>> ERIN NGUYEN NEFF:  But welcome to the Home and Community-Based Services 101 Under CalAIM. I will be one of your presenters today. My name is Erin.  I'm a staff attorney at Disability Rights Education and Defense Fund.  I have been here for almost a year now. My background is predominantly in housing, particularly tenant rights, representing tenants and representing unhoused people. And I'll pass it over to Silvia to introduce herself.

>> SILVIA YEE:  Thank you, Erin.  My name is Silvia Yee, I am a senior staff attorney with Disability Rights Education and Defense Fund.  I use she/her pronouns and I have short dark hair and I wear glasses, I have tasteful earrings and my background is blurred.
I think I'm going to ‑‑ that's it, that's all you need to know.  Hand it back to you, Erin.  

>> ERIN NGUYEN NEFF:  Thanks.  I forgot my own description.  I am wearing a red plaid shirt, I have a blurred background, and I have short dark hair as well.
Silvia and I actually look quite alike [laughs] 

>> SILVIA YEE:  Yes. 

>> ERIN NGUYEN NEFF:  So the training today is focusing on housing services for people, predominant independently people with disabilities, people who are homeless or at risk for homelessness, and different programs and services are available through Medi‑Cal and through the new initiatives under CalAIM to keep people in their homes and with the help of supportive services.
So there is a lot that falls under this category.  So it's very much, too much to go over in an hour, so we're choosing a few things to focus on.
And then we'll be sending the slides out afterward.  And just to note that as part of the presentation, under the notes section, which isn't part of the slide, but is notes attached to the slide, there will be additional links and resources on there where you can get more detailed information beyond what's presented in the slide and what will be presented in the training.
So, if we could go to the next slide.
So, before we dive into some of the newer initiatives, under CalAIM, there are already some preexisting programs and some pilot programs under Medi‑Cal and the later in the presentation, we will go through housing and community‑based waivers that could be used as well.
So one pilot program that Medi‑Cal had previously or still has is a health homes program.
So this is a program that is benefitting people who are at risk of homelessness, who have chronic health conditions, and particularly multiple health conditions.
And people who have experienced in‑patient services, hospitalizations, or institutionalization.
And the health homes program provides in services to people and this includes, like a health action plan, coordination between different providers for the clients, different training services to help with self‑management and self‑care to enable persons to live independently.
As well as transitional services for people leaving a nursing home or an institution.
There's also services in how to ‑‑ in educating people about healthy living and healthy behaviors.
And it's also a program that helps connect people with other services and provider roles and stuff like that.
And Medi‑Cal is funded through state and federal funding.  And under a lot of the new initiatives that we're going through, it helps with different housing initiatives.
However, federal money, under Medicaid, cannot be used for housing under Medi‑Cal, but certain state funding can.
And if you could onto the next slide.
So, this is the ‑‑ so now we're going to do an overview of more of the newer resources under CalAIM for housing and community support.
So, this was released in January 1st of 2022.  So these are programs that have been available for about the last two years.
And this ‑‑ the purpose of the housing community support is to keep people in the least restrictive environment possible.  People who are Medi‑Cal beneficiaries to have an alternative to institutionalization, to nursing homes, and to help keep people in the community.
The way it works is if you are under the Managed Care Plan, the Managed Care Plan can choose one of the listed services here.  These are pre‑approved services that can be a substitute for other services that a client could have.
Now, it's sort of up to the managed care plans to choose these services.  They don't necessarily have to.
And I'm sure some of you are asking well, where ‑‑ who has of the Managed Care Plans have chosen these services.
So I am going to put in the chat a link from a report that came out recently in August, and this shows the different counties and health plans that have chosen to adopt some or all of these services.
So you can, you know, it wouldn't make sense to go through it here, but you can check out the link to ‑‑ sorry.  You can check out the link to see the different counties and stuff.
And just another link I'm going to provide is to this report that just came out in August that has additional information ‑‑ I think ‑‑ is Tina already putting those links out?  Sorry.
So, that has ‑‑ so you can see what counties are providing these services and get additional information to see how these services are ‑‑ have been panning out over the last two years in more detail.
Since it's been released, there have been over 36,000 people who have been able to take advantage of these services.
So, we can't go into detail on each one, but just as a quick overview, a lot of the services provided is finding housing.  CalAIM can't actually, like, give you the housing, because they don't own housing, but they help with referrals and services to transition people into housing.
They can help with certain monetary things, like providing housing deposits, moving costs and expenses.
They cannot help provide rent on a monthly basis, unfortunately, but certain one‑time payments are available through this program.
Programs to support and maintain safe and stable housing, that can include housing inspections and managing relationships with landlords and management companies.
We'll go into a little bit more detail about that.
There's a program for recuperative care, so this is for short‑term residential care for those who don't have housing, to be able to recuperate after an illness or an injury when they're no longer able to be in the hospital.
And there's also short‑term post‑hospitalization housing.  This is similar, but it's a recovery place after institutional care from medical and behavioral issues.
There are also respite services, day habilitation which we will go to in a minute and support for transition into housing, after hospitalization and sobering centers and also medically supportive food.
And... and I go to ‑‑ oh, one other link I want to share that this is the policy guide, and this will also be included in ‑‑ this will also be included in the PowerPoint that we sent out too.  But I wanted to make sure that people have the links before we send out the PowerPoint.
But this next one goes into all the programs I just listed in more detail, including the eligibility for each program, because each program has a different eligibility that we will go over briefly.
Next slide, please.
Okay.  So we're going to go into a little bit more detail on the housing transition navigation services.
So, this provides a wide‑range of services for people, predominantly people who are either unhoused, formerly unhoused, at risk for being unhoused, or in a housing situation that's not stable, particularly for people who have serious disabilities, serious mental health issues, and people who were formerly incarcerated.
Among the services that this program provides includes tenant screening and assessment.  So this is looking at what are some of the barriers to obtaining housing and helping people overcome those barriers.
So this can include helping people with the application process, gathering documents for applying for rental housing, helping out with security deposits.
As part of the program, you create an individualized housing support plan, which creates short and long‑term goals for the client to keep and maintain housing.
The program also helps with housing searches.  This could be looking for housing that is low‑income housing, permanent supportive housing, and different types of housing that will meet that person's needs.  And allow referrals and connecting with different agencies.
Helping out with housing expenses, and this can include moving.  This also includes adaptive aids.  This also includes any reasonable modifications needed to the apartment to help provide money for that.  So if you need a ramp, if you need bars in the shower, providing the money as a one‑time expense to cover reasonable modifications for people with disabilities.
It also helps with certain financial needs, such as doing benefits advocacy for receiving SSI.  Helping people go through the process to obtain a rental subsidy or other financial coverage for rental expenses.
And another thing to keep in mind is with these services, a lot of it is connecting people to services, making people aware of the services, and helping them go through the application process.
But doesn't necessarily guarantee that they will receive the services.
For instance, with Section 8 housing choice voucher, there is a long waiting list for that.  So although this service can help someone navigate getting on that waiting list, providing recertification materials, it doesn't necessarily mean that they would get a Section 8 voucher.
The program also helps with creating a housing crisis plan.  The purpose of the housing crisis plan is to also ensure people maintain their housing by identifying issues that might cause them to lose their housing and put in preventive measures or intervening.
The program also helps with reasonable accommodation requests you might need to make to your landlord, such as maybe changing the date that you pay rent to coincide with SSI payments or other rental subsidy payments.
It also helps with communicating with the landlord or management company or whoever is the person in charge of the housing to maintain a healthy communication between both parties.
I think one thing to keep in mind with this is that, you know, in my experience, having done housing law for, like, six years and interacted with a lot of landlords, a lot of landlords might not want to engage in this process and they're not ‑‑ might feel like, you know, they're not technically legally required to.
However, because this program is meant to benefit people with disabilities, one way to get around unresponsive landlord would be to ask for a reasonable accommodation request for their disability to engage with the case worker or case manager who is helping the client with the housing transition navigation services.
So, if the landlord is refusing to participate in the engagement services and communication services provided, you can request a reasonable accommodation.  If they refuse to do that, you know, that is potentially a violation of FEHA and other people with disabilities in housing.
And then this program, similarly to others, is also focused on people who are unhoused, at risk of being unhoused, formerly incarcerated, and people with serious disabilities and mental health issues.
And then another thing that they do is inspecting to ensure it's actually a healthy safe environment for people to live in.
And then the last thing is that although they will ‑‑ this program will help with some one‑time monetary payments, like deposits and reasonable modifications, they cannot help pay rent on a regular basis.
If we can move to the next slide.
So, day habilitation programs, this program is meant to help people who ‑‑ help people providing services within the home.
So, if you ‑‑ if the person has a home, then a peer mentor can come and help them learn different life skills.
If a person doesn't have a home, there can be, like, a physical location created by the peer mentor or other worker at the program to set up a place for someone to go if they are unhoused, for example, but sort of the point for the day habilitation program is to provide services and skills‑building for people who are not in an institution or a facility.
So, the peer mentoring is meant to help with social skills, so that a person can sort of function independently in their environment.
So, again, this can include communicating with landlord, neighbors, managers of the building.
It also helps with skills to live a more independent life; understanding how to use public transportation, building skills and conflict resolution with people, learning how to manage interpersonal relationships and function in the community.
It also provides specific services that people might need to live in the home, so this could be understanding how to obtain a roommate and how to interact with that roommate, how to get furniture and other furnishings for your home, and how to manage finances for the home.
And it also has services to have people understand communicating with the community and available community services, like how to contact a fire station, police department, ambulance.
And also sort of living within the home, so understanding how to cook, how to clean, how to do laundry, how to manage your money within the home.
A lot of it is also centered around self‑advocacy, understanding your rights, understanding your rights as a tenant, understanding your rights as a citizen, and being able to advocate for yourself.
It also comes with benefits advocacy similar to the transition navigation services.
And this program can be administered to individuals or to, like, a group, depending on the situation.
And this is specifically for people who were ‑‑ who have been unhoused in the last 24 months or who have been housed in the last 24 months, but was unhoused before that.  So new to being housed, to help them maintain that housing, as well as people who are at risk of being unhoused, people who are currently unhoused, and people who are in other unstable living situations.
Next slide, please.
Sorry, can you go back one?  For the eligibility?
No, sorry [chuckles].  

[Pause]. 

>> ERIN NGUYEN NEFF:  Okay, yeah ‑‑ oh, back one.  There we go!  [Chuckles].
Sorry.  I said eligibility earlier, but it's the one before that.  The housing tenancy and sustaining support services.  Yes, right there.  Thank you.
So, the housing tenancy and sustaining services, so this is somewhat similar to the other programs, but focusing a little bit more on the interactions a tenant might have with a landlord.
So, one is providing some sort of intervention plan or services when a person might be at risk of losing their housing.
So this could be if someone is violating their lease, if someone is behind on rent, if someone is hoarding, and other behaviors like that.
It involves educating the person of their rights as a tenant.  And also educating the landlord.
And coaching to maintain relationships between the landlord and the tenants.
I think one thing that's really important to keep in mind, if you have a client who is using these services, is that you don't want to make a landlord aware of the things that your tenant is doing ‑‑ the things that a tenant is doing wrong in a rental unit.
If you have a client who is hoarding and their landlord doesn't know it, you don't want to inform that landlord and engage in the services of communicating with the landlord, 'cause the eviction process in California is very quick; it is probably quicker than these services would provide for managing the relationships between the two parties.
For example, if someone is hoarding, a landlord could give them just three days to fix the hoarding before starting an unlawful detainer to evict them.
Of course, in that situation, what you want to do is request a reasonable accommodation for more time to fix the hoarding issue.  But if the landlord is not aware of the issue, the best thing to do in that situation is try to help your client out without making the landlord aware.  Because that could make them at risk for being evicted.
Of course if the landlord is already aware of it, maybe that's how the tenant became engaged with these services or became engaged with you as an attorney, you would want to try to implement these services and might want to ask for a reasonable accommodation to enable these services to play out before an eviction occurs.
Since these services are meant to help people with disabilities.
So, in addition to that, a lot of dispute, conflict resolution with landlords and with neighbors, because disputes with neighbors can also lead to an eviction if it's considered a nuisance or that person is complaining a lot to the landlord.
So this is mostly correcting people with services, like eviction defense lawyers and other services to help prevent eviction.
Again, benefits advocacy, help with recertification, so if someone has a subsidy, a voucher, they generally need to recertificate every year.  If someone is in a low‑income housing tax credit, they may have to recertify their income once a year or on a regular basis, so that process can be kind of complicated.
So these services help tenants to navigate that, obtaining the financial documents that are needed, making sure that information is submitted in on time.
And health and safety visits, so making sure that the home is, you know, free of mold, is actually a healthy place to live, and providing different independent living services similar to the day habilitation program.
So, the way this program works is that it is only provided once during a person's use of this program.
The duration of which can last a long time, but it's only provided once.
And then once it's considered not effective anymore or no longer needed, the program ends and a person cannot take advantage of the program again unless they're able to show some sort of change in circumstances, that would show that this program would be effective, where it wasn't effective before.
And that is a little bit different from the other programs that we went over earlier, where you can engage in the program ‑‑ can't engage in the program more than once, where the housing tenancy and sustaining services, you can only engage in once.
And this is for people who are formerly incarcerated, who have been institutionalized, or have a chronic disability or are at risk of being unhoused.
And the last thing I will sort of add about these services is that I think that with all the services, one should really take into consideration incorporating other aspects of the law, to ensure that your client can engage with these services, like asking for reasonable accommodation under FEHA, being aware of disability discrimination under FEHA and under the ADA.
Because the way some of these programs, the way this program is sort of set up is it sort of assumes that the tenant is the one that needs the intervention and needs these behavioral management, and that the landlord just needs sort of education.
But in my own experience, you know, a landlord ‑‑ I always say, like, a landlord unlike a public interest lawyer or a nurse, they're not there to provide a service for people, they're there to make money.
And so they're not always going to have the best interest of the tenant in mind.  So use sort of every tool at your disposal to make sure that your client is able to take advantage of these programs.
And next slide, please.
So, I kind of went over this with each program.  But each program under the housing community supports for CalAIM have different eligibility requirements.
So in the last link I sent, under each program it says what the eligibility is, so you can check that out to see if your client fits into that.
But in general, these programs are meant for people who are either unhoused or at risk of being unhoused and the definition for that is the same definition used for HUD.
People with serious mental illness, people with serious chronic conditions, and people at risk for institutionalization.  And it's a program that children can also take advantage of, if they're at risk of being unhoused or part of the transition‑age youth who have other barriers to housing.
And next slide.
So these are the HCBS waivers, and Silvia will be taking over.  

>> SILVIA YEE:  As soon as Silvia figures out how to unmute herself... there!
Thank you, Erin, that was really helpful!  And I really appreciate your bringing your housing and tenancy experience to the application of these HCBS waivers and especially these new services.
So, with the HCBS waivers, I'm going to provide a little bit of framing, a little bit of background on waivers.  I mean, California is moving to a place and pretty well has succeeded in placing virtually all of the state's Medi‑Cal population under that.  That's how they get Medi‑Cal now, they get it through a plan.
There are waivers offered to specific populations, geographic areas for specific purposes and these are administered by the Department of Healthcare Services, the state, not the plan.
These home and community‑based services are administered by the Department of Healthcare Services who is the Medicaid agency, the single Medicaid agency for California.
Waivers are named that way and I know some of you are very well aware of this, and some of you may not be.  Waivers are named this way because they allow states to waive the normal Medicaid requirements.
Under the Medicaid Act, there are rules set out for the joint federal and state program and they are established by the Federal Government.  Basically if you want to take Medicaid money, follow the rules.
And a few provisions in the rules allow the states to waive some of the normal rules and create programs that are intended, with some Medi‑Cal beneficiaries for specific purposes.
These special programs are also, in turn, and rather confusingly called waivers.  Erin went over some of these services available in a big waiver, the CalAIM in California is to transfer overall service delivery and the entire California Medicaid program and trying to push towards a better transition in the critical housing needs.
There has been evidence for a while now that housing is a really a linchpin of health and housing has more to do with avoiding unnecessary emergency visits than a lot of other programs, like enhanced case management, for example.
So that's why it's so linked together.  It's so personal.
Though as well, obviously, things like enhanced case management and in lieu of services are important too.
And just to note, ILO services and CalAIM services are potentially available to any Medi‑Cal beneficiary, but in practice, it's generally recognized that a clear minority of Medi‑Cal beneficiaries will actually need those services.
Those who have more complex care conditions, people with disabilities, some older people, and especially those who are unhoused and in need of housing.
So I'm going to go over just a few of the more traditional waiver programs ‑‑ not CalAIM ‑‑ that are still around even as the big overall changes move forward.
These are programs designed specifically for Medi‑Cal beneficiaries who have significant level of care needs, as an institutional or nursing home level care.
And they're intended to allow these individuals to remain in the community.
For the most part, these are waivers that are authorized under Section 1915C and they're sometimes called 1915C waivers and they're named as such because Section 1915C is a section of the Medicaid Act that authorizes the existence.
Each one has their own application and timeline.  We have them listed on here.  There's the assisted living waiver, the home and community based alternatives waiver, HCBA, home and community‑based services waiver for the developmentally disabled.
The multi‑purpose senior surfaces waiver.
And the Medi‑Cal waiver program.  And that last one used to be known as the AIDS waiver.
Excuse me once in a while if I cough; I'm just getting over something.  

[Pause]. 

>> SILVIA YEE:  All right.  So moving onto the first one we have here, the next slide, the assisted living waiver.
The assisted living, it envisions the assisted living setting as an alternative, a more community‑based alternative than an actual institutionalization or placement in a nursing facility.
And the assisted living waiver is actually set to expire on February 29, 2024.  And yes, 2024 is a Leap Year.
The Department of Healthcare Services does intend to renew this waiver for another five‑year term, beginning on March 1, 2024.
And actually the public comment period for that renewed waiver application just ended on October 5.
There is an assisted living waiver fact sheet which we should include with these slides.  This waiver facilitates a transition of members who are already in an institution to a less restrictive setting, an assisted living setting.
And also is meant to help prevent institutionalization in a nursing facility.
These are people who have ‑‑ this is intended for beneficiaries who have care needs equal to those on Medi‑Cal‑funded residents who are already living and receiving care in nursing facilities.
But they are willing and able to live in an assisted living facility or a publicly subsidized housing.
As an alternative to the nursing facility.
Eligibility requires someone to be age 21 or older.  And receive full‑scope Medi‑Cal eligibility.  With no share of cost.
So these are people that are considered able and willing to reside safely in an assisted living facility or publicly subsidized housing.
So by a community, by an assisted living facility, we're thinking of something like a community, an acquired home‑like setting, a care facility for a home person, an ARF, or subsidized public housing, using assisted living facilities.
And the intent is to offer eligible seniors and persons with disabilities this other option, a more community‑based option, one where they can actually get out and be in the community using and visit and see their families and friends more often.
So I'll move onto the next slide. 
This is the home and community‑based alternatives waiver, the HCBA waiver, and it is one that is needed and used very often by people with significant disabilities who would qualify for the medical and personal care assistance needs, that level of need that is provided in a nursing home.
So, care management services to persons at risk for nursing home or institutional care, and this is a waiver that provides enough hours of care and enough services and enough intensity that will allow people, adults and children, with significant disabilities to actually stay safely in their home.
The eligibility covers any age.  You do have to be Medi‑Cal eligible.  And I say Medi‑Cal eligible, because it does cover, let's say children with significant healthcare needs, premature children, children with very specific conditions who need really almost round‑the‑clock kind of healthcare, with those high levels of healthcare needs.
So even if their parents would normally not qualify for Medi‑Cal, they make too much to qualify for Medi‑Cal, it's possible to get services for a child who has significant healthcare needs.
It will ‑‑ this ‑‑ the HCBA waiver will cover those who are already living in a hospital or a nursing facility, or those who are at risk of institutionalization within 30 days.
So institutionalization has to be quite imminent, potentially.
The big thing about this waiver is that it hit a waiting list as of July 12, 2023.  And so that means that in July of last year, it hit that close to 2,000 limit; I think it was 8,974, and anyone else who applied after that was put on a waiting list.
And that's one of the conditions of ‑‑ that's waived in a waiver.  Medi‑Cal, in general ‑‑ Medi‑Cal is just Medicaid in California ‑‑ is a ‑‑ oh, the phrase... the phrase when you are ‑‑ an entitlement program, which means typically if you qualify for it, you are eligible.  You apply ‑‑ you get the services.
You can't be just made to wait, typically, because the money has run out, say.
With a waiver, with a waiver program like the HCBA waiver, the State, potentially, can place a cap on it, and it has done so with this program.
And what's difficult is that there is an institutional bias in the Medicaid program.  Institutional care is required.  It's covered by Medicaid, nursing home care is covered by Medicaid as a matter of federal law, and it's in California's State Plan.
But home and community‑based services are optional in the plan and under federal law.
So, that means that there is this waiting list.  And our colleagues at Disability Rights California have called for 50,000 slots in the state, with the ability to add more, if needed.
They believe very strongly that shorting the program will result in unnecessary institutionalization of thousands of Californians, and that is in ‑‑ that is in violation of the 1999 Supreme Court case of Olmstead, and in what we would regard of Civil Rights for people with disabilities to live in the community and in the most integrated environment.
So there's a big difference between a call for 50,000 slots and the currently‑existing cap of just under 9,000.
We will note that this is for all the waivers, there is a need for cost neutrality; that is, someone who is living in the community cannot cost Medicaid more than if that person were living in a nursing home.
I mean, in general, the average cost of someone living with an HCBA waiver in the community is less than 48,000 annually, overall.
And you can compare that with close to 129,000 annually for the same kinds of patients, the same kinds of care needs who are living in a skilled nursing facility.
And these are, according to estimates from the California Department of Healthcare Services.
When the State sought approval for the program, it said participation would be capped at just under 9,000 people.  And that it would be over the next two years adding increases ‑‑ over the next three years, adding increases to reach 12,300.
I think it was six years ago is the last time that the HCBA waiver hit the cap.  And some ‑‑ the Department and some advocates think that the fact of COVID, the reality of COVID and the pandemic and the many deaths that took place in institutions has upped the desire for a waiver.
Something that allows people with significant disabilities to live in the community rather than in an institution.
Okay.  So, I will go onto the next waiver and the next slide.
We also have home and community‑based services waiver for the developmentally disabled, and that allows person with developmental disabilities to live in the home or in the community rather than residing in a licensed health facility.
Eligibility requires the person or the family member to have a formal diagnosis of intellectual disability or developmental disability.
And requires the person to be a regional‑centered consumer.
The level of care need is that required of someone who is in a licensed healthcare facility for people with intellectual disabilities.
And the person has full scope Medi‑Cal eligibility.
And here again is that sort of institutional deeming for those under 18.
Institutional deeming is a special Medi‑Cal eligibility rule that considers only the personal income and resources of a person under the age of 18 or a married adult who is otherwise eligible for the waiver.
And doing so means that you can ‑‑ you cannot think of ‑‑ you cannot take into account the income of parents or of a spouse's income or resources.
And that's because there's such a huge gap, a huge gap between the amount that ‑‑ the amount that is needed for personal care systems and the services that one needs to live in the community when you have a significant disability, and the amount that people make for a living.
There's this big ‑‑ there's this big gap.  And if you don't ‑‑ if you cannot qualify for Medicaid, not qualify for Medi‑Cal, and have nowhere near the amount of money that you need to take care of the services that you need as a person with significant disabilities to live in the community.
So, institutional deeming is very helpful to allow a child under 18 to remain in the community and to be eligible for Medi‑Cal services.
And just a small note to be looking at, personal care assistance are very, very important to the lives of people with disabilities.  Most personal care assistants in California, as in elsewhere, are women, people of color, often older.
These are individuals who deserve a living wage.  And part of that living wage, for someone who has a lot of personal care assistance needs, means that personal care assistance will be very expensive.
And it's a well‑earned wage and it needs to be ‑‑ it needs to be a living wage, so that people will be attracted to the positions who fill the jobs well.
But it does also mean that paying fully out‑of‑pocket for personal care assistants is almost impossible and this one is very wealthy.
On June 23, the Centers for Medicaid approved the HCBS‑DD waiver and has a retroactive start date and also just noting for the DD waiver, California has one of the largest DD waivers in the country, if not the largest.
One of the last two we're looking at, the multi‑purpose senior services waiver, it's an alternative to nursing care, a nursing care facility for those with a nursing level of care, again, like others, or most of the others.
It provides a series of services and you have to be 65 and older to be eligible, Medi‑Cal eligible.
And you have to live in or be willing to move to one of the counties where the waiver is available.  So it's not necessarily a waiver that is available in every, like, throughout California.
This is an important one, because there are seniors ‑‑ there are seniors who may not actually want the obligation and the work of fully managing their own services, and especially seniors who have acquired a disability for the very first time as an older person.
This waiver is actually managed by the California Department of Aging.  The individual has to be a fully qualified Medi‑Cal beneficiary.
The MSSP waiver provides both social and healthcare management services to assist individuals to remain in their own homes and communities.
That's something else to note about these waivers.  Traditionally, they have ‑‑ as Erin has said, Medicaid doesn't cover housing.  That's been a long time policy and these are not waivers that will necessarily ‑‑ these waivers, these traditional waivers are not necessarily things that will help with housing.
Though they can, by providing services in the home, help someone remain in a home they already have.  They can help someone to age in place, for example.
MSSP provides ongoing care coordination, which I indicated can be very important to seniors who are just not able, don't want to coordinate all the level of services that they need now.
And a lot of people who have MSSP also do have IHSS, it's not meant to replace one or the other.
Cost neutrality is of course the combined cost of care management and services must be lower than the cost of receiving care in a skilled nursing facility.
And a team of health and social service professionals provides each MSSP participant with a health and social services and you can see some of the services that are available, case management is indicated, personal care services and adult daycare.
Respite care, which can be very important when a spouse is taken care of a senior who has dementia, for example; transportation, personal emergency response systems, a list of services, and that can be very important to seniors as well.
And then I'm just going to move quickly onto this last one, the Medi‑Cal waiver program, which was formerly known as the AIDS waiver.  It provides case management and direct care services to persons living with HIV or AIDS.  As an alternative to nursing facility care or hospitalization.
Again, you can see this push towards allowing people to live in the community where their support networks are, their family is, where their friends are.
Living at home instead of an institution.
Eligibility requires Medi‑Cal recipients who are eligible for a nursing facility level of care or hospitalization, and that have the aid code with full benefits.
Codes are something ‑‑ codes are what Medicaid assigns for Medi‑Cal beneficiaries.
And these are also individuals who are not involved or not enrolled in a care for the elderly, that's a separate program.
So HIV or AIDS, individuals have to have HIV or AIDS with related signs, symptoms, or disabilities.
And children under 13 years with HIV, AIDS, or symptoms also qualify.  And it provides individuals with a home setting that is intended to be safe for both the client and the service providers.
This approval has also been approved for a five‑year period with a retroactive start date of January 1 of 2023.  California's adoption of this waiver was approved on February 16 and it went back an a little bit; a couple months.
Okay.  And just my final note for all the waivers is that across all of these waivers, or most of these waivers, DHC has pretty much received a waiver that adds telehealth as a permanent service delivery option.  So telehealth was originally approved, it was an emergency waiver service under the pandemic.
So with this approval from the feds, from the center for Medicaid and Medicare services, some of the waivers have been approved permanently, and for this waiver, for the Medi‑Cal waiver program waiver, psychotherapy, case management, and nutritional counseling have been made permanently available through telehealth.
So, to get us quickly at the end here, the Medi‑Cal hearings, this is basically how when appeals ‑‑ the denial of a Medi‑Cal service or the stopping of a Medi‑Cal service, and even denial of eligibility, actually, is a possibility.
So, with the services that Erin has covered, in lieu of services, the new housing related services, under CalAIM, enhanced case management services, those are all obtained through a plan.  And so the first step with a denial of those services is to file a formal compliant or a grievance with your plan.
And you are supposed to get a response in 30 days, or in three days if it's a very urgent need.
This ‑‑ once you have that, you can go to the Medi‑Cal fair hearing, a state fair hearing.  So that's a county or Department of Healthcare Services California eligibility, you have to file a request within 90 days of receiving the notice of action or the good cause.
And so a notice of action is a written notice that gives Medi‑Cal applicants and beneficiaries an explanation of their eligibility for medical coverage or benefits and the notice of action should include the eligibility decision, the effective date of coverage, as well as any changes made in the eligibility state or level of benefits.
The notice of action must include information about your hearing rights and how to appeal the decision if you disagree with the eligibility determination.
It's also possible, California is somewhat unique amongst the states in having a Department of Managed Healthcare and they have ‑‑ I don't think I have this as a... sorry... oh, right, that's on the next page.  So I'm just going to go to that next slide, actually, quickly, to look at the Medi‑Cal hearings.
Because ‑‑ no, not Medi‑Cal hearings, I'm sorry, the Medicaid review and complaint process.
That's one thing, when you are getting services through a plan, you can also go on ‑‑ you can also ask for an independent medical review and a complaint process through DMHC, so when you health plan denies or changes your medical health services or denies a payment or treatment or refuses to have an investigational treatment for a serious medical condition, you can file that grievance.
And then if you're denied, you can file a complaint with DMHC.
And they also have this emergency expedited independent medical review process, and that's a really important one to note.
If you have a very limited amount of time to try to get a service that you feel is very important, very necessary, very ‑‑ very important for your client and you're looking at imminent action, imminent fear of institutionalization, of losing the housing, of not getting needed housing, IMR might be a possibility.
I kind of doubt it, because it's usually confined to medical review.  And it's interesting to see how this ‑‑ how this process is going to work together.
I suspect that most of the ECM and in due of services will be fund through the complaint process.  But I don't think all of that is fully determined yet.
And I would love to hear from any of you what you're seeing on the ground.  And when it comes right down to it, all of these services can be a fantastic help.  They're intended to be a fantastic help, but it depends so much on plans recognizing where the need is, saying yes, and not gatekeeping.
And on advocates, knowing when to push for them.  And that's a hefty process.  That's a lot to be done, to try to get to that point where these services become real for people who are on the ground.
So I'm actually going to end it there, which leaves us only a couple of minutes for questions.  But there might be ‑‑ there might be one that we can address.  

[Pause].  

>> TINA PINEDO:  This is Tina, there's one question in the chat from Lordes (sp):  Can you define institutionalized as how much time and how far back?  

>> SILVIA YEE:  Institutionalized as in...?  Like, how long someone has been in institutionalization, in an institution ‑‑ in a nursing facility, let's say?
I think ‑‑ I'm going to look at it that way.  And it doesn't... I don't think there's really a time limit for that.
If you're living ‑‑ if you've been ‑‑ if your client is in a nursing home and wants to leave and they're saying, you know, they won't let her leave, that's a ‑‑ even if she's only been there for one week or two days, the only thing is if she's in there on a temporary status to begin with, you know, you're in the nursing facility and it's for two weeks ‑‑ I guess the fear is always that even then, even then, if the thought is that she's ‑‑ that the client may potentially be losing their housing or no one's paying the rent, I mean, that is ‑‑ that is part of institutionalization and being at risk of institutionalization.
If I'm not answering the question or if there's something I'm missing, I'm happy to also be in touch with you after, too, if you want to send me your e‑mail.  

[Pause].  

>> SILVIA YEE:  Is there anything else from anyone who has ‑‑ we are very close to the end of time ‑‑ for Erin or myself?  

[Pause]. 

>> ERIN NGUYEN NEFF:  We can also unmute people, if someone wants to ask a question verbally.  

>> SILVIA YEE:  You can give a hand raise if you want that.  

[Pause].  

>> TINA PINEDO:  I see Judith is raising her hand.  I will allow Judith to unmute.  

>> Thank you.  I just had a question about some of the effective dates you were mentioning, 'cause it sounds like a lot of them are retroactive?  

>> SILVIA YEE:  Yes, for some of the waivers.  Is that what ‑‑ 

>> Yeah, oh, okay, for some of the waivers.  So the June 23rd approval, that became retroactive when?  

>> SILVIA YEE:  I think it went earlier to 2023.  Let me ‑‑ it was in one of the slides and I'm just going to look for that.  

>> Yeah, it... oh.  

>> SILVIA YEE:  Yeah, as far as I know, there are not any holes in these waivers, the ones that we've covered here.  There's no... there's none ‑‑ and they do ‑‑ yeah, they get in there, they know the date is coming up, they prepare, and we are talking about pages and pages and pages of application.  

>> Oh, really?  [Laughs]. 

>> SILVIA YEE:  Yeah.  I guess that's why ‑‑ and then we don't ‑‑ the State doesn't necessarily have full control of how long CMS takes to review something.  

>> I got it. 

>> SILVIA YEE:  That's actually sort of what happens.  But with these waivers, with the waivers we covered here, I don't think we're really looking at ‑‑ and there's not a huge risk of sort of an out‑right denial, I'll say, of these.  They won't say no, you can't have the AIDS waiver anymore.  

>> Ah. 

>> SILVIA YEE:  That's not in general how that works for these waivers.  I think the biggest big change here was the whole big CalAIM waiver and that was approved in 2022.  

>> Oh, okay.  So there's one for 2022.  

>> SILVIA YEE:  Yeah, and for this, and for a number of years coming up, and they're sort of rolling out these services, like the ones that Erin has gone through.  

>> Okay.  

>> SILVIA YEE:  Does that help?  

>> Yeah.  Thank you.  

>> SILVIA YEE:  Sure.  

>> ERIN NGUYEN NEFF:  I think we should probably close it out.  But y'all have our e‑mails here.  If you have any other questions, since we didn't get to spend a lot of time on questions.
And then you will also be getting an e‑mail from us with a certificate from the MCLE and with the PowerPoint presentation.
Thank you all for taking the time to join us in this training.  And enjoy the rest of your day!  Thank you, bye.