TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Fast-Track Regulation

Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-70; repealing 12VAC30-50-470).

12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (repealing 12VAC30-60-160).

12VAC30-120. Waivered Services (amending 12VAC30-120-630).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: June 4, 2025.

Effective Date: June 19, 2025.

Agency Contact: Syreeta Stewart, Regulatory Coordinator, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 298-3863, FAX (804) 786-1680, TDD (800) 343-0634, or email syreeta.stewart@dmas.virginia.gov.

Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance, and § 32.1-324 of the Code of Virginia authorizes the Director of the Department of Medical Assistance Services (DMAS) to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority, as established by § 1902(a) of the Social Security Act (42 USC § 301 et seq.), provides governing authority for payments for services.

Purpose: These amendments remove outdated language related to case management services for recipients of auxiliary grants. These services have not been provided in over 10 years and the requirements can be repealed. The changes are essential to the health, safety, and welfare of Medicaid recipients because the changes ensure that the regulations align with current DMAS practices and the state plan.

Rationale for Using Fast-Track Rulemaking Process: This action is expected to be noncontroversial and therefore appropriate for the fast-track rulemaking process because DMAS has not provided case management services to recipients of auxiliary grants in over 10 years, and the provisions have had no effect since then.

Substance: The amendments remove outdated language related to case management services for recipients of auxiliary grants and bring the regulations into alignment with the state plan and DMAS current practices.

Issues: These changes create no disadvantages to the public, the agency, the Commonwealth, or the regulated community. The primary advantage is that the changes repeal outdated language to align the regulations with the state plan and DMAS current practices.

Department of Planning and Budget Economic Impact Analysis:

The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Code of Virginia and Executive Order 19. The analysis presented represents DPB's best estimate of the potential economic impacts as of the date of this analysis.¹

Summary of the Proposed Amendments to Regulation. The Director of Medical Assistance Services, on behalf of the Board of Medical Assistance Services (board), proposes to repeal the regulation concerning the provision of case management services to assisted living facility residents who receive auxiliary grants.

Background. This action would repeal coverage for case management services provided to assisted living facility residents who receive auxiliary grants. Auxiliary grants are a state supplement to supplemental security income, or for individuals who are aged, blind, or disabled. Previously, auxiliary grant recipients that resided in assisted living facilities were provided case management services through Medicaid. However, the utilization of this service was very low. Only 11 persons received services in 2011 and none since that time. The last claims paid for this service were in calendar year 2012. As a result, the Department of Medical Assistance Services (DMAS) submitted a state plan amendment to the Centers for Medicare and Medicaid Services to remove the outdated case management language from the state plan and the change was approved on September 11, 2024. The proposed repeal of the regulation would align the Virginia Administrative Code with the state plan language.

Estimated Benefits and Costs: The proposed changes would eliminate language pertaining to the provision of Medicaid case management services to auxiliary grant recipients residing in assisted living facilities. Since these services have not been provided under the regulatory authority being repealed in this action for over 10 years, no significant economic impact is expected other than aligning the regulatory text with the state plan and eliminating the potential for confusion. Further, DMAS states that if these individuals met the criteria, they may receive other types of state plan case management services (e.g., developmental disabilities case management, mental health case management, substance use disorder case management).

Businesses and Other Entities Affected. The proposed amendments should not affect any entity since no services have been provided under the regulatory authority for over 10 years. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.² An adverse impact is indicated if there is any increase in net cost or reduction in net benefit for any entity, even if the benefits exceed the costs for all entities combined.³ Since the proposal does not increase net costs or reduce net benefits for any entity, no adverse impact is indicated.

Small Businesses⁴ Affected.⁵ The proposed amendments do not adversely affect small businesses.

Localities⁶ Affected.⁷ The proposed amendments do not introduce costs, nor do they disproportionally affect localities.

Projected Impact on Employment. No impact on employment is expected.

Effects on the Use and Value of Private Property. No impact on the use and value of private property nor on real estate development costs is expected.

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¹ Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

² Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

³ Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation. As a result, DPB has adopted a definition of adverse impact that assesses changes in net costs and benefits for each affected Virginia entity that directly results from discretionary changes to the regulation.

⁴ Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁵ If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

⁶ "Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

⁷ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Department of Medical Assistance Services has reviewed the economic impact analysis prepared by the Department of Planning and Budget and raises no issues with this analysis.

Summary:

The amendments remove provisions associated with case management services for assisted living facility residents receiving auxiliary grants. The Department of Medical Assistance Services (DMAS) has not provided this service for over 10 years, so the regulations are outdated, and the provisions must be removed to align with current practices. DMAS submitted a state plan amendment (SPA) to the Centers for Medicare and Medicaid Services to remove the outdated case management language from the state plan. The SPA was approved on September 11, 2024, and this action will align the Virginia Administrative Code with state plan language.

12VAC30-50-70. Services or devices not provided to the medically needy.

The following services and devices shall not be provided to the medically needy:

1. Chiropractor services.

2. Private duty nursing services.

3. Dentures.

4. Diagnostic or preventive services other than those provided elsewhere in the State Plan.

5. Inpatient hospital services, skilled nursing facility services, and intermediate care facility services for individuals 65 years of age or older in institutions for mental diseases.

6. Intermediate care facility services (other than such services in an institution for mental diseases) for persons determined in accordance with § 1905(a)(4)(A) of the Social Security Act (the Act), to be in need of such care in a public institution, or a distinct part thereof, for persons with intellectual or developmental disability or related conditions.

7. (Reserved.)

8. Special tuberculosis services under § 1902(z)(2)(F) of the Act.

9. Respiratory care services (in accordance with § 1920(e)(9)(A) through (C) of the Act).

10. Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period by a qualified provider (in accordance with § 1920 of the Act).

11. Personal care services in a recipient's home, prescribed in accordance with a plan of treatment and provided by a qualified person under supervision of a registered nurse.

12. Home and community care for functionally disabled elderly individuals, as defined, described and limited in 12VAC30-50-470.

13. Personal care services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for intellectually or developmentally disabled persons, or institution for mental disease that are (i) authorized for the individual by a physician in accordance with a plan of treatment, (ii) provided by an individual who is qualified to provide such services and who is not a member of the individual's family, and (iii) furnished in a home.

12VAC30-50-470. Case management for recipients of auxiliary grants. (Repealed.)

A. Target group. Recipients of optional state supplements (auxiliary grants) as defined in 12VAC30-40-350 (Attachment 2.6 B), who reside in licensed adult care residences.

B. Services will be provided in the entire state.

C. Services are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Act is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act.

D. Definition of services. The case management services will provide assessment, service location, coordination and monitoring for aged, blind and disabled individuals who are applying for or receiving an optional state supplement (auxiliary grant) to pay the cost of residential or assisted living care in a licensed adult care residence in order to facilitate access to and receipt of the most appropriate placement. In addition, the case management services will provide for periodic reassessment to determine whether the placement continues to meet the needs of the recipient of optional state supplement (auxiliary grant) and to arrange for transfer to a more appropriate placement or arrange for supplemental services as the needs of the individual change.

E. Qualifications of providers. A qualified case manager for recipients of auxiliary grants must be a qualified employee of a human service agency as required in § 63.1-25.1 of the Code of Virginia. To qualify as a provider of case management for auxiliary grant recipients, the human service agency:

1. Must employ or contract for case managers who have experience or have been trained in establishing, and in periodically reviewing and revising, individual community care plans and in the provision of case management services to elderly persons and to disabled adults;

2. Must have signed an agreement with the Department of Medical Assistance Services to deliver case management services to aged, blind and disabled recipients of optional state supplements (auxiliary grants);

3. Shall have written procedures for assuring the quality of case management services; and

4. Must ensure that claims are submitted for payment only when the services were performed by case managers meeting these qualifications. The case manager must possess a combination of work experience in human services or health care and relevant education which indicates that the individual possesses the following knowledge, skills, and abilities at entry level. These must be documented on the job application form or supporting documentation.

a. Knowledge of:

(1) Aging;

(2) The impact of disabilities and illnesses on elderly and nonelderly persons;

(3) Conducting client assessments (including psychosocial, health and functional factors) and their uses in care planning;

(4) Interviewing techniques;

(5) Consumers' rights;

(6) Local human and health service delivery systems, including support services and public benefits eligibility requirements;

(7) The principles of human behavior and interpersonal relationships;

(8) Effective oral, written, and interpersonal communication principles and techniques;

(9) General principles of record documentation; and

(10) Service planning process and the major components of a service plan.

b. Skills in:

(1) Negotiating with consumers and service providers;

(2) Observing, recording and reporting behaviors;

(3) Identifying and documenting a consumer's needs for resources, services and other assistance;

(4) Identifying services within the established services system to meet the consumer's needs;

(5) Coordinating the provision of services by diverse public and private providers; and

(6) Analyzing and planning for the service needs of elderly or disabled persons.

c. Abilities to:

(1) Demonstrate a positive regard for consumers and their families;

(2) Be persistent and remain objective;

(3) Work as a team member, maintaining effective inter- and intra-agency working relationships;

(4) Work independently, performing position duties under general supervision;

(5) Communicate effectively, verbally and in writing;

(6) Develop a rapport and communicate with different types of persons from diverse cultural backgrounds; and

(7) Interview.

d. Individuals meeting all the above qualifications shall be considered a qualified case manager; however, it is preferred that the case manager possess a minimum of an undergraduate degree in a human services field, or be a licensed nurse. In addition, it is preferable that the case manager have two years of experience in the human services field working with the aged or disabled.

e. To obtain DMAS payment, the case management provider must maintain in a resident's record a copy of the resident's assessment, plan of care, all reassessments, and documentation of all contacts, including but not limited to face-to-face contacts with the resident, made in regard to the resident.

F. The state assures that the provision of case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act.

G. Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

H. Payment for case management services is limited to no more than one visit during each calendar quarter. In order to bill for case management services during a calendar quarter, the case manager must comply with the documentation requirements of subdivision E 4 e of this section and have documented contact with the resident during that quarter.

12VAC30-60-160. Utilization review of case management for recipients of auxiliary grants. (Repealed.)

A. Criteria of need for case management services. It shall be the responsibility of the assessor who identifies the individual's need for residential or assisted living in an adult care residence to assess the need for case management services. The case manager shall, at a minimum, update the assessment and make any necessary referrals for service as part of the case management annual visit. Case management services may be initiated at any time during the year that a need is identified.

B. Coverage limits. DMAS shall reimburse for one case management visit per year for every individual who receives an auxiliary grant. For individuals meeting the following ongoing case management criteria, DMAS shall reimburse for one case management visit per calendar quarter:

1. The individual needs the coordination of multiple services and the individual does not currently have support available that is willing to assist in the coordination of and access to services, and a referral to a formal or informal support system will not meet the individual's needs; or

2. The individual has an identified need in his physical environment, support system, financial resources, emotional or physical health which must be addressed to ensure the individual's health and welfare and other formal or informal supports have either been unsuccessful in their efforts or are unavailable to assist the individual in resolving the need.

C. Documentation requirements.

1. The update to the assessment shall be required annually regardless of whether the individual is authorized for ongoing case management.

2. A care plan and documentation of contacts must be maintained by the case manager for persons authorized for ongoing case management.

a. The care plan must be a standardized written description of the needs which cannot be met by the adult care residence and the resident-specific goals, objectives and time frames for completion. This care plan must be updated annually at the time of reassessment, including signature by both the resident and case manager.

b. The case manager shall provide ongoing monitoring and arrangement of services according to the care plan and must maintain documentation recording all contacts made with or on behalf of the resident.

12VAC30-120-630. Covered services.

A. The MCO shall, at a minimum, provide all medically necessary Medicaid covered services required under the state plan (12VAC30-50-10 through 12VAC30-50-310, 12VAC30-50-410 through 12VAC30-50-430, and 12VAC30-50-470 12VAC30-50-480 through 12VAC30-50-580) and; Elderly and Disabled with Consumer Direction waiver regulations (12VAC30-120-924 and 12VAC30-120-927) and the Technology Assisted waiver regulations (12VAC30-120-1720); and, effective January 1, 2018, community mental health services (12VAC30-50-130 and 12VAC30-50-226).

B. The following services are not covered by the MCO and shall be provided through fee-for-service outside the CCC Plus MCO contract:

1. Dental services (12VAC30-50-190);

2. School health services (12VAC30-50-130);

3. Preadmission screening (12VAC30-60-303);

4. Individual and Developmental Disability Support waiver services (12VAC30-120-700 et seq.);

5. Intellectual Disability Waiver (12VAC30-120-1000 et seq.); or

6. Day Support Waiver (12VAC30-120-1500 et seq.); or

4. Community waiver services for individuals with developmental disabilities (12VAC30-122).

C. The Program of All-Inclusive Care for the Elderly, or PACE, is not available to CCC Plus members.