Update : Medi-Cal Update DHS Waiver Programs Changes and Clarifications

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1 Santa Clara County Social Services page 1 Date: 04/15/02 References: ACWDL #01-09, 01-12, 01-24, 01-67; MEPM #255 Cross-References: Clerical: Handbook Revision: Distribution: None Yes Yes Medi-Cal Update Distribution List Update : Medi-Cal Update DHS Waiver Programs Changes and Clarifications Background/ Policy The goal of Department of Health Services (DHS) Waiver Programs is to provide a greater range of home health care services allowing the individual to be cared for in the home or community, rather than in a more costly institutional setting. Waiver Programs There are currently six Waiver programs in effect. Waiver Programs Processed By Eligibility Workers Two Waiver programs have special Medi-Cal eligibility determination requirements and are processed at the county level by Eligibility Workers (EWs). Department of Developmental Services Home and Community-Based Services (DDS-HCBS) Waiver Model-Nursing Facility (Model-NF) Waiver. Waiver Programs Processed by the State DHS The last four Waiver programs follow regular Medi-Cal eligibility rules and are administered by DHS and are included only for informational and referral purposes. In-Home Medi-Cal Care Services (IHMC) Waiver Nursing Facility (NF) Services Waiver Acquired Immune Deficiency Syndrome (AIDS) Waiver Multipurpose Senior Service Program (MSSP) Waiver.

2 page 2 Update : Medi-Cal Update Changes/ Clarifications This Update contains the following changes and clarifications related to the Waiver programs: Chapter 40 is reformatted for better clarity A description of the Medi-Cal In-Home Operations (IHO) A description of the Personal Care Services Program (PCSP) An update on the DDS-HCBS Waiver An update on the Model-NF Waiver An update on the NF Waiver An update on the AIDS Waiver An update on the MSSP Waiver A clarification on the Medi-Cal Family Budget Unit (MFBU). Chapter 40 DHS Waiver programs are moved to the beginning of the chapter. IHO The DHS In-Home Operations (IHO) oversees the development and implementation of home nursing programs. The IHO authorizes medically necessary long-term shift nursing services in the home for Medi-Cal clients who are eligible for the Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) program and/or one of the three federal waiver programs (Model-NF, IHMC, and NF Waivers). These home nursing services are authorized as an alternative for individuals who would otherwise qualify for care in nursing facilities recognized by Medi-Cal. The request for these nursing services is done through IHO by the Medi-Cal provider. [Section ] EPSDT EPSDT is a Medi-Cal program under the responsibility of the IHO for individuals who are under age 21 and who have full scope Medi-Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Based upon the identified health care need, diagnostic and treatment services are provided. This program also allows for the provision of shift nursing services in the home of these individuals. [Section ] PCSP The Personal Care Services Program (PCSP) is a component of the In-Home Supportive Services (IHSS) program. Unlike IHSS, PCSP does not allow a parent of a minor child or spouse to be the care provider. Who Is Eligible To PCSP Clients who are receiving benefits under either the Model-NF or the DDS-HCBS Waivers that disregard parental/spousal income and property AND who are not eligible for IHSS services only because that program does not disregard parental/spousal income, are eligible for PCSP.

3 Update : Medi-Cal Update page 3 Services PCSP Provides PCSP provides the following services: Assistance in walking Bathing, oral hygiene, dressing, and grooming Care and assistance with prosthetic devices Bowel, bladder and menstrual care Repositioning, range of motion exercises and transfers Feeding and assurance of adequate fluid intake Respiration and paramedical services Assistance with self-administration of medications Ancillary services (e.g., meal preparation, laundry, domestic services). When the State releases the final regulations and procedures for PCSP, another Update will be released to staff clarifying issues as appropriate. [Section ] DDS-HCBS Waiver The client must meet ALL regular Medi-Cal eligibility requirements when determining eligibility for the DDS-HCBS Waiver. If the client is eligible for Medi-Cal with zero Share-of-Cost (SOC) without using the special waiver rules, this client is NOT eligible for the DDS-HCBS Waiver. Eligibility Workers must contact the San Andreas Regional Center (SARC) and inform their contact that the Waiver is not appropriate when the client is eligible for Medi-Cal with zero SOC. San Andreas Regional Center (SARC) 300 Orchard City Drive, Suite 170 Campbell, CA Phone: (408) , Fax: (408) New Special Rules If after a preliminary screening, it appears that the client will be property ineligible or has a SOC using parental or spousal income and property, special rules apply as follows: If the client is a child, deeming of parental income and property is waived (even though the child lives in the home) prior to determining Medi-Cal eligibility. If the client is an adult, spousal impoverishment rules apply as if the client were institutionalized. A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the client. Verification must be by the physician s written statement of necessity. The waiver is limited to clients who are eligible for FULL benefits. NOTE: A client residing in a nursing home under the State-only Aid Code 53-0, a client in another limited scope Aid Code, or a client who does not have satisfactory immigration status is NOT eligible for the waiver program.

4 page 4 Update : Medi-Cal Update The EW must use the most beneficial FULL scope Medi-Cal program to determine eligibility that is applicable to the client (e.g., the Aged, Blind and Disabled (ABD), the Medically Needy (MN), the Medically Indigent (MI), or the Federal Poverty Level (FPL) programs). EXAMPLE: A child under 19 who has a SOC in the MN or MI program or excess property may be eligible under the appropriate FPL program which disregards property using a family size of one. A disability determination is not required unless: - Eligibility is based on Medi-Cal requiring that the client be disabled, - The client has no other basis for linkage, or - There would be an advantage if the client were disabled (e.g., income deductions available only to the disabled). This determination of disability may be advantageous when a child becomes an adult. [Section 40.2] Model-NF Waiver The Model-NF Waiver is limited to clients who in the absence of the waiver program would otherwise require the nursing facility level of care or sub-acute services for at least 90 consecutive days but who wish to live at home or in the community. Clients under the age 21 must be able to access a waiver service which is not covered under the EPSDT Inpatient status prior to the enrollment of waiver is no longer required A second vehicle is exempt if the vehicle has been modified to accommodate the physical handicap(s) or medical needs of the client. Verification must be by the physician s written statement of necessity. The Model-NF Waiver has the same Medi-Cal eligibility rules as the DDS-HCBS Waiver. However, for the Model-NF Waiver, In-Home Operations (IHO) will do a prescreening of income and property prior to referring the client to the county. The IHO address and phone number are now included. DHS In-Home Operations (IHO) Intake Unit 700 North Tenth Street P.O. Box Sacramento, CA Phone: (916) , Fax: (916) [Section 40.3] NF Waiver The NF Waiver (formerly referred to as the Skilled Nursing Facility Waiver) is administered by DHS and is limited to clients who in the absence of the waiver program would require care in a nursing facility or a sub-acute facility for at least 90 consecutive days care. Clients under age 21 may access services under the NF Waiver that are not covered under the EPSDT program.

5 Update : Medi-Cal Update page 5 DHS In-Home Operations (IHO) Same address, phone and fax numbers as mentioned above. [Section ] AIDS Waiver The word diagnosis is added to the description of this waiver. AIDS and HIV are spelled out. The AIDS Waiver is administered by DHS and is available to individuals with a diagnosis of Human Immunodeficiency or Acquired Immune Deficiency Syndrome (AIDS) with symptoms related to Human Immunodeficiency Virus (HIV) disease who would otherwise require care in skilled nursing facilities or acute care hospitals. Applicants for the AIDS Waiver must have a medical certification completed by the DHS Office of AIDS prior to referral to the county. The office address, phone and fax numbers are now included. DHS Office of AIDS Community Based Case Section 611 North 7th Street P.O. Box Sacramento, CA Phone: (916) , Fax: (916) [Section ] MSSP Waiver The Multipurpose Senior Service Program (MSSP) Waiver is administered by DHS and is still limited to the frail elderly. However, the new requirements are more specific. The elderly clients must be over sixty-five years of age and in receipt of Medi-Cal. California Department of Aging (CDA) 1600 K Street Sacramento, CA Phone: (916) , Fax: (916) For information and assistance on senior programs in the local area: [Section ] MFBU Clarification Clients in the DDS-HCBS and Model-NF Waivers are placed in their own Medi-Cal Family Budget Unit (MFBU) and are allowed the maintenance need for one. Persons applying for the other four waiver programs are considered part of the household if they are determined to be living in the home and regular Medi-Cal MFBU rules apply.

6 page 6 Update : Medi-Cal Update If it is more beneficial for the client to be in the MFBU with other family members, the waiver applicant may choose not to be in the waiver program and to be determined under regular Medi-Cal rules. The EW must notify the corresponding agency of the client s decision. Implementation The information contained in this Update is effective upon receipt. EW Supervisors EW Supervisors must review this Update at the next unit meeting but no later than April 30, Forms The In-Home Operations Brochure is now available (See attachment #1). NOAs The following State Notices of Action (NOAs) are now available as follows: NUMBER MC 341 MC 341 SP MC 342 MC 342 SP MC 343 MC 343 SP MC 344 MC 344 SP NAME/DESCRIPTION Approval Notice of Action (NOA) for the DDS-HCBS Waiver Approval NOA for the DDS-HCBS Waiver - Spanish Denial or Discontinuance NOA for the DDS-HCBS Waiver Denial or Discontinuance NOA for the DDS-HCBS Waiver - Spanish Approval NOA for the Model-NF Waiver Approval NOA for the Model-NF Waiver - Spanish Denial or Discontinuance NOA for the Model-NF Waiver Denial or Discontinuance NOA for the Model-NF Waiver - Spanish Other Programs These changes and clarifications only apply to the Medi-Cal DHS Waiver Programs. Clerical See Forms and NOAs above. NELLIE JORGE, DIRECTOR Department of Employment and Benefit Services Contact Person(s): Guillermo Cáceres, Medi-Cal Program Coordinator, (408)

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