In March 2006, Medi-Cal began paying for assisted living care to select aged and disabled residents of Los Angeles, Sacramento and San Joaquin counties under the Assisted Living Waiver Pilot Project (ALWPP). The ALWPP was created by legislation that directed the California Department of Health Care Services (DHCS) to develop and implement the project. A key goal of the pilot project 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 the community. The program was approved by the Centers for Medicaid and Medicare and was converted into a five-year federal waiver program as of March 1, 2009.
Scope of Program
ALW serves the counties of Fresno, Los Angeles, Riverside, Sacramento, San Bernardino, San Joaquin and Sonoma.
Participants in ALW have access to four different waivers:
Assisted Living Services: these services are provided in a Residential Care Facility for the Elderly (RCFE) or Assisted Care: which are provided by a licensed home health agency and provided to residents in public housing. The following is a list of some of the services of the assisted living program that must be provided to ALW participants:
A care plan for each resident
Providing personal care and assistance
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: identifying, organizing, coordinating and monitoring services needed by clients.
Nursing Facility Transition Care Coordination: services help transition participants from a nursing home to the community.
Consumer Education: to help the client take control and responsibility for their care and services.
Participants must be eligible for full-scope or 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.
Using the standardized assessment tool, care coordination agencies determine the level of care each participant needs. DHCS established four levels of care - known as tiers - and a payment level for each tier.
Care coordinators establish individualized service plans for each participant, including services that are covered by Medi-Cal through the pilot project and other 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 implements care plans for participants who live at public housing sites. In this setting, the services provided are called Assisted Care.
Participants pay for their own room and board at rates set by facilities. Medi-Cal payments only cover costs for specified care and services.
RCFEs and home health agencies are reimbursed at four levels of care, with daily rates ranging from $52 per day for tier 1 to $82 per day for tier 4. RCFEs and home health agencies cannot negotiate the services to be delivered or the payment rate.
Care coordination agencies will be paid $200 per participant, per month, for care coordination services and for the coordination of other waiver benefits and services.
In addition to care coordination, additional funds are available. Up to $2500 is available to help a nursing home resident return to a community setting, plus $1,000 is available to cover care coordination services for such individuals. Up to $1500 per participant in public housing is available for environmental accessibility adaptations. Other benefits include consumer education and interpretation and translation.
Provider participation is voluntary. Interested providers must enroll as a Medi-Cal assisted living waiver provider.
Below are the basic requirements for the three main care provider types.
RCFEs must be licensed, not be on probation or have pending accusations against their license, and be in substantial compliance with licensing requirements. Additionally, RCFEs must:
Meet care needs of all participants in accordance with their care plans at all four levels of care.
Have awake staff 24 hours a day, except in facilities with 6 or fewer residents.
Employ or contract with a nurse or nursing agency to provide any required nursing services as often as is necessary.
Have a hospice waiver and be able to care for cognitively impaired residents.
Have single occupancy rooms for participants, unless a participant chooses to have a roommate.
Have private bathrooms or bathrooms shared by no more than 2 participants.
Have a kitchenette in the room of each participant, except in facilities with 6 or fewer residents, where the requirement is waived if the resident has continuous access to the facility's kitchen.
Care coordination agencies must have five years experience in this field, have R.N. and social services care coordinators on staff, and meet other requirements.
Home health agencies must be licensed, enter into an operating agreement with the publicly funded housing site where they deliver services, open a branch office at that site, and meet other requirements.
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. All providers are expected to deliver all four levels (tiers) of care.
For more information about how to apply, contact: http://www.dhcs.ca.gov/SERVICES/LTC/Pages/ALWPP.aspx
Long-Term Care Division
1501 Capitol Avenue, MS 4503
PO Box 997419
Sacramento, CA 95899-7419