The In-Home Supportive Services (IHSS) Program is a statewide Medi-Cal program that provides long-term services and supports for aged, blind or disabled California residents who are at risk of nursing home placement. Available benefits include personal care assistance and homemaker services to assist these individuals in living safely and independently in their home or the home of a loved one. Program participants have the option to self-direct their care, which allows them to choose and hire their own caregivers, including friends and relatives.

Within IHSS, there are 4 programs, the first two of which serve the majority of IHSS program beneficiaries.

• Community First Choice Option (CFCO) – for Medi-Cal eligible persons who require a nursing home level of care.
• Personal Care Services Program (PCSP) – for Medi-Cal eligible aged, blind or disabled individuals who require personal care assistance, but do not require the level of care that is provided in a nursing home.
• IHSS Plus Option Program (IPO) – provides payment to spouses or parents of Medi-Cal eligible persons who do not need a nursing home level of care, but require care assistance, and receive it from a spouse or parent. Prior to becoming a Medi-Cal state plan option, this program was previously called the IHSS Plus Waiver.
• IHSS Residual Program (IHSS-R) – provides a pathway of eligibility for persons who are not eligible for Medi-Cal but require IHSS care services.

The In-Home Supportive Services Program is available through California’s regular state Medicaid plan. In California, the Medicaid program is called Medi-Cal.

HCBS Medicaid Waivers versus HCBS State Plan Medicaid?
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

Benefits of the In-Home Supportive Services Program
Follows is a list of the benefits available via the In-Home Supportive Services Program. Program beneficiaries only receive the services required to safely remain in their homes. A needs assessment determines the services required and the number of monthly service hours a program beneficiary can receive. Maximum hours are approximately 195 / month for those who do not have severe impairments, while persons severely limited in their functional ability can receive up to approximately 283 hours of care per month.

• Homemaker Services – housecleaning, laundry, shopping, errands, and cooking
• Paramedical Services – wound care, catheter care, injection assistance, blood sugar checks
• Personal Care Services – non-medical assistance with daily living activities, such as bathing, dressing, toileting, and eating
• Protective Supervision – supervision for cognitively or mentally impaired persons to help prevent accidents and injuries
• Teaching / Demonstration Services – provider taught tasks to teach beneficiary to do housework, prepare meals, bathe, etc.
• Transportation Assistance – to & from medical appointments

IHSS services may be received in one’s home or the home of a family member. Persons cannot live in a community care facility or long-term care facility. This includes assisted living residences and adult foster care homes.

Another option that California residents might want to consider is the Medi-Cal Community-Based Adult Services Program. Although not available statewide, this program offers out-of-home daytime care and supervision at designated CBAS centers.

Eligibility Requirements for In-Home Supportive Services
The IHSS Program is for California residents who are elderly (65+) or disabled. While additional eligibility requirements may vary based on the program within IHSS, follows is the general criteria.

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 138% of the Federal Poverty Level (FPL), which increases annually in January. However, for California Medicaid, the income limits increase each April. Effective April 2022 – March 2023, the monthly income limit for the IHSS program for a single applicant is $1,564. When both spouses are applicants, there is a couple income limit of $2,016 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. Only the applicant spouse’s income is considered, which is limited to $1,564 / month. Furthermore, in some cases, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance The maximum amount that can be transferred is $3,435 / month (effective January 2022 – December 2022) and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than this amount are not entitled to a spousal income allowance.

Assets
Effective July 2022, the asset limit will be $130,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit will be $195,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though sometimes the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse will be able to retain up to $130,000 in assets and the non-applicant spouse can keep up to $137,400. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 30-months of long-term care Medi-Cal application. This is because Medi-Cal has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

California is in the process of eliminating the asset test for all Medi-Cal programs for seniors and disabled persons. This means that there will be no asset limit for eligibility purposes for regular Medicaid (Aged, Blind and Disabled), HCBS (home and community based services) Medicaid Waivers, and nursing home Medicaid. On 7/1/22, the asset limit was increased significantly. For an individual, it will increase from $2,000 to $130,000, and for a couple, it will increase from $3,000 to $195,000. On 1/1/24, the asset limit will be eliminated altogether. Until this time, it is vital that applicants avoid violating Medi-Cal’s 30-month look back period.

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for Medi-Cal eligibility purposes, Medicaid considers the home exempt (non-countable) in the following circumstances.

• The applicant lives in the home or has “intent” to return to the home and indicates it in writing. California is unique from other states in that there is no home equity interest limit. Home equity interest is the current value of the home minus any outstanding mortgage.
• A non-applicant spouse lives in the home.
• The applicant has a dependent relative, such as a disabled child, living in the home.
• The applicant has a child under 21 years of age living in the home.

While the home is likely exempt while one is receiving Medi-Cal benefits, it may not be safe from Medicaid’s estate recovery program unless held correctly by making it a non-probatable asset.

Medical Criteria: Functional Need
A nursing home level of care is not necessarily a requirement to receive care services via Medi-Cal’s In-Home Supportive Services Program. An applicant must have a medical need for care services and be at risk of institutionalization (nursing home care) without program assistance. Recall that within the In-Home Supportive Services Program there are 4 subprograms. To be eligible for the Community First Choice Option, an applicant must require a nursing facility level of care (NFLOC). Upon application for the IHSS program, a needs assessment is completed by the social services agency in one’s county. As part of the assessment, an applicant’s care needs are ranked from 1 to 6. A ranking of 1 indicates that an individual can function independently, while a ranking of 6 indicates an individual requires the greatest level of care available through the program. An applicant’s ability to independently complete activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting) is one area that is considered during the assessment. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive functioning, such as one’s capacity to retain information or problem solve, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Medi-Cal has a share of cost program, which may also be called a medically needy program. With this program, an applicant with income over Medi-Cal’s income limit qualifies for the program by paying a “share of cost” for their care services / medical expenses. This can be thought of as a deductible and is based on one’s monthly income. Once one has paid their share of cost for the month, the IHSS Program will pay for services and supports.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. For couples that have a significant amount of “excess” assets, a Medicaid asset protection trust (MAPT) is a viable option. MAPTs not only help to reduce an applicant’s countable assets, but also protects them from Medicaid’s estate recovery program. Unfortunately, MAPTs violate Medi-Cal’s 30-month look back rule, and therefore, must be implemented well in advance of the need for care. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medi-Cal planners are educated in the planning strategies available in the state of California to meet Medi-Cal’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria but can also protect assets for family as inheritance. These strategies, like MAPTs, often violate Medicaid’s look back rule, and therefore, should be not be implemented without careful planning. There are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s).

How to Apply for In-Home Supportive Services Program

Before You Apply
Prior to submitting an application for the IHSS Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 30-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.

Application Process
To apply for the In-Home Supportive Services Program, applicants should contact the IHSS office in their county and submit an Application for In-Home Supportive Services (SOC 295). Persons not currently enrolled in Medi-Cal, must apply via the Application for Health Insurance. Persons can apply for Medi-Cal independently of applying for the IHSS Program or at the same time. As part of the IHSS application process, an in-home functional needs assessment is completed by a county social worker to determine if services are required to safely live at home, and if so, the level of assistance required. A health care certification form (SOC 873) must be completed and submitted by a licensed health care professional prior to services being provided. Program applicants will receive a notice of action (NOA) indicating whether they have been approved or denied for IHSS services. If approved, the authorized services and total monthly hours of services permitted will be included.

For additional information about the In-Home Supportive Services Program, contract us here at Beyer, Pongratz, & Rosen, A professional Law Corporation. (916) 369-9750. Alternatively, persons can contact their local IHHS county office.

The In-Home Supportive Services Program is administered by the California Department of Health Care Services (DHCS) and the California Department of Social Services (CDSS).

Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.