How to Get on a California Medi-Cal HCBS Waiver

There is no single "California HCBS waiver," because the state runs seven distinct Home and Community-Based Services pathways under Medi-Cal. Families seeking community-based long-term care almost always confront more than one of these structures simultaneously, with different lead state agencies, different eligibility rules, different waitlists, and different application doors.

This guide walks through every pathway: the Home and Community-Based Alternatives (HCBA) waiver, the Assisted Living Waiver (ALW), the Multipurpose Senior Services Program (MSSP), the Self-Determination Program / HCBS-DD waivers, Community-Based Adult Services (CBAS), In-Home Supportive Services (IHSS), and the Program of All-Inclusive Care for the Elderly (PACE). It also covers the cross-cutting eligibility rules, spousal impoverishment, the asset reinstatement under AB 116, and the most consequential California-specific planning lever in the country: HCBS waiver applicants are not subject to transfer penalties.

The 60-Second Version

What Is HCBS, Exactly?

"Home and Community-Based Services" is the federal Medicaid umbrella for long-term services and supports delivered outside of an institution, in your own home, a family member's home, an assisted-living facility, an adult day center, or a Regional Center–coordinated community living arrangement. Federal Medicaid law gives states multiple authorities to deliver HCBS, and California uses every major one:

Every §1915(c) waiver shares two structural features. First, the federal "but-for" test (42 CFR §435.217), the applicant must be assessed at an institutional level of care (nursing facility, ICF/IID, or hospital) such that, but for the waiver, they would require institutional placement. Second, the cost-neutrality formula under 42 CFR 441.303(f)(1), HCBS costs cannot exceed the institutional costs the state would have incurred.

Federal law also requires every HCBS waiver to comply with two cross-cutting rules. Person-Centered Service Planning under ACA §2402(a) and 42 CFR §441.301(c) requires that every plan be developed through a process directed by the individual, in plain language, with conflict-of-interest protections. The HCBS Settings Final Rule (1/16/2014; full compliance 3/17/2023) sets minimum standards for what "community" means: integration in the greater community, individual choice of setting, lockable doors in residential settings, choice of roommates, lease protections, and freedom to control schedule, activities, food access, and visitors. California's Statewide Transition Plan was CMS-approved; DDS issued its final implementation directive 12/1/2023 with on-site verification deadline 8/31/2024.

The Seven California HCBS Pathways at a Glance

Income, Assets, and Cost-Share by Program

Now the deep dives.

HCBA: The Home and Community-Based Alternatives Waiver

HCBA is California's umbrella §1915(c) waiver for medically fragile and complex-needs individuals. It is the broadest in service array, the most acuity-flexible (covering NF-LOC, sub-acute, and pediatric sub-acute), and the only HCBS waiver in California that reaches both elder NF-LOC populations and younger people with severe medical fragility, vent-dependent adults, technology-dependent children, complex chronic conditions.

Authority, Lead Agency, and Capacity

HCBA operates under §1915(c) waiver application CA.0139.R06.00, currently approved through 2027 (the 2023–2027 renewal cycle). It was originally launched in 1982 (the In-Home Medical Care Waiver) and consolidates several legacy waivers (the NF/Sub-Acute Waiver, AIDS Waiver, IHO Waiver) into the current HCBA structure.

DHCS administers HCBA directly and contracts with 9 regional Care Management Agencies (CMAs) to operate the program. In counties without a contracted CMA, currently Alpine, Imperial, Inyo, Marin, Mendocino, Mono, and Napa, DHCS manages waiver services directly.

Capacity has expanded steadily:

As of 10/2025, DHCS reported 9,692 enrolled and 5,975 on the waitlist. The 2026 expansion is intended to absorb a substantial share of the waitlist while creating room for new applicants.

Eligibility, Functional and Financial

Functional eligibility requires one of three institutional levels of care:

• Nursing Facility (NF) level of care, the most common path.
• Sub-acute level of care, vent-dependent, complex wounds, similar high acuity.
• Pediatric sub-acute level of care, for children with comparable acuity.

Financial eligibility for a single applicant (effective 4/1/2026):

• Income: $1,836/mo under the Aged & Disabled Federal Poverty Level methodology. Higher income qualifies through the Medically Needy / Share-of-Cost pathway (income above $600/mo Maintenance Need Level counts toward SOC).
• Assets: $130,000 under the reinstated AB 116 limits (effective 1/1/2026).

For a married applicant with a community spouse, California's W&I §14005.41 spousal impoverishment rules apply:

• Asset limit for the applicant spouse: $130,000.
• Community Spouse Resource Allowance (CSRA): up to $162,660 (2026 federal max).
• Minimum Monthly Maintenance Needs Allowance (MMMNA): $2,643.75 floor / $4,066.50 ceiling.
• 90-day CSRA Transfer Period applies after the Notice of Action approving HCBS.

Combined household countable resources can reach ~$292,660 ($130,000 applicant + $162,660 CSRA). Without §14005.41, the couple would be capped at the standard $195,000.

Critically, no transfer penalty applies, California uniquely does not apply transfer penalties or lookback periods to HCBS waiver applicants. See the Transfer-Penalty Carve-Out section below.

Reserve Capacity Priorities, Who Skips the Waitlist

When DHCS releases HCBA slots, Reserve Capacity rules under HCBA Policy Letter 24-004 (8/27/2024) prioritize three categories ahead of the general queue:

1. Applicants transitioning from another HCBS waiver because their level-of-care needs have escalated beyond what the prior waiver can address (typically ALW or MSSP enrollees whose acuity has progressed).
2. Applicants under age 21, children and young adults, supporting EPSDT-aligned medical-fragility populations.
3. Applicants who have resided in a healthcare facility (NF, hospital, sub-acute) for at least 60 days at application, supports nursing-home-to-community transitions.

When a slot is released, DHCS first sweeps the waitlist for Reserve Capacity-eligible applicants. Slot release deadline: if a complete enrollment packet is not received within 90 days, DHCS releases the slot to the next applicant.

Care Management Agencies, The Operational Backbone

The CMA is the entity that:

• Receives the applicant's referral.
• Conducts the comprehensive in-home assessment.
• Develops the Plan of Treatment (POT), HCBA's person-centered service plan.
• Submits the POT to DHCS for approval.
• Provides ongoing monthly comprehensive care management by an interdisciplinary team (RN + social worker minimum).
• Coordinates HCBA-paid services with State Plan Medi-Cal, IHSS, and community resources.

Sample CMAs: Partners In Care Foundation (LA-area), Sonoma County HHS, San Ysidro Health (San Diego), Center for Elders' Independence (Bay Area), Libertana, Home & Health Care Management.

Services Covered (HCBA)

HCBA's service array is the broadest of any California HCBS waiver outside the developmental-disability programs:

• Care management, RN + social worker care team (the central HCBA benefit).
• Skilled nursing, RN, LVN, including continuous private-duty nursing.
• Waiver Personal Care Services (WPCS), typically delivered by IHSS-employed providers, layered on top of IHSS hours.
• Habilitation, skill-building and community participation supports.
• Community living supports, transition assistance, housing supports.
• Home-delivered meals.
• Family training, caregiver education and skill-building.
• Durable medical equipment above and beyond State Plan DME.
• Home and environmental modifications, ramps, grab bars, accessible bathrooms, lifts.
• Private-duty nursing, continuous nursing for medically complex individuals.
• Personal Emergency Response Systems (PERS).
• Respite care, in-home or facility-based.
• Transitional case management, NF-to-community transitions.
• Assistive technology.

The waiver does not cover room and board, food, or services duplicative of State Plan Medi-Cal.

How to Apply (HCBA)

• Phone: (833) 388-4551
• Email: HCBAlternatives@dhcs.ca.gov
• Web: DHCS HCBA portal

A typical pathway: applicant or family contacts DHCS or the regional CMA → screen → Medi-Cal eligibility verification (or simultaneous Medi-Cal application) → in-home comprehensive assessment → Plan of Treatment development → DHCS approval or waitlist placement.

Common pitfall: Applicants without active Medi-Cal cannot enroll in HCBA. A simultaneous Medi-Cal application is often required. The CMA can assist with the Medi-Cal application but is not a Medi-Cal eligibility worker.

ALW: The Assisted Living Waiver

ALW pays for care in licensed assisted-living settings, but not room and board, and not in most of California.

Geographic Scope, 15 Counties

ALW is geographically limited to 15 counties:

Alameda · Contra Costa · Fresno · Kern · Los Angeles · Orange · Riverside · Sacramento · San Bernardino · San Diego · San Francisco · San Joaquin · San Mateo · Santa Clara · Sonoma

Older advocacy materials sometimes cite an 18-county roster; the current DHCS list is 15.

Eligibility (ALW)

• Age: 21 or older.
• Functional: NF-A or NF-B level of care.
• Setting choice: Willing and able to reside in a participating Residential Care Facility for the Elderly (RCFE), Adult Residential Facility (ARF), or HUD-subsidized public housing partnered with the waiver.
• Financial: Full-scope Medi-Cal eligibility. Income via A&D-FPL or Medically Needy/SOC; assets at $130K/$195K; spousal impoverishment via §14005.41 available.

Enrollment and Waitlist

ALW has the largest waitlist of any California HCBS waiver, and the waitlist is bigger than the enrolled population. In many counties, the wait runs multiple years.

Priority enrollment is given to applicants transitioning from a nursing facility, referrals from Adult Protective Services or the Long-Term Care Ombudsman, and applicants transferring from another HCBS waiver.

What ALW Covers, and What It Does NOT

Covered:

• Care coordination by a Care Coordination Agency (CCA).
• Personal care assistance (ADL/IADL support delivered by RCFE/ARF staff).
• Homemaker services.
• Home health aide services.
• Medication management/oversight.
• Skilled nursing oversight.

NOT covered, the resident pays:

• Room and board. This is the headline limitation of ALW. The waiver does not pay rent or food in the assisted-living setting.

The resident pays room and board from their SSI/SSP non-medical out-of-home care payment. In 2026, that combined SSI + SSP rate is $1,626.07/month. The resident retains $182/month as a Personal Needs Allowance and pays the remaining $1,444.07/month to the residence.

This structure means ALW only fits residents at or near SSI/SSP income levels. A senior with $3,000/month in Social Security generally cannot qualify for ALW: their income disqualifies them from SSI/SSP, and they cannot meet room-and-board on their own without depleting assets that would also disqualify them.

For higher-income seniors who want the assisted-living setting, the realistic options are CalAIM's Nursing Facility Transition/Diversion to Assisted Living Community Support (an MCP-delivered parallel pathway that doesn't require a §1915(c) slot, see CalAIM section below) or private pay.

2026 Rate Update

Effective 1/1/2026, California's statewide minimum wage rose to $16.90/hr. DHCS issued an updated ALW Rate Sheet 2026 with revised tier-based reimbursement rates to RCFEs and ARFs. Care Coordination Compensation for the CCA is $320 per participant per month.

The Care Coordination Agency Model

ALW is operated through certified Care Coordination Agencies (CCAs) that:

• Conduct the standardized assessment.
• Determine the level of care.
• Establish the Individualized Service Plan (ISP), ALW's PCSP, incorporating waiver-paid services and services from other sources.
• Provide ongoing care coordination at the frequency specified in the ISP.

The participating RCFE/ARF then develops a facility-level care plan to operationalize the ISP within the residence.

How to Apply (ALW)

• Web: DHCS ALW page
• CCA Directory: Available through the DHCS ALW page; many regional CCAs (Care Republic, All Hours Adult Care, Home & Health Care Management, GetALW, etc.).

The pathway: applicant or family contacts a CCA in the service county → assessment → ISP development → enrollment if a slot is available, otherwise statewide waitlist placement → move-in to a participating RCFE/ARF.

MSSP: The Multipurpose Senior Services Program

MSSP is California's intensive-care-management waiver for seniors 65+ at NF-LOC who want to stay in the community. Where HCBA serves complex acuity and ALW serves the residential setting, MSSP serves the moderate-need senior who needs care coordination, modest service authorization, and warm handoffs to community supports, and would otherwise drift toward NF placement without it.

Authority and Lead Agency

§1915(c) waiver. Lead agency: California Department of Aging (CDA) under interagency agreement with DHCS. Operated through approximately 38 contracted local sites, typically community-based nonprofits, Area Agencies on Aging, or county aging departments, each serving a defined geographic catchment.

The local-site delivery model is what distinguishes MSSP from HCBA. Where HCBA has 9 regional CMAs covering large multi-county territories, MSSP has nearly 40 smaller sites with deeper county-level penetration and warmer handoffs to local AAA services, senior centers, and community resources.

Eligibility (MSSP)

• Age: 65+.
• Medi-Cal: Full-scope Medi-Cal eligibility required. Same income/asset rules as HCBA. Spousal impoverishment via §14005.41 applies.
• Functional: NF level of care, established by the local MSSP site's care manager.
• Residence: Currently residing in the community (not a NF). MSSP is designed to prevent NF placement, not to facilitate transition out, for that, HCBA, ALW, or CalAIM Community Supports are the primary tools.

The 40:1 Care Management Model

The defining feature of MSSP is intensive care management at a 40 participants per care manager ratio. The team consists of:

• Care Manager, typically MSW or BSW level.
• Public Health Nurse, for clinical assessment and oversight.

The team conducts the initial in-home comprehensive assessment, develops the Individualized Plan of Care (IPC), MSSP's PCSP, authorizes a budgetable mix of waiver services subject to per-participant cost limits, visits the participant in-home no less than every 90 days, and reassesses annually plus when condition changes.

Services Covered (MSSP)

MSSP's authorized service categories are smaller than HCBA's but well-suited to its mission:

• Care coordination (the central benefit).
• Adult day care / social day referrals.
• Personal care, typically delivered by IHSS providers; MSSP does not employ providers directly.
• Homemaker services.
• Respite care, in-home and out-of-home.
• Transportation, medical and non-medical.
• Home-delivered meals.
• Communication devices and PERS.
• Minor home modifications and repairs (capped, major remodels go through HCBA).
• Protective services and supplemental supports.

Capacity, Sites, and How to Apply

MSSP is capped statewide at approximately 12,000 participants and is non-entitlement. When a site reaches its capacity, prospective participants go on a site-level waitlist, some minimal, some 6–18 months in high-demand metros.

To find a local MSSP site:

• Phone: 1-800-510-2020 (California Aging Connection / CDA hotline).
• Web: CDA MSSP directory (county lookup).
• Local: Through your Area Agency on Aging (AAA), which often refers directly.

Sample sites: Partners In Care Foundation (LA, San Fernando Valley, Antelope Valley, Santa Clarita, Santa Barbara, Kern); California Health Collaborative (Central Valley); CHC (Sacramento region); Health Projects Center (Monterey, Santa Cruz, San Benito).

HCBS-DD and the Self-Determination Program (SDP)

California has the largest HCBS waiver for the developmentally disabled in the nation, serving 400,000+ Lanterman/Regional Center consumers. It runs in parallel to the elder-focused waivers (HCBA, ALW, MSSP) and is operated through 21 Regional Centers under contract with the Department of Developmental Services (DDS).

The Lanterman Act Framework

The Lanterman Developmental Disabilities Services Act (W&I Code §4500 et seq.; especially §4512 defining "developmental disability" and §4519.5 establishing the entitlement) is California's foundational statute for services to people with developmental disabilities.

A developmental disability under §4512 is one that originates before age 18, continues or is expected to continue indefinitely, constitutes a substantial disability, and falls within categories including intellectual disability, cerebral palsy, epilepsy, autism, and other neurological conditions.

Eligible individuals are Regional Center consumers, enrolled in one of California's 21 Regional Centers (RCs) operating as nonprofit corporations under contract with DDS.

Critically, Lanterman entitlement is NOT the same as Medi-Cal eligibility. California pays for RC services from state general fund regardless of Medi-Cal status; the federal HCBS-DD waiver match flows for consumers who are also Medi-Cal eligible. A consumer can be Lanterman-eligible without being Medi-Cal eligible, and they will receive the same RC services either way. Medi-Cal eligibility doesn't change services; it opens the federal-match door.

The HCBS-DD Waiver

The HCBS-DD waiver is a §1915(c) waiver administered by DDS in coordination with DHCS, covering Regional Center consumers who meet ICF/IID level of care. Services include:

• Supported living and supported employment.
• Day programs and behavioral services.
• Respite, transportation, vehicle modification, home modification.
• Communication aids, family training, community integration training.
• Crisis intervention.
• Transition services (state developmental center to community).
• Independent facilitation and Financial Management Services (for SDP).

The PCSP is the Individual Program Plan (IPP) required by W&I §4646–§4646.5. It is developed at least annually by the RC service coordinator with the consumer, family, and providers.

The Self-Determination Program (SDP)

SDP is California's self-directed mode of HCBS for Regional Center consumers. It launched in pilot 2018 and opened statewide on 7/1/2021 to all RC consumers. SDP is opt-in: a consumer chooses to leave the traditional service-broker model and instead receives an individualized budget that the consumer or representative directs.

Key SDP elements:

• Individual Budget: Equivalent in dollar value to what services would have cost under the traditional model, calculated by the RC service coordinator.
• Person-Centered Plan: Developed before the budget is finalized; the plan drives the budget, not the other way around.
• Independent Facilitator (IF): Optional but commonly used; helps with PCP development, budget preparation, and vendor selection. Paid from the budget.
• Financial Management Services (FMS) agency: A vendored FMS handles payroll, taxes, and budget tracking. FMS is required.
• Vendor flexibility: Consumer can hire credentialed RC vendors, qualified individuals, or in some cases family members, within the budget.

CRITICAL 4/1/2026 Change: SCDD-Only SDP Orientation

Effective April 1, 2026, two things change for SDP enrollment:

1. The State Council on Developmental Disabilities (SCDD) is the only approved provider of SDP orientation statewide. Previously, RCs and a mix of vendors offered orientation.
2. Orientation is now a 4-hour two-part requirement: Part A (2 hours) and Part B (2 hours). Part A must be completed before Part B. Both parts are required before the consumer can begin SDP transition.

Consumers who completed orientation under the prior framework before 4/1/2026 are not re-required to take the new orientation, but RC service coordinators check documentation at intake and transition gates. Register for SCDD orientation at scdd.ca.gov/sdp-orientation.

CBAS: Community-Based Adult Services

CBAS is the entitlement adult day health benefit for adults at NF-LOC or with qualifying cognitive impairment, delivered through Medi-Cal Managed Care plans. It is the post-2012 successor to Adult Day Health Care (ADHC) following the Darling v. Douglas federal class-action settlement.

Eligibility, Six Categories

Adults age 18+ who meet one of:

• Category 1: NF-A or NF-B level of care.
• Category 2: Mental health diagnosis with significant functional impairment.
• Category 3: Moderate to severe Alzheimer's disease or other dementia.
• Category 4: Mild cognitive disorder (including mild dementia) and need assistance/supervision with two of: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management, hygiene.
• Category 5: Developmental disability with high care needs not met by HCBS-DD.
• Category 6: Brain injury, spinal cord injury, or chronic mental illness with need for skilled rehabilitation/maintenance.

Eligibility is determined by the CBAS Eligibility Determination Tool (CEDT) Version 2.0, administered initially by the CBAS center's RN and reviewed by the MCP.

What CBAS Provides

CBAS is delivered at a licensed CBAS center (the regulatory descendant of ADHC centers). A typical participant attends 2–5 days per week for a half-day or full-day; transportation to/from is included. Center staff provides:

• Skilled nursing assessment and intervention.
• Therapy (PT, OT, speech-language pathology) for maintenance and rehabilitation.
• Social work services and counseling.
• Mental health services (especially valuable for Category 2/3 participants).
• Personal care during the center day.
• Therapeutic activities (cognitive stimulation, group activities, exercise).
• Meals (one or two meals per attendance day).
• Transportation to/from the center.

The center develops an Individualized Plan of Care (IPC) within 30 days of admission, MCP-authorized.

Delivery, All Through Managed Care

CBAS is a carved-in benefit under Medi-Cal Managed Care:

• The MCP authorizes CBAS for its members.
• The MCP contracts with CBAS centers in the network.
• The CBAS center submits claims to the MCP, not directly to DHCS.
• The participant must be enrolled in an MCP (most Medi-Cal members are).

Footprint

California has approximately 230+ licensed CBAS centers statewide, serving roughly 40,000 active participants at any point in time. CBAS is entitlement, no slot waitlist. Each center has its own capacity, and members may need to choose a center with availability.

How to Apply (CBAS)

1. Member or family contacts a CBAS center (CDA directory) or asks their MCP for a CBAS referral.
2. CBAS center sends an RN for a face-to-face assessment using the CEDT.
3. CBAS center submits CEDT and IPC to MCP for prior authorization.
4. Once authorized, member attends per the schedule.

PACE: Program of All-Inclusive Care for the Elderly

PACE combines all of Medicare and Medi-Cal into a single all-inclusive benefit for adults 55+ at NF-LOC. California has the largest PACE network in the country: 33 active organizations, 117 PACE Centers and Alternative Care Sites, 28 counties, and ~7,400+ active participants per CalPACE (2/2026).

History and Authority

PACE traces back to On Lok Senior Health Services, founded in 1971 in San Francisco's Chinatown to keep frail Chinese elders out of nursing homes. The federal PACE statute (§1934 of the Social Security Act for Medicaid; §1894 for Medicare) was created in BBA 1997 and made PACE a permanent benefit.

PACE is structured as a fully-capitated, fully-integrated Medicare and Medicaid program: one organization receives a single per-member per-month capitation payment from CMS (Medicare side) and DHCS (Medicaid side) and is responsible for providing or arranging all medically necessary care.

Eligibility (PACE)

To enroll in PACE, an applicant must:

1. Be age 55 or older.
2. Reside in a PACE service area.
3. Be assessed at nursing facility level of care.
4. Be able to live safely in the community at the time of enrollment, with PACE supports.
5. Agree to disenroll from any other Medicare and Medi-Cal delivery options (FFS Medicare, Medicare Advantage, Medi-Cal Managed Care). PACE becomes the exclusive source of medically necessary services.

Most PACE participants are full-benefit dual eligibles (~90%). Some pay privately; some pay only the Medicare portion via private dollars while being Medi-Cal eligible.

The Interdisciplinary Team

The defining feature of PACE is the Interdisciplinary Team (IDT). By federal regulation (42 CFR Part 460), the IDT must include:

Primary care physician · Registered nurse · Master's-prepared social worker · Physical therapist · Occupational therapist · Recreational therapist or activities coordinator · Dietitian · PACE Center supervisor · Home care coordinator · Personal care attendant · Driver/transportation representative.

The IDT meets regularly (often weekly or biweekly) to review every participant's care plan and respond to changes. Participants typically attend a PACE Center on a schedule the IDT establishes, anywhere from 1 day per week to 5 days per week, and receive primary care, therapies, social engagement, and meals at the Center, plus home-based services (personal care, home-delivered meals, in-home nursing) as needed.

What PACE Covers

PACE covers all services covered by Medicare and Medicaid, plus additional services determined necessary by the IDT, without the limits or coverage carve-outs that normally apply. This includes primary care, specialty care, hospitalization (in or out of network), prescription drugs, nursing facility placement when necessary (PACE participants who develop NF-level needs remain enrolled in PACE and receive NF services through the program), adult day services at the PACE Center, home health, personal care, DME, transportation, therapies, mental health, dental, vision, hearing, podiatry, meals, and family caregiver support and respite.

The California PACE Network

Major operators (some with multiple PACE Centers):

• AltaMed (LA-area)
• On Lok (San Francisco/Alameda/Santa Clara, the founding organization)
• CalOptima Health (Orange County)
• Sutter SeniorCare (Sacramento area)
• St. Paul's PACE (San Diego)
• InnovAge (multi-state operator)
• WelbeHealth (multi-county California operator)
• Brandman PACE (Los Angeles)
• Center for Elders' Independence (Bay Area)

CRITICAL 2026 Update: PACE Application Pause

Effective 12:00 AM on November 20, 2025, DHCS issued Policy Letter 25-02 imposing a two-year freeze on:

• New PACE organization applications.
• Service-area expansion applications for existing PACE organizations.

The pause runs through November 19, 2027 (or until DHCS issues a superseding policy letter). DHCS cited the need to "ensure appropriate resources to operate the PACE program as well as manage the current rate of growth."

Exceptions:

• Applications already received before 11/19/2025 11:59 p.m. continue to be processed.
• Change-of-Ownership (CHOW) applications for existing PACE organizations are not subject to the pause.

What this means for families: Existing PACE organizations in their current service areas continue to enroll new participants without interruption. The pause affects organizational expansion, new orgs, new counties for existing orgs, not individual enrollment in operational programs. A senior in an existing PACE catchment can still apply and enroll. A senior in a county that does not currently have PACE will not gain access during the pause unless an existing org with a previously-submitted expansion application receives DHCS approval.

How to Apply (PACE)

• CalPACE Roster: calpace.org/our-members/pace-organizations
• Path: Senior contacts a PACE organization in their service area → PACE org screening (age 55+, NF-LOC, service area) → financial eligibility → enrollment effective the first of the month following completed Enrollment Agreement.

IHSS: California's State Plan HCBS Workhorse

IHSS is California's Medicaid State Plan Personal Care benefit + §1915(j) Self-Directed PAS + §1915(k) Community First Choice Option, serving ~771,650 recipients in FY 2025-26, by far the largest Medi-Cal HCBS pathway. It is the only major Medicaid program in the country allowing paid spousal caregivers through its main HCBS structure.

For full IHSS coverage, provider hiring, hours allocation, EVV, FLSA overtime, county wage floors, the IRS Notice 2014-7 tax exclusion, and the 2026 changes, see our dedicated IHSS guide.

For HCBS-waiver-readers, the key facts:

• IHSS is not a §1915(c) waiver. It is a state-plan benefit. There is no slot cap, eligible Californians get IHSS as a matter of state-plan entitlement.
• Federal authority stack: State Plan PCS + §1915(j) Self-Directed PAS (paid spouses/parents) + §1915(k) CFC (+6 FMAP for NF-LOC recipients).
• Spousal impoverishment via §14005.41 applies to IHSS at LTSS levels.

IHSS + HCBS Waiver Coordination

IHSS and §1915(c) HCBS waivers can be used in combination:

• HCBA + IHSS: Common combination. HCBA's care management and skilled services layer on top of IHSS personal care. The HCBA Plan of Treatment specifies which services are HCBA-paid versus IHSS-paid.
• ALW vs. IHSS: Mutually exclusive in the residential setting. ALW pays for in-residence personal care; IHSS does not pay providers in licensed facilities (RCFE/ARF). A senior moving into an ALW facility transitions out of IHSS.
• MSSP + IHSS: Common combination. MSSP authorizes care management and supplemental services; IHSS pays for personal care delivered in-home.
• CBAS + IHSS: Common combination. CBAS provides daytime structure and clinical services; IHSS provides home-based personal care other hours.

Cross-Cutting Eligibility, The Rules That Touch Every Pathway

Multiple NF-LOC Assessment Tools

Each pathway uses its own LOC assessment tool, there is no single "California HCBS LOC form."

Medi-Cal Eligibility Doors

To enroll in a §1915(c) waiver, the applicant must have full-scope Medi-Cal. Several doors lead there:

• A&D-FPL, Income up to 138% FPL ($1,836/mo single eff. 4/1/2026). Most HCBS waiver enrollees use this door.
• Medically Needy / Share-of-Cost, Income above the A&D-FPL door but applicant agrees to a monthly Share of Cost. SOC = net income minus the $600 community Maintenance Need Level.
• 250% Working Disabled Program, For working disabled adults; allows higher income with a small premium.
• MAGI-based eligibility, Generally for under-65 non-disabled adults; applies to HCBA pediatric population.
• SSI-linked Medi-Cal, SSI recipients are categorically Medi-Cal eligible; the simplest path to waiver enrollment.

Spousal Impoverishment via W&I §14005.41, California's HCBS Carve-Out

Federal §1924 spousal impoverishment is mandatory for institutional Medi-Cal applicants. ACA §2404 extended it to §1915(c) waivers, originally as a 5-year extension and made permanent by Congress in 2018.

California codifies the extension in W&I §14005.41, applying the same protections to:

• §1915(c) HCBS waivers: HCBA, ALW, MSSP, Self-Determination, HCBS-DD.
• §1915(j)/(k) Community First Choice Option (IHSS at LTSS levels).
• §1915(i) State Plan HCBS where applicable.

Only about 10 states extend spousal impoverishment to HCBS this comprehensively. This is one of California's strongest planning levers for community-based long-term care.

2026 federal standards (per CMS CIB 12/9/2025):

The 90-day CSRA Transfer Period applies to HCBS waiver applicants the same way it applies to NF applicants, after the Notice of Action approving HCBS, the institutionalized spouse has 90 days to retitle joint accounts.

Asset Reinstatement (AB 116, eff. 1/1/2026)

California's asset limits for non-MAGI Medi-Cal were eliminated for the 7/1/2022 – 12/31/2025 window. AB 116 (Ch. 21, Stats. 2025) reinstated them effective 1/1/2026:

• $130,000 for an individual (vs. the historical $2,000).
• $195,000 for a couple.
• +$65,000 for each additional household member.

These limits apply to HCBA, ALW, MSSP, HCBS-DD/SDP, and IHSS applicants. The interaction with spousal impoverishment is favorable, the community spouse can hold up to $162,660 (CSRA) on top of the institutionalized spouse's $130,000, for an effective couple-level countable resources of up to ~$292,660.

The Transfer-Penalty Carve-Out, California's Single Biggest HCBS Planning Lever

California uniquely does not apply transfer penalties to HCBS waiver applicants.

Transfer penalties, and the lookback period (1 month in 1/2026, ramping up to 30 months by 7/2028 under AB 116), apply only to nursing-facility Medi-Cal applicants. They do not apply to:

• HCBA, ALW, MSSP, HCBS-DD, SDP applicants.
• IHSS applicants.
• CBAS applicants.
• PACE applicants.

Practical implication: A senior who transferred $200,000 to family three months ago can apply for HCBA, ALW, MSSP, HCBS-DD/SDP, IHSS, CBAS, or PACE without any transfer-penalty delay. The same senior applying for institutional Medi-Cal would face a transfer-penalty waiting period, at the 2026 Average Private Pay Rate divisor of $14,440/month, $200,000 produces roughly 13.85 months of NF Medi-Cal ineligibility.

This carve-out is a strong incentive to plan around HCBS pathways rather than NF placement when feasible. Estate-planning attorneys familiar only with NF Medi-Cal sometimes apply transfer-penalty thinking to HCBS waiver applicants, a costly mistake that can delay or derail community-based care plans.

UIS Adult Coverage and HCBS, A 2026 Wrinkle

The 2025 Budget Act and Health Omnibus Trailer Bill restructured Medi-Cal for adults 19+ with Unsatisfactory Immigration Status (UIS):

• 1/1/2026: New UIS adult applicants receive only restricted-scope Medi-Cal (full-scope enrollment frozen). SNF benefit eliminated for UIS adults.
• 7/1/2026: Dental benefit eliminated for UIS adults.
• 7/1/2027: $30/month premium begins for non-pregnant UIS adults 19–59 (per AB 116).
• Existing enrollees: UIS adults already enrolled in full-scope Medi-Cal (and IHSS) before 1/1/2026 retain access.

HCBS waiver implications: Existing UIS adults on HCBS waivers retain coverage. New UIS adult applicants face a restricted-scope barrier to new HCBS waiver enrollment, the trailer bill specifically eliminates SNF benefit for UIS adults, and full-scope Medi-Cal is required for new HCBS waiver enrollment. This is an evolving area; advocates including Justice in Aging and Health Consumer Alliance are tracking implementation.

Person-Centered Service Planning, California's Five Documents

Federal law requires every HCBS enrollee to have a person-centered service plan developed through a participant-directed process under ACA §2402(a) and 42 CFR §441.301(c). California implements this through five distinct documents, one per pathway, each with its own name, format, and convention.

Each plan must reflect federal floor requirements: directed by the individual, in plain language, identifying strengths and preferences, including risk factors and mitigation strategies, signed by all participants, and reviewed at least annually.

Waitlist Mechanics, Entitlement vs. Non-Entitlement

For a senior with immediate need facing a multi-year ALW or MSSP waitlist, the realistic options are:

• CBAS, entitlement, not waitlisted.
• IHSS, entitlement, not waitlisted (30–60 day assessment).
• CalAIM Community Supports, NFT/D Assisted Living, MCP-delivered, no §1915(c) slot.
• HCBA Reserve Capacity, for qualifying transitions, applicants under 21, or 60+-day institutional residents.
• PACE in service areas where capacity exists.

The combination of these pathways is often the most realistic plan for a senior in immediate need.

CalAIM Levers, Community Supports and Beyond

California's §1115 demonstration CalAIM runs alongside the §1915(c) waivers and houses adjacent HCBS-like services that don't require a waiver slot:

• 14 Community Supports delivered by Medi-Cal Managed Care plans, including:
  • Nursing Facility Transition/Diversion to Assisted Living Facilities, MCP-delivered parallel pathway to ALW; useful as a bridge for waitlist applicants.
  • Housing Transition Navigation Services and Housing Tenancy and Sustaining Services.
  • Community Transition Services.
  • Medically Tailored Meals/Medically Supportive Food, capped at 12 weeks duration unless extended for medical necessity (effective 1/1/2026).
• Enhanced Care Management (ECM), including Population of Focus 5 (Adults at Risk for LTC Institutionalization) and Population of Focus 6 (Adult NF Residents Transitioning to Community).
• Justice-Involved Reentry, 90-day pre-release Medi-Cal coverage rolling out through 10/1/2026.

CalAIM 1115 renewal status: Current term expires 12/31/2026. DHCS published its renewal application 2/10/2026 with public comment through 3/12/2026. Proposed renewal term: 1/1/2027 – 12/31/2031.

Two CalAIM Community Supports become mandatory for MCPs to offer effective 1/1/2026 per the DHCS Community Supports Policy Guide.

CCT Wind-Down, What Replaces Money Follows the Person

California Community Transitions (CCT), the state's Money Follows the Person demonstration program, is being wound down. Per SB 281 (2021) and W&I §14196.2:

• 12/31/2025: Last enrollment date. DHCS ceased enrolling new beneficiaries 1/1/2026.
• 12/31/2026: Last service-provision date for currently enrolled beneficiaries.
• 1/1/2028: Statutory repeal date.

For two decades, CCT was the workhorse program for nursing-home-to-community transitions, providing transitional case management, environmental modifications, household setup assistance, and service coordination.

What replaces CCT: The functions historically performed by CCT have been redistributed into:

• CalAIM Community Supports, Nursing Facility Transition/Diversion to Assisted Living. MCP-delivered, no §1915(c) slot required.
• CalAIM Community Supports, Housing Transition Navigation and Housing Tenancy/Sustaining Services.
• HCBA Reserve Capacity for applicants in NF for 60+ days at application.
• HCBA Transitional Case Management, a waiver-paid service for NF-to-community transitions.

2026 Changes, A Consolidated Cheat Sheet

12 Common Pitfalls, What Families Get Wrong

1. Thinking HCBA is the umbrella waiver for "all HCBS." It isn't. HCBA is one §1915(c) waiver among five (HCBA, ALW, MSSP, HCBS-DD, SDP). The seven-pathway structure also includes CBAS, IHSS, and PACE. Landing on HCBA's website and applying for HCBA when ALW or MSSP would have been a better fit can lose months of access.

2. Underestimating the ALW waitlist. The 18,365-person ALW waitlist (12/2025) is a multi-year wait in many counties. Bridge solutions, CalAIM NFT/D, HCBA Reserve Capacity, private pay, need to be planned in parallel.

3. MSSP capped enrollment confused with waitlist. MSSP slots are per-site, not per-applicant. A site at capacity has a waitlist; a site with capacity does not. "MSSP is full statewide" is not how the program works, adjacent sites or AAA referrals may have capacity.

4. SDP orientation gating SDP enrollment. Effective 4/1/2026, the 4-hour SCDD-only orientation is required before SDP transition can begin. RC service coordinators are checking documentation. Mid-transition consumers are grandfathered.

5. CBAS misunderstood as "an HCBS waiver." CBAS is an MCP-delivered carved-in benefit operating under §1915(b)+(c) hybrid authority. It is not capped, doesn't have a slot waitlist, and is authorized through the MCP, not DHCS or a CMA.

6. PACE eligibility restricted to dual eligibles 55+. Families assume PACE is "for all seniors." It isn't. The 55+ age (not 65) is broader than expected, but the dual-eligible requirement excludes most seniors with significant Social Security income.

7. Lanterman entitlement vs. Medi-Cal eligibility confused. A Lanterman/RC consumer is entitled to RC services regardless of Medi-Cal status. Medi-Cal eligibility opens the federal HCBS-DD waiver match but doesn't change services. Families sometimes think they "lose" RC services if they go off Medi-Cal, they don't.

8. HCBS waiver applicants assuming transfer penalties apply. They don't. California's transfer-penalty exemption for HCBS waivers, IHSS, and other community-based Medi-Cal is a strong planning advantage. Estate-planning attorneys familiar only with NF Medi-Cal sometimes apply transfer-penalty thinking to HCBS waiver applicants, a costly mistake.

9. Spousal impoverishment via §14005.41 underutilized. Despite being one of the most generous state extensions in the country, §14005.41's HCBS spousal impoverishment protections are often missed by community spouses applying for IHSS, HCBA, or ALW. The result: community spouses unnecessarily depleted to the standard $195K couple limit when they could retain up to $292K.

10. Confusing PACE enrollment with PACE expansion freeze. The 11/20/2025 – 11/19/2027 PACE application pause affects new PACE organizations and service-area expansions, not individual enrollment. Existing PACE orgs continue enrolling new participants. Families sometimes wrongly conclude PACE is closed.

11. CCT availability after 1/1/2026. CCT enrollment is closed. Families discharging a relative from a NF in 2026 cannot access "CCT" as previously known; the substitute pathways are CalAIM NFT/D Community Supports, HCBA Reserve Capacity for 60+-day institutional residents, and HCBA's Transitional Case Management.

12. ALW assumed to cover room and board. It doesn't. ALW pays for care; the resident pays room and board from SSI/SSP at $1,626.07/month. This means ALW only fits residents at or near SSI/SSP income levels, higher-income seniors cannot make the math work without parallel CalAIM Community Supports or private-pay options.

FAQ

The Bottom Line

1. There is no single "California HCBS waiver." Seven distinct pathways operate under different authorities with different lead agencies, eligibility rules, and waitlists. Picking the right door matters more than picking the right form.

2. California's HCBS planning levers are unusually strong. Spousal impoverishment under W&I §14005.41 reaches every major HCBS pathway. The HCBS transfer-penalty carve-out means transfers don't delay HCBS eligibility. Combined with the AB 116 asset reinstatement at $130K/$195K, an HCBS waiver couple can retain up to ~$292,660 in countable resources.

3. Waitlists are real, and parallel applications are standard practice. The 18,365-person ALW waitlist, the 5,975-person HCBA waitlist, and the site-level MSSP waitlists all suggest applying to multiple pathways simultaneously while using entitlement programs (IHSS, CBAS) and CalAIM Community Supports as bridges.

4. 2026 is a year of significant change. HCBA capacity expanded to 14,374 slots. AB 116 reinstated asset limits. PACE applications are frozen through 11/19/2027 (existing orgs continue enrollment). SDP orientation moves to SCDD-only on 4/1/2026. CCT is winding down. UIS adult restrictions tighten.

5. The CalAIM 1115 renewal landing in 2027 will reshape the demonstration's HCBS provisions, Community Supports continuation, ECM expansion, new HCBS investments. Watch DHCS for finalization in late 2026.

6. Federal protections matter. ACA §2402(a) Person-Centered Service Planning and the HCBS Settings Final Rule give you enforceable rights, to a participant-directed plan, to lockable doors and choice of roommates in residential settings, to community integration. Use them.

Reference Numbers and Resources

Learn More

• California Medi-Cal Long-Term Care
• Medi-Cal Eligibility & Income Limits
• California Medi-Cal Asset Limits
• California IHSS Guide
• California Medi-Cal Estate Recovery
• California Medi-Cal Overview

Find personalized help navigating California HCBS waivers at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.