Cal. Code Regs. Tit. 22, § 51344 - In-Home Medical Care Waiver Services and Nursing Facility Waiver Services
(a) In-home medical
care waiver services and nursing facility waiver services are covered when
prescribed by a physician and provided at the beneficiary's place of residence
in accordance with a written treatment plan indicating the need for in-home
medical care waiver services or nursing facility waiver services and in
accordance with a written agreement between the Department and the provider of
service.
(b) All in-home medical
care waiver services are subject to prior authorization. Authorization will be
granted only:
(1) If the beneficiary for whom
in-home medical care waiver services are requested would otherwise require care
in an inpatient acute care hospital for at least 90 consecutive days;
and
(2) If the total cost incurred
by the Medi-Cal program of providing in-home medical care waiver services and
other medically necessary Medi-Cal services to the beneficiary is less than the
total cost incurred by the Medi-Cal program in providing all medically
necessary services to the beneficiary in an inpatient acute care hospital
and;
(3) If the beneficiary under
21 years of age for whom prior authorization for provision of in-home medical
care waiver services in the beneficiary's home is requested has a relative,
foster parent, or related or non-related legal guardian, or other responsible
adult who is willing to become and remain involved in the care of the child,
and become and remain proficient in performing the tasks necessary to care for
the child. This requirement shall not be interpreted to mean that such person
must provide any particular number of daily hours of care to the child.
Notwithstanding this requirement, there shall be a responsible adult who is
able to learn and perform the tasks necessary to care for the child. This
person shall demonstrate his/her proficiency by performing these tasks as
average of four hours per week (minimum of 16 hours each month) in order to
maintain the skills necessary to take care of the child at home.
(4) If the beneficiary for whom in-home
medical care waiver services are requested has, or will be placed in, a
residence which meets the following criteria, as determined by the Department;
(A) The residence is large enough to
accommodate the medical equipment and supplies required to maintain the patient
in the residence; and
(B) The
residence includes those physical adaptations which are necessary to ensure the
health and safety of the waiver beneficiary; and
(C) The residence is clean and free of
insects or pests.
(c) All nursing facility waiver services are
subject to prior authorization. Prior authorization will be granted only:
(1) If the beneficiary for whom nursing
facility waiver services are requested would otherwise require care in an
inpatient nursing facility providing Medi-Cal nursing facility Level A
services, pursuant to Section
51120, or nursing facility Level B
services, pursuant to Section
51123, subacute services, pursuant
to Section
51124.5, or pediatric care
services, pursuant to Section
51124.6, for at least 90
consecutive days; and
(2) If the
total cost incurred by the Medi-Cal program of providing nursing facility
waiver services and other medically necessary Medi-Cal services to the
beneficiary is less than the total cost incurred by the Medi-Cal program in
providing care to the beneficiary in a nursing facility providing all medically
necessary services at the level of Medi-Cal nursing facility service
appropriate to the beneficiary's medical needs; and
(3) If the beneficiary under 21 years of age
for whom prior authorization for provision of nursing facility waiver services
in the beneficiary's home is requested has a relative, foster parent, or
related or non-related legal guardian, or other responsible adult who is
willing to become and remain involved in the care of the child, and become and
remain proficient in performing the tasks necessary to care for the child. This
requirement shall not be interpreted to mean that such person must provide any
particular number of daily hours of care to the child. Notwithstanding this
requirement, there shall be a responsible adult who is able to learn and
perform the tasks necessary to care for the child. This person shall
demonstrate his/her proficiency by performing these tasks an average of 4 hours
per week (minimum of 16 hours each month) in order to maintain the skills
necessary to take care of the child at home.
(4) If the beneficiary for whom nursing
facility waiver services are requested has, or will be placed in, a residence
which meets the following criteria, as determined by the Department:
(A) The residence is large enough to
accommodate the medical equipment and supplies required to maintain the patient
in the residence; and
(B) The
residence includes those physical adaptations which are necessary to ensure the
health and safety of the waiver beneficiary; and
(C) The residence is clean and free of
insects or pests.
Notes
2. Certificate of Compliance transmitted to OAL 12-30-82 and filed 2-2-83 (Register 83, No. 6).
3. Amendment of section heading and subsections (a)-(b)(2), new subsections (a)(3)-(c)(4)(C) and amendment of NOTE filed 10-20-94; operative 10-20-94 (Register 94, No. 42).
4. Editorial correction of HISTORY 3 (Register 95, No. 14).
Note: Authority cited: Section 10725, Welfare and Institutions Code; and Section 57(c), Chapter 328, Statutes of 1982. Reference: Sections 14114 and 14132, Welfare and Institutions Code.
2. Certificate of Compliance transmitted to OAL 12-30-82 and filed 2-2-83 (Register 83, No. 6).
3. Amendment of section heading and subsections (a)-(b)(2), new subsections (a)(3)-(c)(4)(C) and amendment of Note filed 10-20-94; operative 10-20-94 (Register 94, No. 42).
4. Editorial correction of History 3 (Register 95, No. 14).
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