Title of Regulation: 12VAC30-135. Demonstration Waiver Services (amending 12VAC30-135-140).

Statutory Authority: §§ 32.1-324 and 32.1-325 of the Code of Virginia.

Effective Date: July 1, 2010.

Agency Contact: Brian McCormick, Regulatory Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-8856, FAX (804) 786-1680, or email brian.mccormick@dmas.virginia.gov.

Summary:

This amendment is required to comply with Item 297 XX of the 2010 Virginia Appropriation Act, which requires that the Department of Medical Assistance Services amend the Children’s Mental Health Program Waiver to permit a child to be evaluated as a separate assistance unit of one. The Centers for Medicare and Medicaid Services has approved the change in eligibility. This regulatory change allows children to be counted as a family of one when the child is discharged from a Psychiatric Residential Treatment Facility (PRTF).

Currently, when a child is discharged from a PRTF, eligibility is based on the family's income. This may cause the child to lose Medicaid eligibility for community care and may result in the child remaining in the PRTF for a longer stay. The program only has about 25 children enrolled versus a projected 300. This change will result in more children being enrolled in the waiver and save the Commonwealth from having to pay the higher costs of a PRTF.

12VAC30-135-140. Client eligibility requirements and intake process.

A. Virginia will apply the financial eligibility criteria contained in the State Plan for the categorically needy evaluate clients for the CMH waiver as a separate assistance unit of one regardless of whether the child is living in the home with a parent or guardian, or siblings. Under this waiver, clients must meet the financial and nonfinancial Medicaid eligibility criteria and meet the PRTF institutional level-of-care criteria. DMAS shall be the single state agency authority responsible for the supervision and administration of the CMH waiver.

B. The following three criteria shall apply to all CMH waiver services:

1. Clients qualifying for CMH waiver services must have a demonstrated need for the service resulting in significant functional limitations. The need for the service must arise from the client having a SED and meeting the level-of-care for admission to a PRTF;

2. The services described in the ISP, and services as delivered, must be consistent with the Medicaid definition of each service; and

3. Services must be recommended based on a current assessment using a DMAS-approved assessment instrument and a client's demonstrated need for each specific service.

C. Assessment, screening, authorization and enrollment in home and community-based care services.

1. To ensure that Virginia's CMH waiver serves only clients who would otherwise remain in a PRTF, home and community-based care services shall be considered only for clients who have resided in a PRTF for at least 90 days to ensure that the client's condition has been stabilized. Home and community-based care services shall be the critical service that enables the client to be discharged home rather than remaining in a PRTF. Clients must receive at least one CMH waiver service to remain in the waiver.

2. CMH waiver services must be determined by DMAS or a DMAS-contracted entity to be an appropriate service alternative as defined in these regulations to remaining in a PRTF.

3. The client shall be recommended for CMH waiver services after completion of a comprehensive assessment of the client's needs and available supports. The completion of an assessment is mandatory before the client can be enrolled in the CMH waiver and Medicaid assumes payment responsibility for the waiver services.

4. The CMH waiver screener shall gather relevant medical, social, and psychological data and identify services to meet the client's needs in the community.

5. The client or family/caregiver, as appropriate, must be offered the choice of CMH waiver services or to remain in the PRTF. If the client chooses CMH waiver services, the client must also be offered the choice of waiver providers.

6. The screener shall explore alternative settings and services to provide the care needed by the client.

7. Medicaid will not pay for any home and community-based care services delivered prior to the authorization date approved by DMAS or a DMAS-contracted entity. Any CSP for home and community-based care services must be preapproved by DMAS prior to Medicaid reimbursement for waiver services.

D. Screening for the CMH waiver.

1. Clients requesting CMH waiver services will be screened and will receive services on a first-come, first-served basis based on the availability of services in the community to support the client.

2. To be eligible for CMH waiver services, the client must:

a. Have been a resident of a PRTF for at least 90 days prior to applying for the CMH waiver;

b. Continue to meet the PRTF criteria described in 12VAC30-50-130;

c. Have services identified in the community to meet the client's needs;

d. Have a case manager assigned; and

e. Continue to meet Medicaid eligibility criteria.

E. Waiver approval process: authorizing and accessing services.

1. The screener is the entity responsible for assessing the client to determine if the client meets the criteria for admission to the CMH waiver.

2. If a client is a CSA client, the screener shall be the CSA representative. If the client is not a CSA client, the screener shall be the mental health or treatment foster care case manager.

3. Once the screener has determined that a client meets the eligibility criteria for CMH waiver services and the client or family/caregiver, as appropriate, has chosen this program, the client or family/caregiver will be provided with a list of available service providers. The client or family/caregiver, as appropriate, must be given a choice of providers if there is more than one provider available that can meet the client's needs. The client or family/caregiver, as appropriate, must also be given a choice of CD or agency-directed respite and companion services, if the client is eligible for these services.

4. When all required information has been submitted to DMAS or its contractor for preauthorization, DMAS or the contractor will have 10 business days to review preauthorization requests. If the request is approved, the client will be sent written notification of enrollment in the CMH waiver and services may begin.

5. Only CMH waiver services authorized on the CSP by the screening entity according to DMAS policies may be reimbursed by DMAS.

6. All CSPs are subject to approval by DMAS.

F. Reevaluation of service need.

1. The comprehensive service plan (CSP).

a. The CSP shall be reviewed at intervals as determined by DMAS with the case manager, client, family/caregiver, service providers, consultants, and others involved in the care of the client based on relevant, current assessment data.

b. The case manager is responsible for continuous monitoring of the appropriateness of the client's services and revisions to the CSP as indicated by the changing needs of the client. The case manager must review the CSP at least every three months to determine whether service goals and objectives are being met and whether any modifications to the CSP are necessary.

c. Any modification to the amount or type of services in the CSP must be approved by the client or family/caregiver, as appropriate, and be pre-authorized by DMAS.

2. Review of level-of-care.

a. The case manager shall complete a reassessment annually, in coordination with the client, family/caregiver, service providers, consultants, and others involved in the care of the client, to ensure that the client continues to meet the PRTF criteria. The reassessment shall include the completion of the assessment instrument and any other appropriate assessment data. If warranted, the case manager shall coordinate a medical examination and a mental health assessment for the client. The CSP shall be revised as appropriate.

b. A new mental health assessment shall be required whenever the current mental health assessment is no longer reflective of the client's current condition.

3. The case manager will monitor the service providers' ISPs to ensure that all providers are working toward the identified goals of the client.

4. Case managers will be required to conduct a minimum of quarterly face-to-face visits for all CMH waiver clients.