Clients eligible for the program must be Medi-Cal recipients: whose health status qualifies them for nursing facility care or hospitalization, in an “Aid Code" with full benefits and not enrolled in the Program of All-Inclusive Care for the Elderly (PACE); have a written diagnosis of HIV disease or AIDS with current signs, symptoms, or disabilities related to HIV disease or treatment; adults who are certified by the nurse case manager to be at the nursing facility level of care and score 60 or less using the Cognitive and Functional Ability Scale assessment tool, children under 13 years of age who are certified by the nurse case manager as HIV/AIDS symptomatic; and individuals with a health status that is consistent with in-home services and who have a home setting that is safe for both the client and service providers.

The California Department of Public Health's (CDPH's) Medi-Cal Waiver Program agencies provide services only in non-institutional settings. The home is the most common place of service. The CDPH contracting agencies are responsible for administering the program, providing nurse care management, and authorizing payment to Medi-Cal Waiver Program services subcontractors.

The CDPH's Office of AIDS contracts with agencies throughout California to administer the Medi-Cal Waiver Program and provide nurse care management services. These agencies subcontract with licensed providers for program services.

CDPH's Medi-Cal Waiver Program care management team locates, coordinates and monitors services for enrollees. This includes developing a written service plan and assessing the service requirements and medical condition of the enrollee. Medi-Cal Waiver Program care management is performed by a team that includes a program nurse care manager, social worker or foster-child case-worker (if needed), attending physician, and member.

The CDPH's Medi-Cal Waiver Program care manager may authorize Medi-Cal FFS in-home skilled nursing care, attendant care, homemaker care, psychosocial counseling, equipment and minor physical adaptations to the home, Medi-Cal supplement for infants and children in foster care, non-emergency medical transportation, non-medical transportation, nutrition counseling, nutritional supplements, and home-delivered meals.

Members must meet the California Department of Public Health's (CDPH's) Medi-Cal Waiver Program eligibility requirements to participate through Health Net. Managed care members are not required to disenroll from Health Net in order to enroll in the Medi-Cal fee-for-service (FFS) Medi-Cal Waiver Program. To qualify, members with AIDS or symptomatic HIV disease must meet the California Department of Public Health's CDPH's criteria:

Members eligible for the CDPH Medi-Cal Waiver Program may remain enrolled in both Health Net's Two-Plan Model and Geographic Model managed care plans. Members accepted into the CDPH Medi-Cal Waiver Program are not required to disenroll from their Heath Net managed care Medi-Cal plans.

These medications are covered through the Medi-Cal Rx program. Providers bill the state directly for these medications under Medi-Cal Rx.

Disputes that arise between the Medi-Cal Waiver Program and Health Net or a participating provider are resolved by Health Net's public programs administrators. During a dispute, the provider and the Health Net Health Services staff continue to manage the member's medical care.

The primary care physician (PCP), Health Net Health Care Services staff or both inform eligible members about the California Department of Public Health's Medi-Cal Waiver Program.

If the member believes he or she is eligible and requests program referral, the type of supportive care needed is identified and the Health Net Health Care Services or Public Program's staff initiates a referral.

The California Department of Public Health's Office of AIDS conducts the assessment of the member based on the CDPH's Medi-Cal Waiver Program criteria for enrollment eligibility.

With the member's consent, the PCP or the Health Net Health Care Services staff, if requested, forwards any available relevant medical documentation to the program, including the member's medical history, lab results and an outline of the therapeutic regimen, if a copy is in the plan's possession.

For members who elect to remain enrolled in both the plan and Medi-Cal Waiver Program, the Health Net Health Care Services staff concurrently institutes a care management plan and coordinates with the member's PCP.

The member's PCP and Health Net Health Care Services staff are responsible for developing a primary care management plan that covers all medically necessary treatment and meets the health care needs of the member diagnosed with AIDS. They are responsible for coordinating and authorizing pharmacy, inpatient services, outpatient services, infusion services, laboratory services, specialty referrals, durable medical equipment (DME), preventive care services, and respiratory care services.

If the member elects to disenroll from the plan, the Health Net Health Care Services staff contacts the Health Net Medi-Cal Member Services Department, Community Health Plan of Imperial Valley Member Services Department or CalViva Health Medi-Cal Member Services Department (for Fresno, Kings and Madera counties) to initiate the disenrollment. The Health Net Health Care Services staff is responsible for authorization of services and coordination of the member's medical care until the member enters the Medi-Cal Waiver program.