to the county to apply for MC. Occasionally, the medical certification is not completed until after MC eligibility is determined.

Important: When determining MC eligibility for the waivers listed above, institutional deeming (or spousal impoverishment) applies as if the client were institutionalized. This means the income and resources that belong to the individual’s parent(s) or spouse will not count toward the individual in the eligibility determination.

Personal Care Services Program

There may be HCBS waiver recipients who requested In-Home Supportive Services (IHSS) but were not eligible under the IHSS residual program because it does not allow for institutional deeming. These individuals would be eligible for the Personal Care Services Program (PCSP) administered through IHSS. Unlike the IHSS residual program, PCSP does not allow a parent of a minor child or spouse to be the care provider.

PCSP provides the following services:

  • Assistance to ambulate (walk around)
  • Bathing, oral hygiene, dressing, and grooming
  • Care and assistance with prosthetic devices
  • Bowel, bladder and menstrual care
  • Repositioning, range of motion exercises and transfers
  • Feeding and assurance of adequate fluid intake
  • Respiration and Paramedical services
  • Assistance with self-administration of medications
  • Ancillary services (e.g., meal preparation, laundry, shopping and domestic services).

HCBS-DD Waiver

The HCBS-DD Waiver Program (formerly DDS-HCBS) was designed to serve developmentally disabled individuals who remain in their communities and homes rather than in an institutional setting.

At the program's onset, a developmentally disabled person was required to meet all the regular
Medi-Cal eligibility requirements. Effective 10/1/93, eligibility requirements for the HCBS-DD program were amended to allow for institutional deeming which includes:

  • The waiving of parental/spousal deeming of income and property prior to determining Medi-Cal eligibility, and
  • The application of spousal impoverishment provisions as if the client were institutionalized.

San Andreas Regional Center (SARC) completes the HCBS-DD waiver medical certification and then forwards the information to the Assistance Application Center (AAC) for a Medi-Cal eligibility determination.

Benefits

The HCBS-DD Waiver Program allows for the additional medical services for certain developmentally disabled individuals who live at home or in the community instead of in an intermediate care facility.

The major differences between regular Medi-Cal and HCBS-DD Waiver Medi-Cal include the following provisions:

  • Spousal impoverishment rules apply as if the applicant were institutionalized. The HCBS-DD applicant may transfer property to the spouse according to Community Spouse Resource Allowance (CSRA) rules.
  1. If the client is a child, parental income and property are not considered even though the child lives in the home.
  2. If the client is an adult, spousal impoverishment rules apply.
  • A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the client. Verification must be by the physician’s written statement of necessity.
  • A separate MFBU is established for an individual who qualifies for Medi-Cal under the HCBS-DD Waiver Program. If other family members wish to be aided, the client may be used to link other family members although the client is not in the family’s MFBU.
  • Individuals certified under the HCBS-DD Waiver Program may receive additional services offered through other funding sources to enhance Medi-Cal, such as skilled nursing at home, home health services, specialized medical equipment and supplies, chore service, etc.

If the client is eligible for zero SOC MC when the income and resources of his/her parents or spouse are considered, there is no need for the special waiver program criteria. The EW must establish regular MC. Individuals eligible for MAGI MC, including the Optional Targeted Low-Income Children’s Program (OTLICP) are eligible for the additional medical services without a change in aid code to 6V or 6W.

An applicant for this program must meet all of the following criteria:

  • Has been certified for the HCBS-DD Waiver Program based on his/her medical, social and developmental care needs by San Andreas Regional Center (SARC).
  • Is ineligible for regular MC or has a SOC when parental/spousal income and resources are considered.
  • Meets all Medi-Cal requirements, however, parental/spousal income and resources are not considered and spousal impoverishment provisions may be applied.
  • Is eligible for full scope MC. (i.e., A person only eligible for restricted 58 MC or a person residing in a nursing home under the State-only Aid Code of 53 is not eligible for the DDS-HCBS Waiver Program.)
  • Must have MC linkage. A DDSD referral is required when no other linkage exists, the client requests it, or it is beneficial to the client.

Note: The EW must use the most beneficial full scope MC program to determine eligibility that is applicable to the client (e.g., ABD, MN, MI, or FPL). Eligibility is based on the DDS-HCBS Waiver client’s own income and property, including amounts remaining after spousal impoverishment rules are applied.

  • A DDSD referral is not required unless:
    • Eligibility is based on MC requiring that the client be disabled,
    • The client has no other basis for linkage, or
    • There would be an advantage if the client were disabled (i.e., income deductions available only to the disabled). This determination of disability may be advantageous when a child becomes an adult.
  • May or may not have a SOC when the HCBS-DD Waiver rules are applied.

Application Referrals

SARC will identify potentially eligible individuals for the HCBS-DD Waiver Program. SARC will then evaluate the client for certification under the Waiver Program based on medical, social and developmental care needs. Only clients who have successfully completed the certification process are referred to the county for a Medi-Cal eligibility determination.

A “Department of Developmental Services Waiver Referral” (DHCS 7096) is mailed directly to the Assistance Application Center (AAC). The referrals are for disabled children under 18 years of age and who are living with their parents. The purpose of the referral is to give the child the advantage of being in a separate MFBU with only their own separate income and property budgeted.

  • If the child is receiving MC but has a SOC, the continuing Supervisor and EW are notified to set up a SARC MFBU for the child.
  • If the child is not currently receiving MC, AAC initiates an application for the child by mailing a letter and an application packet to the parent to complete.

Note: These children are usually approved for SSI when they reach 18 years of age and parental financial responsibility ends.

Referrals may be made for:

  • An application (intake) when the applicant has no current Medi-Cal record.
  • A reevaluation of eligibility when the HCBS-DD applicant has an active Medi-Cal record with a SOC.

Public Agency Representative

As a public agency, SARC may apply for Medi-Cal on behalf of an incompetent person when there are no family or friends to assist them.

Written authorization is not necessary for a public agency representative to apply for Medi-Cal on behalf of incompetent individuals.

Note: Parents must apply for Medi-Cal for their children if they are living together.

MFBU Determination

An individual who qualifies for MC under the HCBS-DD Waiver program is placed in his/her own MFBU.

 

IF...

THEN...

There are multiple individuals in the same household applying for these waivers,

Each person is in his/her own MFBU.

Other family members are applying for or are receiving regular MC,

The HCBS-DD individual is in their own MFBU but can be used to link other family members.

HCBS-DD Aid Codes

The following Aid Codes are used for the HCBS-DD Waiver cases:

 

Aid Code

Description

6V

HCBS-DD Waiver aka DDS-HCBS (No SOC)

6W

HCBS-DD Waiver aka DDS-HCBS (SOC)


Reporting Responsibilities

The client/caretaker relative must report all changes within 10 days.

Budgeting Methodology

Budget methodology for a HCBS-DD case is determined by linkage.

  • If the recipient is disabled (determined disabled by SP-DDSD or in receipt of disability based RSDI), then ABD income deductions are used.
  • If the recipient is eligible for MC based on AFDC-MN/MI linkage, then AFDC-MN/MI budget methodology is used.

Note: The same aid code is used whether the recipient has been determined disabled or not. The EW must enter the waiver information on the Money Management section to ensure that the correct budget methodology is used.

Retro Medi-Cal

HCBS-DD regulations may be applied retroactively if the HCBS-DD Waiver individual has outstanding medical bills from the 3 month period prior to application and the applicant requests it.

HCBS-DD Determination For a New Applicant

The following procedures are followed when determining Medi-Cal under the HCBS-DD waiver program:

  1. SARC    
    1. Initiates an application by mailing a “Department of Developmental Services Waiver Referral” (DHCS 7096) to the Assistance Application Center (AAC).
    2. Instructs client to apply for MC.
  2. HCBS-DD Contact Person at AAC    
    1. Receives DHCS 7096 and/or MC Application.
    2. Ensures a SAWS 1 and SC 41 are completed.

      1. Note: The date AAC receives the referral form is to be used as the application date.

    3. Assigns application as follows:
      1. If there is an open case record, refers application to the current worker's supervisor.
      2. If there is no open case record, refers to I.D. and assigns to AAC intake.
  3. EW    
    1. Receives application/referral and determines who is the representative for the case.
    2. Determines Medi-Cal eligibility under the HCBS-DD Waiver program.
    3. Determines linkage and submits a DDSD packet, if applicable.
      If Applicant: Then a DDSD Referral is:

      Receives Social Security due to own disability.

      Not required since disability has already been established.

      Is an MI Adult and has not been determined disabled (There are no DHCS 7096 referrals on clients over age 18).

      Required. Case will remain in DE-D pending status until DDSD decision is received.

       

      Is an otherwise eligible child (under age 21).

      Recommended, but not required.* Issue MC using Aid Code 6V or 6W.

      • Set up a case alert for DDSD follow-up.
      • Use AFDC-MN/MI budgeting until DDSD decision is received.

      Revise budgets as needed when DDSD decision is received.

      * Note: When a HCBS-DD child enters LTC, the HCBS-DD provisions no longer apply. He/She may only remain in his/her own MFBU if he/she has been determined “disabled.”

HCBS-DD Determination for a Currently Eligible Medi-Cal Recipient

The following procedures are followed when a Department of Developmental Services Waiver Referral (DHCS 7096) is received by a continuing EW, the EW does the following:

  1. Receives the DHCS 7096 and determines who is the case representative. NOTE: A new Application for MC is only needed if the annual RD is due.
  2. Reviews case to determine Medi-Cal eligibility under the HCBS-DD Waiver program, and submits a DDSD packet if necessary.

Notices of Action (NOAs)

Approval, denial and/or discontinuance NOA must be sent to the client and/or their AR, as applicable.

Release of Information

For HCBS-DD applicants/recipients only, a release of information is not required to share ongoing eligibility information with San Andreas Regional Center (SARC).

Redeterminations (RDs)

The EW must complete a MC redetermination annually. Income information must be requested, however, if the attested income is still over the limit for regular Medi-Cal, verification is not required for ongoing eligibility. If the attested income is within regular Medi-Cal income limits, request verification and establish ongoing MC eligibility.

SARC is also required to complete an annual medical recertification for the HCBS-DD waiver program. SARC will forward a copy of the annual medical recertification to the EW which must be sent to IDM. If the EW has not received verification of recertification from SARC by the time the annual MC redetermination is due, the EW must request the SARC liaison to contact SARC for confirmation of medical eligibility for the waiver program.

Termination of HCBS-DD Waiver

Should the individual lose his/her medical certification for the HCBS-DD Waiver, eligibility under the regular Medi-Cal program must be explored prior to discontinuance.

The HCBS-DD waiver does not apply to individuals in LTC.

HCBA Waiver

The HCBA Waiver allows individuals who would otherwise reside in a skilled nursing facility to remain at home and obtain MC eligibility without consideration of a parent’s income or resources if the applicant were a child or used spousal institutional deeming rules if the applicant lived at home with his/her spouse.

The services under the HCBA Waiver program include case management, private duty nursing, home health aides, personal care services, respite care, family training, and minor physical adaptations to the home.

Libertana Home Health is the HCBA Waiver Agency for Santa Clara County.

The three major provisions provided under this program which are not available to other Medi-Cal clients are:

  • Income and resources of the parent/spouse will not be counted if the waiver individual is otherwise ineligible for Medi-Cal.
  • Eligible individuals are provided skilled nursing at home, home health aid services, therapy, etc., in lieu of inpatient services.
  • A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the client. Verification must be by the physician’s written statement of necessity.

Requirements

An applicant for the HCBA Waiver must meet all of the following requirements:

  • Meets certain medical requirements which are determined by Libertana.
  • Is ineligible for regular Medi-Cal or has a SOC when parental/spousal income and property are considered.
  • Meets all Medi-Cal requirements, however, parental/spousal income and property are not considered and spousal impoverishment provisions may be applied.
  • Has MC linkage (i.e., ABD-MN, AFDC-MN). A DDSD referral is required when no other linkage exists, the client requests it, or it is beneficial to the applicant (i.e., additional income deductions will eliminate or reduce the SOC).
  • Is eligible for full scope MC.
  • May or may not have a SOC when the HCBA Waiver rules are applied.

Note: If the individual is eligible for zero SOC MC when the income and resources of his/her parents or spouse are considered, there is no need for the special waiver program criteria. The EW must establish regular MC.

HCBA Waiver Inquiries

Requests for consideration under the HCBA Waiver program can be initiated by the applicant, a physician, friends, family, LTC facility or hospital, or by a community agency. Libertana is the agency that determines if medical requirements of the HCBA Waiver are met.

When Medical Requirements are Met

If the applicant meets or is likely to meet the initial screening criteria, Libertana will refer the applicant to the County Welfare Department for a MC eligibility determination.

Institutional Deeming

The following income/property rules apply when determining MC eligibility and SOC under the HCBA Waiver program:

  • Parental/Spousal income and property are not considered.
  • Spousal Impoverishment rules apply as if the applicant were institutionalized.

MFBU Determination

An individual who qualifies for MC under the HCBA Waiver program is placed in his/her own MFBU. The maintenance need for one ($600) is used to determine the SOC.

The HCBA Waiver client is not included in the MFBU of other family members, but can establish linkage.

HCBA Waiver Aid Codes

The following aid codes are used for the HCBA Waiver program:

 

Aid Code

Description

6X

HCBA Waiver (No SOC) replaces IHO waiver

6Y

HCBA Waiver (SOC) replaces IHO waiver

Reporting Responsibilities

The client/caretaker relative must report all changes within 10 days.

Budget Methodology

Budget methodology for a HCBA Waiver case is determined by linkage.

  • If the recipient is disabled (determined disabled by SP-DDSD or in receipt of Social Security payments based on disability), then ABD income deductions are used.
  • If the recipient is eligible for MC based on AFDC-MN/MI linkage, then AFDC-MN/MI budget methodology is used.

Note: The same aid code is used whether the recipient has been determined disabled or not. The EW must enter the waiver information on the Money Management section to ensure that the correct budget methodology is used.

HCBA Waiver Approval and Beginning Date of Aid

Prior to case authorization, the EW must contact the Libertana representative listed on the referral form to:

  • Notify them of potential eligibility or ineligibility,
  • Request a HCBA Waiver Medical Eligibility Notice confirming medical eligibility, if not already received, and
  • Request the effective date of the HCBA Waiver certification. The EW must inform the Libertana representative if retroactive coverage has been requested.

The beginning date of aid can be no earlier than the effective date of the HCBA Waiver certification.

Notice of Action Requirement

The EW must issue a NOA for approval (MC 343) or denial (MC 344) of MC to all HCBA Waiver applicants (this waiver is replacing MC IHO).

Referring Agency

Libertana Home Health is the referring agency for the HCBA Waiver. Their contact information is as follows:

Libertana Home Health

5805 Sepulveda Blvd

Ste. 605

Sherman Oaks, CA 91411

Phone: 818-902-5000

MSSP Waiver

The Department of Aging Multipurpose Senior Services Program (MSSP) Waiver allows EWs to determine eligibility using institutional deeming rules (spousal impoverishment) for a person who:

  • Moves from the institution and returns home to their spouse, or
  • Is already living at home with his or her spouse.

Benefits

The MSSP provides interdisciplinary (nurse and social work) care management services including the coordination and use of existing community resources. Care managers initiate and monitor the process of assessments, case plan development, service arrangement, ongoing monitoring and reassessments of client’s needs.

To arrange for services, care management staff first explore support that might be available through family, friends and community volunteers. Then they review existing publicly-funded services and make direct referrals. If needed services are not available through these resources, the care management team can authorize the purchase of some services from MSSP funds.

Eligible clients may be linked to services that include, but are not limited to:

 

  • Care Management
  • Personal care
  • Adult social day care
  • Respite care
  • Housing assistance
  • Transportation
  • Protective services
  • Special communications
  • Meal services
  • Skilled nursing health care

Eligibility Requirements

The individual must meet the following MSSP eligibility requirements:

  • Age 65 or older
  • Eligible for full-scope MC
  • Meets all other MC requirements (e.g., residency, etc.)
  • Is medically certified for the MSSP by the local MSSP site
  • Currently or would be ineligible for regular MC due to excess property, has or would have a SOC when spousal income and resources are considered.

Note: If the client is eligible for zero SOC MC even when spousal income and resources are considered, then there is no need to set up an MSSP Waiver.

Referring Agency

The California Department of Aging (CDA) is the referring agency for the MSSP. CDA contracts with either public entities or private nonprofit agencies to operate the MSSP program at the local level.

In Santa Clara County, the Council on Aging of Silicon Valley (COASV) listed below will identify potentially eligible individuals for the MSSP waiver by reviewing the applicant’s health, psychosocial needs, and functional status before making a referral to the Social Services Agency. COASV will refer and complete the “California Department of Aging (CDA) Waiver Referral” (MC 364) and mail it directly to the Assistance Application Center (AAC).

Council on Aging of Silicon Valley, Inc.

2115 The Alameda

San Jose, CA 95126

Phone: (408) 296-8290

Fax: (408) 249-8918

Release of Information

Eligibility Staff may share ongoing eligibility information with COASV. A release of information is not required.

Redeterminations (RD)

The EW must complete a MC redetermination annually. COASV is also required to complete an annual medical recertification for the MSSP waiver program.

COASV will forward a copy of the annual medical recertification to the EW which must be sent to IDM. If the EW has not received verification of recertification from COASV by the time the annual MC redetermination is due, the EW must request it from COASV for confirmation of medical eligibility for the MSSP waiver program.

Termination of MSSP Waiver

If the individual loses his/her medical certification for the MSSP Waiver, eligibility under the regular Medi-Cal program must be explored prior to discontinuance. A 10-day Notice of Action is required.

Eligibility Determination

When an MSSP referral form for a married applicant/ recipient is received and the EW determines that the individual is ineligible for MC due to excess community property or is eligible for MC but would end up with a SOC using regular MC rules, institutional deeming rules apply.

The following MC eligibility determination rules apply:

  • The applicant/recipient is treated as if he or she was in LTC (institutionalized) for purposes of the treatment of income and resources.
  • Spousal impoverishment rules apply.
  • The MSSP eligible individual is in his/her own MFBU. The MSSP individual may be used to link other family members (i.e., ABD-MN) even though the MSSP individual is not in the family’s MFBU.
  • The individual must be eligible for full scope MC benefits.
  • The EW must use the most beneficial full-scope MC program applicable to the client (i.e., Pickle, Aged and Disabled Federal Poverty Level Program, ABD-MN program). Eligibility is based on the individual’s own income and resources, including amounts remaining after spousal impoverishment rules are applied.

MFBU Determination

An individual who qualifies for MC under the MSSP Waiver program is placed in his/her own MFBU.

 

IF...

THEN...

There are multiple individuals in the same household applying for these waivers,

Each person is in his/her own MFBU.

Other family members are applying for or are receiving regular MC,

The MSSP eligible individual is in their own MFBU but can be used to link other family members.

MSSP Determination For a New Applicant

The following procedures are followed when determining Medi-Cal under the MSSP waiver program:

  1. COASV    
    1. Initiates an application by mailing a “California Department of Aging Waiver Referral” (MC 364) to Assistance Application Center (AAC).
  2. COASV Contact Person at AAC    
    1. Receives the MC 364 and monitors the status.
  3. Clerical    
    1. Follows application processing per District Office procedures:
    2. Completes the SAWS 1 and SCD 41

      1. Note: The date the county receives the referral form is to be used as the date of application.

    3. Performs file clearance.
  4. COASV Contact Person at AAC    
    1. Assigns the application as follows:
      1. If there is an open case record, refer the application to the current worker’s supervisor.
      2. If there is no open case record, refer the application to an EW Supervisor who then assigns it to the EW.
  5. EW    
    1. Completes the regular application process.
    2. Determines if there is a SOC under the MSSP Waiver program.

MSSP Determination for a Currently Eligible Medi-Cal Recipient

The following procedures are to be followed when the MC 364 is received by a continuing EW:

  1. EW Supervisor    
    1. Receives the MC 364.
    2. Establishes a control system and assigns to current EW.
  2. EW    
    1. Completes case processing as follows:
    2. Receives the MC 364.
    3. Reviews case to determine Medi-Cal eligibility under the MSSP Waiver program.

      1. Note: The EW must send an MSSP approval, denial or discontinuance NOA as follows:

        1. Original to the MSSP individual
        2. Copy to COASV (MSSP referring site)

MSSP Examples

Example 1

John is a 70-year-old applicant who is referred to the county by the COASV. He is living at home with his spouse. They have no minor children living in the home. The EW determines that he is property eligible but is not eligible for the Aged and Disabled (A&D) Federal Poverty Level Program and would have a SOC as an ABD-MN person. The EW then applies spousal impoverishment rules. John may allocate the lesser of his maximum income available for allocation or the community spouse income allocation (CSIA) to his spouse. His monthly SOC is based on the remaining amount of his income.The EW approves and sets up the individual in the appropriate MSSP aid code. If his spouse has income and is receiving MC, his spouse may have an increased SOC due to the new CSIA and a 10-day NOA is required.

Example 2

Tom is 65 years old and currently eligible in the ABD-MN program with a monthly SOC of $1,000. The EW receives the MSSP referral. He is living at home with his spouse and there are no minor children in the home. After the EW applied the spousal impoverishment rules, he is determined eligible for no SOC MSSP.

Example 3

Paul is 80 years old and referred to the county for an MSSP evaluation. He is living at home with his spouse and there are no minor children in the home. The EW determines that he is property ineligible for any MC program and his own income is below the ABD-MN limit. The EW then applies the spousal impoverishment rules and finds him to be property eligible. Since his income is already below the ABD-MN limit, there is no need to allocate any of his income to his spouse.

Related Topics

Limited Services Due to Program Abuse

Limited Services for MIAs in SNF/ICF

Severely Impaired Working Individuals Program

Waivers/Programs