AIDS Waiver Program
- Participating Physician Groups (PPG)
The California Department of Public Health's (CDPH's) AIDS Waiver Program provides Medi-Cal fee-for-service (FFS) home and community-based services to members with symptomatic HIV disease or AIDS who would otherwise require placement in a skilled nursing facility (SNF), or who are at increased risk for this type of placement. The AIDS Waiver Program is not covered by Health Net but is paid for by FFS Medi-Cal. These CDPH FFS services support home-based care and coordinated care to improve health and prevent costly hospitalizations for members with HIV/AIDS.
The CDPH AIDS Waiver Program contracts with agencies for the provision of care management, 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, home-delivered meals, and administrative expenses.
The California Department of Public Health's (CDPH's) AIDS 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 AIDS Waiver Program services subcontractors.
The CDPH's Office of AIDS contracts with agencies throughout California to administer the AIDS Waiver Program and provide nurse care management services. These agencies subcontract with licensed providers for program services.
CDPH's AIDS 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. AIDS 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 AIDS 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 transporation, nutrition counseling, nutritional supplements, and home-delivered meals.
Members must meet the California Department of Public Health's (CDPH's) AIDS 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) AIDS Waiver Program. To qualify, members with AIDS or symptomatic HIV disease must meet the California Department of Public Health's CDPH's criteria:
- be Medi-Cal enrolled
- have a written diagnosis of HIV disease or AIDS with current signs, symptoms, or disability related to the HIV disease or treatment
- adults who are certified by the CDPH nurse case manager to be at the nursing facility level of care and score 60 or less on the cognitive and functional ability scale assessment tool
- children under age13 who are identified by the CDPH nurse case manager as HIV/AIDS symptomatic (Note: Children who are HIV-positive must be referred to the California Children's Services (CCS) program.)
- individuals with health status consistent with in-home services and who have home settings safe for both members and service providers
- have exhausted other coverage, such as private health insurance for health care benefits similar to those available under the AIDS Waiver Program prior to use of AIDS Waiver Program services
- must not be simultaneously enrolled in Medi-Cal hospice, but may be simultaneously enrolled in Medicare hospice
- must not be simultaneously enrolled in the AIDS Case Management program
- must not simultaneously receive case management services or use State Targeted Case Management Services program funds to supplement the Medi-Cal Waiver Program (MCWP)
- must have an attending primary care physician (PCP) willing to accept full professional responsibility for the recipient's medical care
Members eligible for the CDPH AIDS Waiver Program may remain enrolled in both Health Net's Two-Plan Model and Geographic Model managed care plans. Members accepted into the CDPH AIDS 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 AIDS 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 AIDS 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 AIDS 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 AIDS 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 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 AIDS Waiver program.