What is HCBA?
HCBA, or Home and Community-Based Alternatives waiver, is an essential Medi-Cal funded program that provides intensive case management, care coordination, and comprehensive services and supports to help people with significant medical conditions or disabilities live in their homes rather than in expensive institutions.
Who Does HCBA Serve?
HCBA Participants
- 75% speak English, 14% speak Spanish
- 45% are dually eligible for Medi-Cal and Medicare
- 36% white, 10% Black, 11% Asian
- 18% age 0-20, 50% age 21-59, 26% age 65 or older
*Race/Ethnicity data is from 2022
HCBA is available statewide to Medi-Cal recipients with disabilities, regardless of age, who require nursing facility or hospital level of care. HCBA also provides necessary services to individuals who are dependent on medical supports such as ventilators. The goal of the HCBA program is to support transitions out of hospital or institutional care and to prevent institutional placement. Eligibility does not require additional diagnostic or functional needs criteria beyond the need for nursing facility care.
What Services does HCBA Provide?
Services include:
- Case and care management
- Private duty nursing
- 24-hour personal care services
- Habilitation
- Home and facility respite
- Paramedical service
- Nursing care
- Ventilator dependent care
- Environmental accessibility adaptation
- Transportation services
- Communication services
- Medical Equipment Operating and Personal Emergency Response System
- Assistive technology
HCBA provides comprehensive supports for those with the highest needs
HCBA provides home supports for individuals with complex medical conditions that require a high level of care that is generally not available outside of hospital or institutional settings. The program is delivered through waiver agencies contracted with the state to purchase and coordinate all waiver services. HCBA is the only waiver serving older adults that delivers 24 hours of personal care at participants’ homes, through a service called Waiver Personal Care Services (WPCS). WPCS is available to individuals whose In-Home Supportive Services (IHSS) hours are not sufficient to meet their needs.
Nearly all HCBA recipients—90%—also receive IHSS. HCBA’s agency-delivered personal care services also provide additional supports for individuals who cannot fully access IHSS because they are unable to direct their own care. For example, HCBA’s agency-delivered WPCS can be used to support individuals transitioning from homelessness who cannot direct their care due to mental health and other disabling conditions.
Don’s Story
At 73, Don was not ready to live in a nursing home. Most of his adult life he worked as a graphic designer and ran an independent business from his home. But as his health conditions deteriorated, he lost his clients, then his home and had to move into a motel, in a room up three flights of stairs. He withdrew from many of the activities that gave his life meaning—volunteering in the local school, teaching history during the summer, mentoring his nephew and his friends’ kids.
Don experienced complications from diabetes and a complex heart condition that required surgery and a long recovery in the hospital and then a nursing facility. After intensive physical therapy, his needs were still too great to move back to the motel by himself. Don remained in the nursing facility for two more years before meeting someone from an HCBA agency that was helping another resident. The agency helped him find an accessible home and arranged for the medical equipment that he needed to prevent edema and helped reduce strain on his heart. The agency also coordinated medical care for his complex medical conditions and helped him find a caregiver that would help him live independently in his new home. Since returning home, Don also returned to mentoring youth and spending time with his family.
Living in a nursing home—it’s like living in a prison. Most people are not comfortable with someone else setting rules and dictating terms. You eat three meals a day, sleep in certain times, get up in certain times. It’s so restrictive. I couldn’t even visit my dying sister because I would have lost my placement in the facility if I was gone for more than three days and I had no other place to go to. When I enrolled in HCBA, the waiver agency helped me find a place that I wanted to live in and then got me all the things I needed to be able to live on my own. They helped find a caregiver, build relationships with medical providers, set up my new place. Now I can cook, set my own schedule, be myself again. Be who I was before medical changes and personal challenges. The program helped me get back to who I want to be and need to be.
High Demand, Low Capacity
The comprehensive services available under the HCBA program make it an optimal alternative for the nearly 56,000 Californians currently living in skilled nursing and other long-term care facilities. Unfortunately, there are currently over 6,000 individuals on the program’s waitlist, which has been growing since the waiver reached capacity in 2023. To ensure that individuals in institutional settings are prioritized, 60% of waiver capacity is reserved for institutional transitions. Individuals already enrolled in other HCBS programs whose needs are not currently met are also prioritized for enrollment in the HCBA waiver.
However, unprioritized individuals who are currently living in their homes experience lengthy wait times and enrollment delays. This particularly impacts people with Alzheimer’s or dementia who have relied on family members for care, but whose needs exceed what those caregivers can provide. Administrative complexities, including staffing shortages at DHCS, have also caused delays in waiver enrollment. Waiver agencies and providers also assert that low reimbursement rates can cause provider shortages and further delay access to waiver services.
Lawmakers can support older adults and individuals with disabilities in transitioning from nursing facilities and avoiding long-term hospitalizations by increasing access to this vital program. Investing in HCBA by increasing waiver capacity, ensuring adequate provider participation, and improving administrative processes and staffing are essential to ensure the highest-needs Medi-Cal members have the support they need to live in their homes instead of costly institutions.
