The 2021-22 California Spending Plan

Human Services

Aging-Related Budget Actions

This post provides an overview of budget actions that target or significantly impact older adults and older adults with disabilities. Specifically, the post first summarizes budget actions within the In-Home Supportive Services (IHSS) program and Supplemental Security Income/State Supplementary Payment (SSI/SSP) program. The post then describes aging-related budget actions in other state programs and departments and summarizes progress made in the 2021‑22 budget to implement the policy goals and recommendations included in the Master Plan for Aging (MPA).

IHSS

The spending plan provides a total of $17.2 billion (all funds) for IHSS in 2021‑22, which is $1.9 billion (12 percent) above estimated expenditures in 2020‑21. The spending plan includes $5.6 billion from the General Fund for support of IHSS in 2021‑22, which is a net increase of $1.2 billion (27 percent) relative to estimated 2020‑21 levels. This year-to-year increase in General Fund reflects a faster rate of growth relative to prior budget estimates. The main reason for the year-to-year General Fund cost increase is the anticipated ramp down in temporary federal Medicaid funds, resulting in roughly $460 million in IHSS costs shifting back to the General Fund. Additionally, the spending plan assumes continued year-to-year growth to the three primary IHSS cost drivers: caseload (3.7 percent), hours per case (1 percent), and IHSS provider hourly wages and benefits (6 percent). Additionally, the spending plan provides ongoing General Fund to permanently restore IHSS service hours. We describe in more detail key cost increases and cost shifts in this section.

Permanently Restores IHSS Service Hours. The spending plan includes $456 million General Fund to continue the 7 percent restoration of IHSS service hours in 2021‑22. The state has funded the restoration of IHSS service hours with General Fund since 2016‑17 so long as the managed care organization (MCO) tax established in 2016 was in place. While the 2016 MCO tax expired at the end of 2018‑19, the 2019‑20 budget continued the use of General Fund to restore IHSS service hours, subject to potential suspension on December 31, 2021. In January, the administration proposed to continue the restoration of IHSS service hours and delayed the possible suspension by one year—until December 31, 2022. However, as a part of the May Revision, the administration proposed to eliminate the suspension language and provide ongoing funding to permanently restore IHSS services hours. Additionally, the spending plan eliminated the statutory language that both instituted the 7 percent reduction in IHSS service hours and linked the IHSS service hour restoration to the 2016 MCO tax.

Temporary Increases in Federal Medicaid Funding Offsets Portion of State General Fund Costs. Under the Families First Coronavirus Response Act, the federal government increased the federal match rate for Medicaid services by 6.2 percentage points for the duration of the national public health emergency caused by coronavirus disease 2019 (COVID-19). This increased federal match lowers state costs for Medi-Cal, IHSS, and other programs that rely on federal Medicaid funding. The spending plan assumes this enhanced federal funding is in place from January 1, 2020 through December 31, 2021 and will offset around $460 million in total IHSS General Fund spending in 2021‑22. Additionally, under the American Rescue Plan (ARP) Act, the federal government increased the federal match rate for IHSS and other Medicaid-funded home- and community-based services (HCBS) by an additional 10 percentage points from April 1, 2021 through March 31, 2022. This increase in federal Medicaid funding is expected to offset over $1 billion in total IHSS General Fund spending across 2020‑21 and 2021‑22. Given that the state is still awaiting federal approval for the amount of additional federal Medicaid funding it ultimately will draw down, the spending plan currently does not account for the anticipated General Fund offset resulting from the ARP Act Medicaid increase in estimated 2021‑22 IHSS spending.

Expands Full-Scope Medi-Cal, Including IHSS Eligibility, to Undocumented Older Adults. Historically, income-eligible undocumented immigrants only qualified for “restricted-scope” Medi-Cal coverage, which covers their emergency- and pregnancy-related service costs. In general, beneficiaries of restricted scope Medi-Cal are not eligible for IHSS. To date, the state has expanded comprehensive, or “full-scope,” Medi-Cal coverage, including IHSS eligibility, to income-eligible undocumented immigrants ages 0 through 25. The spending plan further extends full-scope coverage to income-eligible undocumented immigrants ages 50 and older no sooner than May 2022. As a result, income-eligible undocumented immigrants ages 50 and older would be newly eligible for IHSS. While the spending plan does not include any IHSS costs associated with this Medi-Cal expansion in 2021‑22, it is estimated that this policy change will increase IHSS costs over time, reaching ongoing costs of roughly $680 million General Fund in 2024‑25. (Refer to The 2021‑22 California Spending Plan: Health for additional detail on the full-scope Medi-Cal expansion to undocumented older adults.) The spending plan also includes language that clarifies that individuals who are undocumented and eligible for full-scope Medi-Cal will receive IHSS benefits through the IHSS-Residual program, which is fully funded with state General Fund.

Continues Manual Termination Process if IHSS Recipients Do Not Complete Medi-Cal Redetermination. Currently, county IHSS social workers manually terminate IHSS recipients from the program if they become ineligible for Medi-Cal due to a failure to complete the annual Medi-Cal redetermination. If cases are manually terminated, the recipients need to reinstate their Medi-Cal eligibility first to receive paid services through the IHSS program again. However, if the social worker does not manually terminate the case, the recipient, by default, is enrolled into the IHSS-Residual program. The service costs for recipients enrolled in the IHSS-Residual program are fully covered by the state. In the Governor’s 2020 May Revision, the administration proposed to automate the termination process for IHSS recipients who fail to complete the annual Medi-Cal redetermination. As a result, these individuals would not be enrolled into the IHSS-Residual program; instead, individuals would be terminated from IHSS and reenrolled into the federally funded IHSS program after their Medi-Cal eligibility is reinstated. However, the 2020‑21 Budget Act deferred action on this automation proposal. As a part of the 2021‑22 Governor’s January budget, the administration reintroduced the automated termination proposal, resulting in an estimated $43 million General Fund annual savings. Ultimately, the spending plan rejects the administration’s automated termination proposal and maintains the current manual termination process.

Adjusts County and Public Authority Administration Funding for Estimated IHSS Caseload Growth. In January 2020, the administration proposed to increase 2020‑21 IHSS administration funding levels based on estimated IHSS caseload growth. However, the 2020‑21 budget ultimately did not provide the funding increase, resulting in IHSS administration funding levels remaining at 2019‑20 levels. The 2021‑22 spending plan ultimately increases IHSS county and public authority administration funding levels from $325 million General Fund in 2020‑21 to $340 million General Fund in 2021‑22. This increase is based on estimated caseload growth since 2019‑20.

Continuation of COVID-19 Responses and Program Flexibilities. The state implemented numerous IHSS program flexibilities and enhancements to mitigate health and safety risks associated with COVID-19. As shown nearby box, while many of these program flexibilities and enhancements are temporary, the spending plan includes $5.9 million General Fund in 2021‑22 to permanently maintain the back-up provider system and wage differential (which was initially set to expire on December 31, 2021). The 2021‑22 budget includes language that requires the Department of Social Services (DSS), in consultation with stakeholders, to create and provide the Legislature with a policy framework for the permanent back-up provider system that details criteria and circumstances when back-up services may be approved and provided to an IHSS recipient. The permanent back-up provider system will not be implemented until the policy framework is adopted in statute. (As of October 2021, DSS is still working to finalize the policy framework for the permanent back-up provider system.)

Other IHSS-Related Actions. In this section, we summarize other budget and policy changes in IHSS that are included in the 2021‑22 budget.

• Maintain IHSS State and County Sharing Ratios for IHSS Wage and Benefit Increases. Historically, counties paid for 35 percent of the nonfederal costs associated with locally established IHSS wage and benefit increases and the state paid for the remaining 65 percent up to the state participation cap ($14.10 per hour in 2021). Counties paid for 100 percent of costs over the state participation cap. (Currently, the state participation cap increases as the state minimum wage increases, remaining $1.10 per hour above the state minimum wage.) Under the 2019‑20 budget package, once the state minimum wage reached $15.00 per hour (scheduled to occur on January 1, 2022), the cost-sharing ratios for counties would increase from 35 percent to 65 percent with the state paying for the remaining share of cost. Additionally, the state participation cap would be eliminated. The 2021‑22 spending plan, however, includes $57 million General Fund in 2021‑22, and budget-related legislation, to permanently maintain the historical county and state cost-sharing ratios and the state participation cap. The spending plan also includes language that extends the option for counties to temporarily draw down state funds to cover wage and benefit costs above the state participation cap.

• Revises Electronic Visit Verification (EVV) Guiding Principles and Continues to Include EVV Penalty Costs. Federal law requires states to implement an EVV system for Medicaid-funded personal care services, including IHSS, by January 1, 2021. Recently, the federal government notified California that its initial EVV plan for IHSS did not comply with the requirement to electronically capture a non-live-in IHSS provider’s location at the start and end of every work day. The spending plan modifies statutory EVV guiding principles to allow the EVV system to electronically record the real-time location of IHSS providers at the start and end of the work day, and exempt live-in IHSS providers from the EVV system requirements. Additionally, the spending plan includes $42 million General Fund in 2021‑22 to pay for fiscal penalties due to the state not complying with EVV system requirements by the deadline. We understand that DSS will work with stakeholders to identify the least intrusive way the state can comply with the EVV requirements.

• Develop Electronic IHSS Forms and Signature Capacity. The spending plan includes $5 million General Fund in 2021‑22, 2022‑23, and 2023‑24 to develop IHSS electronic forms and electronic signature capacity. Additionally, these funds would support the translation of IHSS forms into all Medi-Cal threshold languages.

• IHSS-Related HCBS Spending Plan Proposals. As previously mentioned, the ARP Act temporarily increases the federal Medicaid match for HCBS services. The state expects to receive, in total, $3 billion in additional federal Medicaid funds (including the estimated $1 billion in additional federal Medicaid funds for the IHSS program). As a condition of receiving these funds, the state will be required to spend an equal amount of funding on new HCBS enhancements and expansions. The state recently submitted its HCBS spending plan detailing various HCBS enhancements and expansions to the federal government for approval. The state’s HCBS spending plan includes two IHSS-related expansions and enhancements: (1) create specialized training opportunities for IHSS providers, and (2) provide one-time COVID-19 incentive payment to IHSS providers who worked during the pandemic (between March 2020 and March 2021). For more information on the state’s HCBS spending plan, refer to The 2021‑22 California Spending Plan: Home- and Community-Based Services Spending Plan post.

SSI/SSP

The spending plan provides a total of $9.7 billion (all funds) for SSI/SSP in 2021‑22, which is $743 million less than estimated expenditure levels in 2020‑21. Similarly, the amount of General Fund for SSI/SSP is expected to decrease from $3.4 billion General Fund in 2020‑21 to $2.9 billion General Fund in 2021‑22. These funding estimates include costs associated with two other state-funded grant programs: (1) the Cash Assistance Program for Immigrants (CAPI), which provides grants to individuals ineligible for SSI/SSP solely due to immigrant status, and (2) the California Veterans Cash Benefit (CVCB) program, which provides a supplemental grant payment to veterans receiving payments from the federal Special Veterans Benefit program. Overall, both the total fund and General Fund decrease are attributed to the expiration of temporary state funding provided in 2020‑21 to issue one-time $600 stimulus payments to SSI/SSP recipients and the continued decline in the caseload. These year-over-year declines in the cost of the program are partially offset by a 23.95 percent increase to SSP grants (discussed in more detail below).

Increase SSP, CAPI, and CVCB Grant Payments. As a part of the May Revision, the administration proposed $66 million General Fund in 2021‑22 (increasing to about $130 million in 2022‑23) to increase monthly SSP grants levels so that all grant levels were at least equal to January 2011 grant levels. Since SSP couple grants were above January 2011 grant levels, only individuals would have experienced an SSP grant increase. Specifically, maximum SSP individual grants would have increased by $10.28 (6.4 percent). This grant increase would have applied to CAPI and CVCB individual grants.

The spending plan ultimately provides a higher and more expansive SSP grant increase than what was proposed by the administration in May. Specifically, the spending plan provides $291 million General Fund in 2021‑22 (increasing to about $580 million in 2022‑23) to increase SSP monthly grants for all recipients—individuals and couples—on January 1, 2022. The spending plan required DSS and the Department of Finance to calculate what SSP percent increase to grant levels the state could accomplished with $291 million General Fund in 2021‑22. Based on recent caseload trends, the administration determined that the state could increase SSP grants by 23.95 percent on January 1, 2022 with the amount of General Fund allocated in the 2021‑22 budget. (This grant increase would also apply to CAPI and CVCB grant levels.) The SSP grant increase will be in addition to the 5.9 percent federal SSI grant increase, which will take effect January 1, 2022. As shown in Figure 1, the combination of the state and federal grant increases will increase maximum SSI/SSP individual grants by $85.49 (9 percent) and maximum SSI/SSP couple grants by $167.51 (10 percent).

Other Aging-Related Budget Actions

In this section, we discuss additional key budget actions that primarily impact older adults.

Implement California Advancing and Innovating Medi-Cal (CalAIM) Package, Including Components That Impact Older Adults and Persons With Disabilities. The CalAIM package includes a number of far-reaching reforms that expand, transform, and streamline Medi-Cal service delivery and financing. As discussed in the nearby box, many of the CalAIM reforms target older adults and persons with disabilities. For example, CalAIM allows Medi-Cal managed care plans to be reimbursed for “in lieu of services” (ILOS), or new optional services intended to address the social determinants of health to avoid higher levels of care. Refer to The 2021‑22 California Spending Plan: Health post for more detailed information on the various components of the CalAIM package.

Phase Out Medi-Cal Asset Test for Seniors and Persons With Disabilities. Currently, seniors (age 65 and older) and person with disabilities in single-person households must have assets that are less than or equal to $2,000 in assets (or $3,000 for couples) to be eligible for Medi-Cal. The multiyear spending plan includes budget-related legislation and annual funding of $197 million General Fund beginning in 2022‑23 to phase-out the Medi-Cal asset test for seniors and persons with disabilities over two and a half years. Specifically, the Medi-Cal asset limit would increase to $130,000 for an individual (plus $65,0000 for each additional family member) no sooner than July 1, 2022. The Medi-Cal asset test would then be fully eliminated no sooner than January 1, 2024.

Support Various Housing and Homelessness Programs Targeting Older Adults and Persons With Disabilities. As we discuss in our The 2021‑22 California Spending Plan: Housing and Homelessness post, the 2021‑22 budget provides $10.7 billion ($4.6 billion General Fund) to about 50 housing and homelessness programs across various state housing departments, as well as to the human services, health, transportation, higher education, veteran services, courts, and labor areas of the budget. Older adults and persons with disabilities are a key target population for some of the housing and homelessness programs included in the spending plan, which we summarize in Figure 2. (The eligibility criteria for many of the other housing and homelessness programs, including Homekey acquisition and Project Roomkey, are broad enough to also include older adults and persons with disabilities.)

Aging-Related HCBS Spending Plan Proposals. As previously mentioned, the state is required to implement new HCBS enhancements and expansions as a condition of receiving additional federal Medicaid funds resulting from the temporary increase in the federal Medicaid match for HCBS services. As shown in Figure 3, the state’s HCBS Spending Plan (pending federal approval) includes a number of HCBS enhancements and expansions that target older adults and long-term care providers. Additional information on these and other HCBS enhancements and expansions can be found in our The 2021‑22 California Spending Plan: Home- and Community-Based Services Spending Plan post.

Support Various Nutrition Programs for Older Adults. The spending plan provide funding to various programs to that expand or enhance nutrition services to older adults, including the following:

• Senior Nutrition Program. The spending plan includes a $35 million ongoing General Fund augmentation, which is in addition to the permanent continuation of the $17.5 million General Fund augmentation that was previously subject to possible suspension on December 31, 2021. Moreover, the spending plan provides $40 million one-time General Fund to issue capacity and infrastructure grants for senior nutrition program vendors.

• Medically Tailored Meals. The spending plan provides $9.3 million one-time General Fund to expand the availability of medically tailored meals to additional populations and counties beyond what is available through the existing medically tailored meal pilot program, which currently provides medically tailored meals to Medi-Cal beneficiaries with congestive heart failure. This funding is intended to maintain medically tailored meals until it becomes available as an ILOS option under CalAIM. (Managed care plans may begin offering ILOS as early as January 1, 2022.) As an ILOS option, medically tailored meals can be provided to individuals with chronic conditions beyond congestive heart failure, individuals at risk of hospitalization or nursing home placement, and individuals with extensive care coordination needs.

• Transitional Nutrition Benefit (TNB). In 2019, the state expanded CalFresh eligibility to SSI/SSP recipients. Individuals that become ineligible for CalFresh benefits as a result of the policy change were transferred into the newly created TNB as a way to continue to receive food assistance. The spending plan includes $5.6 million General Fund to (1) temporarily pause TNB discontinuances for two years, (2) extend the TNB recertification period from every 6 months to every 12 months, and (3) extend the time period discontinued recipients have to restore TNB benefits from 30 days to 90 days.

• CalFresh Application and Outreach Improvements. The spending plan includes language to simplify the CalFresh application for older adults and persons with disabilities on or before July 1, 2023. The spending plan also includes $2 million total funds ($1.1 million General Fund) on an ongoing basis for Area Agencies on Aging (AAA) to conduct CalFresh outreach and application assistance services to older adults.

• Senior Farmer’s Market Nutrition Program. The spending plan provides $500,000 in one-time General Fund to provide low-income older adults with access to locally grown products, including fruits and vegetables, at farmers markets, roadside stands, and community support agricultural programs.

Expand Adult Protective Services (APS) Program. The spending plan provides $70 million General Fund on an ongoing basis to support various expansions to the APS program. Specifically, the spending plan includes language that (1) lowers the eligibility age threshold for APS from age 65 and older to age 60 and older beginning January 1, 2022; (2) expands the APS multidisciplinary team to include additional individuals, including health plan and housing representatives; and (3) allows county APS agencies to refer individuals to the Home Safe program for housing assistance before or after the individual receives APS program services. Additionally, the state is required to create a workgroup to develop a statewide APS case management and data warehouse system.

Improve Access to Technology for Older Adults and Persons With Disabilities. The spending plan includes $50 million one-time General Fund for counties to provide digital devices and arrange reliable internet access to older adults and persons with disabilities. Similarly, the spending plan provides $17 million one-time General Fund for AAAs to provide digital devices and digital education services to older adults and individuals with disabilities. The CDA would oversee the distribution of these funds to counties and AAAs.

Expand Long-Term Care Workforce Training Opportunities and Support. The spending plan provides one-time funding to expand workforce training opportunities for long-term care providers, including: (1) $40.5 million General Fund for certified nursing assistant startup programs, scholarships, and stipends; (2) $5 million General Fund for Healthcare Career Pathways training programs; and (3) $8 million General Fund for geriatric workforce programs. Additionally, the spending plan permanently maintains the $10 million General Fund annual augmentation for Caregiver Resources Centers, which was set to expire at the end of 2021‑22.

Improve Long-Term Services and Support (LTSS) Navigation and Enrollment Services for Older Adults and Persons With Disabilities. The 2021‑22 spending plan includes a number of augmentations intended to improve information and access to LTSS for older adults and persons with disabilities. (LTSS include, among other supports and services, institutional care in nursing homes and HCBS such as home care and personal care services.) Specifically, the spending plan eliminates the previously authorized suspension in funding for Aging and Disability Resource Connection (ADRC) centers, resulting in the continuation of $5 million annual General Fund. This funding is in addition to the $2 million ongoing General Fund for ADRC-related state operation costs in the California Department of Aging (CDA) and $9.4 million one-time General Fund to expand and strengthen local ADRC centers, which were also included in the 2021‑22 spending plan. Moreover, the spending plan provides $12 million General Fund in both 2021‑22 and 2022‑23 to provide support and guidance to older adults transitioning into Medicare.

Maintain Multipurpose Senior Services Program (MSSP) Supplemental Rate and Increase Number of MSSP Slots. The 2019‑20 budget temporarily increased the MSSP provider rate by 25 percent. While the MSSP provider rate increase would have expired at the end of 2021‑22, the spending plan provides about $5 million General Fund annually beginning in 2022‑23 to permanently maintain the MSSP provider rate increase. Additionally, the spending plan provides about $6 million ongoing General Fund to increase the number of MSSP slots to 2008 levels—from 9,283 to 11,780 slots. (We understand that the increase in MSSP slots will take effect once the state receives federal approval through the Medicaid waiver amendment process.)

Increase Baseline Funding for AAAs. Local AAAs primarily administer supportive services for older adults funded through the federal Older American Act. Historically, AAAs were eligible to receive at least $50,000 per year in federal funds to cover baseline program costs. The spending plan includes a total of $3.3 million General Fund to provide all 33 AAAs with an additional $100,000 in baseline funding.

Create Office of the Long-Term Care Patient Representative. Based on a recent court ruling, skilled nursing and intermediate care facilities are required to ensure that a patient representative is included in every interdisciplinary team, especially for patients who lack capacity to make their own health care decisions or do not have a friend, family member, or authorized representative make these decisions on their behalf. To the extent that a resident does not have someone who could act as their patient representative, the facility must locate a person unaffiliated with the facility to act as a patient representative in order to make healthcare decisions through the interdisciplinary team process. To facilitate this process, the spending plan provides $2.5 million General Fund in 2021‑22 and $4 million General Fund in 2022‑23 and ongoing for CDA to establish the Office of Long-Term Care Patient Representative. The Office will provide facilities with unaffiliated patient representatives when needed.

Reduce Community-Based Adult Services (CBAS) Program Certification Backlog. The CBAS program provides community-based day health services to individuals who are at risk of needing institutional-level care and/or have a chronic medical, cognitive, or behavioral health conditions. The CDA is responsible for certifying new CBAS centers and recertifying existing CBAS centers in a timely manner. However, in 2020‑21, CDA had 21 outstanding initial CBAS certification applications and 141 outstanding CBAS recertification applications. The spending plan includes about $2 million total funds (about $1 million General Fund) on an ongoing basis to increase CBAS state operation positions to address the initial CBAS certification and recertification backlogs and increase capacity for future growth in the number of CBAS providers.

Create the Office of Medicare Innovation and Integration. The spending plan includes $600,000 in total funds annually to establish and run the Office of Medicare Innovation and Integration within the Department of Health Care Services. The office will explore innovative approaches to integrate models of care and coordinate access to LTSS for Medi-Cal beneficiaries eligible for Medicare and Medicare-only beneficiaries.

Update on MPA Implementation

In recent years, the Legislature has called for the state to develop a plan for issues related to the growing aging population, including how best to structure state programs to meet the needs of the increasing number of seniors and assess the long-term impact of demographic changes on the state budget. In June 2019, the Governor signed an executive order establishing a formal process for the creation of an MPA. The executive order required the creation of a stakeholder advisory committee, publication of a stakeholder report on LTSS capacity and financing, and publication of a broader statewide MPA. The MPA was released in January 2021. The MPA is structured around five goals and 23 strategies aimed towards building what it describes as a “California for All Ages” by 2030. As shown in Figure 4—and described throughout this post—the spending plan includes over $2.5 billion in General Fund spending for various budget proposals that directly or indirectly support the implementation of MPA goals.