PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Policy/Procedure Number: MCUP3106 Lead Department: Health Services ☒External Policy Policy/Procedure Title: Waiver Programs ☐ Internal Policy Next Review Date: 11/16/2017 Original Date: 04/21/2010 Last Review Date: 11/16/2016 Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees Reviewing ☒ IQI ☐ P & T ☒ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC Entities: ☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH Approval Date: 11/16/2016

I. RELATED POLICIES: A. County specific Regional Center MOUs

II. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services

III. DEFINITIONS: N/A

IV. ATTACHMENTS: N/A

V. PURPOSE: State and Federal Waiver Programs ensure members who may benefit from Medi-Cal Home and Community Based Services (HCBS) Waiver Programs are identified and referred for medical care coordination and care management.

VI. POLICY / PROCEDURE: A. The Department of Health Care Services (DHCS) administers a number of HCBS Waiver Programs. These waiver programs include: A.1. In-Home Operations Waiver (IHO) A.2. Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) Home and Community Based Services Waiver A.3. Home and Community Based Services Waiver for the Developmentally Disabled Partnership HealthPlan of California (PHC)’s providers and/or its Utilization Management (UM)/Care Coordination staff identify and refer members who are eligible for Waiver Programs. Members are not disenrolled from PHC when enrolled in a waiver program. B. Criteria Used For Identification B.1. The Primary Care Provider (PCP), Specialist, and/or PHC Care Coordination/ Utilization Management Departments refer members to Waiver Programs. B.2. Persons with developmental disabilities are identified through coordination with the regional centers and in the course of utilization and case management services. Members with developmental disabilities who may meet the requirements for participation in this waiver are referred to the HCBS

Page 1 of 3 Policy/Procedure Number: MCUP3106 Lead Department: Health Services Policy/Procedure Title: Waiver Programs ☒ External Policy ☐ Internal Policy Original Date: 04/21/2010 Next Review Date: 11/16/2017 Last Review Date: 11/16/2016 Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees administered by the State Department of Developmental Services (DDS).

C. Referrals C.1. The PCP requests prior authorization for services from the appropriate State Waiver Program and provides all appropriate medical information. The PCP may request assistance from the Care Coordination department for the following: C.1.a. Facilitating authorization from appropriate Waiver Program(s) C.1.b. Completion of the Waiver Program application C.1.c. Follow up on status of acceptance to appropriate Waiver Program(s) C.1.d. Medical care coordination of member while awaiting acceptance and/or placement into a Waiver Program Note: No member may be enrolled in more than one Waiver Program at a time. PHC maintains the responsibility to provide comprehensive care management and authorize all medically necessary covered services for members including those accepted into the Waiver Programs. The PCP will continue to treat and coordinate treatment for the member. C.2. Referrals for the In-Home Waiver Program are made via telephone or mail: In-Home Operations Section P.O. Box 942732, Mail Stop 4502 Sacramento, CA 94234-7320 (916) 552-9105 in Sacramento (213) 897-6774 in Los Angeles Fax: (916) 552-9145 C.3. Referrals to the HIV/AIDS Home and Community Based Services Waiver Program are made by requesting a HIV/AIDS Waiver Program Application from: California Department of Health Services Office of AIDS Community-Based Care Section MS 7700 P.O. Box 997426 Sacramento, CA 95899-7426 (916) 449-5900 C.4. Persons with Developmental Disabilities who may qualify for services are referred to the Regional Center responsible for their geographic area or to: California Department of Developmental Services 1600 th Street P. O. Box 944202 Sacramento, CA 94244-2020 Info: (916) 654-1690 TTY: (916) 654-2054

VII. REFERENCES: A. Regulatory: Title 22 California Code of Regulations (CCR) Section 1915 (c) B. DHCS Contract: Exhibit A, Attachment 18, Provision 11.U and Exhibit A, Attachment 11, Provision 9.C

Page 2 of 3 Policy/Procedure Number: MCUP3106 Lead Department: Health Services Policy/Procedure Title: Waiver Programs ☒ External Policy ☐ Internal Policy Original Date: 04/21/2010 Next Review Date: 11/16/2017 Last Review Date: 11/16/2016 Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

VIII. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: 11/28/12; 01/20/16; 11/16/16

PREVIOUSLY APPLIED TO: N/A

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In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:

 Consistent with sound clinical principles and processes  Evaluated and updated at least annually  If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.

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