Medi-Cal Home and Community-Based Services: Understanding Overlaps and Gaps

Introduction

Home and community-based services (HCBS) include a range of services and supports that help older adults and people with disabilities live in their own homes or in home-like settings in the community, rather than in institutions. Medi-Cal, like other state Medicaid programs, provides some HCBS through waivers and demonstration programs. Medi-Cal enrollees participating in an HCBS waiver or demonstration program can receive case management, community transition services, personal care services, home modifications, and other services.

Medi-Cal HCBS waiver and demonstration programs are currently provided by the state on a fee-for-service basis. However, as a part of CalAIM (California Advancing and Innovating Medi-Cal), the California Department of Health Care Services (DHCS) has a goal to integrate certain HCBS programs into its managed care delivery system through a model known as Managed Long-Term Services and Supports (MLTSS). New rules on Medicaid services and managed care  from the Centers for Medicare & Medicaid Services will also affect Medi-Cal HCBS because of new requirements for program administration and managed care oversight.

Medi-Cal managed care plans (MCPs) can currently choose to provide 1 or more of 14 Community Supports to address members’ health-related social needs. Some of these Community Supports provide services that are similar to those provided by HCBS waiver and demonstration programs.

There are several ways DHCS could integrate HCBS into MLTSS:

1. HCBS could continue to be provided through a combination of State Plan benefits, including both fee-for-service and managed care; waivers; and demonstrations.
2. DHCS could require that MCPs offer additional HCBS benefits.
3. MCPs could choose to offer expanded HCBS benefits as optional Community Supports.
4. Some combination of these approaches could be taken.

It is important that policymakers and stakeholders understand how current Medi-Cal HCBS waiver and demonstration programs do and do not overlap with Community Supports to ensure that any future integration of HCBS into managed care does not create gaps in HCBS access that threaten Medi-Cal members’ abilities to live in home and community-based settings.

This series of explainers describes similarities and differences between Community Supports and two Medi-Cal HCBS waiver programs — the Assisted Living Waiver and the Home and Community-Based Alternatives Waiver — as well as one HCBS demonstration program, California Community Transitions (CCT). While CCT is in this series due to its overlap with one of Medi-Cal’s Community Supports, the state is not currently considering it for MTLSS integration. An explainer focused on another HCBS waiver program, the Multipurpose Senior Services Program (MSSP), will be added in spring 2025.

The explainers are intended to provide foundational information for policymakers and HCBS stakeholders as they plan for the future of HCBS, including for the potential increased role of managed care. These resources are based on a review of state documents and other literature, interviews with three HCBS provider organizations, and input from three advocacy organizations.

Assisted Living Waiver

The Assisted Living Waiver (ALW) is designed to help people transition to and live in assisted living facilities or publicly subsidized housing with health care agency supports as an alternative to a nursing facility. For more information on the ALW and its intersections with Community Supports, see Assisted Living Waiver and CalAIM Community Supports: Understanding Overlaps and Gaps (PDF).

Home and Community-Based Alternatives Waiver

The Home and Community Based Alternatives (HCBA) Waiver is designed to help people either move from a nursing facility or hospital to a home or community setting of their choice, or avoid nursing home placement, by delivering a comprehensive set of services, including nursing care. For more information on the HCBA Waiver and its intersections with Community Supports, see Home and Community-Based Alternatives Waiver and CalAIM Community Supports: Understanding Overlaps and Gaps (PDF).

Multipurpose Senior Services Program Waiver

The Multipurpose Senior Services Program (MSSP) Waiver provides comprehensive care management and a wide range of health and social services to older adults (age 60 and older), to help them live independently and avoid or delay placement in a nursing facility. For more information on MSSP and its intersections with both Enhanced Care Management and Community Supports, see Multipurpose Senior Services Program Waiver and Key CalAIM Services: Understanding Overlaps and Gaps (PDF).

California Community Transitions

California Community Transitions (CCT) provides a set of services for 365 days to help people coordinate moving out of a medical facility and into a home or community setting. For more information about CCT and its intersections with Community Supports, see California Community Transitions and CalAIM Community Supports: Understanding Overlaps and Gaps (PDF).

Key Considerations

In addition to outlining areas of overlap and identifying potential gaps that could arise from an MLTSS transition, this work illuminates the following key challenges and opportunities:

MCPs can choose which optional Community Supports they offer, which results in inequities in access to services among Medi-Cal members enrolled in different plans. Data show the availability of Community Supports varies by plan, meaning some Medi-Cal members may not have access to certain services from which they could benefit. Given the variability in Community Supports offerings, stakeholders are often unaware of which Community Supports are offered locally, and many providers and members do not know what they are or how to access them. As the state considers modifying Community Supports offerings for a potential shift to MLTSS, it will be essential to consider certain services as required, rather than optional, to ensure equitable care.

HCBS providers need support to work with MCPs effectively, and some MCP processes should be tailored and standardized to facilitate partnerships and ease administrative burdens for HCBS providers. Like other small community-based service providers, many HCBS providers lack experience working with MCPs and may have limited staff capacity or financial reserves to take on new contracting and administrative responsibilities. Core MCP processes (e.g., authorizations, billing, payments) and requirements (e.g., documentation, reporting) could be standardized and streamlined to improve HCBS providers’ willingness to partner with plans. HCBS providers may also benefit from access to upfront payments to further support a transition to MCP contracting and billing requirements. Engaging HCBS providers to build relationships with MCPs and communicating with them about policy changes early in a transition process could help ease provider hesitation around working with MCPs.

Collecting comprehensive data on the type, quality, and quantity of services offered and provided to Medi-Cal members could identify and address access issues. Data, including enrollee zip codes and HCBS waiver waitlist demographic information, are currently limited, making it difficult to assess access and equity. Under MLTSS, DHCS could require plans to collect information to support access monitoring and ensure data collection is thoughtful and actionable.

To ensure equitable access to HCBS services, an adequate network of qualified providers is needed throughout the state. Interviewees noted that the availability of HCBS providers, most notably assisted living facilities, varies significantly across the state, and the ability to maintain or increase supply is limited by staffing challenges, including a shortage of direct care workers. Through MLTSS, DHCS could incentivize plans to provide HCBS in ways that support provider participation (e.g., setting targets to increase HCBS use or providing flexibility in payment policy). HCBS providers will require resources to scale up processes and invest in workforce development and will need competitive payment rates so that MCPs can provide an adequate network.