Waiver Programs. (All Plans) The member is or will be participating in CLTS, FamilyCare, IRIS, Pace, or Partnership, other home and community waiver programs. The HMO must inform the Enrollment Specialist of the effective dates that the member is/was participating in the waiver program to accommodate a timely disenrollment. Disenrollment shall be effective the first month in which the member entered the other program. Disenrollments are not backdated more than four months from the date the request is received. Any capitation payments made for months subsequent to disenrollment will be recouped.
Waiver Programs. CDHS administers a number of Medi-Cal Home and Community Based Services (HCBS) Waiver Programs authorized under section 1915(c) of the Social Security Act. Contractor shall have procedures in place to identify Members who may benefit from the HCBS Waiver programs, and refer them to the Medical Care Coordination and Case Management Section of CDHS. These waiver programs include the In-Home Medical Care Waiver, the Nursing Facility Subacute Waiver, and the Nursing Facility A/B Waiver. If the agency administering the waiver program concurs with Contractor’s assessment of the Member and there is available placement in the waiver program, Contractor shall initiate disenrollment for the Member. Contractor shall provide documentation to ensure the Member’s orderly transfer to the Medi-Cal Fee-For-Service program. If the Member does not meet the criteria for the waiver program, or if placement is not available, Contractor shall continue comprehensive case management and shall continue to cover all Medically Necessary Covered Services to the Member.
Waiver Programs. Contractor shall initiate disenrollment for the Member if the Member elects to join any of the following waiver programs identified in Section 2.21 b), In-Home Medi-Cal Waiver Program, Skilled Nursing Facility Waiver Program; the Model Waiver Program; the agency administering the waiver program concurs with Contractor’s assessment of the Member; and there is available placement in the waiver program. Contractor shall follow this procedure:
a) Identify and refer Members to the appropriate waiver program;
b) Seek concurrence from the waiver program; and
c) Upon the Member’s acceptance into waiver program provide documentation to ensure the Member’s orderly transfer to the Medi-Cal FFS program. If the Member does not meet the criteria for the waiver program, or if the placement is not available, the Member will not be disenrolled and Contractor shall continue Medical Case Management and provide all Medically Necessary Covered Services to the Member.
Waiver Programs. Contractor shall maintain systems for identifying and referring Members to the appropriate waiver program, including the In-Home Medical Care Waiver Program, the Skilled Nursing Facility Waiver Program, the Model Waiver Program, the Acquired Immune Deficiency (AIDS) and AIDS Related Conditions Waiver Program, and the Multipurpose Senior Services Waiver Program. If the agency administering the waiver program concurs with Contractor's assessment of the Member and there is available placement in the waiver program, Contractor shall initiate Disenrollment for the Member. Contractor shall provide documentation to ensure the Member's orderly transfer to the Medi-Cal Fee-For-Service program. If the Member does not meet the criteria for the waiver program, or if placement is not available, Contractor shall continue to case manage and provide all Medically Necessary Covered Sservices to the Member. 116. Article VI, SCOPE OF WORK, Section 6.7.3.1, Miscellaneous Service Carve Outs, is amended to read:
Waiver Programs. DHCS administers a number of Medi-Cal Home and Community Based Services (HCBS) Waiver programs authorized under Section 1915(c) of the Social Security Act. Contractor shall have procedures in place to identify Members who may benefit from the HCBS Waiver programs, and refer Members to the agency administrating the waiver program. These waiver programs include, but are not limited to, the nursing facility/acute hospital waiver. If the agency administering the waiver program concurs with Contractor’s assessment of the Member and there is available placement in the waiver program, the Member will receive HCBS waiver services while remaining enrolled with Contractor. Contractor shall continue comprehensive case management and shall continue to cover all Medically Necessary Covered Services to the Member. If the Member does not meet the criteria for the HCBS Waiver Program, or if placement is not available, Contractor shall continue to case manage and provide all Medically Necessary covered Services to the Member.
Waiver Programs. DHCS administers a number of Medi-Cal Home and Community Based Services (HCBS) Waiver programs authorized under Section 1915(c) of the Social Security Act. Contractor shall have procedures in place to identify Members who may benefit from the HCBS Waiver programs, and refer Members to the agency administrating the waiver program. These waiver programs include, but are not limited to, the nursing facility/acute hospital waiver. If the agency administering the waiver program concurs with Contractor’s assessment of the Member and there is available placement in the waiver program, the Member will receive HCBS waiver services while remaining enrolled with Contractor. Contractor shall continue comprehensive case management and shall continue to cover all Medically Necessary Covered Services to the Member. If the Member does not meet the criteria for the HCBS Waiver Program, or if placement is not available, Contractor shall continue to case manage and provide all Medically Necessary covered Services to the Member.
1. Subcontracts Contractor shall negotiate in good faith and execute a Subcontract for public health services listed in Paragraph A through Paragraph D below with the Local Health Department (LHD) in each county that is covered by this Contract. The Subcontract shall specify: the scope and responsibilities of both parties in the provision of services to Members; billing and reimbursements; reporting responsibilities; and how services are to be coordinated between the LHD and the Contractor, including exchange of medical information as necessary. The Subcontract shall meet the requirements contained in Exhibit A, Attachment 6, Provision 13, regarding Subcontracts.
A. Family Planning Services: as specified in Exhibit A, Attachment 8, Provision 9.
B. STD services for the disease episode, as specified in Exhibit A, Attachment 8, Provision 10, by DHCS, for each STD, including diagnosis and treatment of the following STDs: syphilis, gonorrhea, chlamydia, herpes simplex, chancroid, trichomoniasis, human papilloma virus, non- gonococcal urethritis, lymphogranuloma venereum and granuloma inguinale.
C. HIV Testing and Counseling as specified in Exhibit A, Attachment 8, Provision 11.
D. Immunizations as specified in Exhibit A, Attachment 8, Provision 12. To the extent that Contractor does not meet this requirement on or before four (4) months after the effective date of this Contract, Contractor shall submit documentation substantiating reasonable eff...
Waiver Programs. The Contractor will maintain systems for identifying and referring Members to the appropriate waiver program. If the agency administering the waiver program concurs with the Contractor's assessment of the Member and there is available placement in the waiver program, the Contractor will initiate Disenrollment for the Member. The Contractor will provide documentation to ensure the Member's orderly transfer to the Medi-Cal Fee-For-Service program. If the Member does not meet the criteria for the waiver program, or if placement is not available, the Contractor will continue to case manage and provide all Medically Necessary services to the Member. Xxxxxx Medical Centers 95-23637 Article VI
