Background
In March 2006, Medi-Cal began paying for assisted living care for qualified aged and disabled residents of Los Angeles, Sacramento and San Joaquin counties under the Assisted Living Waiver (ALW). A key goal of the program was to enable low-income, Medi-Cal eligible seniors and persons with disabilities, who would otherwise require nursing facility services, to remain in or relocate to a community setting in a Residential Care Facility for the Elderly (RCFE) or public subsidized housing. The program was converted into a five-year federal waiver program as of March 1, 2009, and expanded into additional counties.  Subsequently, the waiver program has been renewed for additional time periods and expanded to include 15 counties and a maximum enrollment of 5,744 participants. In 2022, the ALW program was approved to expand by an additional 7,000 spaces. The most recent five-year waiver renewal is effective March 1, 2019 through February 29, 2024.

Scope of Program
The ALW is currently operating in the counties of Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma. However, some of the counties in which the ALW program is operating do not currently have any RCFEs participating in the program. The list of participating RCFEs changes from month to month. For the most updated list of participating facilities, please go to https://www.dhcs.ca.gov/services/ltc/Documents/List-of-RCFE-facilities.pdf.

Overview
Participants in the ALW have access to the following services:
Assisted Living Services: The following is a list of some of the services that must be provided to ALW participants.  These services may be provided in an RCFE, or by a licensed Home Health Agency to residents in public housing.

• Assisting in developing and updating an individualized care plan for each resident
• Personal care and assistance with activities of daily living
• Laundry
• Housekeeping
• Maintenance of the facility
• Providing intermittent skilled nursing care
• Meals and snacks
• Providing assistance with self-administration of medications
• Providing or coordinating transportation
• Providing recreational activities
• Providing social services

Care Coordination: These services include identifying, organizing, coordinating and monitoring services needed by participants.

Nursing Facility Transition Care Coordination: These services help transition participants from a nursing home to the community.

Eligibility
Participants must be eligible for full-scope, no share-of-cost Medi-Cal benefits and require a nursing facility level of care. The latter requirement is key to eligibility because the program is designed to serve people who would otherwise need nursing home care. Contracted Care Coordination Agencies use a standardized assessment tool to determine the clients need for nursing home level of care. The project serves people age 21 and older.

People living in other counties can receive services if they are otherwise qualified, willing to relocate to one of the participating counties, and work with an enrolled care coordination agency.

Care Planning
Using the standardized assessment tool, care coordination agencies will determine the level of care and services necessary for each participant.  Care coordinators will establish individualized service plans for each participant, including services that are covered by Medi-Cal and services funded by other sources. Participating RCFEs must develop a care plan to implement the service plan for each resident.

A licensed, Medi-Cal certified home health agency will implement care plans for participants who live at public housing sites. In this setting, the services provided are called Assisted Care.

Payment Rates
Participants pay for their room and board, and Medi-Cal pays for their care and services. In 2023, for participants with monthly SSI income of $1,492.82, the room and board rate is $1,324.82. For participants with income over $1,492.82, the room and board rate is $1,344.82. Medi-Cal pays the RCFEs and home health agencies for five levels of care and services, with daily rates ranging from $78 per day for tier 1 to $200 per day for tier 5. RCFEs and home health agencies cannot negotiate the services to be delivered or the payment rate.

Choosing a Facility
Participants select the facility or provider of their choice. Care coordination agencies will inform participants about available facilities and providers. RCFEs are allowed to reject a participant. However, once a facility admits someone, it must provide necessary services and adapt services as the person’s needs change.

Waitlist Status
In 2017 the ALW program reached its capacity of participants and the Department of Healthcare Services (DHCS) instituted a waitlist.  and is accepting “Waitlist Request Forms.” Current enrollment and waitlist information for the ALW can be found on the enrollment dashboard, updated monthly, at https://www.dhcs.ca.gov/services/ltc/Pages/AssistedLivingWaiver.aspx.

Open waiver slots are released to Care Coordination Agencies on a monthly basis.   Individuals interested in holding a spot on the waitlist should contact a Care Coordination Agency in their county to complete a one-page Waitlist Request Form. (For a list of Care Coordination Agencies, please see: https://www.dhcs.ca.gov/services/ltc/Documents/Care-Coordination-Agencies.pdf

Please be advised that there are currently very significant wait times, due to the existing backlog of applications held by DHCS. Individuals are nevertheless encouraged to submit a Waitlist Request Form to hold a spot on the list and to demonstrate to the State that there is strong demand for this program, and a need for expansion.

In September 2020, the Centers for Medicare and Medicaid Services (CMS) authorized California’s request to temporarily modify enrollment policy for the ALW to prioritize intake processing of waiver applicants residing in hospitals and skilled nursing facilities in areas of the state identified as “hotspots.” The temporary enrollment flexibility only applies to individuals within counties with the highest rates of new COVID-19 infections. For more information, please see COVID-19 Hotspot Enrollment at https://www.dhcs.ca.gov/services/ltc/Pages/AssistedLivingWaiver.aspx.

In 2022, CMS approved DHCS’ amendment to the ALW to add 7,000 slots to eliminate the current waitlist and expand waiver capacity. DHCS has released guidance to Care Coordination Agencies on how these expansion slots will be released, with priority for individuals who are institutionalized. Read the guidance at: https://www.dhcs.ca.gov/services/ltc/Documents/ALW-PL-22-01-WL-Release.pdf.

How to Apply
To begin the application process, contact the Care Coordination Agency in your county: https://www.dhcs.ca.gov/services/ltc/Documents/Care-Coordination-Agencies.pdf

For more information about the ALW program, contact:
www.dhcs.ca.gov/services/ltc/Pages/AssistedLivingWaiver.aspx

Assisted Living Waiver
Department of Health Care Services
Long-Term Care Division
1501 Capitol Avenue, MS 4503
PO Box 997437
Sacramento, CA 95899-7437

ALW Hotline – 916-552-9322