Medi-Cal
The Medi-Cal Assisted Living Waiver, for RCFE operators
Short answer
The Assisted Living Waiver is a California Medi-Cal home and community-based services waiver, administered by the Department of Health Care Services. It pays for assisted living services for eligible Medi-Cal beneficiaries who meet a nursing-facility level of care but want to live in an RCFE or adult residential facility instead. It operates in a defined set of counties, not statewide.
Two things surprise operators most. First, the waiver does not pay room and board — that stays with the resident, typically paid from SSI/SSP. Second, the facility does not set the resident's tier: a Care Coordination Agency assesses the resident and authorizes it, and the facility bills what was authorized.
What the waiver covers
ALW services centre on the care a resident needs to live in a residential setting rather than a nursing facility: assistance with activities of daily living and instrumental activities of daily living, health-related services including skilled nursing such as medication management and treatments, care coordination, social services and recreational activity, meals, housekeeping and laundry, and arranging transportation. Participating facilities are expected to have licensed nursing staff employed or on call.
Room and board is not in there — and this trips people up
The waiver pays for the services component only. Room and board remains the resident's responsibility, most often paid out of SSI/SSP, and the resident needs enough left over for personal and incidental needs.
Practically, that means every waiver resident generates two billing streams: a Medi-Cal claim for services and a room-and-board statement to the resident or responsible party. Facilities that budget as though the waiver covers everything get an unpleasant surprise in month one.
The specific SSI/SSP and room-and-board figures change every January — get the current year's numbers from the state rather than from any summary page, this one included.
Who does what
DHCS
Administers the waiver, enrolls providers, publishes the rates, and pays the claims.
The Care Coordination Agency
A separately enrolled ALW provider type, and the organization that shapes your resident's authorization. A CCA evaluates referrals, performs the assessment and reassessment, develops and implements the Individual Service Plan with the participant involved, coordinates and monitors services, and submits enrollment packages to DHCS. Reassessment happens at least every six months, or sooner if the resident's condition changes.
Your facility
Provides the care, documents the service days, and bills the tier that was authorized for the dates it was authorized. Notably, you are not the one deciding acuity — the CCA's assessment does that.
Nothing should ever suggest a tier to you
The tier comes from an external assessment, and a facility that bills a tier it was not authorized for is looking at recoupment and an audit finding rather than a correction. This is why CareMAR records the authorization and refuses to compute or recommend a tier — a convenience feature there would be a liability, not a benefit.
How a facility becomes an ALW provider
Enrollment is separate from holding an RCFE licence, and it runs on two tracks that are reviewed independently. Both have to complete before you are fully approved.
- The ALW program application, submitted to the DHCS Provider and Facility Site Review Unit.
- The Medi-Cal enrollment packet, which is mailed — DHCS requires original wet signatures, so this one cannot be done electronically.
Facilities are expected to be licensed by CDSS Community Care Licensing and in substantial compliance and good standing. Your licensing record is part of your waiver application, in other words — the two are not separate worlds.
Fees, forms, and checklists are published by DHCS and change; use the provider enrollment page linked below rather than a third-party checklist.
Where the waiver operates
The ALW runs in a subset of California counties rather than statewide, and the list can change within a waiver term. Rather than print a list here that may be stale by the time you read it, check the DHCS program page — it also publishes the current participating facilities and Care Coordination Agencies, which is the fastest way to find the CCAs operating near you.
Billing, in one paragraph
Waiver facility services are billed per participant per day at the authorized tier's rate, for the days the resident was actually served. DHCS publishes the tier rates and updates them — the 2026 rates took effect on January 1, 2026. The mechanics of building the claim, including the tier codes, the service-day log, and printing the UB-04 so it lands in register on the preprinted form, are covered on the ALW billing page.
One thing worth confirming with DHCS directly rather than assuming: how billing is handled when a resident's tier changes part-way through a month. We would rather tell you to ask than print a rule we cannot verify.
What does not change
A waiver resident is still an RCFE resident. The same medication records, the same LIC forms, the same Title 22 obligations, the same licensing visits. What splits at the payer line is billing and paperwork, not the chart.
Common questions
What is the Medi-Cal Assisted Living Waiver?
The Assisted Living Waiver is a California Medi-Cal program, administered by the Department of Health Care Services, that pays for assisted living services for eligible Medi-Cal beneficiaries in participating facilities as an alternative to nursing-facility placement. It operates in a defined set of counties rather than statewide.
Does the ALW pay for room and board?
No. The waiver covers the assisted living services component. Room and board remains the resident's responsibility and is typically paid from their own income, which is why an ALW resident generates both a Medi-Cal claim and a separate room-and-board statement to the resident or their responsible party.
Who decides a resident's ALW tier?
The tier is authorized externally, through the resident's Care Coordination Agency, based on an assessment — not by the facility and not by software. A facility bills the tier that was authorized for the dates it was authorized. Any system that suggests a tier for you is inviting a recoupment conversation.
How does an RCFE become an ALW provider?
Through DHCS provider enrollment for the waiver, which is separate from holding an RCFE licence. Requirements, forms, and the current participating counties are published by DHCS on the Assisted Living Waiver program pages — start there rather than with a third-party summary, because the program's operational details change between waiver renewals.
How are ALW claims submitted?
ALW facility services are billed on a UB-04 (CMS-1450) claim form. CareMAR generates the claim from the authorized tier and the logged service days and prints it onto the preprinted form, including a printer-calibration step so fields land in register. CareMAR does not submit claims electronically and is not a clearinghouse — the claim is mailed.
Official sources
Regulations change and this page is a plain-English summary, not the law. Before you act on anything here, read the current text at the agency that issued it.