CalAIM Transitions vs. the Assisted Living Waiver

CalAIM Assisted Living Facility Transitions and California’s Assisted Living Waiver both support community-based living as an alternative to nursing-facility care. That shared goal often causes confusion. They are separate Medi-Cal pathways with different administrators, rules and enrollment processes.

Two programs with a similar goal—and different rules

Assisted Living Facility Transitions is a CalAIM Community Support delivered through participating Medi-Cal managed care plans. The plan reviews the request, determines eligibility and authorization, and arranges covered services through its provider network and service plan.

The Assisted Living Waiver is a Home and Community-Based Services waiver administered by the California Department of Health Care Services through approved care coordination agencies and participating settings. It has its own eligibility, geographic and enrollment requirements.

What CalAIM Assisted Living Facility Transitions involves

At a high level, the CalAIM Community Support may include:

• Review and authorization through the member’s Medi-Cal managed care plan.
• General eligibility tied to nursing-facility level-of-care needs and the ability to live safely in an assisted living setting.
• Time-limited transition services and certain allowable move-related expenses.
• Ongoing assisted living services when authorized.
• Member responsibility for room and board.

Service availability, provider participation and the member’s individualized plan remain subject to the managed care plan’s current requirements.

How the Assisted Living Waiver generally differs

The ALW pathway has a different structure. Important features include:

At-a-glance differences

When comparing the programs, focus on who makes the decision and which rules govern the placement:

• CalAIM transition: managed care plan review and authorization
• ALW: DHCS waiver requirements and approved care coordination pathway
• CalAIM transition: plan network, service availability and individualized authorization
• ALW: designated counties, participating settings and available waiver capacity
• Both: nursing-facility level-of-care considerations, safe community living and separate room-and-board responsibility

Questions to ask before choosing a pathway

The member’s plan or waiver coordinator can help clarify which route is appropriate. Ask:

• Which exact program is being considered, and who makes the authorization or enrollment decision?
• Is the service available in the member’s county and through the relevant plan?
• Must the RCFE participate in a specific network or waiver program?
• Is there an enrollment waitlist or capacity limit?
• Can any services overlap, and which costs remain the member’s responsibility?

How Zeal can help

Zeal helps families separate the practical questions associated with each pathway and understand which parties need to be involved. Our role is to support an organized exploration—not to substitute for the health plan, DHCS or a waiver care coordinator.

A member may fit more than one pathway, but services cannot simply be stacked

DHCS guidance indicates a member may potentially meet criteria for both the CalAIM Community Support and ALW, but cannot receive overlapping services from both at the same time. The responsible plan and waiver professionals should determine how the rules apply to the individual situation.