Home and Community Based Waiver
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
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 and the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Medi-Cal for Kids & Teens Services 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. By providing in-home care, this program seeks to ensure that the medical needs of physically and mentally disabled Medi-Cal members are met.
Coordination of Care
Services provided under the HCBA Waiver program are not covered under the Plan’s Managed Medi-Cal Contracts (Two-Plan and Geographic Models). The Plan maintains procedures for identifying members who may be eligible for the HCBA waiver and facilitates the referrals of these members. The Plan endeavors to monitor and ensure the coordination of services with the HCBA Waiver and to provide all medically necessary covered services to its Medi-Cal members.
Eligibility
To qualify for potential enrollment into the HCBA waiver, members must meet the following criteria:
- Must have full-scope Medi-Cal eligibility
- Physically disabled (no age limit)
- This waiver will serve Medi-Cal beneficiaries, who in the absence of this waiver, and as a matter of medical necessity, would require care in an inpatient nursing facility (NF) providing the following types of care:
- Nursing Facility (NF) B level of care
- NF A level of care
- NF Level B Pediatric Services
- NF Subacute Services
- NF Pediatric Subacute Services
The Health Net Population Health Department monitors and reviews all inpatient stays for proper use and to identify members who may benefit from Home and Community Based Services (HCBS) Waiver programs.
HCBS Waiver Services Available
The HCBA Waiver provides care management services to persons at risk or nursing home or institutional placement. The care management services are provided by a multidisciplinary Care Management Team (CMT) comprised of a nurse and social worker. The CMT coordinates Waiver and State Plan services (such as medical, behavioral health, In-Home Supportive Services) and arranges for other long-term services and supports available in the local community. Care management and Waiver services are provided in the participant’s community-based residence. This residence can be privately owned, secured through a tenant lease arrangement, or the residence of a participant’s family member.
Referrals to HCBS
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 Population Health 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.