TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Fast-Track Regulation

Title of Regulation: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (adding 12VAC30-50-492).

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: October 21, 2026.

Effective Date: November 5, 2026.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

Basis: Section 32.1-325 of the Code of Virginia authorizes the Board of Medical Assistance Services to administer and amend the Plan for Medical Assistance and to promulgate regulations. Section 32.1-324 of the Code of Virginia grants the Director of the Department of Medical Assistance Services (DMAS) the authority of the board when it is not in session.

Purpose: This regulatory action is essential to protect the health, safety, and welfare of Medicaid and Children's Health Insurance Program (CHIP) members who demonstrate the need for these case management services because these services help individuals with severe brain injuries and their family members in accessing necessary medical, social, educational, and other services essential to meeting individual recovery goals.

Rationale for Using Fast-Track Rulemaking Process: This rulemaking is expected to be noncontroversial because these services are already being provided to eligible Medicaid and CHIP members.

Substance: The amendments establish new requirements for the coverage of Brain Injury Services Case Management services in 12VAC30-50-492.

Issues: The advantages of these changes to the public and the Commonwealth are that the amendments align the regulation with federal and state requirements. These changes create no disadvantages to the public, DMAS, the Commonwealth, or the regulated community.

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. Pursuant to Chapter 11 of the 2022 General Assembly Special Session I (Chapter 11),² the director of the Department of Medical Assistance Services, on behalf of the Board of Medical Assistance Services (board), proposes to establish regulations to provide targeted case management services for individuals with severe traumatic brain injury.

Background. Chapter 11 directed the board to start providing coverage for targeted case management services for individuals with severe traumatic brain injury. These services help individuals with severe brain injuries and their family members access necessary medical, social, educational and other services essential to meeting individual recovery goals. Following the passage of Chapter 11, the Department of Medical Assistance Services (DMAS) obtained approval from the Centers for Medicare and Medicaid Services on November 22, 2023, and May 17, 2024; DMAS started providing these services on January 1, 2024. This action would incorporate the provision of the services into the Virginia Administrative Code.

Estimated Benefits and Costs. The fiscal impact statement for Chapter 11 estimated that approximately 1,698 Medicaid members would be eligible for targeted case management services for severe brain injury and the total estimated annual expenditures would be $6,018,734 ($1,782,456 in general fund and $4,236,278 in federal match) in fiscal year 2025.³ However, DMAS reports that the actual use of these services has remained significantly below the 2022 estimates. More specifically, in 2025 the total expenditures for this service amounted to $40,338 for 38 recipients. Of this total, $21,691 (approximately $10,930 in general fund and $10,761 in federal match) was for 20 recipients in traditional Medicaid and $18,647 (approximately $16,782 in provider assessment and $10,761 in federal match) was for 18 recipients in the Medicaid expansion population. Generally, provision of a new Medicaid service benefits recipients by addressing their health care needs; benefits providers by creating a new revenue source; brings in federal funds to the Commonwealth through the federal match; costs the state a portion of the total cost for traditional Medicaid (i.e., 50.39%); and costs the Medicaid providers a small portion of the total cost for Medicaid expansion (i.e., 10 percent) population. While similar effects would be expected in this case as well, it is notable that the actual case management expenditures in 2025 for recipients with severe brain injury were significantly lower than the projections. Additionally, the new expenditures result from the legislation rather than the regulation. Thus, the main effect of this regulatory action is compliance with the legislation.

Businesses and Other Entities Affected. This regulation directly applies to individuals in the traditional Medicaid and Medicaid expansion populations with severe brain injury, and to providers enrolled in Medicaid. In 2025, 38 recipients received this service, but the usage may grow over time based on the 2022 estimates. Currently, there are seven providers enrolled to provide these services. No entity appears to be particularly impacted. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁴ 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.⁵ The main effect of this regulatory action is compliance with the legislation. Thus, no adverse impact is indicated on account of this regulatory action.

Small Businesses⁶ Affected.⁷ The proposed amendments do not adversely affect small businesses.

Localities⁸ Affected.⁹ The proposed amendments do not introduce costs for localities, nor do they particularly affect any locality.

Projected Impact on Employment. No impact on employment is expected on account of this regulatory action.

Effects on the Use and Value of Private Property. No effect 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 https://legacylis.virginia.gov/cgi-bin/legp604.exe?222+ful+CHAP0011.

³ https://legacylis.virginia.gov/cgi-bin/legp604.exe?222+oth+HB680F122+PDF.

⁴ 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.

⁵ 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.

⁶ 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."

⁷ 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.

⁸ "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.

⁹ 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:

Coverage for targeted case management for individuals with severe brain injuries was approved by the Centers for Medicare and Medicaid Services on November 22, 2023, and May 17, 2024, and the amendments incorporate those changes into the Virginia Administrative Code in the State Plan for Medical Assistance for both Medicaid and Children's Health Insurance Program members.

12VAC30-50-492. Brain injury services case management.

A. Brain injury case management services are intended for Medicaid and Family Access to Medical Insurance Security (FAMIS) eligible individuals 18 years of age and older who have a physician or primary care physician documented diagnosis of a severe traumatic brain injury (TBI). Individuals younger than 21 years of age may receive case management services through other state plan options, including developmental disability case management (12VAC30-50-490), mental health and addictions treatment case management (12VAC30-50-430 and 12VAC30-50-491), treatment foster care case management (12VAC30-50-480), or early intervention case management for individuals younger than three years of age (12VAC30-50-415) who meet the criteria to receive case management services. Medicaid and FAMIS eligible individuals who qualify for other state plan targeted case management options may only receive one targeted case management service at a time. The individual will need to choose the targeted case management service option that meets individualized service and support needs. Brain damage secondary to other neurological insults (e.g., infection of the brain, stroke, brain tumor, Alzheimer's disease, and similar neuro-degenerative diseases) shall not be covered. The TBI shall be severe as indicated by a T-score of 50 or above on the Mayo-Portland Adaptability Inventory (MPAI-4).

B. Case management services will be made available for up to 180 days consecutive days of a covered stay in a medical institution. This does not apply to individuals between 22 and 64 years of age who are served in institutions for mental disease or individuals who are inmates of public institutions.

C. Services will be provided to the entire state.

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

E. Brain injury services case management services are services furnished to assist individuals eligible under the State Plan in gaining access to needed medical, social, educational, and other services. An individual receiving brain injury services case management services shall have an individual service plan that requires a minimum of one brain injury services case management service activity each month and at least one face-to-face contact with the individual at least every 90 calendar days.

Brain injury case management service activities to be provided shall include:

1. Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social, or other services, including services provided as an Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service if applicable. These assessment activities include:

a. Taking client history;

b. Identifying the individual's needs and completing related documentation;

c. Gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary) to form a complete assessment of the eligible individual; and

d. Periodic reassessments, including evaluating and updating the individual's progress toward meeting the individual service plan objectives and shall occur as needed and at a minimum every 90 calendar days during a review of the individual service plan with the individual.

2. Development (and periodic revision) of a specific individual service plan that is based on the information collected through the assessment that:

a. Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

b. Includes activities, such as ensuring the active participation of the eligible individual and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals; and

c. Identifies a course of action to respond to the assessed needs of the eligible individual.

3. Referral and related activities, such as scheduling appointments for the individual, to help the eligible individual obtain needed services, including activities that help link the individual with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the individual service plan, and

a. Enhancing and linking to community integration through increased opportunities for community access and involvement, such as opportunities to learn living skills to promote community adjustment to the maximum extent possible, vocational, civic, recreational services, and the use of other local community resources available to the general public;

b. Making collateral contacts for the direct benefit of the individual with the individual's significant others (i.e., legally responsible individuals, legal guardians, service providers, anyone with a role in the individual's recovery) with properly authorized releases to promote implementation of the individual's individual service plan and community adjustment;

c. Assisting the individual directly to locate, develop, or obtain needed services, resources, and appropriate public benefits to promote implementation of the individual's individual service plan and community adjustment; and

d. Ensuring the coordination of services and service planning within a provider agency, with other providers, and with other human service agencies and systems, such as local health and social services departments.

4. Monitoring and follow-up activities:

a. Activities and contacts necessary to ensure the individual service plan is implemented and adequately addresses the eligible individual's needs that may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary and including at least one annual monitoring to determine whether the following conditions are met:

(1) Services are being furnished in accordance with the individual's individual service plan;

(2) Services in the individual service plan are adequate; and

(3) Changes in the needs or status of the individual are reflected in the individual service plan. Monitoring and follow-up activities include making necessary adjustments in the individual service plan and service arrangements with providers.

b. On an annual basis, the person-centered individual service plan is conducted to review current status and changes from previous years. It also includes a review of provider plans. As needed outside the annual review, the case manager may convene a meeting to re-evaluate the appropriateness of the plan if the individual's needs have changed. Case managers conduct reviews every 90 calendar days of a services plan and effectiveness of that plan to determine if it remains appropriate and whether modifications are needed.

F. Brain injury services case management includes contacts with noneligible individuals who are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs.

G. Qualifications of providers:

1. The provider of brain injury case management services must meet the following criteria:

a. The enrolled provider must be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) or be licensed by the Department of Behavioral Health and Developmental Services (DBHDS) as a provider of case management services;

b. The enrolled provider shall guarantee that individuals have access to emergency services on a 24-hour basis;

c. The enrolled provider shall demonstrate the ability to serve individuals in need of comprehensive services regardless of the individual's ability to pay or eligibility for Medicaid or Children's Health Insurance Program (CHIP) reimbursement;

d. The enrolled provider must have the administrative and financial management capacity to meet state and federal requirements; and

e. The enrolled provider must have the ability to document and maintain individual case records in accordance with state and federal requirements.

2. Providers may bill Medicaid or CHIP for brain injury case management only when the services are provided by a professional or professionals who meet the following criteria:

a. At least a bachelor's degree from an accredited college or university and a Qualified Brain Injury Support Provider (QBISP) or Certified Brain Injury Specialist (CBIS) or

b. Licensure by the Commonwealth as a registered nurse and a QBISP or CBIS.

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

1. Eligible recipients will have free choice of the providers of brain injury services case management services.

2. Eligible recipients will have free choice of the providers of other services under the plan.

I. The Commonwealth ensures the following regarding access to services:

1. Case management services will not be used to restrict an individual's access to other Medicaid or CHIP services.

2. Individuals will not be compelled to receive case management services, condition receipt of case management services on receipt of other Medicaid or CHIP services, or condition receipt of other Medicaid or CHIP services on receipt of case management services, and the receipt of case management services shall not be a condition for receipt of other Medicaid or CHIP services.

3. Providers of case management services do not exercise Department of Medical Assistance (DMAS) authority to authorize or deny the provision of other Medicaid or CHIP services.

J. Payment for brain injury case management services under the State Plan does not duplicate payments for other case management made to public agencies or private entities under other program authorities for this same purpose.

K. Brain injury case management shall not include the following:

1. Activities not consistent with the definition of case management services in 42 CFR 440.169.

2. The direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred.

3. Activities integral to the administration of foster care programs.

4. Activities for which third parties are liable to pay, except for case management that is included in an individualized education program or individualized family service plan consistent with § 1903(c) of the Act.