Yasmin Peled: Hello everyone, and welcome to today’s webinar presentation, Advocating for Consumer Access to HCBS in California. I’m Yasmin Peled, director of California Government Affairs here at Justice in Aging. And today I’m joined by two of my colleagues from Justice in Aging, Hagar Dickman, director of California LTSS Advocacy and Tiffany Huyenh-Cho, director of California Medicare and Medicaid Advocacy.
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Justice in Aging is a national organization that uses the power of law to fight senior poverty by securing access to affordable healthcare, economic security, and the courts for older adults with limited resources. Since 1972, we’ve been focused our efforts primarily on fighting for people who have been marginalized and excluded from justice, such as women, people of color, LGBTQ+ individuals, and people with limited English proficiency.
Justice in Aging is committed to advancing equity for low-income older adults in economic security, healthcare, housing, and elder justice initiatives. We strive to address the enduring harms and inequities caused by systemic racism and other forms of discrimination that uniquely impact low-income older adults in marginalized communities.
Thank you for sticking with us through that background information. As a quick review of today’s presentation, we have four main topic areas. The first being the what, who and why of California’s Medi-Cal covered home and community-based services. The second being accessing services, applying across the different systems. Third, overcoming denials and reductions in services, and fourth, grievances and appeals. And then we’ll have time for Q&A.
Now I’ll turn it over to Hagar to get us started.
Hagar Dickman: Thank you, Yasmin. Good morning. Thank you for joining us. I’m going to start by just giving us some in-depth overview of Medi-Cal home and community-based services for older adults and people with disabilities, and then we’ll dive right in.
So Medi-Cal covers over 14 million low-income individuals in California and about 2.3 million of whom are older adults and people with disabilities. And the state receives around $112 billion in federal funding, which covers over 50% of Medi-Cal costs. Because of the financial contribution by the federal government, the Medi-Cal program has to be compliant with federal regulations and rules, which we’ll discuss further in just a bit. Medi-Cal covers much more than Medi-Cal services. It covers home care, medical transportation, and dental, vision, and hearing. And these are services that are not necessarily covered by Medicare.
Medi-Cal is also essential for dual eligible individuals to access Medicare covered health services. Dually eligible individuals are older adults and people with disabilities who receive Medicare and are also low income enough to be eligible for Medi-Cal. For duals, Medi-Cal is often essential for accessing Medicare services because Medicare premiums and out-of-pocket costs can be quite pricey, and Medicare savings program covers those expenses and makes them affordable. Medicare also doesn’t cover much long-term care and Medi-Cal is the main payer of home care and skilled nursing facility care.
For individuals who are above the Medi-Cal income limit but cannot afford paying for home care out of pocket, share of cost Medi-Cal provides access to Medi-Cal coverage of those services, but only after individuals spend all but $600 of their monthly income on medical costs. Because it’s nearly impossible to meet one’s basic needs on $600 a month, very few people meet their monthly share of cost. There are about 140,000 older adults and people with disabilities and share of cost Medi-Cal living in the community, but only about 7% or 10,000 individuals are actually meeting their share of cost each month. Medi-Cal also is the main payer for long-term care, and as you can see on the slide, about two-thirds of California’s nursing facility residents are on Medi-Cal. And then home and community-based services through waivers often help older adults age in place. And this is, again, the only way to receive coverage or generally the way to receive coverage for those services is through Medi-Cal.
Federal law requires all states to include institutional care as a Medi-Cal state benefit, Medicaid state benefit. But states can choose which, if any, home and community-based services to offer. The discretion that states have in offering home and community-based services drives much of the disparities and difficulties in accessing these community services in comparison to the more widely available services and skilled nursing facilities. So just as a recap, home and community-based services are services that support older adults and people with disabilities with activities of daily living in community settings. Medi-Cal is the main payer of HCBS, and they’re optional for California to include as a Medi-Cal benefit under federal law, which often in bad budget years makes them vulnerable for cuts.
There are also several federal authorities that allow states to offer home and community-based services. And the federal authority that the state chooses really drives what the services look like and how available they are, easily accessible they are. When a HCBS benefit is included in a state plan, in the state’s Medicaid plan, the state is not allowed to put any caps on that particular service, and therefore there are no wait lists for a state plan service. And a state plan service also is not allowed to have geographic restrictions. When a state uses a Medicaid waiver authority, it can put caps and have wait lists for the service. It requires the state to only allow individuals accessing the service to have a nursing facility level of care, so the highest level of care for access, and the state can also impose geographic restrictions, which causes discrepancy and disparities across the state.
Finally, the state can also offer managed care services, and those services can often be optional for the managed care plans to decide whether they want to offer or not. And when the plans can decide whether they want to offer a home and community-based service as part of their benefit package, that also creates variations not only across geographies, but also across plans themselves. So in a particular county, for example, different individuals or Medi-Cal members can have access to different kinds of services depending on which plan they’re in.
California has several state plan home and community-based services. There are the mandatory services, which are the nursing facility care services and home health, but then we also have several optional services. Right now, we have a state plan benefit for the developmentally disabled population, and California is in the process of moving its community-based adult services program or adult day health into a state plan benefit. The most commonly known state plan home and community-based services benefit is the In-Home Supportive Services program. And it’s actually that particular program uses several federal authorities to make sure that people in the state can receive that service.
We also have several waivers. These are administered by different departments, including the Department of Healthcare Services, Department of Developmental Services, and Department of Aging. And today we’re mostly going to talk about the Assisted Living Waiver and the Home and Community-Based Alternatives Waiver, but it’s important to at least be aware that there are other services available out there.
Just as a recap, the California Community Transitions Program offers skilled nursing residents services that they may need in order to move out of institutional settings and into the community. This program is administered through lead waiver agencies that contract with the Department of Healthcare Services, which oversees the program overall. The Assisted Living Waiver Program is available for individuals 21 years and older in licensed board and care facilities. The HCBA program supports medically fragile, high acuity individuals of all ages in their homes, and the Multipurpose Senior Services Program administered by the Department of Aging offers additional services to older adults over age 60 to meet all their needs and avoid institutional placement. All of these programs require medical necessity, cost neutrality, and individuals must meet the nursing facility or acute hospital level of care.
Managed care plans also offer some home and community-based services. You may have heard of community supports. These are HCBS-like services that managed care plans may, if they so choose, elect to provide for their members because they are at the plans option. There’s significant variety across plans in terms of what services are offered and how they’re administered. PACE is also a managed care-like service. It’s an integrated Medicare and Medi-Cal healthcare plan for individuals over age 55 who require nursing facility level of care. PACE plans also cover HCBS. They should be coordinating all and meeting all of their members’ health and home care needs, so PACE recipients cannot receive non-PACE HCBS services, including IHSS. And finally, the community-based adult services program, which offers health, therapeutic, social, and other services in licensed adult day health centers is also offered mainly through managed care plans. While this service has been limited to only 28 counties, the state is working on making the service available statewide.
Oh, it says… This is a typo. So of the 900,000 people who receive IHSS, around 55% of them are older adults, and IHSS is available for individuals who already meet the nursing facility level of care or are at risk of needing that level of care if they don’t receive IHSS services. And 87% of California’s waiver recipients are also older adults, and the waivers are specifically limited to individuals who require nursing facility level of care. So this is a higher level of care than what IHSS requires.
And then just as a note about caregiving and who the providers are for these programs, it’s really important to keep in mind that about half of IHSS caregivers are also covered by Medi-Cal, and so are really dependent on IHSS income for their own income and are also really struggling to meet their own basic needs.
And here you can see this chart, the most common HCBS services in the state. So the most common is the IHSS service, which has around 925,000 individuals receiving the service statewide and does not allow wait lists. And then you can see that other programs have less participants but need to have significant wait times, and specifically the Assisted Living Waiver and the Home and Community-Based Alternatives Waiver have really large wait lists and people in the community who are on those wait lists have to wait between three to four years to actually get a slot allocated to them.
So we’re actually now going to move to… Tiffany’s going to cover managed care long-term services and supports and I’m going to just turn it over to her now. Thank you, Tiffany.
Tiffany Huyenh-Cho: Thanks, Hagar. Hi everybody. So yes, we’ll talk a little bit about the long-term services and supports that are provided by Medi-Cal plans. In California, almost everyone that is on Medi-Cal today is enrolled in a Medi-Cal Managed Care plan. Again, these are health plans that provide Medi-Cal benefits to Medi-Cal enrollees. They do come with provider networks, prior authorization, and some other limitations, but older adults and dual eligibles are required to be in Medi-Cal Managed Care today. Some of the long-term services and supports that are offered through Managed Care include CBAS, like Hagar mentioned, that’s community-based adult services as well as new services that were created under CalAIM. So I’ll talk a little bit about CalAIM and those new services. CBAS is that managed care long-term service and support option, but we’ll just note that not all managed care plans or counties have CBAS as an option. They are run by centers, they’re community-based day health programs, and there is not necessarily a CBAS center in every county or in every plan.
With CalAIM, it is… You probably have heard of it, but California launched CalAIM several years ago. It is basically just a term for a broad multi-year plan by the Department of Healthcare Services, which is the government agency that oversees the Medi-Cal program. DHCS created CalAIM as a initiative to improve health outcomes in Medi-Cal. There are millions of people enrolled in Medi-Cal, and Cal-AIM is an effort to improve the care that Medi-Cal enrollees receive, improve health outcomes, and CalAIM puts forth a lot of new changes. It’s standardized how benefits are delivered. That is partly why most people are now in Medi-Cal Managed Care. And then CalAIM also introduced two new services to address health, including home and community-based services. So the first one is enhanced care management, and the second is community supports. With both enhanced care management and community supports, these services are delivered by third-party community-based organizations, not the plan itself.
We don’t have enough time to go too in depth on enhanced care management, but in short, it is care management provided to Medi-Cal Managed Care enrollees who have high health needs, high health needs and complex conditions. With ECM or enhanced care management, the goal is to provide intensive care management to coordinate both medical and non-medical needs, things like housing or food insecurity. So people who receive enhanced care management get a care manager who is responsible for coordinating their physical, behavioral, health, dental care, social services. So it’s not only focused on those medical needs, but also the other pieces of someone’s life that will impact their health.
People that are eligible for enhanced care management include people experiencing homelessness, people at risk of institutionalization into a nursing facility, as well as people that live in a nursing facility but can return to the community. Again, it is a Managed Care only service, ECM, but the care management is provided by those third party community-based organizations that meet with people to provide that care management.
And then community supports is the other new CalAIM service. Community supports are also a Managed Care only benefit, and it’s considered a substitute for other state plan Medi-Cal benefits. So instead of care in a nursing home, you may receive a different community support to prevent entering a nursing home in a first place. So community supports are very much HCBS-like services. They have a different name, but they do mirror a lot of other existing waivers or state Medi-Cal services that are provided. And community supports is also designed to prevent entry into a nursing facility or emergency department use at a hospital. It is designed to address social needs that impact your health, such as a lack of housing or simply the fact that there aren’t enough supports for someone living at home so that they can stay at home and not move into a nursing facility.
There are 15 total community support options, and we’ll cover that a little bit on the next slide. One thing to know is that community supports are optional for a Medi-Cal plan to provide. So there are 15 community support options and the Managed Care plans can decide which of those 15 they want to offer. Most Medi-Cal plans offer… Well, all Medi-Cal plans offer at least one community support, but because it is optional, you’ll see a lot of variation with the type of community supports that a plan will offer.
Community supports may also have restrictions on the length of time you can receive that specific community support or a dollar amount. So there are not necessarily indefinite ongoing services that you can receive for years or months on end. It will vary a lot by the individual support. So one example, there is a community support to help with security deposits, to secure a lease for an apartment or a home, but this support is limited and you cannot repeatedly qualify to receive housing deposits year after year. It is a limited benefit.
Another example is there is a ceiling on the expenses that a community support may provide. So for the community transition support, which help people transition out of a nursing facility and into the community, there is a $7,500 limit on the setup costs that the community support will provide. So setup costs include things to set up a household like utility fees or a security deposit, or it could pay for equipment that someone might need to live safely in their home, like an air conditioner or other home modification.
So it’s important to really read the policy guide (vol. 1, vol. 2), which we have linked later on the slides, which list all the different eligibility criteria. And because community supports are optional, plans can also choose to stop offering a community support. If they do so, they must give notice to the state and also to the enrollee as well.
Next slide, please. And then these are the 15 community supports that plans can offer. As you’ll notice, several of them deal with how to find housing, how to secure housing, how to navigate the housing market. The transitional rent will provide time limited rent subsidy. There’s also other community supports for helping people avoid institutionalization or to return to the community. The personal care and homemaker services is very similar to the IHSS program, and then we also have medically tailored meals as well. So you can see that they are quite varied.
Next slide, please. So for eligibility, again, each community support has its own different criteria to qualify. You have to be in Medi-Cal Managed Care. So if someone is in the Medi-Cal fee-for-service system, they cannot receive community supports. It’s not an option, unfortunately. One thing that we get questions about a lot is whether you can receive both enhanced care management and a community support. The answer is yes, you can receive both. It is not uncommon. Oftentimes, the care manager with ECM is also involved with referring their patients to community support so that they get set up with that sort of assistance and additional help.
As you, again, might have noticed, community supports are very similar to Medi-Cal home and community-based services. This was purposeful. It was designed to help fill in the gaps in our home and community-based system because HCBS is a patchwork of programs and are not uniformly offered statewide or in every county. So some of those community supports may be offered in areas where an equivalent HCBS program is not available. That’s common with the community transition services and nursing facility transition community support, that is very similar to the waiver program community transitions.
Next slide, please. And to actually get these services, there are different channels to apply or to request to be assessed. So for Medi-Cal plan members to be assessed for enhanced care management or community supports, there are different ways. You can self-refer by calling the health plan and asking to be assessed. If you do so, you may then get referred to the actual third-party provider providing that service to get screened. You can also directly contact the community support or enhanced care management provider to get screened as well for those services. Managed care plans are also responsible for conducting their own internal review of their enrollees and identify folks that may be eligible themselves. So you can see this happen when the plan may send a list of potential people that they’ve identified as eligible for community supports or ECM.
Of course, there are always exceptions, and for some community supports, the referral pathways are more limited. For example, for medically tailored meals and asthma remediation, you do have to go through specific referral pathways for those community supports. Such as for the medically tailored meals, the referral must originate from the person’s healthcare team itself. And same thing with asthma remediation, it requires a referral from the Asthma Preventive Services program. So it is a little complicated. Unfortunately, the referral pathways are not uniform across plans or by states, but most plans do have an online page where they have an online form or telephone phone number where you can call and ask to be assessed.
And with that, I’ll turn it over to Hagar.
Hagar Dickman: I’m going to go over how to apply for different HCBS programs, and I’m going to give an overview for most of the programs just because it’s going to take me a very long time to go through each and every program, but just keeping in mind that for all HCBS programs, it’s important to identify which department administers the program, whether that program requires working with an agency, a waiver agency, what the financial eligibility criteria is, and what the level of care and medical necessity criteria are.
So just a quick word about financial eligibility. So most of the waiver programs require individuals to have no share of cost Medi-Cal, and so that means that share of cost Medi-Cal is going to be a barrier to accessing the program. Now, this is not a barrier for the IHSS program. Individuals in IHSS can have a share of cost. But several of the HCBS waivers require individuals to use strategies to reduce their countable income so that they could be in the full scope Medi-Cal category. Spousal impoverishment protections allow spouses to allocate their income between the spouse that requires long-term services and supports to the community spouse in order to make sure that the LTSS spouse can be in full scope Medi-Cal. And I’ve included a fact sheet about spousal impoverishment since we’re not going to be able to go deep into financial strategies. So there is at the end of the slides a fact sheet on spousal impoverishment specifically. Individuals can also purchase supplemental health insurance that will reduce their countable income to the Medi-Cal income limit.
And then for the Assisted Living Waivers specifically, there are financial strategies and a kind of complex calculation that allows a reduction of a part of the room and board from countable income that allows individuals also to become eligible for full scope Medi-Cal. And California Advocates for Nursing Home Reform have a good fact sheet on this particular strategy. Just wanted to highlight it here just in case you are assisting somebody with eligibility for that particular program.
I think the greatest barrier for HCBS access is that there’s really no right door for entering into that system. We’ve got IHSS, which is covered by or administered by the Department of Social Services and County IHSS eligibility departments. And then we’ve got Department of Healthcare Services. I see the letters are flipped here by DHCS. They administer the Assisted Living Waiver, the HCBA program and the Medi-Cal Waiver Program, which is for individuals with AIDS and HIV. And then Department of Aging administers the MSSP program and CBAS. Although again, CBAS is really falling under a managed care benefit, so it’s sort of straddling both worlds here. Both Department of Aging oversees it and it is administered by managed care plans. So you really have to connect with the right waiver agency to apply. And in order to find out which that right agency is, you need to go to the right website.
So DHCS will have websites on the three programs it administers, and then CDA has its own websites. Those websites will tell you which waiver agency to contact. When your county doesn’t have a specific contracted waiver agency, then applications generally go through the Department of Healthcare Services directly. For the Assisted Living Waiver, the Assisted Living Waiver provides specific services like personal care, meals, transportation, therapeutic, and socialization services in a licensed facility. So those two licensed facilities are the residential care facilities for the elderly and adult residential care facilities.
In LA County, there are also eight participating public subsidized housing unit settings that also provide Assisted Living Waiver participants with support services through a home health agency, but that’s really specific to LA County and to those participating housing settings. You can find a list of all participating assisted living facilities on the DHCS website. ALW is, again, not available for individuals with a share of costs. So you have to use one of the strategies I just mentioned to lower your countable income so that you could be eligible for full scope Medi-Cal. It’s available to individuals 21 years or older, and you need to require a nursing facility care, but not actually need skilled nursing.
Individuals have to be able to pay for their room and board. And this is really important because federal law does not allow Medi-Cal to cover room and board fees. And the Assisted Living Waiver is the only HCBS program that is provided outside of the individual’s home. And so that particular program requires that room and board payment. For SSI recipients, that room and board payment is actually set and it is a protected rate at about $1,441 per month. And for individuals who have SSI plus another source of income, that room and board rate is $20 more than that 1,441 rate. Individuals who don’t have SSI as part of their income don’t have room and board protection. And so their room and board fee is going to be entered into an agreement between the facility and the individual.
And the other thing to note is that the Assisted Living Waiver is one of the only waivers remaining with the geographic limitations. It’s only available in these 15 counties that are listed on this slide. Individuals who want to participate in Assisted Living Waiver who are outside of those counties have to be willing to move into a participating county. So if you are living in a non-ALW county, you can still apply for the waiver, but then once you get a slot, you need to be moving into an RCFU or a facility that’s in a participating county.
To apply for Assisted Living Waiver, individuals have to contact a care coordinating agency in your county, and it’s called CCA. And the CCA must accept and assess individuals who contact them. They will do a tier assessment to determine what level of care the individual requires at the facility. So not only does the individual have to be assessed for level of care to make sure they meet the nursing facility level of care, they also have to be placed in a tier. And there are five tiers and the tier dictates what kind of services the individual needs and also what the rate is that the assisted living provider is going to get for serving that particular individual. So a person who is assessed a tier one will provide a lower rate of payment for the provider and a person in level four or five, which requires very high needs and a lot of care. Those facilities serving them receive a higher rate for those folks.
Care coordinating agencies will also create an individual service plan together with the applicant and that individual service plan will list all of the different services that the individual needs. They will also fill out a medical assessment form and a residential appraisal form and will require the individual often to waive some of the federal setting room requirements. So for example, individuals should be able to be offered a single room, a fridge and a microwave and those can be waived sometimes in order to be able to access a slot.
CCAs have to confirm receipt of request to be on the Assisted Living Waiver wait list and they have to screen individuals for reserve capacity, and I’ll go over reserve capacity in a minute for that wait list, and add individuals to the wait list within seven days. And then a notice has to be sent of the effective date of placement on that wait list within three days. So once you contact your care coordinating agency and go through all of these assessments and provide all the different forms, that agency should be placing you on the wait list and then also letting you know when the placement happened.
All right. So the other suggestion here is that we have a little advocacy tip here, which is to connect with the legal aid or other organization for assistance with power of attorneys. Because what we’ve heard from both the state and other advocates is that sometimes people go into assisted living with mild cognitive impairment and sometimes as cognition gets worse, there are issues down the line with capacity. And so putting in place a power of attorney and making sure that the individual is supported and dictates how they want to handle their affairs and decision making moving forward can be really helpful. And that’s especially because reassessments have to happen every six months. And so having somebody assigned to be able to assist with those reassessments and to be able to make changes to the individual plan of care is going to be really important.
The other thing, again, I wanted to highlight is that the SSI room and board protection. So for individuals on SSI, the residential care facility or the adult residential facility are not able to charge a higher rate from that individual. So as care needs increase, those care needs should be met through the Medi-Cal side through tier increases, not through room and board rate changes.
So just a word about the Assisted Living Waiver wait list. So there are about 18,000 people on that wait list. The state has told us that if you are transitioning from a nursing facility, it takes about a year to receive a slot. And then if you are transitioning from the community, it can take three to four years to receive a slot. The Assisted Living Waiver has a wait list prioritization policy and it is available on the DHCS website. Individuals will be prioritized for a slot if they’re residing in an institutional setting for more than 60 days and are able to safely transition to the facility. Or if they’re a community member and have an imminent need for services that’s documented through referrals from APS, so Adult Protective Services, that can also prioritize placement on the Assisted Living wait list.
Again, the APS referral requires documentation from Adult Protective Services, usually of neglect, either self-neglect or neglect by others or elder abuse or other situations that require imminent need and that are under the jurisdiction of Adult Protective Services. And then individuals in long-term care. So these are for individuals who are already in a skilled nursing facility and have an imminent need for services. Those individuals can receive a referral from their long-term care ombudsman. And so if you are in a facility and your needs are not being met in the facility or you need assistance in leaving the facility and those needs are imminent, this is particularly important for folks who are in long-term care but have been assessed to no longer meeting the nursing facility level of care. So they’re at risk of being discharged. Those individuals should really be calling the long-term care ombudsman for a prioritization letter to exit the facility and be placed in assisted living instead.
So the HCBA Waiver, unlike the ALW, the HCBA Waiver provides assistance for individuals in their home. So it doesn’t require an individual to give up their community home and move into an assisted living facility. These are services that are available for the highest acuity consumers in Medi-Cal. The services include a variety of intensive services including private duty nursing, home health aids, paramedical services, caregiving training, personal care services for up to 24 hours a day, habilitation, assistive technology, nursing supports, and nursing supports both for ventilator and non-ventilator dependent individuals. So really high acute care. And folks that receive the service often leave or are receiving the service after a long hospital stay or staying in a nursing facility or acute or subacute facility.
The service requires full scope Medi-Cal and substantial limitations in adaptive functioning as well as medical fragility or technology dependent individuals. It’s important to keep in mind that for people with Alzheimer’s or dementia, the Home and Community-Based Alternatives Waiver is really the only way to truly receive 24 hour care at home and staying outside of a nursing home or a long-term care facility.
The HCBA is a little bit different in terms of the agencies available. So agencies that are available are actually dictated by ZIP Code and you have to go onto the DHCS website to see which agency actually treats your or serves your particular area. You would need to fill out an HCBA application and a plan of treatment. Once you fill out that HCBA application, the waiver agency should assist with the plan of treatment and any other assessments that you might need. Waiver personal care services are services that are available under HCBA. And I think one of the main reasons that people apply for Home and Community-Based Alternatives Waiver, it’s really the only way to get 24 hour direct care. In order to receive waiver personal care services, you need to first apply for IHSS. So you have to receive IHSS, max out your hours and need additional hours as well.
The HCBA Waiver application requires an assessment or a case management report, the plan of treatment, a freedom of choice form and home safety evaluation, as well as an acuity tool that assesses individuals for acuity of their needs. One of the things to keep in mind about HCBA is even though you need to receive IHSS together with HCBA, you can’t also be enrolled in an additional waiver. So you should be receiving IHSS plus HCBA, but no other waiver. And then there is a 24-hour direct care limit, which is hands-on care support that meets the needs of the waiver participant and you cannot receive more than 24 hours of direct care under this waiver.
So just another word on HCBA and the ALW wait list. The way the slots are processed based on waiver policy, there has to be a distribution of slots, so 60% of slots are coming in from institutional transitions and 40% are coming out of community enrollment. There can’t be a higher percent of community enrollment folks from the wait list in either of these waivers. And this has to do with both a prioritization of de-institutionalizing individuals, but also for the state to meet its budget neutrality requirements or its cost neutrality requirements. The state has to show to the federal government that on average individuals are receiving lower cost care on the HCBA Waiver than they were before in institutional care. So that 60/40% really helps the state meet that obligation.
The way that this is implemented is that the state will release slots to waiver agencies that keep with that 60/40 ratio. So the state will look at how a waiver agency is administering its slots and make sure that the slots are administered at 60% from the institutional placements and then 40% from community. And if the agency is meeting those requirements, they will often release more slots as they become available.
For institutional placement, you really, by federal regulations, have to have 60 or more days in institutional care. And waiver agencies have 60 days to submit a complete application once a slot is available. So an individual will not really be hearing directly from the Department of Healthcare Services. The department will let the particular agency know that a slot is available and that a person’s name is being called up and that person will now need to submit a full application within 60 days. If they are not meeting that 60 day requirement, that slot will often be distributed to somebody else.
And just keeping in mind some advocacy tips, it can be very difficult for individuals waiting three to four years on these wait lists to stay on top of their Medi-Cal applications, of meeting all of the different requirements for the waivers. So if you’re able to ensure that once an individual’s slot is released or even before, just making sure that their eligibility is maintained for Medi-Cal so that once the slot is released, they’re eligible to apply. And then consider even during that three to four year period whether circumstances have changed and whether the individual, even if they haven’t met a priority category before, maybe they meet one now. And if that’s the case, then definitely a good idea to let the waiver agency know.
And I think there is one… And I’m going to go over the HCBA wait list prioritization group, which is slightly different from ALW in just a second. So there’s a couple of other things to keep in mind there. And then in order to make sure that individuals meet that 60-day application requirements so that the slot is fully released to them, just providing additional support for timely completion of forms, making sure that medical documentation is there when needed, especially for the HCBA Waiver, which requires additional acuity and medical assessments in order to complete the application.
Just another quick word on the HCBA wait list. So like the ALW, individuals are prioritized when they live at a facility for longer than 60 days. But another criteria to keep in mind is Medi-Cal members may be prioritized when they’re transitioning from another HCBS program because their skilled care needs and level of care are no longer met by that program. For example, I think MSSP is a very common one for folks to transition over because MSSP provides additional personal care on top of IHSS, but that’s very, very limited. It’s maybe six, seven hours a week additional personal care services. And as individuals needs increase, they might no longer be able to remain at home with a low allocation of hours and may need waiver personal care hours. And so, if that is the case and there is documentation to show that there’s a gap in care, it may be worth transitioning over to the HCBA Waiver and getting onto that prioritized reserve capacity wait list.
So with that, I’m going to pass on the baton back to Tiffany to go over grievances and appeals.
Tiffany Huyenh-Cho: Thanks, Hagar. So quick reminder, Medi-Cal is a government benefit, so specific due process rights apply and these rights also extend to home and community-based services. So people who receive HCBS always have the right to file an appeal or file a grievance about their HCBS.
Next slide, please. So quickly, you often hear the term appeal or grievance. So an appeal is a formal review of a decision to deny, reduce, or terminate a requested service or a service that is ongoing. Maybe there is a notice that you are getting a waiver of service and they find that you no longer qualify, so they’re going to terminate that. That is an appealable decision. You can say, “I disagree and I want a formal review of that decision to terminate or deny a service.” If you are appealing that decision, you’re asking for a second review. You’re asking for that decision to be reversed.
A grievance is separate. A grievance is to file something in writing about a dissatisfaction about an issue that you’re unhappy with. So it doesn’t fall under a formal plan decision to approve or deny a service, but it’s much broader. If it’s about the quality of care that you received, that’s a grievance. If it’s about the customer service that you received by an office staff member, by a waiver agency staff member, or by a Medi-Cal plan representative, that is a grievance. So a grievance is much broader than appeal, can deal with the quality of care receiving, the quality of service, the professionalism that was provided to you as well. But it is not a formal review about eligibility for a Medi-Cal service or benefit, so it does not fall under the appeal right.
Appeals and grievances are separate, so they do have specific formal definitions and then different deadlines to file. One thing to note is if someone labels something as a grievance and you file that with your managed care plan, but it actually meets the criteria for an appeal because the underlying issue is about a service being terminated, for example, it will be treated as an appeal. But it is important to pay attention to the definitions because the deadlines to file an appeal is much shorter than the deadline to file a grievance. So that’s where it’s very important to understand the difference between the two.
Next slide, please. So for appeal rights, written notice, one, is always required, that is one of the due process rights that Medi-Cal enrollees have in regards to eligibility and the services that they are receiving or have requested. So if a Medi-Cal plan, a waiver agency, if the state decides to deny, reduce, or terminate a service, written notice is required. And if you do not get written notice, you can appeal that as well. For an appeal, it’s important to pay attention to the date on the notice because you do have to file an appeal within a specific deadline. If you missed that deadline, you missed your right to appeal that specific decision. There’s always some exceptions, so there could be good cause exception for missing a deadline, but that’s really difficult to prove.
The notice requirement is federal and state law, but notices may go by different names depending on how someone is receiving that service. In a Medi-Cal plan, the notice is called an Adverse Benefit Determination, or ABD. Outside of Managed Care, it’s called a Notice of Action, or NOA. Notices of Action must be in writing. They also must explain the reason why something was either denied, reduced, or terminated so that if you appeal it, you understand how to fight that, how to argue against that appeal, that denial or termination. And then also you may request aid paid pending that allows you to keep your current benefits continuing while you wait for an appeal decision. So if a service was terminated, if you request aid paid pending, that service can continue during the appeal process. You must file that before the effective date of your termination, or within 10 days.
Next slide, please. So your appeal pathways, again, will vary also on delivery system. In Managed Care, once you get that notice of ABD, Adverse Benefit Determination, you can file a first level plan appeal within 60 days. If that is not in your favor, you can go to the state fair hearing. And state fair hearings are impartial independent processes to review that first level decision. They’re informal. They’re not like a courtroom TV sort of hearing, and it’s in front of an administrative law judge where evidence can be presented by both sides. If you’re outside of Managed Care, there is no plan level appeal because the plan is not involved. There, you can file a state fair hearing and you have 90 days to appeal from the date of the notice.
Next slide, please. So when to file an appeal? Again, there’s a lot of different reasons to file one, but if the plan has denied a request for community supports, or maybe you are receiving a community support and they found that you no longer qualify and will terminate that service, you can file your plan level appeal. If you’re getting a waiver service and the waiver agency issues a decision that you no longer qualify and you don’t meet the required level of care, that’s also appealable. Appeals can always be filed by phone, by mail, or online. Look at the written notice, it will have directions on how to file that appeal and where. You can also go to your health plan website to file an appeal as well and get more information.
Next slide, please. And then for grievances, again, this is more about your quality of care professionalism. Within Managed Care, you can file that at any time. It can be submitted also online by phone or in writing, and there is a 30-day deadline for a plan decision. One thing to note with a grievance, you don’t have to file a grievance before you file for a state fair hearing. I forgot to mention that on the previous slide, but with appeals, if you’re in managed care, you do have to go through your managed care appeal process first before you go to a state fair hearing. But with grievances, that’s not required.
Next slide, please. And then for waiver grievances, if you are dissatisfied with the waiver services you’re receiving, you can also file a grievance. Where you file is going to depend on the HCBS waiver you’re getting itself. So you may file that grievance with the care coordination agency or the waiver agency. If you’re dissatisfied with the waiver agency itself, such as how it’s coordinating your care, typically you file that grievance with the government agency overseeing that specific waiver. So it could be the Department of Healthcare Services or the Department of Aging, for example.
And then lastly, if you’re unhappy with your person-centered service plan or how it was developed, you can file a grievance or you may file an appeal. You can do both. If you’re filing a grievance, you can contact the email compliance on the page, on the slide, or you can file a state fair hearing. And on our next slide, we do have a link to the Department of Healthcare Services, HCBS grievances and appeals, and they go through where exactly to apply. Fortunately, it’s not so standard. HCBS, as you might have noticed, is complex, and same thing with appeals and grievances.
And with that, I think we have some time for Q&A.
Yasmin Peled: Thank you everyone. We are almost at time, but like I said, we’re going to go a little bit over today to answer some questions, but any unanswered questions will be followed up with after the webinar via email. So if we don’t have a chance to get to your question, you will get a response. So starting off, there are a couple of questions about the HCBA Waiver.
The first question is about the wait list and how long the current wait list is for the HCBA Waiver.
Hagar Dickman: I have to go back to my chart here. I believe there’s about, last I checked, there were 6,500 individuals on that wait list, but all of those individuals are on the community wait list. So the reserve capacity wait list should be, or at last conversation with Department of Healthcare Services has been cleared. So all of those folks are community individuals, and that wait list takes about approximately three to four years to get through. So people should anticipate if they’re getting on the wait list now, they will Be on that wait list for quite some time.
But that should not discourage you. You should definitely get onto that wait list. Slots do become available. The state sometimes increases slots. The waiver is going to be up for renewal this next year, and so we’re hoping to also ask for additional slots. So it’s always a good idea to get onto that wait list. And like I said before, if you, while on that wait list, become eligible to be on the prioritization reserve capacity list, that also helps. So there’s really no harm done in being on the wait list, even if currently it’s a long one.
Yasmin Peled: So another clarifying question about the HCBA Waiver is that it’s only available to you if you are also maxed out on IHSS hours.
Hagar Dickman: Yeah, but there’s no requirement specifically that says you have to get the maximum IHSS hours. By being maxed out it means that you have been allocated a certain number of hours through IHSS. Those hours are insufficient to meet your needs and you need additional hours. So by maxing out, that does not mean you are already at protective supervision, you’re getting 283 hours. It means that you’re getting those hours and they’re not enough to meet your needs.
Yasmin Peled: Moving on now to the Assisted Living Waiver, a question about the ALW wait list and if DHCS is planning any slot expansions or changes to the wait list management and any tips for RCFEs with residents who qualify but are stuck on a long wait list.
Hagar Dickman: A lot of questions. Okay. So there are about 18,000 people on that wait list. For an individual who is already in an assisted living facility, that is a community transition, so that wait list is approximately three to four years. There is an automatic slot increase in I believe February of this year. There will be an additional 1,800 slots that are released. Obviously not enough to even make a dent in that 18,000 number. And then I think keeping in mind that those additional slots again will need to be distributed as 60% from institutional placement and 40% from community. So generally if you’re in the community, it is highly unlikely that you’re going to get a part of those 1,800.
I think as far as strategies are concerned, the best strategy at the moment is to be on that wait list and to try to get assisted living community transitions support from your managed care plan if possible. Particularly it would be very important for the individual or for the current resident to need nursing facility level of care and have their room and board not currently cover sufficient services. So the recommendation is really to look to the managed care plan to see if they can be the bridge until the individual gets off that wait list. Otherwise, there’s no real way to expedite someone’s community placement on the wait list. You just have to wait for a very long time, unfortunately. Or participate in our advocacy to make Assisted Living Waiver and other home and community-based services into state plan benefits and remove the wait list, which is again, that’s our policy focus but not the current direction that the state has been taking.
Yasmin Peled: Another question related to the Assisted Living Waiver is about how individuals are getting their needs met while they are stuck on the wait list.
Hagar Dickman: Well, if you are at home, I think a lot of people rely on IHSS. Unfortunately, I think a lot of people who are on that very long wait list have experienced a lot of gaps in care. And if you have a consumer or member that you are assisting at home who’s on the wait list and is really struggling to meet those gaps, please reach out because we do have a story collection effort as part of our advocacy and are interested in hearing in the gaps in care that people are experiencing while they wait on that list. Unfortunately, we do hear from other advocates and waiver agencies that people, while they’re on the wait list, are often experiencing really adverse health outcomes, increased falls, increased hospitalizations. And so I think if you are able to share those stories, that’s always really helpful.
But in the meantime, you really have to look outside of the ALW. If you’re in a CBAS county, talking to your managed care plan about participating in CBAS, that also can provide some respite for individuals. And then really patching together a combination of services, including services from the managed care plan to make sure that individuals get as many services as they can while they’re awaiting. No good great answer there, unfortunately.
Yasmin Peled: There’s a similar question about filling gaps for folks on the HCBA wait list. I assume it’s a similar answer.
Hagar Dickman: I think so. I think the HCBA Waiver, especially because it has these very specialized services could be really difficult. And looking to managed care plans, there are some overlaps. So looking at, for example, if the individual needs environmental adaptability services for their home, you can look to the managed care plan for that particular service. Personal care, community support can help supplement some personal care needs. So I think really trying to patch together some of those services can help at least address some gaps. But I think particularly for the HCBA, there’s no real other service that is as comprehensive to support somebody at home.
Yasmin Peled: Starting to wind down here, we have a question here about the upcoming UIS changes and those affecting individuals receiving CBAS services and if those changes to the UIS population will impact those utilizing CBAS.
Tiffany Huyenh-Cho: I can answer that. So yes, there are some people, some certain immigrants that don’t qualify for federal funding. They’re in Medi-Cal Managed Care today, but because of other federal policy changes, they will be moving to the fee-for-service system on January 1st. So they won’t be a Medi-Cal Managed Care enrollee. They can still receive CBAS. CBAS can be provided through fee-for-service as well. So there should not be a change in any benefits. Of course, if you hear of complications, once this change takes effect January 1st, let us know. But CBAS access is still preserved.
Yasmin Peled: And then just our last question here, sort of a process question about somebody who’s currently on Medicare getting onto Medi-Cal, what is that process? And is it similar to applying for county social services?
Tiffany Huyenh-Cho: Yeah, pretty much. What we cover today are services provided through the Medi-Cal programs. You do have to have Medi-Cal. You can apply at the county social services department. You can also apply online through Covered California or BenefitsCal for an application too.
Yasmin Peled: Thank you again everyone for joining us today. As a reminder, all unanswered questions will be followed up on via email, and please feel free to reach out to Hagar or Tiffany with any additional questions. Please don’t forget to fill out the post-webinar survey. Your feedback on these webinars is very important to us. Thank you and have a great rest of your day.
