Home and Community Based Waiver
- Participating Physician Groups (PPG)
The Home and Community-Based Services (HCBS) Waiver program offers an array of services designed to support an individual in his or her home as an alternative to care in a licensed health care facility. These waivers include the In-Home Medical Care Waiver, the Nursing Facility Subacute Waiver the Nursing Facility Waiver, and the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. EPSDT shift nursing is a benefit for members under the age of 21. Medical management of chronically ill Medi-Cal members, including those with catastrophic illnesses, those who are dependent on life-sustaining equipment and those at risk of life-threatening occurrences, requires close coordination between Health Net and the HCBS Waiver program administered by the In-Home Operations (IHO) intake unit within the Department of Health Care Services (DHCS). By providing in-home care, this program seeks to ensure that the medical needs of physically and mentally disabled Medi-Cal members are met.
Upon acceptance by the In-Home Operations (IHO) intake unit into a local home health agency, the Health Net Medi-Cal Health Services Department initiates the member's disenrollment process and facilitates an orderly transfer of medical service responsibility from Health Net to the Medi-Cal fee-for-service (FFS) program.
The Health Net Medi-Cal Health Services Department monitors and reviews all inpatient stays for proper use and to identify members who may benefit from one of the three Home and Community Based Services (HCBS) Waiver programs. The Health Net Medi-Cal Health Services Department also works to ensure that potentially eligible members are referred to the In-Home Operations (IHO) intake unit in a timely manner. A Medi-Cal or waiver service provider must make actual requests for HCBS services.
The In-Home Operations (IHO) intake unit staff is responsible for processing EPSDT private duty nursing and pediatric day health care requests. This unit is also responsible for reviewing all new requests statewide for HCBS waiver services. Upon receipt and review of the HCBS application, the request for HCBS waiver services is then forwarded to the appropriate regional office for completing the intake process and ongoing administrative case management. Provision of waiver services depends on concurrence of the member, guardian or authorized representative, primary care physician (PCP), and a licensed and Medi-Cal-certified home health agency. The Department of Health Care Services (DHCS) requires that each party sign a letter of agreement to ensure that all participants understand their roles and responsibilities and the benefits and limitations of the waiver.
The Department of Health Care Services (DHCS) Medi-Cal In-Home Operations Division administers three Home and Community Based Services (HCBS) Waiver programs for chronically ill members:
- The In-Home Medical Care (IHMC) Waiver is designed for Medi-Cal beneficiaries who, in the absence of the waiver, would be expected to require at least 90 days or more of acute hospital care. This waiver is for individuals who have a catastrophic illness, may be technology-dependent and have a risk for life-threatening incidence.
- The Nursing Facility (NF) Waiver is designed for those who are physically disabled or aged and would require at least 180 days or more of NF care. The level of service under NF subacute include the adult subacute and pediatric subacute.
- The Nursing Facility (NF) A/B Waiver is designed for persons who are physically disabled and would be expected to require at least 365 days or more of nursing facility care. This waiver includes NF A (Intermediate Care Facility) and B (Skilled Nursing Facility).
The IHO-administered HCBS Waiver program provides long-term care to recipients. If a Health Net member meets the criteria for HCBS services and is accepted into the HCBS Waiver program, the member is disenrolled from Health Net and enrolled in the Medi-Cal fee-for-service (FFS) program.
The following services are available under the Medi-Cal fee-for-service (FFS) program and are coordinated and authorized through In-Home Operations (IHO):
- Homemaker - General household activities (meal preparation and routine household care) provided by a trained homemaker when the person regularly responsible for them is absent or unable to manage the home and provide care.
- Home health aide services - Services provided by a licensed registered nurse (RN), a licensed practical or vocational nurse under the supervision of an RN, or through a home health agency.
- Personal care services - Services include assistance with eating, bathing, dressing, personal hygiene, laundry, shopping and other activities of daily living.
- Respite care - Services given to individuals unable to care for themselves and provided on a short-term basis because of absence or need for relief of those normally providing the care.
- Day habilitation - Assistance with acquisition, retention or improvement of self-help, socialization and adaptive skills.
- Environmental accessibility adaptations - Changes in the home, including installing ramps and grab bars, widening doorways, modifying bathrooms, or installing electric and plumbing systems necessary for medical equipment and supplies.
- Skilled nursing - Services provided by a RN or by a licensed practical or vocational nurse under the supervision of a RN.
- Transportation - Service offered to help the member get waiver and other community services. It includes transportation aides and other assistance necessary for safe transport.
- Specialized medical equipment and supplies - Includes devices, controls or appliances that enable members to increase their ability to perform activities of daily living or to perceive, control or communicate.
- Chore services - Includes heavy household chores performed for safety reasons, such as washing floors, windows and walls, tacking down loose rugs and tiles, and moving heavy furniture.
- Personal emergency response system - A 24-hour emergency assistance service that enables the member to get immediate help in an emergency
- Adult foster care - Personal care and services, attendant care and companion services, usually provided in a licensed private home by a principal care provider (not a parent) who lives in the home.
- Assisted living - Personal care services provided to members while living in a licensed community care facility, including homemaker, chore, attendant care, and companion services, medication oversight and therapeutic social and recreational programs.
- Vehicle adaptations - Devices, controls or services that enable members to increase their independence or physical safety and allow them to live at home.
- Communication aides - Human services necessary to assist members with hearing, speech or vision impairment to communicate effectively.
- Mobile crisis intervention - Immediate therapeutic intervention on a 24-hour emergency basis for a member exhibiting acute personal, social or behavioral problems.
- Crisis intervention facility services - Immediate, temporary (less than 30 days) placement in a specialized residence and immediate, intensive, face-to-face therapeutic treatment services for members exhibiting acute personal, social or behavioral problems that are an immediate and serious threat to the health and safety of the member or others.
- Respiratory therapy services - Services that target members who require them but do not meet the criteria for regular Medi-Cal or are provided in addition to regular Medi-Cal services.
- Nutritional consultation - Services include consultation and assistance in planning to meet the nutritional and special dietary needs of members.
Physical therapy (PT), occupational therapy (OT) and psychological services are offered in addition to those available through regular Medi-Cal in order to provide the amount of care necessary to prevent institutionalization.
The home health care agency prepares all necessary letters of agreement and the Treatment Authorization Request (TAR). Home health care agencies are encouraged to identify the waiver recipient by highlighting IHO Waiver Recipient in the provider address section of the TAR. The home health care agency submits the information to In-Home Operations.
The home health care agency sends a copy of the documentation to the Health Net Medi-Cal Health Services Department for tracking and follow-up.
In-Home Operations (IHO) staff assess the member's medical condition to determine whether waiver services are necessary and which waiver program (In-Home Medical Care (IHMC) or Skilled Nursing Facility (SNF)) is more appropriate.
IHO reviews the request for necessity and suitability and assists the waiver participant and provider with documentation. IHO evaluates level of care, whether durable medical equipment (DME) is required, medication, nursing hours, cost-effectiveness, and sufficiency of the home for the member's health and safety needs. Final approval is subject to review by a Medi-Cal physician and IHO headquarters in Sacramento.
IHO may authorize:
- Home health care management, consisting of weekly registered nurse (RN) supervisory services.
- Skilled nursing care, which are hourly nursing services provided by RNs or licensed vocational nurses (LVNs).
- Home health aide services, which are services provided by a certified person and supervised by an RN or LVN.
- Modification of the home, consisting of minor changes that enable the member to receive care at home.
- Reimbursement for utility costs incurred due to continuous operation of life-sustaining equipment. Refer to the HCBS Waiver Services Available for a complete list of services available.
IHO may approve services up to 24 hours per day if prescribed by the member's primary care physician (PCP).
In-Home Operations (IHO) determines eligibility, and the home health agency's care managers are responsible for care management. If Health Net or a participating provider disagrees with the IHO decision or recommendation concerning the provision of waiver services, Health Net's public programs administrators are responsible for resolving the dispute. The Health Net Medi-Cal Health Services Department continues to coordinate and authorize all immediate health care needs for the member in collaboration with the primary care physician (PCP) until the matter is resolved.
The primary care physician (PCP) needs to inform the member, guardian or authorized representative about the availability of in-home care alternatives.
On consent of the member, guardian or authorized representative, the Health Net Medi-Cal Health Services Department coordinates with the inpatient facility discharge planner and care manager to refer the member to a licensed and Medi-Cal-certified home health care agency for evaluation. The home health agency care managers evaluate the member's health care needs and whether they can be met in the member's home.