Title of Regulation: 12VAC30-120. Waivered Services (adding 12VAC30-120-199, 12VAC30-120-990).

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

Effective Dates: September 4, 2012, through September 3, 2013.

Agency Contact: Melissa Fritzman, Project Manager, Division of Long Term Care Services, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 225-4206, FAX (804) 612-0040, or email melissa.fritzman@dmas.virginia.gov.

Preamble:

The department is promulgating these emergency regulations to comply with Chapter 890, Item 297 CCCCC of the 2011 Acts of Assembly, The department's waiver programs, prior to this mandate, did not limit personal care services. The legislative mandate requires the department to limit personal care services to 56 hours per week and develop criteria by which a waiver individual could qualify for more than 56 hours of personal care services in a week. The department has initiated the new limit of 56 hours of personal care services in a separate final exempt regulatory action.

The Children's Mental Health Waiver and Alzheimer's Assisted Living Waiver are not included in this regulatory action because those waivers do not cover personal care services. The only Medicaid waivers that are covered by this mandate that do cover personal care services are the HIV/AIDS and Elderly or Disabled with Consumer Direction waivers.

12VAC30-120-199. Exception criteria for personal care services.

DMAS shall apply the following criteria to individuals who request approval of more personal care hours than the maximum allowed 56 hours per week. The waiver individual shall:

1. Presently have a minimum level of care of B (the waiver individual's composite Activities of Daily Living (ADL) score is between seven and 12 and have a medical nursing need) or C (the waiver individual's composite ADL score is nine or higher and have a skilled medical nursing need).

2. In addition to meeting the requirements set out in subdivision 1 of this subsection, the individual shall have one or more of the following:

a. Documentation of dependencies in all of the following activities of daily living: bathing, dressing, transferring, toileting, and eating/feeding, as defined by the current pre-admission screening criteria (submitted to the service authorization contractor via DMAS-99);

b. Documentation of dependencies in both Behavior and Orientation as defined by the current pre-admission screening criteria (submitted to the service authorization contractor via DMAS-99); or

c. Documentation from the local Department of Social Services that the individual has an open case with either Adult Protective Services (APS) or Child Protective Services (CPS) (as described in subdivisions (1) and (2) of this subdivision) and is in need of additional services above the 56 hour per week cap. Documentation can be in the form of a phone log contact or any other documentation supplied (submitted to the service authorization contractor via attestation).

(1) For APS: Is defined as a substantiated APS case with a disposition of needs protective services and the adult accepts the needed services.

(2) For CPS: Is defined as being open to CPS investigation if it is both founded by the investigation and the completed family assessment documents the case with moderate or high risk.

12VAC30-120-990. Exception criteria for personal care services.

DMAS shall apply the following criteria to individuals who request approval of more personal care hours than the maximum allowed 56 hours per week. The waiver individual shall:

1. Presently have a minimum level of care of B (the waiver individual's composite Activities of Daily Living (ADL) score is between seven and 12 and have a medical nursing need) or C (the waiver individual's composite ADL score is nine or higher and have a skilled medical nursing need).

2. In addition to meeting the requirements set out in subdivision 1 of this subsection, the individual shall have one or more of the following:

a. Documentation of dependencies in all of the following activities of daily living: bathing, dressing, transferring, toileting, and eating/feeding, as defined by the current pre-admission screening criteria (submitted to the service authorization contractor via DMAS-99);

b. Documentation of dependencies in both Behavior and Orientation as defined by the current pre-admission screening criteria (submitted to the service authorization contractor via DMAS-99); or

c. Documentation from the local Department of Social Services that the individual has an open case with either Adult Protective Services (APS) or Child Protective Services (CPS) (as described in subdivisions (1) and (2) of this subdivsion) and is in need of additional services above the 56 hour per week cap. Documentation can be in the form of a phone log contact or any other documentation supplied (submitted to the service authorization contractor via attestation).

(1) For APS: Is defined as a substantiated APS case with a disposition of needs protective services and the adult accepts the needed services.

(2) For CPS: Is defined as being open to CPS investigation if it is both founded by the investigation and the completed family assessment documents the case with moderate or high risk.