Paying for care

Staying Home Instead of a Nursing Home: California's Medi-Cal HCBS Waivers

Last reviewed July 29, 2026

If your loved one qualifies for nursing-home-level care but wants to stay home, California's Medi-Cal Home- and Community-Based Services (HCBS) waivers can pay for that care at home or in assisted living instead. The main options are the HCBA waiver, the Assisted Living Waiver, and MSSP. All require full-scope Medi-Cal and a nursing-home level of care, and most have waiting lists—so get on a list as early as you can.

Key points

HCBS waivers let someone who qualifies for nursing-home care receive that care at home or in assisted living instead—paid by Medi-Cal.
The three main options are HCBA (medically fragile, any age), the Assisted Living Waiver (assisted living, 21+, 15 counties), and MSSP (seniors 60+).
Every waiver requires full-scope Medi-Cal plus a nursing-home level of care; the Assisted Living Waiver needs a zero share of cost.
Waiting lists are real: HCBA has had one since July 12, 2023, and ALW releases limited slots. Apply early to hold your place.
IHSS and CBAS have no waiver waiting list and can start quickly—use them while waiting, and keep them alongside a waiver.
PACE (55+) is still open to individuals where plans already operate, despite a November 20, 2025 freeze on new PACE providers and new service areas.
Apply through the program's own door: county Medi-Cal and IHSS offices, your county's HCBA Waiver Agency, or an ALW Care Coordination Agency.

What shortcuts do most families miss?

Here are the easy-to-miss angles — the early-eligibility rules and quiet ways families leave money or help on the table. Each one is explained in full below.

Get on the HCBA waiting list even though it says 'full.' The list has been open since July 12, 2023 and costs nothing to join—being in a health care facility 60+ days, or under 21, moves you up faster under 'Reserve Capacity.'
IHSS has NO nursing-home-level-of-care test and NO waiver waiting list. Most families can start paid in-home help (often paying a family caregiver) within weeks while a waiver slot is pending—and keep it afterward.
You can stack programs. IHSS + CBAS + a waiver can run together, and you can sit on more than one waiting list at the same time.
Spousal impoverishment rules let a married applicant qualify for the zero-share-of-cost Medi-Cal the Assisted Living Waiver requires without wiping out the healthy spouse—ask the county eligibility worker by name.
The Assisted Living Waiver is the legal way to make assisted living affordable on Medi-Cal: the state pays the care, and the resident pays only room and board out of their own income.
PACE individual enrollment is still open in areas already served—don't be scared off by the November 20, 2025 pause, which only freezes new PACE providers and new service areas.
California Community Transitions specifically funds moving someone who's already been in a nursing home 60+ days back home—ask about it before assuming a placement is permanent.

What are Medi-Cal HCBS waivers, and how do they keep someone out of a nursing home?

A Home- and Community-Based Services (HCBS) waiver is a Medi-Cal program that pays for the kind of intensive care a person would get in a nursing facility, but delivers it in their own home, a family member's home, or an assisted living setting instead.

California runs several of these under a federal rule called 1915(c). The state says the point is to 'develop creative alternatives for individuals who would otherwise require care in a nursing facility or hospital.' To use a waiver, a person must have full-scope Medi-Cal and be assessed as needing a 'nursing facility or acute hospital level of care.' The care must also cost Medi-Cal no more than a nursing home would.

In plain terms: if a doctor or assessor says your loved one is sick or frail enough to belong in a nursing home, a waiver can be the legal, funded way to keep them at home instead.

What's the difference between HCBA, ALW, MSSP, IHSS, CBAS, and PACE?

These names get confusing because they overlap. Here is the short version of who each one is really for:

HCBA (Home and Community-Based Alternatives) waiver — the main 'medically fragile, wants to stay home' waiver. A nurse-and-social-worker team coordinates all the care. Any age. Statewide, but there is a waiting list.
ALW (Assisted Living Waiver) — for people who need nursing-home-level care but would rather live in a licensed assisted living facility or subsidized senior housing. Medi-Cal pays for the care; the resident pays only room and board. Age 21+, 15 counties only.
MSSP (Multipurpose Senior Services Program) — care management plus extra help (respite, transportation, home repairs, meals) for people age 60+ who could otherwise end up in a nursing home.
IHSS (In-Home Supportive Services) — the workhorse program that pays a caregiver (often a family member) for hands-on help with daily tasks. It is NOT a waiver, has no nursing-home-level-of-care requirement, and has no waiting list. Many families use IHSS while waiting for a waiver slot.
CBAS (Community-Based Adult Services) — a Medi-Cal day program (nursing, therapy, meals, activities) that gives the person structure and the family a daytime break. It is delivered as a Medi-Cal managed-care benefit, not a standalone waiver you apply to.
PACE (Program of All-Inclusive Care for the Elderly) — an all-in-one plan for people 55+ that becomes the person's whole health system (doctors, day center, home care, hospital, drugs). It replaces regular Medi-Cal/Medicare managed care rather than adding to them.

Does my loved one qualify for a waiver?

Two things are almost always required, no matter which waiver:

Full-scope Medi-Cal. For the Assisted Living Waiver this must specifically be Medi-Cal with a zero share of cost. A benefits worker can help arrange this, and 'spousal impoverishment' rules often let a married applicant qualify without impoverishing the healthy spouse.
A nursing-home (nursing facility) level of care. This means an assessor agrees the person is medically or functionally at risk of nursing-home placement. MSSP phrases it as being 'certified or certifiable for placement' in a skilled nursing facility.
Age rules vary: HCBA is open to any age, the Assisted Living Waiver requires age 21+, MSSP requires age 60+, and PACE requires age 55+.
Living safely at home or in the community must be possible with the services in place—waivers are for people who can be kept safe outside an institution, not for anyone whose needs truly can't be met at home.

What does the HCBA waiver cover, and how do I get on the list?

HCBA gives each person a Care Management Team—a nurse and a social worker—who coordinate all their services and connect them to community help. Covered waiver services include case management, comprehensive care management, family and caregiver training, help transitioning out of a facility, and Waiver Personal Care Services (extra in-home care hours).

Be honest with yourself about timing: HCBA reached maximum capacity and has run a waiting list since July 12, 2023. You can and should still apply to get on that list now. Certain people move up faster under 'Reserve Capacity'—those under 21, those transitioning from another HCBS waiver whose needs can no longer be met, and those who have been residing in a health care facility for at least 60 days when they apply.

You apply through the HCBA Waiver Agency assigned to your county. Find your agency by county or ZIP on the DHCS HCBA page, then call them to request the application (available in English, Spanish, Chinese, Vietnamese, Tagalog, Armenian, Russian, and Arabic). For general questions call (833) 388-4551 or email HCBAlternatives@dhcs.ca.gov.

What is the Assisted Living Waiver, and who is it for?

The Assisted Living Waiver (ALW) is for someone who needs nursing-home-level care but would do better living in a licensed assisted living facility (RCFE) or subsidized senior apartment. Medi-Cal pays for the personal care, homemaker, and home-health-aide services; the resident pays only their own room and board out of their income.

To qualify you must be 21 or older, have full-scope Medi-Cal with zero share of cost, need care equal to a nursing-facility resident, be willing to live in assisted living as the alternative, and have enough personal income to cover room and board.

ALW runs in only 15 counties: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, and Sonoma. It is currently approved through February 28, 2029. There is a waiting list; open slots are released to Care Coordination Agencies, and DHCS posts a monthly enrollment and waitlist dashboard. To start, contact a Care Coordination Agency in your county, or email ALWP.IR@dhcs.ca.gov.

Where do MSSP and PACE fit in?

MSSP is a good fit for an older adult (60+) who is mostly managing at home but needs coordination and a few extra supports to avoid a nursing home—things like respite for the caregiver, transportation, minor home repairs, personal care, and meals. A care manager arranges it all, and the total cost must stay below what a nursing home would cost. Find your local MSSP site through the California Department of Aging's 'Find Services in My County' page.

PACE is more all-encompassing. For people 55+ who need nursing-home-level care and live in a PACE service area, PACE becomes their entire care system—medical, a day center, in-home help, and hospital care, all under one roof. Because it replaces regular Medi-Cal and Medicare coverage, it's a bigger commitment, but for the right person it removes almost all the paperwork.

One honest note on PACE: DHCS paused new PACE organization applications and service-area expansions effective November 20, 2025 for at least two years. That freeze is about new PACE providers and new coverage areas—it does not stop an individual from enrolling in a PACE plan that already serves their area. Check the DHCS PACE service-area locator for your ZIP code.

Are there really waiting lists? Be honest with me.

Yes. Waiver slots are limited by law, and the two biggest home-care waivers reflect that: HCBA has had a waiting list since July 12, 2023, and the Assisted Living Waiver releases a limited number of slots as they open. MSSP capacity varies by local site. This is the single most important thing to understand—waivers are not first-come, same-day help.

That's exactly why you should apply early, even if you don't need the help this month. Getting a name on a list costs nothing and protects your place. And while you wait, you are not stuck with nothing: IHSS and CBAS have no waiver waiting list, and a person can use those right away and keep them even after a waiver slot comes through.

How do I actually apply or get on a list?

There is no single door—each program has its own. Here is a practical order:

1. Lock in Medi-Cal first. Apply for or confirm full-scope Medi-Cal through your county Medi-Cal office (or BenefitsCal.com). For ALW you need zero share of cost—ask the eligibility worker about spousal impoverishment rules if there's a spouse.
2. Start IHSS now. Call your county IHSS office to request an assessment. A county social worker visits, and a licensed health professional signs a health care certification. There's no waiting list, so this can be help within weeks, not years.
3. Get on the HCBA list. Look up your county's HCBA Waiver Agency on the DHCS HCBA page, call to request the application, and submit it even though the list is long. Mention if the person is in a facility, under 21, or moving from another waiver—that can speed things up.
4. For assisted living, contact an ALW Care Coordination Agency in one of the 15 ALW counties, or email ALWP.IR@dhcs.ca.gov to find one.
5. For MSSP or PACE, use the California Department of Aging 'Find Services in My County' page for MSSP, and the DHCS PACE service-area locator to see if a PACE plan covers your ZIP.
6. Ask about California Community Transitions if your loved one is already in a nursing home—it helps move people who've been in a facility 60+ days back into the community.

Frequently asked questions

Can my mom get a waiver if she's already in a nursing home?

Often yes. Being in a facility for at least 60 days can actually move an HCBA application up the list under 'Reserve Capacity.' Ask about California Community Transitions, which is designed to help people who've been in a nursing home move back into the community.

How long is the wait for the HCBA waiver?

There's no fixed timeline—HCBA has had a waiting list since July 12, 2023, and how fast a slot opens depends on your county's Waiver Agency and your priority category. Apply now to hold your place, and use IHSS in the meantime since it has no waiting list.

Does my loved one need Medi-Cal before applying?

Yes. Every HCBS waiver requires full-scope Medi-Cal, and the Assisted Living Waiver specifically requires Medi-Cal with a zero share of cost. Sort out Medi-Cal first through your county office or BenefitsCal, then apply for the waiver.

Can we use IHSS and a waiver at the same time?

Yes. IHSS and HCBS waivers are designed to work together—in fact HCBA's Care Management Team coordinates IHSS along with waiver services. Start IHSS right away while you wait for a waiver slot.

What's the difference between the Assisted Living Waiver and just paying for assisted living?

With the Assisted Living Waiver, Medi-Cal pays for the care services in a participating assisted living facility, and your loved one pays only room and board out of their own income. Without it, families pay the full private cost, which is usually thousands of dollars a month.

Is PACE closed because of the 2025 pause?

No. The pause that started November 20, 2025 stops new PACE companies from applying and stops existing ones from expanding into new areas. If a PACE plan already covers your ZIP code, your loved one can still enroll.

Which program is fastest to get help from?

IHSS, by far. It has no nursing-home-level-of-care requirement and no waiting list—just a county assessment and a health care certification. The waivers give richer coordination but come with waiting lists, so most families start with IHSS.

Sources

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This guide is educational and is not medical advice. In an emergency, call 911.