After ALW enrollment: what happens each month, and who to call

Once you're enrolled in the Assisted Living Waiver (ALW), you live in the home you chose, the home provides the care in your plan, and your care coordinator makes a monthly visit to check that the plan is happening. For most problems, call your coordinator. If someone is in danger right now, call 911.

Request a callback

This page describes Beta's ALW team. If another Care Coordination Agency is your agency, call that agency instead.

Important: A reassessment is a repeat of the nurse assessment when your needs change. It can confirm your care plan or change it, including your care tier (the level that sets what Medi-Cal pays the home for your care), and we can't promise in advance what it will decide.

Your first two weeks

Check these before the first monthly visit:

• You have your care coordinator's number and the home's main contact.
• You have a copy of the care plan, which the state calls the Individualized Service Plan (ISP), or know how to see it.
• Medications, equipment, outside providers and transportation are set up as the plan says.
• The home's admission agreement is signed, and you know the monthly amount and when it's due.
• You know what to do in an emergency and how to raise a concern.

The monthly visit

Your care coordinator makes a monthly visit, which may be by video or phone if you choose. The coordinator checks that the services in the plan are happening, that you're safe and that the home still fits. Say anything you're unsure about. If the plan needs to change, the coordinator starts that. How video and phone visits work.

Your agency also checks your Medi-Cal every month, and the county's yearly renewal continues, so answer the county's letters and report any Medi-Cal change.

Tell your coordinator right away if

Keep this list where you can see it. Call when any of these happens:

1. A hospital or emergency-room visit, or a fall.
2. More help needed with moving or transfers, or a new wound, oxygen or treatment.
3. A change in memory, mood or behavior.
4. A medication change.
5. New home health or hospice involvement.
6. A notice from the home, or any talk of discharge.
7. A change of representative, income or Medi-Cal.
8. A move, or a planned move, including into or out of a hospital or nursing home. ALW services are not provided while someone is a hospital or nursing-home inpatient, so your coordinator needs to know.
9. A service in the plan that isn't happening.
10. Anything that makes you feel unsafe.

If the home stops being the right fit

The first response is usually a plan change: new services or equipment, a care-tier review, or a different provider. If that isn't enough, the options are another home that takes ALW or a nursing home. Each home decides its own admissions, and a safe move takes Beta, the home and the providers working together. See homes on the state list.

If you want a different agency, you ask on the state's form, DHCS 0061. The state's form says your benefits will not be altered or interrupted, and your monthly visits and records transfer. How to change your agency.

Who to call about what

Contacts can change, so confirm the current destination on the DHCS ALW grievance page first.

Your rights and how to complain

Call (747) 293-5777 and ask for your care coordinator, or request a callback.