Section 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.Cal. Code Regs. Tit. 22, § 51344
1. New section filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
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.
1. New section filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
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).