TITLE 2. AGRICULTURE
VA.R. Doc. No. R17-4805; Filed August 31, 2016, 11:15 a.m.
TITLE 2. AGRICULTURE
VA.R. Doc. No. R16-4712; Filed August 31, 2016, 11:24 a.m.
TITLE 4. CONSERVATION AND NATURAL RESOURCES
VA.R. Doc. No. R16-4803; Filed August 19, 2016, 1:28 p.m.
TITLE 4. CONSERVATION AND NATURAL RESOURCES
VA.R. Doc. No. R17-4826; Filed August 25, 2016, 2:36 p.m.
TITLE 4. CONSERVATION AND NATURAL RESOURCES
VA.R. Doc. No. R17-4867; Filed August 25, 2016, 3:57 p.m.
TITLE 4. CONSERVATION AND NATURAL RESOURCES
VA.R. Doc. No. R17-4866; Filed August 26, 2016, 2:36 p.m.
TITLE 6. CRIMINAL JUSTICE AND CORRECTIONS
VA.R. Doc. No. R15-4108; Filed August 23, 2016, 3:58 p.m.
TITLE 9. ENVIRONMENT
VA.R. Doc. No. R17-4834; Filed August 30, 2016, 8:41 a.m.
TITLE 9. ENVIRONMENT
VA.R. Doc. No. R17-4860; Filed August 30, 2016, 8:21 a.m.
TITLE 11. GAMING
VA.R. Doc. No. R17-4844; Filed August 23, 2016, 11:47 a.m.
TITLE 11. GAMING
VA.R. Doc. No. R17-4845; Filed August 23, 2016, 11:56 a.m.
TITLE 12. HEALTH
VA.R. Doc. No. R15-4176; Filed August 19, 2016, 3:16 p.m.
TITLE 12. HEALTH
Title of Regulation: 12VAC5-90. Regulations for
Disease Reporting and Control (amending 12VAC5-90-10, 12VAC5-90-80,
12VAC5-90-90, 12VAC5-90-100, 12VAC5-90-110, 12VAC5-90-280; repealing
12VAC5-90-50, 12VAC5-90-290 through 12VAC5-90-360).
Statutory Authority: § 32.1-35 of the Code of
Virginia.
Effective Date: October 20, 2016.
Agency Contact: Diane Woolard, Ph.D., Director, Division
of Surveillance and Investigation, Department of Health, 109 Governor
Street, Richmond, VA 23219, telephone (804) 864-8124, or email
diane.woolard@vdh.virginia.gov.
Summary:
The amendments (i) update the reportable disease list to
reflect current national recommendations and language; (ii) update the list of
conditions reportable by laboratory directors to reflect current laboratory
technology and public health standards; (iii) increase the information reported
by laboratory directors for hepatitis B and human immunodeficiency virus
testing and the specimens to be submitted to the Division of Consolidated
Laboratory Services or other laboratory designated by the agency for advanced
laboratory testing; (iv) clarify agency role in interstate and national
notifications; (v) clarify level of information that may be shared with the
agency by schools and other facilities; and (vi) update reporting of dangerous
microbes and pathogens sections to reflect federal code section numbering
changes and other requirements.
Summary of Public Comments and Agency's Response: A
summary of comments made by the public and the agency's response may be
obtained from the promulgating agency or viewed at the office of the Registrar
of Regulations.
Part I
Definitions
12VAC5-90-10. Definitions.
The following words and terms when used in this chapter shall
have the following meanings unless the context clearly indicates otherwise:
[ "Acute care hospital" means a hospital as
defined in § 32.1-123 of the Code of Virginia that provides medical
treatment for patients having an acute illness or injury or recovering from
surgery.
"Adult intensive care unit" means a nursing care
area that provides intensive observation, diagnosis, and therapeutic procedures
for persons 18 years of age or more who are critically ill. Such units may also
provide intensive care to pediatric patients. An intensive care unit excludes
nursing areas that provide step-down, intermediate care, or telemetry only. ]
"Affected area" means any part or the whole of the
Commonwealth, which has been identified as where persons reside, or may be
located, who are known to have been exposed to or infected with, or who are
reasonably suspected to have been exposed to or infected with, a communicable
disease of public health threat. "Affected area" shall include, but
not be limited to, cities, counties, towns, and subsections of such areas,
public and private property, buildings, and other structures.
"Arboviral infection" means a viral illness that is
transmitted by a mosquito, tick, or other arthropod. This includes, but is not
limited to, chikungunya [ (CHIK) ], dengue, eastern equine
encephalitis (EEE), LaCrosse encephalitis (LAC) [ , also known as
California encephalitis ], St. Louis encephalitis (SLE), [ and ]
West Nile virus (WNV) [ , and Zika virus (Zika) ] infection.
"Board" means the State Board of Health.
"Cancer" means all carcinomas, sarcomas, melanomas,
leukemias, and lymphomas excluding localized basal and squamous cell carcinomas
of the skin, except for lesions of the mucous membranes.
"CDC" means the Centers for Disease Control and
Prevention of the U.S. Department of Health and Human Services.
[ "Central line-associated bloodstream
infection" means a primary bloodstream infection identified by laboratory
tests, with or without clinical signs or symptoms, in a patient with a central
line device, and meeting the current ] Centers for Disease Control
and Prevention (CDC) [ CDC surveillance definition for
laboratory-confirmed primary bloodstream infection.
"Central line device" means a vascular infusion
device that terminates at or close to the heart or in one of the ] greater
[ great vessels. The following are considered great vessels for
the purpose of reporting central line infections and counting central line
days: aorta, pulmonary artery, superior vena cava, inferior vena cava,
brachiocephalic veins, internal jugular veins, subclavian veins, external iliac
veins, and common femoral veins. ]
"Child care center" means a child day center, child
day program, family day home, family day system, or registered family day home
as defined by § 63.2-100 of the Code of Virginia, or a similar place providing
day care of children by such other name as may be applied.
"Clinic" means any facility, freestanding or
associated with a hospital, that provides preventive, diagnostic, therapeutic,
rehabilitative, or palliative care or services to outpatients.
"Commissioner" means the State Health Commissioner
or his duly designated officer or agent, unless stated in a provision of
[ these regulations this chapter ] that it applies to
the State Health Commissioner in his sole discretion.
"Communicable disease" means an illness due to an
infectious agent or its toxic products which is transmitted, directly or
indirectly, to a susceptible host from an infected person, animal, or arthropod
or through the agency of an intermediate host or a vector or through the
inanimate environment.
"Communicable disease of public health
significance" means an illness caused by a specific or suspected
infectious agent that may be transmitted directly or indirectly from one
individual to another. This includes but is not limited to infections caused by
human immunodeficiency viruses, bloodborne pathogens, and tubercle bacillus.
The State Health Commissioner may determine that diseases caused by other
pathogens constitute communicable diseases of public health significance.
"Communicable disease of public health threat"
means an illness of public health significance, as determined by the State
Health Commissioner in accordance with [ these regulations this
chapter ], caused by a specific or suspected infectious agent that may
be reasonably expected or is known to be readily transmitted directly or
indirectly from one individual to another and has been found to create a risk
of death or significant injury or impairment; this definition shall not,
however, be construed to include human immunodeficiency viruses or the tubercle
bacilli, unless used as a bioterrorism weapon.
"Companion animal" means [ , consistent
with the provisions of § 3.2-6500 of the Code of Virginia, ] any
domestic or feral dog, domestic or feral cat, nonhuman primate, guinea pig,
hamster, rabbit not raised for human food or fiber, exotic or native animal,
reptile, exotic or native bird, or any feral animal or any animal under the
care, custody, or ownership of a person or any animal that is bought, sold,
traded, or bartered by any person. Agricultural animals, game species, or any
animals regulated under federal law as research animals shall not be considered
companion animals for the purpose of this [ regulation chapter ].
"Condition" means any adverse health event, such as
a disease, an infection, a syndrome, or as indicated by a procedure (including
but not limited to the results of a physical exam, laboratory test, or imaging
interpretation) suggesting that an exposure of public health importance has
occurred.
"Contact" means a person or animal known to have
been in such association with an infected person or animal as to have had an
opportunity of acquiring the infection.
"Contact services" means a broad array of services
that are offered to persons with infectious diseases and their contacts.
Contact services include contact tracing, providing information about current
infections, developing risk reduction plans to reduce the chances of future
infections, and connecting to appropriate medical care and other services.
"Contact tracing" means the process by which an
infected person or health department employee notifies others that they may
have been exposed to the infected person in a manner known to transmit the
infectious agent in question.
[ "Coronavirus infection, severe" means
suspected or confirmed infection with severe acute respiratory syndrome
(SARS)-associated coronavirus (SARS-CoV), Middle East respiratory syndrome
(MERS)-associated coronavirus (MERS-CoV), or another coronavirus causing a
severe acute illness. ]
"Decontamination" means the use of physical or
chemical means to remove, inactivate, or destroy hazardous substances or
organisms from a person, surface, or item to the point that such substances or
organisms are no longer capable of causing adverse health effects and the
surface or item is rendered safe for handling, use, or disposal.
"Department" means the State Department of Health
[ , also referred to as the Virginia Department of Health (VDH) ].
"Designee" or "designated officer or
agent" means any person, or group of persons, designated by the State
Health Commissioner, to act on behalf of the commissioner or the board.
"Ehrlichiosis/anaplasmosis" "Ehrlichiosis/Anaplasmosis"
means human infections caused by Ehrlichia chaffeensis (formerly included in
the category "human monocytic ehrlichiosis" or "HME"),
Ehrlichia ewingii or Anaplasma phagocytophilum (formerly included in the
category "human granulocytic ehrlichiosis" or "HGE").
"Epidemic" means the occurrence in a community or
region of cases of an illness clearly in excess of normal expectancy.
"Essential needs" means basic human needs for
sustenance including but not limited to food, water, [ clothing, ]
and health care, (e.g., medications, therapies, testing, and
durable medical equipment).
"Exceptional circumstances" means the presence, as
determined by the commissioner in his sole discretion, of one or more factors
that may affect the ability of the department to effectively control a
communicable disease of public health threat. Factors to be considered include
but are not limited to: (i) characteristics or suspected characteristics of the
disease-causing organism or suspected disease-causing organism such as
virulence, routes of transmission, minimum infectious dose, rapidity of disease
spread, the potential for extensive disease spread, and the existence and
availability of demonstrated effective treatment; (ii) known or suspected risk
factors for infection; (iii) the potential magnitude of the effect of the
disease on the health and welfare of the public; and (iv) the extent of
voluntary compliance with public health recommendations. The determination of
exceptional circumstances by the commissioner may take into account the
experience or results of investigation in Virginia, another state, or another
country.
"Foodborne outbreak" means two or more cases of a
similar illness acquired through the consumption of food contaminated with
chemicals or an infectious agent or its toxic products. Such illnesses include
but are not limited to heavy metal intoxication, staphylococcal food poisoning,
botulism, salmonellosis, shigellosis, Clostridium perfringens food poisoning,
hepatitis A, and Shiga toxin-producing Escherichia coli O157:H7
infection.
"Healthcare-associated infection" (also known as
nosocomial infection) means a localized or systemic condition resulting from an
adverse reaction to the presence of an infectious agent or agents or its toxin
or toxins that (i) occurs in a patient in a healthcare health care
setting (e.g., a hospital or outpatient clinic), (ii) was not found to be
present or incubating at the time of admission unless the infection was related
to a previous admission to the same setting, and (iii) if the setting is a
hospital, meets the criteria for a specific infection site as defined by CDC.
"Hepatitis C, acute" means the following clinical
characteristics are met: (i) discrete onset of symptoms indicative of viral
hepatitis and (ii) jaundice or elevated serum aminotransferase levels and the
following laboratory criteria are met: (a) serum alanine aminotransferase
levels (ALT) greater than [ 400 200 ] IU/L; (b) IgM
anti-HAV negative (if done); (c) IgM anti-HBc negative (if done); and (d)
hepatitis C virus antibody (anti-HCV) [ screening test ]
positive [ with a signal-to-cutoff ratio predictive of a true positive
as determined for the particular assay as defined by CDC, HCV antibody positive
by immunoblot (RIBA) ], [ HCV antigen positive, ] or
HCV RNA positive by nucleic acid test.
"Hepatitis C, chronic" means that the laboratory
criteria specified in clauses (b), (c) and (d) listed above for an acute case
are met but clinical signs or symptoms of acute viral hepatitis are not present
and serum alanine aminotransferase (ALT) levels do not exceed [ 400
200 ] IU/L. This category will include cases that may be acutely
infected but not symptomatic.
"Immunization" means a procedure that increases the
protective response of an individual's immune system to specified pathogens.
"Independent pathology laboratory" means a
nonhospital or a hospital laboratory performing surgical pathology, including
fine needle aspiration biopsy and bone marrow specimen examination services,
which reports the results of such tests directly to physician offices, without
reporting to a hospital or accessioning the information into a hospital tumor
registry.
"Individual" means a person or companion animal.
When the context requires it, "person or persons" shall be deemed to
include any individual.
"Infection" means the entry and multiplication or
persistence of a disease-causing organism (prion, virus, bacteria, fungus,
parasite, or ectoparasite) in the body of an individual. An infection may be
inapparent (i.e., without recognizable signs or symptoms but identifiable by
laboratory means) or manifest (clinically apparent).
"Influenza A, novel virus" means infection of a
human with an influenza A virus subtype that is different from currently
circulating human influenza H1 and H3 viruses. Novel subtypes include H2, H5,
H7, and H9 subtypes or influenza H1 and H3 subtypes originating from a nonhuman
species.
"Invasive" means the organism is affecting a
normally sterile site, including but not limited to blood or cerebrospinal
fluid.
"Investigation" means an inquiry into the
incidence, prevalence, extent, source, mode of transmission, causation of, and
other information pertinent to a disease occurrence.
"Isolation" means the physical separation,
including confinement or restriction of movement, of an individual or
individuals who are infected with, or are reasonably suspected to be infected
with, a communicable disease in order to prevent or limit the transmission of
the communicable disease to uninfected and unexposed individuals.
"Isolation, complete" means the full-time
confinement or restriction of movement of an individual or individuals infected
with, or reasonably suspected to be infected with, a communicable disease in
order to prevent or limit the transmission of the communicable disease to
uninfected and unexposed individuals.
"Isolation, modified" means a selective, partial
limitation of freedom of movement or actions of an individual or individuals
infected with, or reasonably suspected to be infected with, a communicable
disease. Modified isolation is designed to meet particular situations and
includes but is not limited to the exclusion of children from school, the
prohibition or restriction from engaging in a particular occupation or using
public or mass transportation, or requirements for the use of devices or
procedures intended to limit disease transmission.
"Isolation, protective" means the physical
separation of a susceptible individual or individuals not infected with, or not
reasonably suspected to be infected with, a communicable disease from an
environment where transmission is occurring, or is reasonably suspected to be
occurring, in order to prevent the individual or individuals from acquiring the
communicable disease.
"Laboratory" as used herein means a clinical
laboratory that examines materials derived from the human body for the purpose
of providing information on the diagnosis, prevention, or treatment of disease.
"Laboratory director" means any person in charge of
supervising a laboratory conducting business in the Commonwealth of Virginia.
"Law-enforcement agency" means any sheriff's
office, police department, adult or youth correctional officer, or other agency
or department that employs persons who have law-enforcement authority that is
under the direction and control of the Commonwealth or any local governing
body. "Law-enforcement agency" shall include, by order of the
Governor, the Virginia National Guard.
[ "Lead, elevated blood levels" means a
confirmed blood level greater than or equal to ] 10 micrograms of
lead per deciliter (µg/dL) of whole blood in a child or children 15 years
of age and younger, a venous blood lead level greater than or equal to 25
µg/dL in a person older than 15 years of age, or such lower blood lead
level as may be recommended for individual intervention by the department or
the Centers for Disease Control and Prevention [ the reference
value established by the CDC. In 2012, the reference value was 5 µg/dL in
children and 10 µg/dL for persons "Lead, reportable
levels" means any detectable blood lead level in children 15 years of age
and younger and levels greater than or equal to 5 µg/dL in a person ]
older than 15 years of age.
"Least restrictive" means the minimal limitation of
the freedom of movement and communication of an individual while under an order
of isolation or an order of quarantine that also effectively protects unexposed
and susceptible individuals from disease transmission.
"Medical care facility" means any hospital or
nursing home licensed in the Commonwealth, or any hospital operated by or
contracted to operate by an entity of the United States government or the
Commonwealth of Virginia.
"Midwife" means any person who is licensed as a
nurse midwife by the Virginia Boards of Nursing and Medicine or who is licensed
by the Board of Medicine as a certified professional midwife.
"National Healthcare Safety Network (NHSN)" or
"NHSN" means a surveillance system created by the CDC for
accumulating, exchanging, and integrating relevant information on infectious
adverse events associated with healthcare health care delivery.
"Nucleic acid detection" means laboratory testing
of a clinical specimen to determine the presence of deoxyribonucleic acid (DNA)
or ribonucleic acid (RNA) specific for an infectious agent using any method,
including hybridization, sequencing, or amplification such as polymerase chain
reaction.
"Nurse" means any person licensed as a professional
nurse or as a licensed practical nurse by the Virginia Board of Nursing.
"Occupational outbreak" means a cluster of illness
or disease that is indicative of a work-related exposure. Such conditions include
but are not limited to silicosis, asbestosis, byssinosis, pneumoconiosis, and
tuberculosis.
"Outbreak" means the occurrence of more cases of a
disease than expected.
"Period of communicability" means the time or times
during which the etiologic agent may be transferred directly or indirectly from
an infected person to another person, or from an infected animal to a person.
"Physician" means any person licensed to practice
medicine or osteopathy by the Virginia Board of Medicine.
"Quarantine" means the physical separation,
including confinement or restriction of movement, of an individual or
individuals who are present within an affected area or who are known to have
been exposed, or may reasonably be suspected to have been exposed, to a
communicable disease and who do not yet show signs or symptoms of infection
with the communicable disease in order to prevent or limit the transmission of
the communicable disease of public health threat to unexposed and uninfected
individuals.
"Quarantine, complete" means the full-time
confinement or restriction of movement of an individual or individuals who do
not have signs or symptoms of infection but may have been exposed, or may
reasonably be suspected to have been exposed, to a communicable disease of
public health threat in order to prevent the transmission of the communicable
disease of public health threat to uninfected individuals.
"Quarantine, modified" means a selective, partial
limitation of freedom of movement or actions of an individual or individuals
who do not have signs or symptoms of the infection but have been exposed to, or
are reasonably suspected to have been exposed to, a communicable disease of
public health threat. Modified quarantine may be designed to meet particular situations
and includes but is not limited to limiting movement to the home, work, and/or
or one or more other locations, the prohibition or restriction from
using public or mass transportation, or requirements for the use of devices or
procedures intended to limit disease transmission.
"Reportable disease" means an illness due to a
specific toxic substance, occupational exposure, or infectious agent, which
affects a susceptible individual, either directly, as from an infected animal
or person, or indirectly through an intermediate host, vector, or the
environment, as determined by the board.
[ "SARS" means severe acute respiratory
syndrome (SARS)-associated coronavirus (SARS-CoV) disease, Middle East
respiratory syndrome (MERS)-associated coronavirus (MERS-CoV) disease, or
another coronavirus causing a severe acute illness. ]
"School" means (i) any public school from
kindergarten through grade 12 operated under the authority of any locality
within the Commonwealth, (ii) any private or [ parochial religious ]
school that offers instruction at any level or grade from kindergarten through
grade 12; [ and ] (iii) any private or [ parochial
religious ] nursery school or preschool, or any private or [ parochial
religious ] child care center [ required to be ]
licensed by the Commonwealth [ ; and (iv) any preschool handicap
classes or Head Start classes ].
"Serology" means the testing of blood, serum, or
other body fluids for the presence of antibodies or other markers of an
infection or disease process.
"Surveillance" means the ongoing systematic
collection, analysis, and interpretation of outcome-specific data for use in
the planning, implementation, and evaluation of public health practice. A
surveillance system includes the functional capacity for data analysis as well
as the timely dissemination of these data to persons who can undertake
effective prevention and control activities.
"Susceptible individual" means a person or animal
who is vulnerable to or potentially able to contract a disease or condition.
Factors that affect an individual's susceptibility include but are not limited
to physical characteristics, genetics, previous or chronic exposures, chronic
conditions or infections, immunization history, or use of medications.
"Toxic substance" means any substance, including
any raw materials, intermediate products, catalysts, final products, or
by-products of any manufacturing operation conducted in a commercial
establishment, that has the capacity, through its physical, chemical or
biological properties, to pose a substantial risk of death or impairment either
immediately or over time, to the normal functions of humans, aquatic organisms,
or any other animal but not including any pharmaceutical preparation which
deliberately or inadvertently is consumed in such a way as to result in a drug
overdose.
"Tubercle bacilli" means disease-causing organisms
belonging to the Mycobacterium tuberculosis complex and includes Mycobacterium
tuberculosis, Mycobacterium bovis, and Mycobacterium africanum or other members
as may be established by the commissioner.
"Tuberculin skin test (TST)" means a test for
demonstrating infection with tubercle bacilli, performed according to the
Mantoux method, in which 0.1 ml of 5 TU strength tuberculin purified protein
derivative (PPD) is injected intradermally on the volar surface of the arm. Any
reaction is observed 48-72 hours after placement and palpable induration is
measured across the diameter transverse to the long axis of the arm. The
measurement of the indurated area is recorded in millimeters and the
significance of the measured induration is based on existing national and
department guidelines.
"Tuberculosis" means a disease caused by tubercle
bacilli.
"Tuberculosis, active disease" (also "active
tuberculosis disease" and "active TB disease"), as defined by
§ 32.1-49.1 of the Code of Virginia, means a disease caused by an airborne
microorganism and characterized by the presence of either (i) a specimen of
sputum or other bodily fluid or tissue that has been found to contain tubercle
bacilli as evidenced by culture or nucleic acid amplification, including
preliminary identification by rapid methodologies; (ii) a specimen of sputum or
other bodily fluid or tissue that is suspected to contain tubercle bacilli as
evidenced by smear, and where sufficient clinical and radiographic evidence of
active tuberculosis disease is present as determined by a physician licensed to
practice medicine in Virginia; or (iii) sufficient clinical and radiographic
evidence of active tuberculosis disease as determined by the commissioner is
present, but a specimen of sputum or other bodily fluid or tissue containing,
or suspected of containing, tubercle bacilli is unobtainable.
"Tuberculosis infection in children age less than 4
<4 years" means a significant reaction resulting from a
tuberculin skin test (TST) or other approved test for latent infection without
clinical or radiographic evidence of active tuberculosis disease, in children
from birth up to their fourth birthday.
"Vaccinia, disease or adverse event" means vaccinia
infection or serious or unexpected events in persons who received the smallpox
vaccine or their contacts, including but not limited to bacterial infections,
eczema vaccinatum, erythema multiforme, generalized vaccinia, progressive
vaccinia, inadvertent inoculation, post-vaccinial encephalopathy or
encephalomyelitis, ocular vaccinia, and fetal vaccinia.
"Waterborne outbreak" means two or more cases of a
similar illness acquired through the ingestion of or other exposure to water contaminated
with chemicals or an infectious agent or its toxic products. Such illnesses
include but are not limited to giardiasis, viral gastroenteritis,
cryptosporidiosis, hepatitis A, cholera, and shigellosis. A single case of
laboratory-confirmed primary amebic meningoencephalitis or of waterborne
chemical poisoning is considered an outbreak.
12VAC5-90-50. Applicability. (Repealed.)
A. This chapter has general application throughout the
Commonwealth.
B. The provisions of the Virginia Administrative Process
Act, which is codified as Chapter 40 (§ 2.2-4000 et seq.) of Title 2.2 of the
Code of Virginia shall govern the adoption, amendment, modification, and
revision of this chapter, and the conduct of all proceedings and appeals
hereunder. All hearings on such regulations shall be conducted in accordance
with § 2.2-4007.01 of the Code of Virginia.
Part III
Reporting of Disease
12VAC5-90-80. Reportable disease list Lists of
diseases that shall be reported.
A. Reportable disease list. The board declares
suspected or confirmed cases of the following named diseases, toxic effects,
and conditions to be reportable by the persons enumerated in 12VAC5-90-90.
Conditions identified by an asterisk (*) require immediate communication to the
local health department by the most rapid means available upon suspicion or
confirmation, as defined in subsection C of this section. Other conditions
should be reported within three days of suspected or confirmed diagnosis.
Acquired immunodeficiency syndrome (AIDS)
Amebiasis
*Anthrax
Arboviral infections (e.g., [ CHIK, ] dengue,
EEE, LAC, SLE, WNV) [ WNV, Zika) ]
Babesiosis
*Botulism
*Brucellosis
Campylobacteriosis
Chancroid
Chickenpox (Varicella)
Chlamydia trachomatis infection
*Cholera
[ *Coronavirus infection, severe ]
Creutzfeldt-Jakob disease if <55 years of age
Cryptosporidiosis
Cyclosporiasis
*Diphtheria
*Disease caused by an agent that may have been used as a
weapon
Ehrlichiosis/Anaplasmosis
Escherichia coli infection, Shiga toxin-producing
Giardiasis
Gonorrhea
Granuloma inguinale
*Haemophilus influenzae infection, invasive
Hantavirus pulmonary syndrome
Hemolytic uremic syndrome (HUS)
*Hepatitis A
Hepatitis B (acute and chronic)
Hepatitis C (acute and chronic)
Hepatitis, other acute viral
Human immunodeficiency virus (HIV) infection
Influenza
*Influenza-associated deaths in children <18 years of age
Lead, [ elevated blood reportable ]
levels
Legionellosis
Leprosy (Hansen (Hansen's disease)
Leptospirosis
Listeriosis
Lyme disease
Lymphogranuloma venereum
Malaria
*Measles (Rubeola)
*Meningococcal disease
*Monkeypox
Mumps
Ophthalmia neonatorum
*Outbreaks, all (including but not limited to foodborne,
[ healthcare-associated health care-associated ], occupational,
toxic substance-related, and waterborne)
*Pertussis
*Plague
*Poliovirus infection, including poliomyelitis
*Psittacosis
*Q fever
*Rabies, human and animal
Rabies treatment, post-exposure
*Rubella, including congenital rubella syndrome
Salmonellosis
[ *Severe acute respiratory syndrome (SARS),
including any coronavirus causing a severe acute illness ]
Shigellosis
*Smallpox (Variola)
Spotted fever rickettsiosis
Staphylococcus aureus infection, vancomycin-intermediate or
vancomycin-resistant
Streptococcal disease, Group A, invasive or toxic shock
Streptococcus pneumoniae infection, invasive, in children
<5 years of age
Syphilis (report *primary and *secondary syphilis by rapid
means)
Tetanus
Toxic substance-related illness
Trichinosis (Trichinellosis)
*Tuberculosis, active disease
Tuberculosis infection in children <4 years of age
*Tularemia
*Typhoid/Paratyphoid fever
*Unusual occurrence of disease of public health concern
*Vaccinia, disease or adverse event
*Vibrio infection
*Viral hemorrhagic fever
*Yellow fever
Yersiniosis
B. Conditions reportable by directors of laboratories.
Conditions identified by an asterisk (*) require immediate
communication to the local health department by the most rapid means available
upon suspicion or confirmation, as defined in subsection C of this section.
Other conditions should be reported within three days of suspected or confirmed
diagnosis.
Amebiasis - by microscopic examination, culture, antigen
detection, nucleic acid detection, or serologic results consistent with recent
infection
*Anthrax - by culture, antigen detection [ or, ]
nucleic acid detection [ , or serologic results consistent with recent
infection ]
Arboviral infection [ e.g., CHIK, dengue, EEE,
LAC (also known as California encephalitis), SLE, WNV, Zika ] - by
culture, antigen detection, nucleic acid detection, or serologic results
consistent with recent infection
Babesiosis - by culture, antigen detection, nucleic acid
detection, [ microscopic examination, ] or serologic
results consistent with recent infection
*Botulism - by culture, nucleic acid detection, or
identification of toxin neurotoxin in a clinical specimen
*Brucellosis - by culture, antigen detection, nucleic acid
detection, or serologic results consistent with recent infection
Campylobacteriosis - by culture [ or
culture-independent diagnostic test (CIDT) (i.e. ], antigen
detection [ , ] or nucleic acid detection
[ ) ]. [ For CIDT, also ] submit all
[ available ] culture results (positive or negative)
associated with a positive [ antigen detection test
result ].
Chancroid - by culture, antigen detection, or nucleic acid
detection
Chickenpox (varicella) (Varicella) - by culture,
antigen detection, nucleic acid detection, or serologic results consistent with
recent infection
Chlamydia trachomatis infection - by culture, antigen
detection, nucleic acid detection or, for lymphogranuloma venereum, serologic
results consistent with recent infection
*Cholera - by culture [ , antigen detection, nucleic acid
detection, ] or serologic results consistent with recent infection
[ *Coronavirus infection, severe - by culture, nucleic
acid detection, or serologic results consistent with recent infection ]
Creutzfeldt-Jakob disease if <55 years of age by histopathology
in patients under the age of 55 years
Cryptosporidiosis - by microscopic examination, antigen
detection, or nucleic acid detection
Cyclosporiasis - by microscopic examination or nucleic acid
detection
*Diphtheria - by culture or histopathology
Ehrlichiosis/Anaplasmosis - by culture, nucleic acid
detection, [ microscopic examination, ] or serologic results
consistent with recent infection
Escherichia coli infection, Shiga toxin-producing - by culture
of E. coli O157 or other Shiga toxin-producing E. coli, Shiga toxin
detection (e.g., [ by nucleic acid detection, ] EIA),
or [ nucleic acid detection serologic results consistent with
recent infection ]
Giardiasis - by microscopic examination or,
antigen detection, or nucleic acid detection
Gonorrhea - by microscopic examination of a urethral smear
[ specimen ] (males only) [ or endocervical smear
(females only) ], culture, antigen detection, or nucleic acid
detection. Include available antimicrobial susceptibility findings in
report.
*Haemophilus influenzae infection, invasive - by culture,
antigen detection, or nucleic acid detection from a normally sterile site
Hantavirus pulmonary syndrome - by antigen detection
(immunohistochemistry), nucleic acid detection, or serologic results consistent
with recent infection
*Hepatitis A - by detection of IgM antibodies
Hepatitis B (acute and chronic) - by detection of HBsAg,
HBeAg, or IgM antibodies or nucleic acid detection. For any reportable
hepatitis finding, submit all available results from the hepatitis panel.
[ Submit all findings for hepatitis B testing in children younger
than two years of age. ]
Hepatitis C (acute and chronic) - by hepatitis C virus
antibody (anti-HCV) [ screening test ] positive [ with
a signal-to-cutoff ratio predictive of a true positive as determined for the
particular assay as defined by CDC, HCV antibody positive by immunoblot (RIBA) ],
[ HCV antigen positive, ] or HCV RNA positive by nucleic acid
test. For all hepatitis C patients, also report available results of serum
alanine aminotransferase (ALT) [ , anti-HAV IgM, anti-HBc IgM, and
HBsAg. For any reportable hepatitis finding, submit and ]
all available results from the hepatitis panel.
Hepatitis, other acute viral – any finding indicative of
acute infection with hepatitis D, E, or other cause of viral hepatitis. For any
reportable hepatitis finding, submit all available results from the hepatitis
panel.
Human immunodeficiency virus (HIV) infection - by
culture, antigen detection, nucleic acid detection, or detection of antibody confirmed
with a supplemental test. For HIV-infected patients, report all results of
CD4 and HIV viral load tests [ and, including
undetectable viral loads. For HIV-infected patients, report ] all
HIV genetic [ nucleotide ] sequence data associated
with HIV drug resistance tests [ by electronic submission ].
For children [ from birth to less than ] three
years of age, report all tests regardless of the test findings (e.g., negative
or positive).
Influenza - by culture, antigen detection by direct
fluorescent antibody (DFA), or nucleic acid detection
Lead, [ elevated blood reportable ]
levels - [ by blood lead level greater than or equal to ] 10
µg/dL in children ages 0-15 years, or greater than or equal to 25
µg/dL in persons older than 15 years of age [ the reference
value established by CDC. The reference value established in 2012 was 5 µg/dL
in children and 10 by any detectable blood lead level in children
ages 0-15 years or levels greater than or equal to 5 ] µg/dL
in persons older than 15 years of age [ . ]
Legionellosis - by culture, antigen detection (including
urinary antigen), nucleic acid detection, or serologic results consistent with
recent infection
Leptospirosis - by culture, microscopic examination by dark
field microscopy, nucleic acid detection, or serologic results consistent with
recent infection
Listeriosis - by culture [ from a normally sterile
site. If associated with miscarriage or stillbirth, by culture from placental
or fetal tissue ]
Lyme disease - by culture, antigen detection, or detection of
antibody confirmed with a supplemental test
Malaria - by microscopic examination, antigen detection, or
nucleic acid detection
*Measles (rubeola) (Rubeola) - by culture,
antigen detection, nucleic acid detection, or serologic results consistent with
recent infection
*Meningococcal disease - by culture [ , nucleic acid
detection, ] or antigen detection from a normally sterile site
*Monkeypox - by culture or nucleic acid detection
Mumps - by culture, nucleic acid detection, or serologic
results consistent with recent infection
*Mycobacterial diseases - (See 12VAC5-90-225 B) Report any of
the following:
1. Acid fast bacilli by microscopic examination;
2. Mycobacterial identification - preliminary and final
identification by culture or nucleic acid detection;
3. Drug susceptibility test results for M. tuberculosis.
*Pertussis - by culture, antigen detection, [ or ]
nucleic acid detection [ , or serologic results consistent with recent
infection ]
*Plague - by culture, antigen detection, nucleic acid
detection, or serologic results consistent with recent infection
*Poliovirus infection - by culture
*Psittacosis - by culture, antigen detection, nucleic acid
detection, or serologic results consistent with recent infection
*Q fever - by culture, antigen detection, nucleic acid
detection, [ immunohistochemical methods, ] or serologic
results consistent with recent infection
*Rabies, human and animal - by culture, antigen detection by
direct fluorescent antibody test, nucleic acid detection, or, for humans only,
serologic results consistent with recent infection
*Rubella - by culture, nucleic acid detection, or serologic
results consistent with recent infection
Salmonellosis - by culture [ or, ]
antigen detection [ , or nucleic acid detection ]
[ *Severe acute respiratory syndrome, including any
coronavirus causing a severe acute illness - by culture, nucleic acid
detection, or serologic results consistent with recent infection ]
Shigellosis - by culture [ or, ]
antigen detection [ , or nucleic acid detection ]
*Smallpox (variola) (Variola) - by culture or
nucleic acid detection
Spotted fever rickettsiosis - by culture, antigen detection
(including immunohistochemical staining), nucleic acid detection, or serologic
results consistent with recent infection
Staphylococcus aureus infection, resistant, as defined below.:
1. Methicillin-resistant - by antimicrobial susceptibility
testing of a Staphylococcus aureus isolate, with a susceptibility result
indicating methicillin resistance, cultured from a normally sterile site
2. Vancomycin-intermediate or vancomycin-resistant
Staphylococcus aureus infection - by antimicrobial susceptibility testing of a
Staphylococcus aureus isolate, with a vancomycin susceptibility result of
intermediate or resistant, cultured from a clinical specimen. Include
available antimicrobial susceptibility findings in report.
Streptococcal disease, Group A, invasive or toxic shock -
[ for invasive disease, ] by culture from a normally sterile
site [ ; for streptococcal toxic shock, by culture from any body site ]
Streptococcus pneumoniae infection, invasive, in children
<5 years of age - by culture from a normally sterile site in a child under
the age of five years
*Syphilis - by [ microscopic examination (including
dark field) darkfield microscopy, ] antigen detection, [ (including
direct fluorescent antibody) nucleic acid detection, ] or
serology by either treponemal or nontreponemal methods
Toxic substance-related illness - by blood or urine laboratory
findings above the normal range, including but not limited to heavy metals,
pesticides, and industrial-type solvents and gases. When applicable and
available, report speciation of metals when blood or urine levels are elevated
in order to differentiate the chemical species (elemental, organic, or
inorganic).
Trichinosis (trichinellosis) (Trichinellosis) -
by microscopic examination of a muscle biopsy or serologic results consistent
with recent infection
*Tularemia - by culture, antigen detection, nucleic acid
detection, or serologic results consistent with recent infection
*Typhoid/Paratyphoid fever - by culture [ , antigen
detection, or nucleic acid detection ]
*Vaccinia, disease or adverse event - by culture or nucleic
acid detection
*Vibrio infection - [ by culture. Include
Photobacterium damselae and Grimontia hollisae as well as Vibrio species.
isolation of any species of the family Vibrionaceae (other than toxigenic
Vibrio cholera O1 or O139, which are reportable as cholera) from a clinical
specimen by culture, antigen detection, or nucleic acid detection ]
*Viral hemorrhagic fever - by culture, antigen detection
(including immunohistochemical staining), nucleic acid detection, or serologic
results consistent with recent infection
*Yellow fever - by culture, antigen detection, nucleic acid
detection, or serologic results consistent with recent infection
Yersiniosis - by culture, nucleic acid detection, or serologic
results consistent with recent infection
C. Reportable diseases requiring rapid communication. Certain
of the diseases in the list of reportable diseases, because of their extremely
contagious nature or their potential for greater harm, or both, require
immediate identification and control. Reporting of persons confirmed or
suspected of having these diseases, listed below, shall be made immediately by
the most rapid means available, preferably that of telecommunication (e.g.,
by telephone, telephone transmitted facsimile, pagers, etc.) to
the local health director or other professional employee of the
department. (These same diseases are also identified by an asterisk (*) in subsection
A and subsection B subsections A and B, where applicable, of this
section.)
Anthrax
Botulism
Brucellosis
Cholera
[ Coronavirus infection, severe ]
Diphtheria
Disease caused by an agent that may have been used as a weapon
Haemophilus influenzae infection, invasive
Hepatitis A
Influenza-associated deaths in children <18 years of age
Influenza A, novel virus
Measles (Rubeola)
Meningococcal disease
Monkeypox
Outbreaks, all
Pertussis
Plague
Poliovirus infection, including poliomyelitis
Psittacosis
Q fever
Rabies, human and animal
Rubella, including congenital rubella syndrome
[ Severe acute respiratory syndrome (SARS),
including any coronavirus causing a severe acute illness ]
Smallpox (Variola)
Syphilis, primary and secondary
Tuberculosis, active disease
Tularemia
*Typhoid/Paratyphoid Typhoid/Paratyphoid fever
Unusual occurrence of disease of public health concern
Vaccinia, disease or adverse event
Vibrio infection
Viral hemorrhagic fever
Yellow fever
D. Toxic substance-related illnesses. All toxic
substance-related illnesses, including pesticide and heavy metal poisoning or
illness resulting from exposure to an occupational dust or fiber or radioactive
substance, shall be reported.
If such illness is verified or suspected and presents an
emergency or a serious threat to public health or safety, the report of such
illness shall be by rapid communication as in subsection C of this section
made immediately by the most rapid means available [ ,
preferably by telephone ].
E. Outbreaks. The occurrence of outbreaks or clusters of any
illness which may represent a group expression of an illness which may be of
public health concern shall be reported to the local health department immediately
by the most rapid means available [ , preferably by telephone ].
F. Unusual or ill-defined diseases or emerging or reemerging
pathogens. Unusual or emerging conditions of public health concern shall be
reported to the local health department immediately by the most rapid
means available [ , preferably by telephone ]. In addition,
the commissioner or his designee may establish surveillance systems for
diseases or conditions that are not on the list of reportable diseases. Such
surveillance may be established to identify cases (delineate the magnitude of
the situation), to identify the mode of transmission and risk factors for the
disease, and to identify and implement appropriate action to protect public
health. Any person reporting information at the request of the department for
special surveillance or other epidemiological studies shall be immune from
liability as provided by § 32.1-38 of the Code of Virginia.
12VAC5-90-90. Those required to report.
A. Physicians. Each physician who treats or examines any
person who is suffering from or who is suspected of having a reportable disease
or condition shall report that person's name, address, age, date of birth,
race, sex, and pregnancy status for females; name of disease diagnosed or
suspected; the date of onset of illness; [ available laboratory tests
and results; ] and the name, address, and telephone number of the
physician and medical facility where the examination was made, except that
influenza should be reported by number of cases only (and type of influenza, if
available). Reports are to be made to the local health department serving the
jurisdiction where the physician practices. A physician may designate someone
to report on his behalf, but the physician remains responsible for ensuring
that the appropriate report is made. Any physician, designee, or organization
making such report as authorized herein shall be immune from liability as
provided by § 32.1-38 of the Code of Virginia.
Such reports shall be made on a form to be provided by the
department (Form Epi-1) Form Epi-1, a computer generated printout
containing the data items requested on Form Epi-1, or a Centers for Disease
Control and Prevention (CDC) CDC [ or VDH ]
surveillance form that provides the same information and shall be made within
three days of the suspicion or confirmation of disease unless the disease in
question requires rapid reporting under 12VAC5-90-80 C except that those
identified in 12VAC5-90-80 C shall be reported immediately by the most rapid
means available [ , preferably by telephone, ] to the
local health department serving the jurisdiction in which the facility is
located. Reporting may be done by means of secure electronic transmission
upon agreement of the physician and the department.
Pursuant to § 32.1-49.1 of the Code of Virginia,
additional Additional elements are required to be reported for
individuals with confirmed or suspected active tuberculosis disease. Refer to
Part X (12VAC5-90-225 et seq.) for details on these requirements.
B. Directors of laboratories. [ Any person ]
who is [ in charge of a laboratory conducting business in the
Commonwealth Laboratory directors ] shall report any laboratory
examination of any clinical specimen, whether performed in-house or referred to
an out-of-state laboratory, which yields evidence, by the laboratory method(s)
indicated or any other confirmatory test, of a disease listed in 12VAC5-90-80
B.
Each report shall give the source of the specimen and the
laboratory method and result; the name, address, age, date of birth, race, sex,
and pregnancy status for females (if known) of the person from whom the
specimen was obtained; and the name, address, and telephone number of the
physician [ for whom at whose request ] and
medical facility for whom at which the examination was made. When
the influenza virus is isolated, the type should be reported, if available.
Reports shall be made within three days of identification of evidence of
disease, except that those identified by an asterisk in 12VAC5-90-80
C shall be reported immediately by the most rapid means available,
[ , preferably by telephone, ] to the local health department
serving the jurisdiction in which the laboratory is located. Reports shall be
made on Form Epi-1 or on the laboratory's own form if it includes the required
information. Computer generated reports containing the required information may
be submitted. Reporting may be done by means of secure electronic transmission
upon agreement of the laboratory director and the department. [ Reports
of HIV genetic nucleotide sequence data associated with HIV drug resistance
tests must be submitted electronically. ] Any person making such
report as authorized herein shall be immune from liability as provided by §
32.1-38 of the Code of Virginia.
A laboratory identifying evidence of any of the following
conditions shall notify the local health department of the positive
culture or other positive test result within the timeframes specified in
12VAC5-90-80 and submit the initial isolate or other initial specimen
to the Virginia Division of Consolidated Laboratory Services (DCLS)
within seven days of identification. All specimens must be identified
with the patient and physician information required in this subsection.
Anthrax
[ Botulism ]
Brucellosis
Cholera
Diphtheria
E. coli infection, Shiga toxin-producing. (Laboratories that
use a Shiga toxin EIA methodology but do not perform simultaneous culture for
Shiga toxin-producing E. coli should forward all positive stool specimens or
positive broth cultures enrichment broths to DCLS the
Division of Consolidated Laboratory Services for confirmation and further
characterization.)
Haemophilus influenzae infection, invasive
[ Human immunodeficiency virus (HIV) (Submit all
remnant HIV diagnostic sera to the Division of Consolidated Laboratory Services
or other laboratory designated by the department for HIV recency testing.) ]
Influenza A, novel virus
Listeriosis
Meningococcal disease
Pertussis
Plague
Poliovirus infection
Q fever
Salmonellosis
Shigellosis
Streptococcal disease, Group A, invasive
Tuberculosis (A laboratory identifying Mycobacterium
tuberculosis complex (see 12VAC5-90-225) shall submit a representative and
viable sample of the initial culture to DCLS the Division of
Consolidated Laboratory Services or other laboratory designated by the
board to receive such specimen.)
[ Tularemia ]
Typhoid/Paratyphoid fever
Vancomycin-intermediate or vancomycin-resistant Staphylococcus
aureus infection
Vibrio infection, including infections due to
Photobacterium damselae and Grimontia hollisae
Yersiniosis
Other diseases as may be requested by the health department
When a clinical specimen yields evidence indicating the
presence of a select agent or toxin as defined by federal regulations in 42 CFR
Part 73, the person in charge of the laboratory shall contact the Division of
Consolidated Laboratory Services and arrange to forward an isolate for
confirmation. If a select agent or toxin has been confirmed in a clinical
specimen, the laboratory director shall consult with Division of Consolidated
Laboratory Services or CDC regarding isolate transport or destruction.
Laboratories operating within a medical care facility shall
be considered to be in compliance with the requirement to notify the local
health department when the director of that medical care facility assumes the
reporting responsibility; however, laboratories are still required to submit
isolates to DCLS the Division of Consolidated Laboratory Services
or other designated laboratory as noted above in this subsection.
C. Persons in charge of a medical care facility. Any person
in charge of a medical care facility shall make a report to the local health
department serving the jurisdiction where the facility is located of the
occurrence in or admission to the facility of a patient with a reportable
disease listed in 12VAC5-90-80 A unless he has evidence that the occurrence has
been reported by a physician. Any person making such report as authorized herein
shall be immune from liability as provided by § 32.1-38 of the Code of
Virginia. The requirement to report shall include all inpatient, outpatient,
and emergency care departments within the medical care facility. Such report
shall contain the patient's name, address, age, date of birth, race, sex, and
pregnancy status for females; name of disease being reported; [ available
laboratory tests and results; ] the date of admission; hospital chart
number; date expired (when applicable); and attending physician. Influenza
should be reported by number of cases only (and type of influenza, if
available). Reports shall be made within three days of the suspicion or
confirmation of disease unless the disease in question requires rapid
reporting under 12VAC5-90-80 C and except that those identified in
12VAC5-90-80 C shall be reported immediately by the most rapid means available
[ , preferably by telephone, ] to the local health
department serving the jurisdiction in which the facility is located. Reports
shall be made on Form Epi-1, a computer generated printout containing the data
items requested on Form Epi-1, or a Centers for Disease Control and
Prevention (CDC) CDC [ or VDH ] surveillance form
that provides the same information. Reporting may be done by means of secure
electronic transmission upon agreement of the medical care facility and the
department.
A person in charge of a medical care facility may assume the
reporting responsibility on behalf of the director of the laboratory operating
within the facility.
D. Persons in charge of a residential or day program,
service, or facility licensed or operated by any agency of the Commonwealth, or
a school, child care center, or summer camp. Any person in charge of a
residential or day program, service, or facility licensed or operated by any
agency of the Commonwealth, or a school, child care center, or summer camp as
defined in § 35.1-1 of the Code of Virginia shall report immediately to
the local health department the presence or suspected presence in his program,
service, facility, school, child care center, or summer camp of persons who
have common symptoms suggesting an outbreak situation. Such persons may report
additional information, including individual cases of identifying and
contact information for individuals with communicable diseases of public
health concern or individuals who are involved in outbreaks that occur in
their facilities, as necessary to facilitate public health investigation and
disease control. Any person so reporting shall be immune from liability as
provided by § 32.1-38 of the Code of Virginia.
E. Local health directors. The local health director shall
forward any report of a disease or report of evidence of a disease which has
been made on a resident of his jurisdiction to the Office of Epidemiology
within three days of receipt. This report shall be submitted immediately by the
most rapid means available if the disease is one requiring rapid communication,
as required in 12VAC5-90-80 C. All such rapid reporting shall be confirmed in
writing and submitted to the Office of Epidemiology, by either a paper
report or entry into a shared secure electronic disease surveillance system,
within three days. Furthermore, the local health director shall immediately
forward to the appropriate local health director any disease reports on
individuals residing in the latter's jurisdiction or to the Office of
Epidemiology on individuals residing outside Virginia. The Office of
Epidemiology shall be responsible for notifying other state health departments
of reported illnesses in their residents and [ of for ]
notifying CDC as necessary and appropriate.
F. Persons in charge of hospitals, nursing facilities or
nursing homes, assisted living facilities, and correctional facilities. In
accordance with § 32.1-37.1 of the Code of Virginia, any person in charge of a
hospital, nursing facility or nursing home, assisted living facility, or
correctional facility shall, at the time of transferring custody of any dead
body to any person practicing funeral services, notify the person practicing
funeral services or his agent if the dead person was known to have had,
immediately prior to death, an infectious disease which may be transmitted
through exposure to any bodily fluids. These include any of the following
infectious diseases:
Creutzfeldt-Jakob disease
Human immunodeficiency virus infection
Hepatitis B
Hepatitis C
Monkeypox
Rabies
Smallpox
Syphilis, infectious
Tuberculosis, active disease
Vaccinia, disease or adverse event
Viral hemorrhagic fever
G. Employees, [ applicants, conditional
employees, ] and persons in charge of food establishments.
12VAC5-421-80 of the Food Regulations requires a food employee or applicant
conditional employee to notify the person in charge of the food
establishment when diagnosed with certain diseases that are transmissible
through food. 12VAC5-421-120 and requires the person in charge of
the food establishment to notify the health department regulatory
authority. Refer to the appropriate sections of the Virginia Administrative
Code 12VAC5-421-80 for further guidance and clarification regarding
these reporting requirements.
Part IV
Control of Disease
12VAC5-90-100. Methods.
The board and commissioner shall use appropriate disease
control measures to manage the diseases listed in 12VAC5-90-80 A, including but
not limited to those described in the "Methods of Control" sections
of the 18th 20th Edition of the Control of Communicable Diseases
Manual (2004) (2015) published by the American Public Health
Association. The board and commissioner reserve the right to use any legal
means to control any disease which is a threat to the public health.
When notified about a disease specified in 12VAC5-90-80, the
local health director or his designee shall have the authority and responsibility
to perform contact tracing/contact services for HIV infection, infectious
syphilis, and active tuberculosis disease and may perform contact services for
the other diseases if deemed necessary to protect the public health. All
contacts of HIV infection shall be afforded the opportunity for appropriate
counseling, testing, and individual face-to-face disclosure of their test
results. In no case shall names of informants or infected individuals be
revealed to contacts by the health department. All information obtained shall
be kept strictly confidential.
The local health director or his designee shall review
reports of diseases received from his jurisdiction and follow up such reports,
when indicated, with an appropriate investigation in order to evaluate the
severity of the problem. The local health director or his designee may
recommend to any individual or group of individuals appropriate public health
control measures, including but not limited to quarantine, isolation,
immunization, decontamination, or treatment. He shall determine in consultation
with the Office of Epidemiology and the commissioner if further investigation
is required and if one or more forms of quarantine and/or,
isolation, or both will be necessary.
Complete isolation shall apply to situations where an
individual is infected with a communicable disease of public health
significance (including but not limited to active tuberculosis disease or HIV
infection) and is engaging in behavior that places others at risk for infection
with the communicable disease of public health significance, in accordance with
the provisions of Article 3.01 (§ 32.1-48.02 32.1-48.01 et seq.) of
Chapter 2 of Title 32.1 of the Code of Virginia.
Modified isolation shall apply to situations in which the
local health director determines that modifications of activity are necessary
to prevent disease transmission. Such situations shall include but are not
limited to the temporary exclusion of a child with a communicable disease from
school, the temporary exclusion of an individual with a communicable disease
from food handling or patient care, the temporary prohibition or restriction of
an individual with a communicable disease from using public transportation, the
requirement that a person with a communicable disease use certain personal
protective equipment, or restrictions of other activities that may pose a risk
to the health of others.
Protective isolation shall apply to situations such as the
exclusion, under § 32.1-47 of the Code of Virginia, of any unimmunized child
from a school in which an outbreak, potential epidemic, or epidemic of a
vaccine preventable disease has been identified.
To the extent permitted by the Code of Virginia, the local
health director may be authorized as the commissioner's designee to implement
the forms of isolation described in this section. When these forms of isolation
are deemed to be insufficient, the local health director may use the provisions
of Article 3.01 (§ 32.1-48.01 et seq.) of Chapter 2 of Title 32.1 of the
Code of Virginia for the control of communicable diseases of public health
significance or, in consultation with the Office of Epidemiology, shall provide
sufficient information to enable the commissioner to prepare an order or orders
of isolation and/or, quarantine, or both under Article
3.02 (§ 32.1-48.05 et seq.) of Chapter 2 of Title 32.1 of the Code of
Virginia for the control of communicable diseases of public health threat.
Part V
Immunization of Persons Less Than 18 Years of Age
12VAC5-90-110. Dosage and age requirements for immunizations;
obtaining immunizations.
A. Every person in Virginia less than 18 years of age shall
be immunized in accordance with the most recent Immunization Schedule developed
and published by the Centers for Disease Control and Prevention (CDC) CDC,
Advisory Committee on Immunization Practices (ACIP), the American Academy of
Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).
Requirements for school and day care attendance are addressed in 12VAC5-110.
B. The required immunizations may be obtained from a
physician licensed to practice medicine or from the local health department,
registered nurse, or other licensed professional [ as ] authorized
by the Code of Virginia [ to administer immunizations at
locations to include private settings or local health departments ].
Part XIII
Reporting of Dangerous Microbes and Pathogens
12VAC5-90-280. Definitions. Reporting of dangerous
microbes and pathogens.
A. Definitions. The following words and terms when
used in this part shall have the following meanings unless the context clearly
indicates otherwise:
"Biologic agent" means any microorganism
(including, but not limited to, bacteria, viruses, fungi, rickettsiae, or protozoa),
or infectious substance, or any naturally occurring, bioengineered, or
synthesized component of any such microorganism or infectious substance,
capable of causing death, disease, or other biological malfunction in a human,
an animal, a plant, or other living organism; deterioration of food, water,
equipment, supplies, or material of any kind; or deleterious alteration of the
environment.
"CDC" means the Centers for Disease Control and
Prevention of the U.S. Department of Health and Human Services.
"Diagnosis" means the analysis of specimens for the
purpose of identifying or confirming the presence or characteristics of
a select agent or toxin, provided that such analysis is directly related to
protecting the public health or safety.
"Proficiency testing" means a sponsored,
time-limited analytical trial whereby one or more analytes, previously
confirmed by the sponsor, are submitted to the testing laboratory for analysis
and where final results are graded, scores are recorded and provided to participants,
and scores for participants are evaluated.
"Responsible official" means any person in charge
of directing or supervising a laboratory conducting business in the
Commonwealth of Virginia. At colleges and universities, the responsible
official shall be the president of the college or university or his designee.
At private, state, or federal organizations, the responsible official
shall be the laboratory director or a chief officer of the organization or his
designee.
"Select agent or toxin" or "select agent and
toxin" means all those biological agents or toxins as defined by federal
regulations in 42 CFR Part 73, including: 1. Health and Human
Services (HHS) select agents and toxins, as outlined in 42 CFR 73.4
and overlap select agents and toxins.
2. HHS overlap select agents and toxins, as outlined in 42
CFR 73.5.
"Toxin" means the toxic material or product of
plants, animals, microorganisms (including but not limited to bacteria,
viruses, fungi, rickettsiae, or protozoa); or infectious substances; or a
recombinant or synthesized molecule, whatever the origin and method of
production; and includes any poisonous substance or biological product that may
be engineered as a result of biotechnology or produced by a living organism; or
any poisonous isomer or biological product, homolog, or derivative of such a
substance.
"Verification" means the process required to assure
the accuracy, precision, and the analytical sensitivity and specificity of any
procedure used for diagnosis.
B. Administration. The dangerous microbes and pathogens
will be known as "select agents and toxins." The select agent and
toxin registry will be maintained by the Virginia Department of Health, Office
of Epidemiology, Division of Surveillance and Investigation.
C. Reportable agents. The board declares the select agents
and toxins and overlap select agents and toxins outlined in 42 CFR Part 73 to
be reportable and adopts it herein by reference including subsequent amendments
and editions. The select agents and toxins are to be reportable by the persons
enumerated in subsection F of this section.
D. Items to report. Each report shall be made on a form
determined by the department and shall contain the following: name, source and
characterization information on select agents and toxins and quantities held;
objectives of the work with the agent; location (including building and room)
where each select agent or toxin is stored or used; identification information
of persons with access to each agent; identification information of the person
in charge of each of the agents; and the name, position and identification
information of one responsible official as a single point of contact for the
organization. The report shall also indicate whether the laboratory is
registered with the CDC Select Agent Program and may contain additional
information as required by 42 CFR Part 73 or the department.
E. Timing of reports. Reports shall be made to the
department within seven calendar days of submission of an application to the
CDC Select Agent Program. By January 31 of every year, laboratories shall
provide a written update to the department, which shall include a copy of the
federal registration certificate received through the CDC Select Agent Program.
In the event that a select agent or toxin that has
previously been reported to the department is destroyed, a copy of federal
forms addressing the destruction of the select agent or toxin must be submitted
to the department within seven calendar days of submission to the CDC Select
Agent Program.
In the event that a select agent or toxin, or a specimen
or isolate from a specimen containing a select agent or toxin, has previously
been reported to the department and is subsequently transferred to a facility
eligible for receiving the items, a copy of federal forms addressing the
transfer of the select agent or toxin must be submitted to the department
within seven calendar days of submission to the CDC Select Agent Program.
In the event of a suspected release, loss, or theft of any
select agent or toxin, the responsible official at a laboratory shall make a
report to the department immediately by the most rapid means available,
preferably by telephone. The rapid report shall be followed up by a written
report within seven calendar days and shall include the following information:
1. The name of the biologic agent and any identifying
information (e.g., strain or other characterization information);
2. An estimate of the quantity released, lost, or stolen;
3. An estimate of the time during which the release, loss,
or theft occurred; and
4. The location (building, room) from or in which the
release, loss, or theft occurred. The report may contain additional information
as required by 42 CFR Part 73 or the department.
The department [ must shall ]
be notified in writing of any change to information previously submitted to
the department. If a new application or an amendment to an existing application
is filed with the CDC Select Agent Program, a copy of the application or
amendment [ must shall ] be submitted to
the department within seven calendar days of submission to the CDC Select Agent
Program.
F. Those required to report. The [ responsible
official in charge of a laboratory conducting business in the Commonwealth
laboratory director ] shall be responsible for annual reporting of
select agents and toxins to the Virginia Department of Health and for the
reporting of any changes within the time periods as specified within these
regulations. Such reports shall be made on forms to be determined by the department.
Any person making such reports as authorized herein shall be immune from
liability as provided by § 32.1-38 of the Code of Virginia.
G. Exemption from reporting. A person who detects a select
agent or toxin for the purpose of diagnosing a disease, verification, or
proficiency testing and either transfers the specimens or isolates containing
the select agent or toxin to a facility eligible for receiving them or destroys
them on site is not required to make a report except as required by 12VAC5-90-80
and 12VAC5-90-90. Proper destruction of the agent [ must
shall ] take place through autoclaving, incineration, or by a
sterilization or neutralization process sufficient to cause inactivation. The
transfer or destruction [ must shall ] occur
within seven calendar days after identification of a select agent or toxin used
for diagnosis or testing and within 90 calendar days after receipt for
proficiency testing.
Any additional exemptions from reporting under 42 CFR Part
73, including subsequent amendments and editions, are also exempt from
reporting under this regulation; however, the department [ must
shall ] be notified of the exemption by submitting a copy of
federal forms addressing the exemption within seven calendar days of submission
to the CDC Select Agent Program.
H. Release of reported information. Reports submitted to
the select agent and toxin registry shall be confidential and shall not be a
public record pursuant to the Freedom of Information Act, regardless of
submitter. Release of information on select agents or toxins shall be made only
by order of the State Health Commissioner to the CDC and state and federal
law-enforcement agencies in any investigation involving the release, theft, or
loss of a select agent or toxin required to be reported to the department under
this regulation.
12VAC5-90-290. Authority. (Repealed.)
Chapter 2 (§ 32.1-35 et seq.) of Title 32.1 of the Code of
Virginia authorizes the reporting of dangerous microbes and pathogens to the
department. Specifically, § 32.1-35 directs the board to promulgate regulations
specifying which dangerous microbes and pathogens are to be reportable and the
method and timeframe by which they are to be reported by laboratories.
12VAC5-90-300. Administration. (Repealed.)
The dangerous microbes and pathogens will be known as
"select agents and toxins." The select agent and toxin registry will
be maintained by the Virginia Department of Health, Office of Epidemiology,
Division of Surveillance and Investigation.
12VAC5-90-310. Reportable agents. (Repealed.)
The board declares the select agents and toxins outlined
in 42 CFR 73.4 and 42 CFR 73.5 to be reportable, and adopts it herein by
reference including subsequent amendments and editions. The select agents and
toxins are to be reportable by the persons enumerated in 12VAC5-90-340.
12VAC5-90-320. Items to report. (Repealed.)
Each report shall be made on a form determined by the
department and shall contain the following: name, source and characterization
information on select agents and toxins and quantities held; objectives of the
work with the agent; location (including building and room) where each select
agent or toxin is stored or used; identification information of persons with
access to each agent; identification information of the person in charge of
each of the agents; and the name, position and identification information of
one responsible official as a single point of contact for the organization. The
report shall also indicate whether the laboratory is registered with the CDC
Select Agent Program and may contain additional information as required by 42
CFR Part 73 or the department.
12VAC5-90-330. Timing of reports. (Repealed.)
Initial reports shall be made by October 26, 2004.
Thereafter, reports shall be made to the department within seven calendar days
of submission of an application to the CDC Select Agent Program. By January 31
of every year, laboratories shall provide a written update to the department,
which shall include a copy of the federal registration certificate received
through the CDC Select Agent Program.
In the event that a select agent or toxin that has
previously been reported to the department is destroyed, a copy of federal
forms addressing the destruction of the select agent or toxin must be submitted
to the department within seven calendar days of submission to the CDC Select
Agent Program.
In the event that a select agent or toxin, or a specimen
or isolate from a specimen containing a select agent or toxin, has previously
been reported to the department and is subsequently transferred to a facility
eligible for receiving the items, a copy of federal forms addressing the
transfer of the select agent or toxin must be submitted to the department
within seven calendar days of submission to the CDC Select Agent Program.
In the event of a suspected release, loss or theft of any
select agent or toxin, the responsible official at a laboratory shall make a
report to the department within 24 hours by the most rapid means available,
preferably that of telecommunication (e.g., telephone, telephone transmitted
facsimile, pagers, etc.) The rapid report shall be followed up by a written
report within seven calendar days and shall include the following information:
1. The name of the biologic agent and any identifying
information (e.g., strain or other characterization information);
2. An estimate of the quantity released, lost or stolen;
3. An estimate of the time during which the release, loss
or theft occurred; and
4. The location (building, room) from or in which the
release, loss or theft occurred. The report may contain additional information
as required by 42 CFR Part 73 or the department.
The department must be notified in writing of any changes
to information previously submitted to the department. If a new application or
an amendment to an existing application is filed with the CDC Select Agent Program,
a copy of the application or amendment must be submitted to the department
within seven calendar days of submission to the CDC Select Agent Program.
12VAC5-90-340. Those required to report. (Repealed.)
The responsible official in charge of a laboratory
conducting business in the Commonwealth shall be responsible for annual
reporting of select agents and toxins to the Virginia Department of Health and
for the reporting of any changes within the time periods as specified within
these regulations. Such reports shall be made on forms to be determined by the
department. Any person making such reports as authorized herein shall be immune
from liability as provided by § 32.1-38 of the Code of Virginia.
12VAC5-90-350. Exemption from reporting. (Repealed.)
A person who detects a select agent or toxin for the
purpose of diagnosing a disease, verification, or proficiency testing and
either transfers the specimens or isolates containing the select agent or toxin
to a facility eligible for receiving them or destroys them onsite is not
required to make a report. Proper destruction of the agent must take place
through autoclaving, incineration, or by a sterilization or neutralization
process sufficient to cause inactivation. The transfer or destruction must
occur within seven calendar days after identification of a select agent or
toxin used for diagnosis or testing and within 90 calendar days after receipt
for proficiency testing.
Any additional exemptions from reporting under 42 CFR
73.6, including subsequent amendments and editions, are also exempt from
reporting under this regulation; however, the department must be notified of
the exemption by submitting a copy of federal forms addressing the exemption
within seven calendar days of submission to the CDC Select Agent Program.
12VAC5-90-360. Release of reported information. (Repealed.)
Reports submitted to the select agent and toxin registry
shall be confidential and shall not be a public record pursuant to the Freedom
of Information Act. Release of information on select agents or toxins shall be
made only by order of the State Health Commissioner to the CDC and state and
federal law-enforcement agencies in any investigation involving the release,
theft, or loss of a select agent or toxin required to be reported to the
department under this regulation.
NOTICE: The following
forms used in administering the regulation were filed by the agency. The forms
are not being published; however, online users of this issue of the Virginia
Register of Regulations may click on the name of a form with a hyperlink to
access it. The forms are also available from the agency contact or may be
viewed at the Office of the Registrar of Regulations, General Assembly
Building, 2nd Floor, Richmond, Virginia 23219.
FORMS (12VAC5-90)
Virginia Department of Health Confidential Morbidity
Report, Epi-1 (rev. 3/07)
Confidential
Morbidity Report, Epi-1 (rev. 10/11)
Virginia Cancer Registry Reporting Form (rev. 1/98)
DOCUMENTS INCORPORATED BY REFERENCE (12VAC5-90)
Control of Communicable Diseases Manual, 18th Edition,
American Public Health Association, 2004.
Control
of Communicable Diseases Manual, 20th Edition, 2015, American Public Health
Association
VA.R. Doc. No. R13-3366; Filed August 19, 2016, 3:15 p.m.
TITLE 12. HEALTH
VA.R. Doc. No. R15-4176; Filed August 19, 2016, 3:16 p.m.
TITLE 12. HEALTH
VA.R. Doc. No. R16-4550; Filed August 19, 2016, 3:48 p.m.
TITLE 12. HEALTH
VA.R. Doc. No. R17-4646; Filed August 26, 2016, 11:36 a.m.
TITLE 12. HEALTH
Titles of Regulations: 12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-130).
12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-25).
12VAC30-70. Methods and Standards for Establishing Payment Rates - Inpatient Hospital Services (amending 12VAC30-70-201, 12VAC30-70-321; adding 12VAC30-70-415, 12VAC30-70-417).
12VAC30-80. Methods and Standards for Establishing Payment Rates; Other Types of Care (amending 12VAC30-80-21).
12VAC30-130. Amount, Duration and Scope of Selected Services (amending 12VAC30-130-850, 12VAC30-130-890).
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Public Hearing Information: No public hearings are scheduled.
Public Comment Deadline: November 19, 2016.
Agency Contact: Emily McClellan, Regulatory Supervisor, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804) 786-1680, or email emily.mcclellan@dmas.virginia.gov.
Basis: Item 307 CCC of Chapter 3 of the 2012 Acts of the Assembly, Special Session I, directed the Department of Medical Assistance Services (DMAS) to develop changes to requirements for nonfacility services furnished to individuals residing in institutions of mental disease (residential treatment centers and freestanding psychiatric hospitals) in order to comply with federal law. Item 307 CCC of Chapter 806 of the 2013 Acts of the Assembly directed DMAS to require that institutions that treat mental diseases provide referral services to their inpatients when the inpatients need services and to document such referrals and receipt of nonfacility services.
Item 301 XX of Chapter 3 of the 2014 Acts of the Assembly directed DMAS to revise reimbursement for services furnished Medicaid members in residential treatment centers and freestanding psychiatric hospitals to include professional, pharmacy, and other services to be reimbursed separately as long as the services are in the plan of care developed by the residential treatment center or the freestanding psychiatric hospital and arranged by the residential treatment center or the freestanding psychiatric hospital. The same authority exists in the Item XX of Chapter 665 of the 2015 Acts of the Assembly.
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. Section 32.1-324 of the Code of Virginia authorizes the Director of 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 § 1396a) provides governing authority for payments for services.
Purpose: The U.S. Department of Health and Human Services Office of Inspector General (OIG) audited DMAS' claims for nonfacility services furnished to individuals younger than 21 years of age who reside in inpatient psychiatric facilities (IPFs) and issued its report on March 17, 2004. Thereport concluded that DMAS must refund to the Centers for Medicare and Medicaid Services (CMS) $3.9 million for disallowed claims (mostly physician and pharmacy claims) for services furnished to children who resided in IPFs from July 1, 1997, through June 30, 2001, because these services were not part of the allowable inpatient psychiatric benefit. These services were not included in the reimbursement rates for the IPFs but were billed and paid separately to other providers of services.
Based on the OIG report, CMS issued a disallowance on February 29, 2008. DMAS appealed the CMS disallowance but each appeal was denied resulting in a final decision being issued by the U.S. Court of Appeals on May 8, 2012.
In response to that decision, and in accordance with CMS guidance on the inpatient psychiatric benefit, DMAS implemented emergency regulations to permit separate billing for services (referred to by CMS and in the regulations as "services provided under arrangement") when rendered to members under 21 years of age in IPFs when the IPF (i) arranges for and oversees the provision of all services, including services furnished through contracted providers; (ii) maintains all records of medical care furnished to these individuals; and (iii) ensures that all services are furnished under the direction of a physician.
DMAS will continue to enforce the requirement that written plans of care for individuals in IPFs be comprehensive, covering medical, psychological, social, behavioral, and developmental needs (including emergency services). In addition, the previous emergency regulations, as well as these proposed regulations will require IPFs to (i) contract with non-employee providers of services under arrangement (to the extent non-employee providers are providing services under arrangement); (ii) make referrals to employee and contracted providers of services provided under arrangement; and (iii) obtain and maintain medical records from all providers of services provided under arrangement that are not covered by the facility's per diem. If these requirements are met, DMAS will continue to directly reimburse providers of services under arrangement using existing reimbursement methodologies.
These regulations will have no effect on the health, safety or welfare of either Medicaid eligible individuals or on citizens of the Commonwealth.
Substance: The sections of the State Plan for Medical Assistance that are affected by this action are (i) Amount, Duration, and Scope of Medical and Remedial Services Provided to Categorically/Medically Needy Individuals-EPSDT Services (12VAC30-50-130); (ii) Standards Established and Methods Used to Assure High Quality of Care (Utilization control: freestanding psychiatric hospitals (12VAC30-60-25)); (iii) Methods and Standards for Establishing Payment Rates-Inpatient Hospital Services (12VAC30-70-201, 12VAC30-70-321, 12VAC30-70-415, and 12VAC30-70-417); and (iv) Methods and Standards for Establishing Payment Rates-Other Types of Providers (inpatient psychiatric services in residential treatment facilities (under EPSDT (12VAC30-80-21)). The state-only regulations that are affected by this action are Residential Psychiatric Treatment for Children and Adolescents (plans of care; review of plans of care (12VAC30-130-850 through 12VAC30-130-890)).
Prior to the emergency regulations, DMAS paid separately for professional services, such as physician or pharmacy services, that were furnished in facilities (hospitals, nursing facilities, residential treatment centers, etc.) to inpatients or residents. At that time, each provider was only required to maintain records for the services they furnished directly. The facilities (hospitals, nursing facilities, and residential treatment centers) were not required to make referrals for or maintain results of these services.
When a child is in an inpatient psychiatric facility (either freestanding public or private psychiatric hospitals or residential treatment centers), under CMS interpretation as a result of the referenced court order, these separate payments to the providers of professional services and for drugs are not eligible for federal Medicaid matching funds unless the services are part of the inpatient psychiatric benefit. To be part of the inpatient psychiatric benefit and eligible for federal Medicaid matching funds, the IPF must oversee and arrange for these services, maintain the medical records of care furnished to these individuals, and ensure that services are furnished under the direction of a physician. If these requirements are met, DMAS may continue to directly reimburse providers of services under arrangement using existing reimbursement methodologies.
Certain services are already covered by these facilities' per diem payments. Therefore, the list of services provided under arrangement affected by this proposed regulation varies by each facility type (state freestanding psychiatric hospital, private freestanding psychiatric hospital, and residential treatment center).
The following chart lists the services provided under arrangement that may be billed separately for each provider type, provided that the requirements discussed are met. No other services may be billed for members under 21 years of age residing in IPFs.
Services Provided Under Arrangement | Residential Treatment Centers - Level C | Private Freestanding Psychiatric Hospitals | State Freestanding Psychiatric Hospitals |
Physician services | Yes | Yes | No |
Other medical and psychological services including those furnished by licensed mental health professionals and other licensed or certified health professionals (i.e., oral surgeons, nutritionists, podiatrists, respiratory therapists, substance abuse treatment practitioners) | Yes | Yes | No |
Outpatient hospital services | Yes | Yes | No |
Pharmacy services | Yes | No | Yes |
Physical therapy, occupational therapy and therapy for individuals with speech, hearing or language disorders | Yes | Yes | No |
Durable medical equipment (including prostheses/orthopedic services and supplies and supplemental nutritional supplies) | Yes | No | No |
Vision services | Yes | Yes | No |
Dental and orthodontic services | Yes | Yes | No |
Nonemergency transportation services | Yes | Yes | No |
Emergency services (including outpatient hospital, physician and transportation services) | Yes | Yes | Yes |
Issues: There are no advantages or disadvantages to private citizens in these changes. The primary advantages to the agency and the Commonwealth are that these changes will comport with federal requirements as a result of the lawsuit. These changes could be seen as a disadvantage to institutions that treat mental disease and providers of services under arrangement because of the additional referral and service documentation requirements but the changes are necessary to continue to use Medicaid funds to reimburse for these services.
Department of Planning and Budget's Economic Impact Analysis:
Summary of the Proposed Amendments to Regulation. As the result of a federal court decision,1 the Department of Medical Assistance Services (DMAS) proposes to change the requirements for inpatient psychiatric facilities (IPFs) and for providers that offer certain services (such as physician services, medical and psychologic services, vision, dental and emergency services) to residents of IPFs.
Result of Analysis. The benefits likely exceed the costs for all proposed changes.
Estimated Economic Impact. The U.S. Department of Health and Human Services Office of Inspector General (OIG) audited DMAS' claims for non-facility services furnished to individuals younger than 21 years of age who reside in IPFs and issued its report on March 17, 2004. The report concluded that DMAS must refund to the federal Centers for Medicare & Medicaid Services (CMS) $3.9 million for disallowed claims (mostly physician and pharmacy claims) for services furnished to children who resided in IPFs from July 1, 1997 through June 30, 2001 because these services were not part of the allowable inpatient psychiatric benefit. These services were not included in the reimbursement rates for the IPFs but were billed and paid separately to other providers of services.
Based on the OIG report, CMS issued a disallowance on February 29, 2008. DMAS appealed the CMS disallowance but each appeal was denied resulting in a final decision being issued by the U.S. Court of Appeals on May 8, 2012.
In response to that decision, and in accordance with CMS' guidance on the inpatient psychiatric benefit, DMAS implemented emergency regulations to permit separate billing for services (referred to by CMS and in the regulations as "services provided under arrangement") when rendered to members under age 21 in IPFs when the IPF: i) arranges for and oversees the provision of all services, including services furnished through contracted providers; ii) maintains all records of medical care furnished to these individuals; and iii) ensures that all services are furnished under the direction of a physician. DMAS proposes to make the amendments made in the emergency regulation permanent.2
The proposed amendments are necessary in order to continue to use federal Medicaid funds to reimburse for the IPF services detailed above. DMAS receives and passes on to the IPFs approximately $25 million from CMS annually. The proposed amendments require additional IPF staff time for records keeping, billing, physician oversight, and time educating and attempting to obtain contracts from providers in the community in a timely manner. Based on a small survey of IPFs, the proposed requirements in effect currently under the emergency regulation have cost IPFs approximately $50,000 to $150,000 (on annual basis) per facility for additional required staff time. There are 29 IPFs in the Commonwealth. Thus the proposed requirements increase costs statewide by approximately $1.45 million to $4.35 million. The proposed amendments do produce a net benefit in that they help ensure that approximately $25 million in federal dollars are received for IPF services, whereas the cumulative cost of the additional staff time is less than $5 million.
Businesses and Entities Affected. The proposed amendments affect the approximately 21 residential treatment centers, 6 private psychiatric hospitals, and 2 state facilities serving members under the age of 21 in the Commonwealth, and numerous providers of services under arrangement (physicians, psychologists, pharmacies, outpatient hospitals, dentists, etc.).
Localities Particularly Affected. The proposed amendments do not disproportionately affect particular localities.
Projected Impact on Employment. The proposed amendments increase staffing needs for inpatient psychiatric facilities.
Effects on the Use and Value of Private Property. The proposed amendments require private inpatient psychiatric facilities to employ additional staff hours. This may moderately reduce their value. The proposed amendments are necessary in order to continue to receive federal funding that exceeds the increased cost of additional staff time.
Real Estate Development Costs. The proposed amendments do not affect real estate development costs.
Small Businesses:
Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, 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 $6 million."
Costs and Other Effects. The 21 residential treatment centers are likely small businesses. The proposed amendments increase costs for the residential treatment centers through required additional staff time.
Alternative Method that Minimizes Adverse Impact. The proposed amendments are necessary in order to continue to receive federal funding that exceeds the increased cost of additional staff time. Thus there is no alternative method that minimizes adverse impact.
Adverse Impacts:
Businesses. The proposed amendments increase costs for the residential treatment centers and private psychiatric hospitals through required additional staff time.
Localities. The proposed amendments do not adversely affect localities.
Other Entities. The proposed amendments increase costs for the two affected state facilities through required additional staff time.
___________________________
1See https://www.cadc.uscourts.gov/internet/opinions.nsf
/0B411CD77E39203C852579F8004E388A/$file/11-5161-1372715.pdf.
2There are minor wording differences in this proposed regulation versus the emergency regulation. The differences do not substantially change requirements.
Agency's Response to Economic Impact Analysis: The agency has reviewed the economic impact analysis prepared by the Department of Planning and Budget regarding the regulations concerning the Institutions for Mental Disease Reimbursement Changes. The agency raises no issues with this analysis
Summary:
As a result of a federal court decision, the Department of Medical Assistance Services (DMAS) proposes to change the requirements for inpatient psychiatric facilities (IPFs) and providers that offer certain services, such as physician, medical, psychological, vision, dental, and emergency services, to residents of IPFs. The affected IPFs are state freestanding psychiatric hospitals, private freestanding psychiatric hospitals, and residential treatment facilities (Level C). Item 307 CCC of Chapter 3 of the 2012 Acts of the Assembly, Special Session I, directs DMAS to develop changes to requirements for nonfacility services furnished to individuals residing in IPFs to comply with the court order and a prospective payment methodology to reimburse institutions treating mental disease (residential treatment centers and freestanding psychiatric hospitals) for services furnished by the facility and by others.
Item 307 CCC of Chapter 806 of the 2013 Acts of the Assembly directs DMAS to require that institutions that treat mental diseases provide referral services to their inpatients when an inpatient needs ancillary services. Item 301 XX of Chapter 3 of the 2014 Acts of the Assembly, Special Session I, and Item 301 XX of Chapter 665 of the 2015 Acts of the Assembly direct DMAS to revise reimbursement for services furnished to Medicaid members in residential treatment centers and freestanding psychiatric hospitals to include professional, pharmacy, and other services to be reimbursed separately as long as the services are in the plan of care developed by the residential treatment center or the freestanding psychiatric hospital and arranged by the residential treatment center or the freestanding psychiatric hospital.
The amendments conform the regulations to these requirements.
12VAC30-50-130. Skilled nursing Nursing facility services, EPSDT, including school health services and family planning.
A. Skilled nursing Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or performed within the scope of a license of the practitioner of the healing arts.
B. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.
1. Payment of medical assistance services shall be made on behalf of individuals under 21 years of age, who are Medicaid eligible, for medically necessary stays in acute care facilities, and the accompanying attendant physician care, in excess of 21 days per admission when such services are rendered for the purpose of diagnosis and treatment of health conditions identified through a physical examination.
2. Routine physicals and immunizations (except as provided through EPSDT) are not covered except that well-child examinations in a private physician's office are covered for foster children of the local social services departments on specific referral from those departments.
3. Orthoptics services shall only be reimbursed if medically necessary to correct a visual defect identified by an EPSDT examination or evaluation. The department shall place appropriate utilization controls upon this service.
4. Consistent with the Omnibus Budget Reconciliation Act of 1989 § 6403, early and periodic screening, diagnostic, and treatment services means the following services: screening services, vision services, dental services, hearing services, and such other necessary health care, diagnostic services, treatment, and other measures described in Social Security Act § 1905(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services and which are medically necessary, whether or not such services are covered under the State Plan and notwithstanding the limitations, applicable to recipients ages 21 and over, provided for by the Act § 1905(a) of the Social Security Act.
5. Community mental health services. These services in order to be covered (i) shall meet medical necessity criteria based upon diagnoses made by LMHPs who are practicing within the scope of their licenses and (ii) are reflected in provider records and on providers' claims for services by recognized diagnosis codes that support and are consistent with the requested professional services.
a. Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise:
"Activities of daily living" means personal care activities and includes bathing, dressing, transferring, toileting, feeding, and eating.
"Adolescent or child" means the individual receiving the services described in this section. For the purpose of the use of these terms, adolescent means an individual 12-20 years of age; a child means an individual from birth up to 12 years of age.
"Behavioral health services administrator" or "BHSA" means an entity that manages or directs a behavioral health benefits program under contract with DMAS.
"Care coordination" means collaboration and sharing of information among health care providers, who are involved with an individual's health care, to improve the care.
"Certified prescreener" means an employee of the local community services board or behavioral health authority, or its designee, who is skilled in the assessment and treatment of mental illness and has completed a certification program approved by the Department of Behavioral Health and Developmental Services.
"Clinical experience" means providing direct behavioral health services on a full-time basis or equivalent hours of part-time work to children and adolescents who have diagnoses of mental illness and includes supervised internships, supervised practicums, and supervised field experience for the purpose of Medicaid reimbursement of (i) intensive in-home services, (ii) day treatment for children and adolescents, (iii) community-based residential services for children and adolescents who are younger than 21 years of age (Level A), or (iv) therapeutic behavioral services (Level B). Experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience. The equivalency of part-time hours to full-time hours for the purpose of this requirement shall be as established by DBHDS in the document entitled Human Services and Related Fields Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"DBHDS" means the Department of Behavioral Health and Developmental Services.
"DMAS" means the Department of Medical Assistance Services and its contractor or contractors.
"EPSDT" means early and periodic screening, diagnosis, and treatment.
"Human services field" means the same as the term is defined by DBHDS in the document entitled Human Services and Related Fields Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.
"Individual service plan" or "ISP" means the same as the term is defined in 12VAC30-50-226.
"Licensed mental health professional" or "LMHP" means a licensed physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, or certified psychiatric clinical nurse specialist.
"LMHP-resident" or "LMHP-R" means the same as "resident" as defined in (i) 18VAC115-20-10 for licensed professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment practitioners. An LMHP-resident shall be in continuous compliance with the regulatory requirements of the applicable counseling profession for supervised practice and shall not perform the functions of the LMHP-R or be considered a "resident" until the supervision for specific clinical duties at a specific site has been preapproved in writing by the Virginia Board of Counseling. For purposes of Medicaid reimbursement to their supervisors for services provided by such residents, they shall use the title "Resident" in connection with the applicable profession after their signatures to indicate such status.
"LMHP-resident in psychology" or "LMHP-RP" means the same as an individual in a residency, as that term is defined in 18VAC125-20-10, program for clinical psychologists. An LMHP-resident in psychology shall be in continuous compliance with the regulatory requirements for supervised experience as found in 18VAC125-20-65 and shall not perform the functions of the LMHP-RP or be considered a "resident" until the supervision for specific clinical duties at a specific site has been preapproved in writing by the Virginia Board of Psychology. For purposes of Medicaid reimbursement by supervisors for services provided by such residents, they shall use the title "Resident in Psychology" after their signatures to indicate such status.
"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as "supervisee" as defined in 18VAC140-20-10 for licensed clinical social workers. An LMHP-supervisee in social work shall be in continuous compliance with the regulatory requirements for supervised practice as found in 18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered a "supervisee" until the supervision for specific clinical duties at a specific site is preapproved in writing by the Virginia Board of Social Work. For purposes of Medicaid reimbursement to their supervisors for services provided by supervisees, these persons shall use the title "Supervisee in Social Work" after their signatures to indicate such status.
"Progress notes" means individual-specific documentation that contains the unique differences particular to the individual's circumstances, treatment, and progress that is also signed and contemporaneously dated by the provider's professional staff who have prepared the notes. Individualized and member-specific progress notes are part of the minimum documentation requirements and shall convey the individual's status, staff interventions, and, as appropriate, the individual's progress, or lack of progress, toward goals and objectives in the ISP. The progress notes shall also include, at a minimum, the name of the service rendered, the date of the service rendered, the signature and credentials of the person who rendered the service, the setting in which the service was rendered, and the amount of time or units/hours required to deliver the service. The content of each progress note shall corroborate the time/units billed. Progress notes shall be documented for each service that is billed.
"Psychoeducation" means (i) a specific form of education aimed at helping individuals who have mental illness and their family members or caregivers to access clear and concise information about mental illness and (ii) a way of accessing and learning strategies to deal with mental illness and its effects in order to design effective treatment plans and strategies.
"Psychoeducational activities" means systematic interventions based on supportive and cognitive behavior therapy that emphasizes an individual's and his family's needs and focuses on increasing the individual's and family's knowledge about mental disorders, adjusting to mental illness, communicating and facilitating problem solving and increasing coping skills.
"Qualified mental health professional-child" or "QMHP-C" means the same as the term is defined in 12VAC35-105-20.
"Qualified mental health professional-eligible" or "QMHP-E" means the same as the term is defined in 12VAC35-105-20 and consistent with the requirements of 12VAC35-105-590.
"Qualified paraprofessional in mental health" or "QPPMH" means the same as the term is defined in 12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.
"Service-specific provider intake" means the face-to-face interaction in which the provider obtains information from the child or adolescent, and parent or other family member or members, as appropriate, about the child's or adolescent's mental health status. It includes documented history of the severity, intensity, and duration of mental health care problems and issues and shall contain all of the following elements: (i) the presenting issue/reason for referral, (ii) mental health history/hospitalizations, (iii) previous interventions by providers and timeframes and response to treatment, (iv) medical profile, (v) developmental history including history of abuse, if appropriate, (vi) educational/vocational status, (vii) current living situation and family history and relationships, (viii) legal status, (ix) drug and alcohol profile, (x) resources and strengths, (xi) mental status exam and profile, (xii) diagnosis, (xiii) professional summary and clinical formulation, (xiv) recommended care and treatment goals, and (xv) the dated signature of the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.
"Services provided under arrangement" means the same as defined in 12VAC30-130-850.
b. Intensive in-home services (IIH) to children and adolescents under age 21 shall be time-limited interventions provided in the individual's residence and when clinically necessary in community settings. All interventions and the settings of the intervention shall be defined in the Individual Service Plan. All IIH services shall be designed to specifically improve family dynamics, provide modeling, and the clinically necessary interventions that increase functional and therapeutic interpersonal relations between family members in the home. IIH services are designed to promote psychoeducational benefits in the home setting of an individual who is at risk of being moved into an out-of-home placement or who is being transitioned to home from an out-of-home placement due to a documented medical need of the individual. These services provide crisis treatment; individual and family counseling; communication skills (e.g., counseling to assist the individual and his parents or guardians, as appropriate, to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); care coordination with other required services; and 24-hour emergency response.
(1) These services shall be limited annually to 26 weeks. Service authorization shall be required for Medicaid reimbursement prior to the onset of services. Services rendered before the date of authorization shall not be reimbursed.
(2) Service authorization shall be required for services to continue beyond the initial 26 weeks.
(3) Service-specific provider intakes shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider intakes or ISPs shall be denied reimbursement. Requirements for service-specific provider intakes and ISPs are set out in this section.
(4) These services may only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.
c. Therapeutic day treatment (TDT) shall be provided two or more hours per day in order to provide therapeutic interventions. Day treatment programs, limited annually to 780 units, provide evaluation; medication education and management; opportunities to learn and use daily living skills and to enhance social and interpersonal skills (e.g., problem solving, anger management, community responsibility, increased impulse control, and appropriate peer relations, etc.); and individual, group and family counseling.
(1) Service authorization shall be required for Medicaid reimbursement.
(2) Service-specific provider intakes shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider intakes or ISPs shall be denied reimbursement. Requirements for service-specific provider intakes and ISPs are set out in this section.
(3) These services may be rendered only by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.
d. Community-based services for children and adolescents under 21 years of age (Level A) pursuant to 42 CFR 440.130(d).
(1) Such services shall be a combination of therapeutic services rendered in a residential setting. The residential services will provide structure for daily activities, psychoeducation, therapeutic supervision, care coordination, and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual® Criteria or an equivalent standard authorized in advance by DMAS, shall be required for this service.
(2) In addition to the residential services, the child must receive, at least weekly, individual psychotherapy that is provided by an LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.
(3) Individuals shall be discharged from this service when other less intensive services may achieve stabilization.
(4) Authorization shall be required for Medicaid reimbursement. Services that were rendered before the date of service authorization shall not be reimbursed.
(5) Room and board costs shall not be reimbursed. DMAS shall reimburse only for services provided in facilities or programs with no more than 16 beds.
(6) These residential providers must be licensed by the Department of Social Services, Department of Juvenile Justice, or Department of Behavioral Health and Developmental Services under the Standards for Licensed Children's Residential Facilities (22VAC40-151), Standards for Interim Regulation of Children's Residential Facilities (6VAC35-51) Regulation Governing Juvenile Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's Residential Facilities (12VAC35-46).
(7) Daily progress notes shall document a minimum of seven psychoeducational activities per week. Psychoeducational programming must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, stress management, and any care coordination activities.
(8) The facility/group home must coordinate services with other providers. Such care coordination shall be documented in the individual's medical record. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.
(9) Service-specific provider intakes shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services based upon incomplete, missing, or outdated service-specific provider intakes or ISPs shall be denied reimbursement. Requirements for intakes and ISPs are set out in 12VAC30-60-61.
(10) These services may only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.
e. Therapeutic behavioral services (Level B) pursuant to 42 CFR 440.130(d).
(1) Such services must be therapeutic services rendered in a residential setting that provides provide structure for daily activities, psychoeducation, therapeutic supervision, care coordination, and psychiatric treatment to ensure the attainment of therapeutic mental health goals as identified in the individual service plan (plan of care). Individuals qualifying for this service must demonstrate medical necessity for the service arising from a condition due to mental, behavioral or emotional illness that results in significant functional impairments in major life activities in the home, school, at work, or in the community. The service must reasonably be expected to improve the child's condition or prevent regression so that the services will no longer be needed. The application of a national standardized set of medical necessity criteria in use in the industry, such as McKesson InterQual® Criteria, or an equivalent standard authorized in advance by DMAS shall be required for this service.
(2) Authorization is required for Medicaid reimbursement. Services that are rendered before the date of service authorization shall not be reimbursed.
(3) Room and board costs shall not be reimbursed. Facilities that only provide independent living services are not reimbursed. DMAS shall reimburse only for services provided in facilities or programs with no more than 16 beds.
(4) These residential providers must be licensed by the Department of Behavioral Health and Developmental Services (DBHDS) under the Regulations for Children's Residential Facilities (12VAC35-46).
(5) Daily progress notes shall document that a minimum of seven psychoeducational activities per week occurs. Psychoeducational programming must include, but is not limited to, development or maintenance of daily living skills, anger management, social skills, family living skills, communication skills, and stress management. This service may be provided in a program setting or a community-based group home.
(6) The individual must receive, at least weekly, individual psychotherapy and, at least weekly, group psychotherapy that is provided as part of the program.
(7) Individuals shall be discharged from this service when other less intensive services may achieve stabilization.
(8) Service-specific provider intakes shall be required at the onset of services and ISPs shall be required during the entire duration of services. Services that are based upon incomplete, missing, or outdated service-specific provider intakes or ISPs shall be denied reimbursement. Requirements for intakes and ISPs are set out in 12VAC30-60-61.
(9) These services may only be rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.
(10) The facility/group home shall coordinate necessary services with other providers. Documentation of this care coordination shall be maintained by the facility/group home in the individual's record. The documentation shall include who was contacted, when the contact occurred, and what information was transmitted.
6. Inpatient psychiatric services shall be covered for individuals younger than age 21 for medically necessary stays in inpatient psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the purpose of diagnosis and treatment of mental health and behavioral disorders identified under EPSDT when such services are rendered by: a. A (i) apsychiatric hospital or an inpatient psychiatric program in a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations;or (ii) a psychiatric facility that is accredited by the Joint Commission on Accreditation of Healthcare Organizations, or the Commission on Accreditation of Rehabilitation Facilities, the Council on Accreditation of Services for Families and Children or the Council on Quality and Leadership. b. Inpatient psychiatric hospital admissions at general acute care hospitals and freestanding psychiatric hospitals shall also be subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and 12VAC30-60-25. Inpatient psychiatric admissions to residential treatment facilities shall also be subject to the requirements of Part XIV (12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services12VAC30-130.
a. The inpatient psychiatric services benefit for individuals younger than 21 years of age shall include services defined at 42 CFR 440.160 that are provided under the direction of a physician pursuant to a certification of medical necessity and plan of care developed by an interdisciplinary team of professionals and shall involve active treatment designed to achieve the child's discharge from inpatient status at the earliest possible time. The inpatient psychiatric services benefit shall include services provided under arrangement furnished by Medicaid enrolled providers other than the inpatient psychiatric facility, as long as the inpatient psychiatric facility (i) arranges for and oversees the provision of all services, (ii) maintains all medical records of care furnished to the individual, and (iii) ensures that the services are furnished under the direction of a physician. Services provided under arrangement shall be documented by a written referral from the inpatient psychiatric facility. For purposes of pharmacy services, a prescription ordered by an employee or contractor of the facility who is licensed to prescribe drugs shall be considered the referral.
b. Eligible services provided under arrangement with the inpatient psychiatric facility shall vary by provider type as described in this subsection. For purposes of this section, emergency services means the same as is set out in 12VAC30-50-310 B.
(1) State freestanding psychiatric hospitals shall arrange for, maintain records of, and ensure that physicians order these services: (i) pharmacy services and (ii) emergency services.
(2) Private freestanding psychiatric hospitals shall arrange for, maintain records of, and ensure that physicians order these services: (i) medical and psychological services including those furnished by physicians, licensed mental health professionals, and other licensed or certified health professionals (i.e., nutritionists, podiatrists, respiratory therapists, and substance abuse treatment practitioners); (ii) outpatient hospital services; (iii) physical therapy, occupational therapy, and therapy for individuals with speech, hearing, or language disorders; (iv) laboratory and radiology services; (v) vision services; (vi) dental, oral surgery, and orthodontic services; (vii) transportation services; and (viii) emergency services.
(3) Residential treatment facilities, as defined at 42 CFR 483.352, shall arrange for, maintain records of, and ensure that physicians order these services: (i) medical and psychological services, including those furnished by physicians, licensed mental health professionals, and other licensed or certified health professionals (i.e., nutritionists, podiatrists, respiratory therapists, and substance abuse treatment practitioners); (ii) pharmacy services; (iii) outpatient hospital services; (iv) physical therapy, occupational therapy, and therapy for individuals with speech, hearing, or language disorders; (v) laboratory and radiology services; (vi) durable medical equipment; (vii) vision services; (viii) dental, oral surgery, and orthodontic services; (ix) transportation services; and (x) emergency services.
c. Inpatient psychiatric services are reimbursable only when the treatment program is fully in compliance with (i) 42 CFR Part 441 Subpart D, as contained in specifically 42 CFR 441.151(a) and (b) and 441.152 through 441.156, and (ii) the conditions of participation in 42 CFR Part 483 Subpart G. Each admission must be preauthorized and the treatment must meet DMAS requirements for clinical necessity.
d. Service limits may be exceeded based on medical necessity for individuals eligible for EPSDT.
7. Hearing aids shall be reimbursed for individuals younger than 21 years of age according to medical necessity when provided by practitioners licensed to engage in the practice of fitting or dealing in hearing aids under the Code of Virginia.
C. School health services.
1. School health assistant services are repealed effective July 1, 2006.
2. School divisions may provide routine well-child screening services under the State Plan. Diagnostic and treatment services that are otherwise covered under early and periodic screening, diagnosis and treatment services, shall not be covered for school divisions. School divisions to receive reimbursement for the screenings shall be enrolled with DMAS as clinic providers.
a. Children enrolled in managed care organizations shall receive screenings from those organizations. School divisions shall not receive reimbursement for screenings from DMAS for these children.
b. School-based services are listed in a recipient's individualized education program (IEP) and covered under one or more of the service categories described in § 1905(a) of the Social Security Act. These services are necessary to correct or ameliorate defects of physical or mental illnesses or conditions.
3. Service providers shall be licensed under the applicable state practice act or comparable licensing criteria by the Virginia Department of Education, and shall meet applicable qualifications under 42 CFR Part 440. Identification of defects, illnesses or conditions and services necessary to correct or ameliorate them shall be performed by practitioners qualified to make those determinations within their licensed scope of practice, either as a member of the IEP team or by a qualified practitioner outside the IEP team.
a. Service providers shall be employed by the school division or under contract to the school division.
b. Supervision of services by providers recognized in subdivision 4 of this subsection shall occur as allowed under federal regulations and consistent with Virginia law, regulations, and DMAS provider manuals.
c. The services described in subdivision 4 of this subsection shall be delivered by school providers, but may also be available in the community from other providers.
d. Services in this subsection are subject to utilization control as provided under 42 CFR Parts 455 and 456.
e. The IEP shall determine whether or not the services described in subdivision 4 of this subsection are medically necessary and that the treatment prescribed is in accordance with standards of medical practice. Medical necessity is defined as services ordered by IEP providers. The IEP providers are qualified Medicaid providers to make the medical necessity determination in accordance with their scope of practice. The services must be described as to the amount, duration and scope.
4. Covered services include:
a. Physical therapy, occupational therapy and services for individuals with speech, hearing, and language disorders, performed by, or under the direction of, providers who meet the qualifications set forth at 42 CFR 440.110. This coverage includes audiology services;
b. Skilled nursing services are covered under 42 CFR 440.60. These services are to be rendered in accordance to the licensing standards and criteria of the Virginia Board of Nursing. Nursing services are to be provided by licensed registered nurses or licensed practical nurses but may be delegated by licensed registered nurses in accordance with the regulations of the Virginia Board of Nursing, especially the section on delegation of nursing tasks and procedures. The licensed practical nurse is under the supervision of a registered nurse.
(1) The coverage of skilled nursing services shall be of a level of complexity and sophistication (based on assessment, planning, implementation and evaluation) that is consistent with skilled nursing services when performed by a licensed registered nurse or a licensed practical nurse. These skilled nursing services shall include, but not necessarily be limited to dressing changes, maintaining patent airways, medication administration/monitoring and urinary catheterizations.
(2) Skilled nursing services shall be directly and specifically related to an active, written plan of care developed by a registered nurse that is based on a written order from a physician, physician assistant or nurse practitioner for skilled nursing services. This order shall be recertified on an annual basis.
c. Psychiatric and psychological services performed by licensed practitioners within the scope of practice are defined under state law or regulations and covered as physicians' services under 42 CFR 440.50 or medical or other remedial care under 42 CFR 440.60. These outpatient services include individual medical psychotherapy, group medical psychotherapy coverage, and family medical psychotherapy. Psychological and neuropsychological testing are allowed when done for purposes other than educational diagnosis, school admission, evaluation of an individual with intellectual disability prior to admission to a nursing facility, or any placement issue. These services are covered in the nonschool settings also. School providers who may render these services when licensed by the state include psychiatrists, licensed clinical psychologists, school psychologists, licensed clinical social workers, professional counselors, psychiatric clinical nurse specialist, marriage and family therapists, and school social workers.
d. Personal care services are covered under 42 CFR 440.167 and performed by persons qualified under this subsection. The personal care assistant is supervised by a DMAS recognized school-based health professional who is acting within the scope of licensure. This practitioner develops a written plan for meeting the needs of the child, which is implemented by the assistant. The assistant must have qualifications comparable to those for other personal care aides recognized by the Virginia Department of Medical Assistance Services. The assistant performs services such as assisting with toileting, ambulation, and eating. The assistant may serve as an aide on a specially adapted school vehicle that enables transportation to or from the school or school contracted provider on days when the student is receiving a Medicaid-covered service under the IEP. Children requiring an aide during transportation on a specially adapted vehicle shall have this stated in the IEP.
e. Medical evaluation services are covered as physicians' services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR 440.60. Persons performing these services shall be licensed physicians, physician assistants, or nurse practitioners. These practitioners shall identify the nature or extent of a child's medical or other health related condition.
f. Transportation is covered as allowed under 42 CFR 431.53 and described at State Plan Attachment 3.1-D (12VAC30-50-530). Transportation shall be rendered only by school division personnel or contractors. Transportation is covered for a child who requires transportation on a specially adapted school vehicle that enables transportation to or from the school or school contracted provider on days when the student is receiving a Medicaid-covered service under the IEP. Transportation shall be listed in the child's IEP. Children requiring an aide during transportation on a specially adapted vehicle shall have this stated in the IEP.
g. Assessments are covered as necessary to assess or reassess the need for medical services in a child's IEP and shall be performed by any of the above licensed practitioners within the scope of practice. Assessments and reassessments not tied to medical needs of the child shall not be covered.
5. DMAS will ensure through quality management review that duplication of services will be monitored. School divisions have a responsibility to ensure that if a child is receiving additional therapy outside of the school, that there will be coordination of services to avoid duplication of service.
D. Family planning services and supplies for individuals of child-bearing age.
1. Service must be ordered or prescribed and directed or performed within the scope of the license of a practitioner of the healing arts.
2. Family planning services shall be defined as those services that delay or prevent pregnancy. Coverage of such services shall not include services to treat infertility nor services to promote fertility.
12VAC30-60-25. Utilization control: freestanding psychiatric hospitals.
A. Psychiatric services in freestanding psychiatric hospitals shall only be covered for eligible persons younger than 21 years of age and older than 64 years of age.
B. Prior authorization required. DMAS shall monitor, consistent with state law, the utilization of all inpatient freestanding psychiatric hospital services. All inpatient hospital stays shall be preauthorized prior to reimbursement for these services. Services rendered without such prior authorization shall not be covered.
C. All Medicaid services are subject to utilization review and audit. Absence of any of the required documentation may result in denial or retraction of any reimbursement. In each case for which payment for freestanding psychiatric hospital services is made under the State Plan:
1. A physician must certify at the time of admission, or at the time the hospital is notified of an individual's retroactive eligibility status, that the individual requires or required inpatient services in a freestanding psychiatric hospital consistent with 42 CFR 456.160.
2. The physician, physician assistant, or nurse practitioner acting within the scope of practice as defined by state law and under the supervision of a physician, must recertify at least every 60 days that the individual continues to require inpatient services in a psychiatric hospital.
3. Before admission to a freestanding psychiatric hospital or before authorization for payment, the attending physician or staff physician must perform a medical evaluation of the individual and appropriate professional personnel must make a psychiatric and social evaluation as cited in 42 CFR 456.170.
4. Before admission to a freestanding psychiatric hospital or before authorization for payment, the attending physician or staff physician must establish a written plan of care for each recipient patient as cited in 42 CFR 441.155 and 456.180. The plan shall also include a list of services provided under written contractual arrangement with the freestanding psychiatric hospital (see 12VAC30-50-130) that will be furnished to the patient through the freestanding psychiatric hospital's referral to an employed or contracted provider, including the prescribed frequency of treatment and the circumstances under which such treatment shall be sought.
D. If the eligible individual is 21 years of age or older, then, in order to qualify for Medicaid payment for this service, he must be at least 65 years of age.
E. If younger than 21 years of age, it shall be documented that the individual requiring admission to a freestanding psychiatric hospital is under 21 years of age, that treatment is medically necessary, and that the necessity was identified as a result of an early and periodic screening, diagnosis, and treatment (EPSDT) screening. Required patient documentation shall include, but not be limited to, the following:
1. An EPSDT physician's screening report showing the identification of the need for further psychiatric evaluation and possible treatment.
2. A diagnostic evaluation documenting a current (active) psychiatric disorder included in the DSM-III-R that supports the treatment recommended. The diagnostic evaluation must be completed prior to admission.
3. For admission to a freestanding psychiatric hospital for psychiatric services resulting from an EPSDT screening, a certification of the need for services as defined in 42 CFR 441.152 by an interdisciplinary team meeting the requirements of 42 CFR 441.153 or 441.156 and the ThePsychiatric Inpatient Treatment of Minors Act (§ 16.1-335 et seq. of the Code of Virginia).
F. If a Medicaid eligible individual is admitted in an emergency to a freestanding psychiatric hospital on a Saturday, Sunday, holiday, or after normal working hours, it shall be the provider's responsibility to obtain the required authorization on the next work day following such an admission.
G. The absence of any of the required documentation described in this subsection shall result in DMAS' denial of the requested preauthorization and coverage of subsequent hospitalization.
F. H. To determine that the DMAS enrolled mental hospital providers are in compliance with the regulations governing mental hospital utilization control found in the 42 CFR 456.150, an annual audit will be conducted of each enrolled hospital. This audit may be performed either on site or as a desk audit. The hospital shall make all requested records available and shall provide an appropriate place for the auditors to conduct such review if done on site. The audits shall consist of review of the following:
1. Copy of the mental hospital's Utilization Management Plan to determine compliance with the regulations found in the 42 CFR 456.200 through 456.245.
2. List of current Utilization Management Committee members and physician advisors to determine that the committee's composition is as prescribed in the 42 CFR 456.205 and 456.206.
3. Verification of Utilization Management Committee meetings, including dates and list of attendees to determine that the committee is meeting according to their utilization management meeting requirements.
4. One completed Medical Care Evaluation Study to include objectives of the study, analysis of the results, and actions taken, or recommendations made to determine compliance with 42 CFR 456.241 through 456.245.
5. Topic of one ongoing Medical Care Evaluation Study to determine the hospital is in compliance with 42 CFR 456.245.
6. From a list of randomly selected paid claims, the freestanding psychiatric hospital must provide a copy of the certification for services, a copy of the physician admission certification, a copy of the required medical, psychiatric, and social evaluations, and the written plan of care for each selected stay to determine the hospital's compliance with §§ 16.1-335 through 16.1-348 of the Code of Virginia and 42 CFR 441.152, 456.160, 456.170, 456.180 and 456.181. If any of the required documentation does not support the admission and continued stay, reimbursement may be retracted.
I. The freestanding psychiatric hospital shall not receive a per diem reimbursement for any day that:
1. The initial or comprehensive written plan of care fails to include within three business days of the initiation of the service provided under arrangement all services that the individual needs while at the freestanding psychiatric hospital and that will be furnished to the individual through the freestanding psychiatric hospital's referral to an employed or contracted provider of services under arrangement;
2. The comprehensive plan of care fails to include within three business days of the initiation of the service the prescribed frequency of such service or includes a frequency that was exceeded;
3. The comprehensive plan of care fails to list the circumstances under which the service provided under arrangement shall be sought;
4. The referral to the service provided under arrangement was not present in the patient's freestanding psychiatric hospital record;
5. The service provided under arrangement was not supported in that provider's records by a documented referral from the freestanding psychiatric hospital;
6. The medical records from the provider of services under arrangement (i.e., admission and discharge documents, treatment plans, progress notes, treatment summaries, and documentation of medical results and findings) (i) were not present in the patient's freestanding psychiatric hospital record or had not been requested in writing by the freestanding psychiatric hospital within seven days of completion of the service or services provided under arrangement or (ii) had been requested in writing within seven days of completion of the service or services, but had not been received within 30 days of the request, and had not been re-requested;
7. The freestanding psychiatric hospital did not have a fully executed contract or an employee relationship with the provider of services under arrangement in advance of the provision of such services. For emergency services, the freestanding psychiatric hospital shall have a fully executed contract with the emergency services hospital provider prior to submission of the ancillary provider's claim for payment.
J. The provider of services under arrangement shall be required to reimburse DMAS for the cost of any such service billed prior to receiving a referral from the freestanding psychiatric hospital or in excess of the amounts in the referral.
K. The hospitals may appeal in accordance with the Administrative Process Act (§ 9-6.14:1 2.2-4000 et seq. of the Code of Virginia) any adverse decision resulting from such audits which thatresults in retraction of payment. The appeal must be requested within 30 days of the date of the letter notifying the hospital of the retraction pursuant to the requirements of 12VAC30-20-500 et seq.
Part V
Inpatient Hospital Payment System
Article 1
Application of Payment Methodologies
12VAC30-70-201. Application of payment methodologies.
A. The state agency will pay for inpatient hospital services in general acute care hospitals, rehabilitation hospitals, and freestanding psychiatric facilities licensed as hospitals under a prospective payment methodology. This methodology uses both per case and per diem payment methods. Article 2 (12VAC30-70-221 et seq.) of this part describes the prospective payment methodology, including both the per case and the per diem methods.
B. Article 3 (12VAC30-70-400 et seq.) of this partdescribes a per diem methodology that applied to a portion of payment to general acute care hospitals during state fiscal years 1997 and 1998, and that will continue to apply to patient stays with admission dates prior to July 1, 1996. Inpatient hospital services that are provided in long stay hospitals shall be subject to the provisions of Supplement 3 (12VAC30-70-10 through 12VAC30-70-130).
C. Inpatient hospital facilities operated by the Department of Behavioral Health and Developmental Services (DBHDS) shall be reimbursed costs except for inpatient psychiatric services furnished under early and periodic screening, diagnosis, and treatment (EPSDT) services for individuals younger than age 21. These inpatient services shall be reimbursed according to 12VAC30-70-415 and shall be provided according to the requirements set forth in 12VAC30-50-130 and 12VAC30-60-25 H. Facilities may also receive disproportionate share hospital (DSH) payments. The criteria for DSH eligibility and the payment amount shall be based on subsection F of 12VAC30-70-50. If the DSH limit is exceeded by any facility, the excess DSH payments shall be distributed to all other qualifying DBHDS facilities in proportion to the amount of DSH they otherwise receive.
D. Transplant services shall not be subject to the provisions of this part. Reimbursement for covered liver, heart, and bone marrow/stem cell transplant services and any other medically necessary transplantation procedures that are determined to not be experimental or investigational shall be a fee based upon the greater of a prospectively determined, procedure-specific flat fee determined by the agency or a prospectively determined, procedure-specific percentage of usual and customary charges. The flat fee reimbursement will cover procurement costs; all hospital costs from admission to discharge for the transplant procedure; and total physician costs for all physicians providing services during the hospital stay, including radiologists, pathologists, oncologists, surgeons, etc. The flat fee reimbursement does not include pre-hospitalization and post-hospitalization for the transplant procedure or pretransplant evaluation. If the actual charges are lower than the fee, the agency shall reimburse the actual charges. Reimbursement for approved transplant procedures that are performed out of state will be made in the same manner as reimbursement for transplant procedures performed in the Commonwealth. Reimbursement for covered kidney and cornea transplants is at the allowed Medicaid rate. Standards for coverage of organ transplant services are in 12VAC30-50-540 through 12VAC30-50-580.
E. Reduction of payments methodology.
1. For state fiscal years 2003 and 2004, the Department of Medical Assistance Services (DMAS) shall reduce payments to hospitals participating in the Virginia Medicaid Program by $8,935,825 total funds, and $9,227,815 total funds respectively. For purposes of distribution, each hospital's share of the total reduction amount shall be determined as provided in this subsection.
2. Determine base for revenue forecast.
a. DMAS shall use, as a base for determining the payment reduction distribution for hospitals Type I and Type II, net Medicaid inpatient operating reimbursement and outpatient reimbursed cost, as recorded by DMAS for state fiscal year 1999 from each individual hospital settled cost reports. This figure is further reduced by 18.73%, which represents the estimated statewide HMO average percentage of Medicaid business for those hospitals engaged in HMO contracts, to arrive at net baseline proportion of non-HMO hospital Medicaid business.
b. For freestanding psychiatric hospitals, DMAS shall use estimated Medicaid revenues for the six-month period (January 1, 2001, through June 30, 2001), times two, and adjusted for inflation by 4.3% for state fiscal year 2002, 3.1% for state fiscal year 2003, and 3.7% for state fiscal year 2004, as reported by DRI-WEFA, Inc.'s, hospital input price level percentage moving average.
3. Determine forecast revenue.
a. Each Type I hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 a of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type I hospitals.
b. Each Type II, including freestanding psychiatric, hospital's individual state fiscal year 2003 and 2004 forecast reimbursement is based on the proportion of non-HMO business (see subdivision 2 of this subsection) with respect to the DMAS forecast of SFY 2003 and 2004 inpatient and outpatient operating revenue for Type II hospitals.
4. Each hospital's total yearly reduction amount is equal to theirits respective state fiscal year 2003 and 2004 forecast reimbursement as described in subdivision 3 of this subsection, times 3.235857% for state fiscal year 2003, and 3.235857%, for the first two quarters of state fiscal year 2004 and 2.88572% for the last two quarters of state fiscal year 2004, not to be reduced by more than $500,000 per year.
5. Reductions shall occur quarterly in four amounts as offsets to remittances. Each hospital's payment reduction shall not exceed that calculated in subdivision 4 of this subsection. Payment reduction offsets not covered by claims remittance by May 15, 2003, and 2004, will be billed by invoice to each provider with the remaining balances payable by check to the Department of Medical Assistance Services before June 30, 2003, or 2004, as applicable.
F. Consistent with 42 CFR 447.26 and effective July 1, 2012, the Commonwealth shall not reimburse inpatient hospitals for provider-preventable conditions (PPCs), which include:
1. Health care-acquired conditions (HCACs). HCACs are conditions occurring in any hospital setting, identified as a hospital-acquired condition (HAC) by Medicare other than deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.
2. Other provider preventable conditions (OPPCs) as follows: (i) wrong surgical or other invasive procedure performed on a patient; (ii) surgical or other invasive procedure performed on the wrong body part; or (iii) surgical or other invasive procedure performed on the wrong patient.
12VAC30-70-321. Hospital specific operating rate per day.
A. The hospital specific operating rate per day shall be equal to the labor portion of the statewide operating rate per day, as determined in subsection A of 12VAC30-70-341, times the hospital's Medicare wage index plus the nonlabor portion of the statewide operating rate per day.
B. For rural hospitals, the hospital's Medicare wage index used in this section shall be the Medicare wage index of the nearest metropolitan wage area or the effective Medicare wage index, whichever is higher.
C. Effective July 1, 2008, and ending after June 30, 2010, the hospital specific operating rate per day shall be reduced by 2.683%.
D. The hospital specific rate per day for freestanding psychiatric cases shall be equal to the hospital specific operating rate per day, as determined in subsection A of this section plus the hospital specific capital rate per day for freestanding psychiatric cases.
E. The hospital specific capital rate per day for freestanding psychiatric cases shall be equal to the Medicare geographic adjustment factor for the hospital's geographic area, times the statewide capital rate per day for freestanding psychiatric cases times the percentage of allowable cost specified in 12VAC30-70-271.
F. The statewide capital rate per day for freestanding psychiatric cases shall be equal to the weighted average of the GAF-standardized capital cost per day of freestanding psychiatric facilities licensed as hospitals.
G. The capital cost per day of freestanding psychiatric facilities licensed as hospitals shall be the average charges per day of psychiatric cases times the ratio total capital cost to total charges of the hospital, using data available from Medicare cost report.
12VAC30-70-415. Reimbursement for freestanding psychiatric hospital services under EPSDT.
A. The freestanding psychiatric hospital specific rate per day for psychiatric cases shall be equal to the hospital specific operating rate per day, as determined in subsection A of 12VAC30-70-321 plus the hospital specific capital rate per day for freestanding psychiatric cases.
B. The freestanding psychiatric hospital specific capital rate per day for psychiatric cases shall be equal to the Medicare geographic adjustment factor (GAF) for the hospital's geographic area times the statewide capital rate per day for freestanding psychiatric cases times the percentage of allowable cost specified in 12VAC30-70-271.
C. The statewide capital rate per day for psychiatric cases shall be equal to the weighted average of the GAF-standardized capital cost per day of facilities licensed as freestanding psychiatric hospitals.
D. The capital cost per day of facilities licensed as freestanding psychiatric hospitals shall be the average charges per day of psychiatric cases times the ratio total of capital cost to total charges of the hospital, using data available from Medicare cost report.
E. Effective July 1, 2014, services provided under arrangement, as defined in subdivisions B 6 a and B 6 b of 12VAC30-50-130, shall be reimbursed directly by DMAS, according to the reimbursement methodology prescribed for each provider in 12VAC30-80 or elsewhere in the State Plan, to a provider of services under arrangement if all of the following are met:
1. The services are included in the active treatment plan of care developed and signed as described in subdivision C 4 of 12VAC30-60-25; and
2. The services are arranged and overseen by the freestanding psychiatric hospital treatment team through a written referral to a Medicaid enrolled provider that is either an employee of the freestanding psychiatric hospital or under contract for services provided under arrangement.
12VAC30-70-417. Reimbursement for inpatient psychiatric services in residential treatment facilities (Level C) under EPSDT.
A. Effective January 1, 2000, DMAS shall pay for inpatient psychiatric services in residential treatment facilities provided by participating providers under the terms and payment methodology described in this section.
B. Effective January 1, 2000, payment shall be made for inpatient psychiatric services in residential treatment facilities using a per diem payment rate as determined by DMAS based on information submitted by enrolled residential psychiatric treatment facilities. This rate shall constitute direct payment for all residential psychiatric treatment facility services, excluding all services provided under arrangement that are reimbursed in the manner described in subsection D of this section.
C. Enrolled residential treatment facilities shall submit cost reports on uniform reporting forms provided by DMAS at such time as required by DMAS. Such cost reports shall cover a 12-month period. If a complete cost report is not submitted by a provider, DMAS shall take action in accordance with its policies to assure that an overpayment is not being made.
D. Effective July 1, 2014, services provided under arrangement, as defined in subdivisions B 6 a and B 6 b of 12VAC30-50-130, shall be reimbursed directly by DMAS to a provider of services provided under arrangement according to the reimbursement methodology prescribed for that provider type elsewhere in the State Plan if all of the following are met:
1. The services provided under arrangement are included in the active written treatment plan of care developed and signed as described in section 12VAC30-130-890; and
2. The services provided under arrangement are arranged and overseen by the residential treatment facility treatment team through a written referral to a Medicaid enrolled provider that is either an employee of the residential treatment facility or under contract for services provided under arrangement.
NOTICE: The following forms used in administering the regulation were filed by the agency. The forms are not being published; however, online users of this issue of the Virginia Register of Regulations may click on the name of a form with a hyperlink to access it. The forms are also available from the agency contact or may be viewed at the Office of the Registrar of Regulations, General Assembly Building, 2nd Floor, Richmond, Virginia 23219.
FORMS (12VAC30-70)
Computation of Inpatient Operating Cost, HCFA-2552‑92 D-1 (12/92).
Apportionment of Cost of Services Rendered by Interns and Residents, HCFA-2552‑92 D-2 (12/92).
Cost Reporting Forms for Hospitals (Map 783 Series), eff. 10/15/93
Certification by Officer or Administrator of Provider
Analysis of Interim Payments for Title XIX Services
Computation of Title XIX Ratio of Cost to Charges
Computation of Inpatient and Outpatient Ancillary Service Costs
Computation of Outpatient Capital Reduction
Computation of Title XIX Outpatient Costs
Computation of Charges for Lower of Cost or Charge Comparison
Computation of Title XIX Reimbursement Settlement
Computation of Net Medicaid Inpatient Operating Cost Adjustment
Calculation of Medicaid Inpatient Profit Incentive for Hospitals
Plant Costs
Education Costs
Obstetrical Care Requirements Certification
Computation for Separating the Allowable Plant and Education Cost (pass-throughs) from the Inpatient Medicaid Hospital Costs
Cost Reporting Form Residential Treatment Facilities, RTF-608 (undated, filed 9/2016)
12VAC30-80-21. Inpatient psychiatric services in residential treatment facilities (under EPSDT). Reimbursement for services furnished individuals residing in a freestanding psychiatric hospital or residential treatment center (Level C).
A. Effective January 1, 2000, the state agency shall pay for inpatient psychiatric services in residential treatment facilities provided by participating providers, under the terms and payment methodology described in this section.
B. Methodology. Effective January 1, 2000, payment will be made for inpatient psychiatric services in residential treatment facilities using a per diem payment rate as determined by the state agency based on information submitted by enrolled residential psychiatric treatment facilities. This rate shall constitute payment for all residential psychiatric treatment facility services, excluding all professional services.
C. Data collection. Enrolled residential treatment facilities shall submit cost reports on uniform reporting forms provided by the state agency at such time as required by the agency. Such cost reports shall cover a 12-month period. If a complete cost report is not submitted by a provider, the Program shall take action in accordance with its policies to assure that an overpayment is not being made.
A. Reimbursement for all services furnished to individuals younger than 21 years of age who are residing in a freestanding psychiatric hospital shall be based on the freestanding psychiatric hospital reimbursement described in 12VAC30-70-415 and the reimbursement of services provided under arrangement described in 12VAC30-80.
B. Reimbursement for all services furnished to individuals younger than 21 years of age who are residing in a residential treatment center (Level C) shall be based on the the residential treatment center (Level C) reimbursement described in 12VAC30-70-417 and the reimbursement of services provided under arrangement described in 12VAC30-80.
Part XIV
Residential Psychiatric Treatment for Children and Adolescents
12VAC30-130-850. Definitions.
The following words and terms when used in this part shall have the following meanings, unless the context clearly indicates otherwise:
"Active treatment" means implementation of a professionally developed and supervised individual plan of care that must be designed to achieve the recipient's discharge from inpatient status at the earliest possible time.
"Certification" means a statement signed by a physician that inpatient services in a residential treatment facility are or were needed. The certification must be made at the time of admission, or, if an individual applies for assistance while in a mental hospital or residential treatment facility, before the Medicaid agency authorizes payment.
"Comprehensive individual plan of care" or "CIPOC" means a written plan developed for each recipient in accordance with 12VAC30-130-890 to improve his condition to the extent that inpatient care is no longer necessary.
"Emergency services" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
"Individual" or "individuals" means a child or adolescent younger than 21 years of age who is receiving a service covered under this part of this chapter.
"Initial plan of care" means a plan of care established at admission, signed by the attending physician or staff physician, that meets the requirements in 12VAC30-130-890.
"Inpatient psychiatric facility" or "IPF" means a private or state-run freestanding psychiatric hospital or psychiatric residential treatment center.
"Recertification" means a certification for each applicant or recipient that inpatient services in a residential treatment facility are needed. Recertification must be made at least every 60 days by a physician, or physician assistant or nurse practitioner acting within the scope of practice as defined by state law and under the supervision of a physician.
"Recipient" or "recipients" means the child or adolescent younger than 21 years of age receiving this covered service.
"RTC-Level C" means a psychiatric residential treatment facility (Level C).
"Services provided under arrangement" means services including physician and other health care services that are furnished to children while they are in an IPF that are billed by the arranged practitioners separately from the IPF per diem.
12VAC30-130-890. Plans of care; review of plans of care.
A. All Medicaid services are subject to utilization review and audit. The absence of any required documentation may result in denial or retraction of any reimbursement.
B. For Residential Treatment Services (Level C) (RTS-Level C), an initial plan of care must be completed at admission and a Comprehensive Individual Plan of Care (CIPOC) must be completed no later than 14 days after admission.
B. C. Initial plan of care (Level C) must include:
1. Diagnoses, symptoms, complaints, and complications indicating the need for admission;
2. A description of the functional level of the recipientindividual;
3. Treatment objectives with short-term and long-term goals;
4. Any orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures recommended for the health and safety of the patient individual and a list of services provided under arrangement (see 12VAC30-50-130 for eligible services provided under arrangement) that will be furnished to the individual through the RTC-Level C's referral to an employed or a contracted provider of services under arrangement, including the prescribed frequency of treatment and the circumstances under which such treatment shall be sought;
5. Plans for continuing care, including review and modification to the plan of care;
6. Plans for discharge; and
7. Signature and date by the physician.
C. D. The CIPOC for Level C must meet all of the following criteria:
1. Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the recipient's individual's situation and must reflect the need for inpatient psychiatric care;
2. Be developed by an interdisciplinary team of physicians and other personnel specified under subsection F G of this section, who are employed by, or provide services to, patients in the facility in consultation with the recipient individual and his parents, legal guardians, or appropriate others in whose care he will be released after discharge;
3. State treatment objectives that must include measurable short-term and long-term goals and objectives, with target dates for achievement;
4. Prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives related to the diagnosis; and
5. Include a list of services provided under arrangement (described in 12VAC30-50-130) that will be furnished to the individual through referral to an employee or a contracted provider of services under arrangement, including the prescribed frequency of treatment and the circumstances under which such treatment shall be sought; and
6. Describe comprehensive discharge plans and coordination of inpatient services and post-discharge plans with related community services to ensure continuity of care upon discharge with the recipient'sindividual's family, school, and community.
D. E. Review of the CIPOC for Level C. The CIPOC must be reviewed every 30 days by the team specified in subsection FG of this section to:
1. Determine that services being provided are or were required on an inpatient basis; and
2. Recommend changes in the plan as indicated by the recipient'sindividual's overall adjustment as an inpatient.
E. F. The development and review of the plan of care for Level C as specified in this section satisfies the facility's utilization control requirements for recertification and establishment and periodic review of the plan of care, as required in 42 CFR 456.160 and 456.180.
F. G. Team developing the CIPOC for Level C. The following requirements must be met:
1. At least one member of the team must have expertise in pediatric mental health. Based on education and experience, preferably including competence in child psychiatry, the team must be capable of all of the following:
a. Assessing the recipient's individual'simmediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities;
b. Assessing the potential resources of the recipient'sindividual's family;
c. Setting treatment objectives; and
d. Prescribing therapeutic modalities to achieve the plan's objectives.
2. The team must include, at a minimum, either:
a. A board-eligible or board-certified psychiatrist;
b. A clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; or
c. A physician licensed to practice medicine or osteopathy with specialized training and experience in the diagnosis and treatment of mental diseases, and a psychologist who has a master's degree in clinical psychology or who has been certified by the state or by the state psychological association.
3. The team must also include one of the following:
a. A psychiatric social worker;
b. A registered nurse with specialized training or one year's experience in treating mentally ill individuals;
c. An occupational therapist who is licensed, if required by the state, and who has specialized training or one year of experience in treating mentally ill individuals; or
d. A psychologist who has a master's degree in clinical psychology or who has been certified by the state or by the state psychological association.
G. All Medicaid services are subject to utilization review. Absence of any of the required documentation may result in denial or retraction of any reimbursement. H. The RTC-Level C shall not receive a per diem reimbursement for any day that:
1. The initial or comprehensive written plan of care fails to include within three business days of the initiation of the service provided under arrangement:
(a) The prescribed frequency of treatment of such service, or includes a frequency that was exceeded; or
(b) All services that the individual needs while residing at the RTC-Level C and that will be furnished to the individual through the RTC-Level C referral to an employed or contracted provider of services under arrangement.
2. The initial or comprehensive written plan of care fails to list the circumstances under which the service provided under arrangement shall be sought;
3. The referral to the service provided under arrangement was not present in the individual's RTC-Level C record;
4. The service provided under arrangement was not supported in that provider's records by a documented referral from the RTC-Level C;
5. The medical records from the provider of services under arrangement (i.e., admission and discharge documents, treatment plans, progress notes, treatment summaries, and documentation of medical results and findings) (i) were not present in the individual's RTC-Level C record or had not been requested in writing by the RTC-Level C within seven days of discharge from or completion of the service or services provided under arrangement or (ii) had been requested in writing within seven days of discharge from or completion of the service or services provided under arrangement, but not received within 30 days of the request, and not re-requested; or
6. The RTC-Level C did not have a fully executed contract or employee relationship with an independent provider of services under arrangement in advance of the provision of such services. For emergency services, the RTC-Level C shall have a fully executed contract with the emergency services provider prior to submission of the emergency service provider's claim for payment.
7. A physician's order for the service under arrangement is not present in the record.
8. The service under arrangement is not included in the individual's CIPOC within 30 calendar days of the physician's order.
I. The provider of services under arrangement shall be required to reimburse DMAS for the cost of any such service provided under arrangement that was (i) furnished prior to receiving a referral or (ii) in excess of the amounts in the referral. Providers of services under arrangement shall be required to reimburse DMAS for the cost of any such services provided under arrangement that were rendered in the absence of an employment or contractual relationship.
H. J. For Therapeutic Behavioral Servicestherapeutic behavioral services for Children children and Adolescentsadolescents under 21 (Level B), the initial plan of care must be completed at admission by the licensed mental health professional (LMHP) and a CIPOC must be completed by the LMHP no later than 30 days after admission. The assessment must be signed and dated by the LMHP.
I. K. For Community-Based Services community-based services for Children children and Adolescents adolescentsunder 21 (Level A), the initial plan of care must be completed at admission by the QMHP and a CIPOC must be completed by the QMHP no later than 30 days after admission. The individualized plan of care must be signed and dated by the program director.
J. L. Initial plan of care for Levels A and B must include:
1. Diagnoses, symptoms, complaints, and complications indicating the need for admission;
2. A description of the functional level of the child individual;
3. Treatment objectives with short-term and long-term goals;
4. Any orders for medications, treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures recommended for the health and safety of the patient;
5. Plans for continuing care, including review and modification to the plan of care; and
6. Plans for discharge.
K. M. The CIPOC for Levels A and B must meet all of the following criteria:
1. Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the child's individual's situation and must reflect the need for residential psychiatric care;
2. The CIPOC for both levels must be based on input from school, home, other healthcare health care providers, the childindividual and family (or legal guardian);
3. State treatment objectives that include measurable short-term and long-term goals and objectives, with target dates for achievement;
4. Prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives related to the diagnosis; and
5. Describe comprehensive discharge plans with related community services to ensure continuity of care upon discharge with the child'sindividual's family, school, and community.
L. N. Review of the CIPOC for Levels A and B. The CIPOC must be reviewed, signed, and dated every 30 days by the QMHP for Level A and by the LMHP for Level B. The review must include:
1. The response to services provided;
2. Recommended changes in the plan as indicated by the child'sindividual's overall response to the plan of care interventions; and
3. Determinations regarding whether the services being provided continue to be required.
Updates must be signed and dated by the service provider.
M. All Medicaid services are subject to utilization review. Absence of any of the required documentation may result in denial or retraction of any reimbursement.
VA.R. Doc. No. R14-3714; Filed August 19, 2016, 3:08 p.m.
TITLE 12. HEALTH
Titles of Regulations: 12VAC30-50. Amount, Duration,
and Scope of Medical and Remedial Care Services (adding 12VAC30-50-455; repealing
12VAC30-50-440, 12VAC30-50-450, 12VAC30-50-490).
12VAC30-60. Standards Established and Methods Used to Assure
High Quality Care (amending 12VAC30-60-360).
12VAC30-80. Methods and Standards for Establishing Payment
Rates; Other Types of Care (amending 12VAC30-80-110).
12VAC30-120. Waivered Services (amending 12VAC30-120-700, 12VAC30-120-710, 12VAC30-120-750,
12VAC30-120-751, 12VAC30-120-752, 12VAC30-120-754, 12VAC30-120-756,
12VAC30-120-758, 12VAC30-120-759, 12VAC30-120-760, 12VAC30-120-761,
12VAC30-120-762, 12VAC30-120-764, 12VAC30-120-766, 12VAC30-120-770,
12VAC30-120-773, 12VAC30-120-774, 12VAC30-120-775, 12VAC30-120-777,
12VAC30-120-779, 12VAC30-120-1000, 12VAC30-120-1005, 12VAC30-120-1020,
12VAC30-120-1030, 12VAC30-120-1070, 12VAC30-120-1090, 12VAC30-120-1500,
12VAC30-120-1510, 12VAC30-120-1520, 12VAC30-120-1540; adding 12VAC30-120-501, 12VAC30-120-505,
12VAC30-120-514, 12VAC30-120-515, 12VAC30-120-525, 12VAC30-120-535,
12VAC30-120-545, 12VAC30-120-570, 12VAC30-120-580, 12VAC30-120-735,
12VAC30-120-782, 12VAC30-120-1019, 12VAC30-120-1021, 12VAC30-120-1022,
12VAC30-120-1023, 12VAC30-120-1024, 12VAC30-120-1025, 12VAC30-120-1026,
12VAC30-120-1027, 12VAC30-120-1028, 12VAC30-120-1029, 12VAC30-120-1031,
12VAC30-120-1032, 12VAC30-120-1033, 12VAC30-120-1034, 12VAC30-120-1035,
12VAC30-120-1036, 12VAC30-120-1037, 12VAC30-120-1038, 12VAC30-120-1039, 12VAC30-120-1058,
12VAC30-120-1059, 12VAC30-120-1061, 12VAC30-120-1063, 12VAC30-120-1064,
12VAC30-120-1065, 12VAC30-120-1066, 12VAC30-120-1067, 12VAC30-120-1068,
12VAC30-120-1069, 12VAC30-120-1552, 12VAC30-120-1554, 12VAC30-120-1556,
12VAC30-120-1558, 12VAC30-120-1560, 12VAC30-120-1580; repealing
12VAC30-120-720, 12VAC30-120-730, 12VAC30-120-740, 12VAC30-120-753,
12VAC30-120-776, 12VAC30-120-1010, 12VAC30-120-1040, 12VAC30-120-1060,
12VAC30-120-1080, 12VAC30-120-1088, 12VAC30-120-1530, 12VAC30-120-1550).
Statutory Authority: § 32.1-325 of the Code of
Virginia; 42 USC § 1396.
Effective Dates: September 1, 2016, through February 28,
2018.
Agency Contact: Emily McClellan, Regulatory Supervisor,
Policy Division, Department of Medical Assistance Services, 600 East Broad
Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804)
786-1680, or email emily.mcclellan@dmas.virginia.gov.
Preamble:
This action concerns the redesign of three of the
Department of Medical Assistance Services (DMAS) existing home and
community-based waivers: Individual and Family Developmental Disabilities
Support Waiver (12VAC30-120-700 et seq.), which is changing to the Family and
Individual Supports Waiver (FIS); Intellectual Disability Waiver
(12VAC30-120-1000 et seq.), which is changing to the Community Living Waiver
(CL); and the Day Support Waiver for Individuals with Mental Retardation
(12VAC30-120-1500 et seq.) is changing to the Building Independence Waiver
(BI).
Section 2.2-4011 of the Code of Virginia states that agencies
may adopt emergency regulations in situations in which Virginia statutory law
or the appropriation act or federal law or federal regulation requires that a
regulation be effective in 280 days or less from its enactment, and the
regulation is not exempt under the provisions of subdivision A 4 of
§ 2.2-4006 of the Code of Virginia.
Item 301 MMMM (2) of Chapter 665 of the 2015 Acts of the
Assembly directed: "The Department of Medical Assistance Services, in
collaboration with the Department of Behavioral Health and Developmental
Services, shall report on plans to redesign the Medicaid comprehensive
Intellectual and Developmental Disability waivers prior to the submission of a
request to the Centers for Medicare and Medicaid Services to amend the waivers.
In developing the report, the departments shall include plans for the list of
services to be included in each waiver, service limitations, provider
qualifications, and proposed licensing regulatory changes; and proposed changes
to the rate structure for services and the cost to implement such changes. The
Department of Medical Assistance Services, in collaboration with the Department
of Behavioral Health and Developmental Services, shall report on how the
individuals currently served in the existing waivers and those expected to
transition to the community will be served in the redesigned waivers based on
their expected level of need for services."
Item 306 CCCC of Chapter 780 of the 2016 Acts of the
Assembly directed:
"1. The Department of Medical Assistance Services
shall adjust the rates and add new services in accordance with the
recommendations of the provider rate study and the published formula for
determining the SIS® levels and tiers developed as part of the redesign of the
Individual and Family Developmental Disabilities Support (DD), Day Support
(DS), and Intellectual Disability (ID) Waivers. The department shall have the
authority to adjust provider rates and units, effective July 1, 2016, in
accordance with those recommendations with the exception that no rate changes
for Sponsored Residential services shall take effect until January 1, 2017. The
rate increase for skilled nursing services shall be 25 percent."
"2. The Department of Medical Assistance Services
shall have the authority to amend the Individual and Family Developmental
Disabilities Support (DD), Day Support (DS), and Intellectual Disability (ID)
Waivers, to initiate the following new waiver services effective July 1, 2016:
Shared Living Residential, Supported Living Residential, Independent Living
Residential, Community Engagement, Community Coaching, Workplace Assistance
Services, Private Duty Nursing Services, Crisis Support Services, Community
Based Crisis Supports, Center-based Crisis Supports, and Electronic Based Home
Supports; and the following new waiver services effective July 1, 2017:
Community Guide and Peer Support Services, Benefits Planning, and Non-medical
Transportation. The rates and units for these new services shall be established
consistent with recommendations of the provider rate study and the published
formula for determining the SIS levels and tiers developed as part of the
waiver redesign, with the exception that private duty nursing rates shall be
equal to the rates for private duty nursing services in the Assistive
Technology Waiver and the EPSDT program. The implementation of these changes
shall be developed in partnership with the Department of Behavioral Health and
Developmental Services."
"3. Out of this appropriation, $328,452 the first year
and $656,903 the second year from the general fund and $328,452 the first year
and $656,903 the second year from nongeneral funds shall be provided for a
Northern Virginia rate differential in the family home payment for Sponsored
Residential services. Effective January 1, 2017, the rates for Sponsored
Residential services in the Intellectual Disability waiver shall include in the
rate methodology a higher differential of 24.5 percent for Northern Virginia
providers in the family home payment as compared to the rest-of-state rate. The
Department of Medical Assistance Services and the Department of Behavioral
Health and Developmental Services shall, in collaboration with sponsored
residential providers and family home providers, collect information and
feedback related to payments to family homes and the extent to which changes in
rates have impacted payments to the family homes statewide."
"4. For any state plan amendments or waiver changes to
effectuate the provisions of paragraphs CCCC 1 and CCCC 2 above, the Department
of Medical Assistance Services shall provide, prior to submission to the
Centers for Medicare and Medicaid Services, notice to the Chairmen of the House
Appropriations and Senate Finance Committees, and post such changes and make
them easily accessible on the department's website."
"5. The department shall have the authority to
implement necessary changes upon federal approval and prior to the completion
of any regulatory process undertaken in order to effect such changes."
The redesign effort, a collaboration among DMAS, the
Department of Behavioral Health and Developmental Services (DBHDS),
consultants, and stakeholders for the last two years, combines the target
populations of individuals with intellectual disabilities and other
developmental disabilities and offers new services that are designed to promote
improved community integration and engagement. This purpose of the redesign is
to (i) better support individuals with disabilities to live integrated and
engaged lives in their communities; (ii) standardize and simplify access to
services; (iii) cover services that promote community integration and
engagement; (iv) improve providers' capacity and quality by increasing
compensation as they increase expertise; (v) achieve better outcomes for
individuals supported in smaller community settings; and (vi) facilitate
meeting the Commonwealth's commitments under the community integration mandate
of the American with Disabilities Act (42 USC § 12101 et seq.), the Supreme
Court's Olmstead Decision, and the 2012 U.S. Department of Justice Settlement
Agreement.
Significant input throughout the redesign process has been
collected from individuals, their families, affected providers, advocates, and
other stakeholders as well as national experts. Extensive data has been collected
to redesign the current waiver system to more closely link medical/support
needs with expenditures. For individuals with intellectual/developmental
disabilities and their families, the system will be accessed via a single local
point of entry (the Community Services Boards/Behavioral Health Authorities
(CSB/BHAs)).
An expanded array of service options over those currently
covered in the existing waivers is recommended to enable individuals with
disabilities to successfully live in their communities. New services include
(i) crisis support (including center-based and community-based) services; (ii)
shared living supports; (iii) independent living supports; (iv) supported
living residential; (v) community engagement supports; (vi) community coaching supports;
(vii) community guide supports; (viii) workplace assistance services; (ix)
private duty nursing; and (x) electronic home based supports.
Some currently existing services are being modified and one
existing service (prevocational services) is being repealed. Current services
include (i) skilled nursing services; (ii) therapeutic consultation; (iii)
personal emergency response systems; (iv) assistive technology; (v)
environmental modifications; (vi) personal assistance services; (vii) companion
services; (viii) respite services; (ix) group day services; (x) group home
services; (xi) sponsored residential services; (xii) individual and family
caregiver training; (xiii) supported living; (xiv) supported employment; (xv)
transition services; and (xvi) services facilitation.
DMAS and DBHDS recommend retaining the consumer-direction
model of service delivery for personal assistance, companion, and respite
services as currently permitted with no further expansion of this model to any
of the other existing or new services.
In addition to these new services, all individuals will be
evaluated with the use of a common assessment instrument (the Supports
Intensity Scale (SIS®)) resulting in the development of their unique individual
service plans. Seven levels of supports will be established for the purpose of
creating the most equitable distribution of funding for core waiver services.
Common definitions of intellectual disability and developmental disability are
recommended. Standards for a single uniform waiting list are also recommended
as well as criteria for how individuals on the waiting list will be provided
their choice of available services. Since the target populations of these three
waivers are being merged under the single definition of developmental
disability, the individual eligibility sections of the regulations are also
being merged into a single set of regulations at 12VAC30-120-500 et seq.
DMAS case management regulations (12VAC30-50-440,
12VAC30-50-450, and 12VAC30-50-490) are being repealed and replaced with updated
case management regulations to be located at 12VAC30-50-455.
DMAS longstanding regulation titled "Criteria for care
in facilities for mentally retarded persons" (12VAC30-60-360) is being
renamed "'Criteria for care in facilities for individuals with
developmental disabilities." The phrase "or waivered rehabilitative
services for the mentally retarded" is being removed from 12VAC30-60-360 B
relevant to this regulatory action because for this waiver redesign, the level
of functioning criteria for institutional services is being replaced with the
Virginia Individual Developmental Disabilities Eligibility (VIDES) Survey (for
infants, children, and adults) as established in 12VAC30-120-500 et seq. The
other changes indicated for 12VAC30-60-360 are technical corrections to update
the regulation to the Registrar's current format and labeling standards.
Current policy:
Individual and Family Developmental Disabilities Support
(DD) Waiver: This waiver was originally developed in 2000 to serve the needs of
individuals, and their families, who require the level of care provided in
Intermediate Care Facilities for Individuals with Intellectual Disabilities
(ICF/IID) (formerly Intermediate Care Facilities for the Mentally Retarded
(ICF/MR)). Such individuals must be older than six years of age and have
diagnoses of either autism or severe chronic disabilities identified in 42 CFR
435.1009 (cerebral palsy or epilepsy, any other condition (other than mental
illness) that impairs general intellectual functioning, manifests itself prior
to the individual's 22nd birthday, is expected to continue indefinitely, and
results in substantial limitation of three or more areas of major life activity
(self-care, language, learning, mobility, self-direction, independent living)).
The originally covered services were (i) in-home residential support; (ii) day
support; (iii) prevocational services; (iv) supported employment services; (v)
therapeutic consultation; (vi) environmental modifications; (vii) skilled
nursing; (viii) assistive technology; (ix) crisis stabilization; (x) personal
care and respite (both agency directed and consumer directed); (xi)
family/caregiver training; (xii) personal emergency response systems; and
(xiii) companion services (both agency directed and consumer directed). In SFY
2015, this waiver served 913 individuals/families with expenditures of
$28,747,525. Acute care costs for these individuals totaled $9,388,868.
Intellectual Disabilities (ID) Waiver: This waiver was
originally developed in 1991 to serve the needs of individuals and their
families, who are determined to require the level of care in an ICF/IID. Such
individuals must have a diagnosis of intellectual disability or if younger than
six years old, be at developmental risk of significant limitations in major
life activities. The services covered in ID are (i) assistive technology; (ii)
companion services (both agency-directed and consumer-directed); (iii) crisis
stabilization; (iv) day support; (v) environmental modifications; (vi) personal
assistance and respite (both agency-directed and consumer-directed); (vii)
personal emergency response systems; (viii) prevocational services; (ix)
residential support services; (x) services facilitation (only for
consumer-directed services); (xi) skilled nursing services; (xii) supported
employment; (xiii) therapeutic consultation; and (xiv) transition services. In
SFY 2015, this waiver served 10,174 individuals/families with expenditures of
$693,861,042. Acute care costs for these individuals totaled $138,928,215.
Day Support (DS) Waiver: This waiver was originally
developed in 2005 to serve the needs of individuals, along with their families,
who have intellectual disabilities and have been determined to require the
level of care in an ICF/IID. This waiver was developed to address the
overwhelming needs of this population of individuals in the Commonwealth,
because the ID waiver operated at capacity and was not funded for the higher
numbers of individuals who required the covered services. This waiver was intended
to be temporary measure while the individuals on the waiting list waited for an
opening in the ID waiver. The services covered in DS are (i) day support; (ii)
prevocational services; and (iii) supported employment. In SFY 2015, this
waiver served 271 individuals/families with expenditures of $3,806,006. Acute
care costs for these individuals totaled $3,103,295.
Issues:
The Commonwealth's three waivers have not been
substantially updated in recent years. DMAS and DBHDS have undertaken this
waiver redesign in consideration of recent federal policy changes to ensure
that Virginia's system of services and supports fully embraces community
inclusion and full access for individuals who have disabilities. This redesign
effort is important to (i) provide community-based services for individuals
with significant medical and behavioral support needs; (ii) expand
opportunities that promote smaller, more integrated independent living options
with needed supports; (iii) enable providers to adapt their service provision
and business model to support the values and expectations of the federally
required community integration mandate; and (iv) comply with Settlement
Agreement elements requiring expansion of integrated residential/day services
and employment options for persons with intellectual/developmental
disabilities.
In Virginia, funding and payment for services are broadly
related to individual support needs. DMAS has found that differing expenditures
have become associated with people who have similar needs. Currently, an
individual's level of need for resources and supports is often not correlated
to waiver expenditures. Over time, DMAS and DBHDS expect that better
correlating individuals' support levels with the costs of their needs will
enable the Commonwealth to more precisely predict costs, thereby leading to
improved budgeting, which is expected to enable serving more individuals within
current appropriations.
Recommendations:
DMAS and DBHDS recommend amending three existing waivers
into three distinct waivers that will support all individuals who are eligible
and have developmental disabilities by (i) integrating individuals with
developmental disabilities into their communities by providing needed supports
and resources; (ii) standardizing and simplifying access to services; (iii)
offering services that promote community integration and engagement; (iv)
improving providers' capacities and quality by increasing reimbursements as
quality improves; (v) aligning this waiver redesign with recent research about
supporting such individuals in smaller communities in order to achieve better
outcomes; and (vi) creating a single, statewide waiting list that DBHDS will
maintain to replace current waiting lists. Individuals will be ranked by
priority based on the degree of jeopardy to their health and safety due to
their unpaid caregivers' circumstances. Individuals and family/caregivers will
have appeal rights for the priority assignment process but not the actual slot
allocation determination.
DMAS and DBHDS believe that these recommendations will
enable the Commonwealth to meet its obligations under the community integration
mandate of the ADA, the Supreme Court's Olmstead Decision, and the 2012
Settlement Agreement with the U.S. Department of Justice.
Family and Individual Supports (FIS) Waiver (formerly the
DD Waiver): This new waiver will continue to support individuals with
disabilities who are living with their families, friends or in their own
residences. It will support individuals who have some medical or behavioral needs
and will be open to children and adults. The following services will be added:
(i) shared living; (ii) supported living residential; (iii) community coaching;
(iv) community engagement; (v) workplace assistance services; (vi) private duty
nursing; (vii) crisis support services; (viii) community-based crisis supports;
(ix) center-based crisis supports; and (x) electronic home based supports.
Community Living Waiver (formerly the ID Waiver): This new
waiver will remain a comprehensive waiver that includes 24/7 residential
support services for those who require this level of support. It will be open
to children and adults with developmental disabilities who may require intense
medical supports, behavioral supports, or both. The following services will be
added: (i) crisis support services; (ii) supported living residential; (iii)
shared living; (iv) electronic home based support; (v) community engagement;
(vi) community coaching; (vii) community guide (peer mentoring); (viii)
community-based and center-based crisis supports; (ix) individual and
family/caregiver training; (x) private duty nursing; and (xi) workplace
assistance services.
Building Independence Waiver (formerly DS Waiver):
This new waiver will support adults (18 years of age and older) who are
able to live in their communities and control their own living arrangements
with minimal supports. The following services will be added: (i) assistive
technology; (ii) community-based and center-based crisis supports; (iii)
environmental modifications; (iv) Personal Emergency Response Systems and
electronic home based supports; (v) transition services; (vi) shared living;
(vii) independent living supports; and (viii) community engagement/ coaching
(peer mentoring) services.
Currently provided prevocational services (defined as
preparing an individual for paid/unpaid employment such as accepting
supervision, attendance, task completion, problem solving, and safety) are
recommended for discontinuation as part of this redesign action.
12VAC30-50-440. Case management services for individuals
with mental retardation. (Repealed.)
A. Target Group. Medicaid eligible individuals who are
mentally retarded as defined in state law.
1. An active client for mental retardation case management
shall mean an individual for whom there is a plan of care in effect which
requires regular direct or client-related contacts or communication or activity
with the client, family, service providers, significant others and others
including at least one face-to-face contact every 90-days. Billing can be
submitted for an active client only for months in which direct or
client-related contacts, activity or communications occur.
2. There shall be no maximum service limits for case
management services except case management services for individuals residing in
institutions or medical facilities. For these individuals, reimbursement for
case management shall be limited to thirty days immediately preceding
discharge. Case management for institutionalized individuals may be billed for
no more than two predischarge periods in twelve months.
B. Services will be provided in the entire State.
C. Comparability of Services: Services are not comparable
in amount, duration, and scope. Authority of section 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. Mental retardation services to
be provided include:
1. Assessment and planning services, to include developing
a Consumer Service Plan (does not include performing medical and psychiatric
assessment but does include referral for such assessment);
2. Linking the individual to services and supports
specified in the consumer service plan;
3. Assisting the individual directly for the purpose of
locating, developing or obtaining needed services and resources;
4. Coordinating services and service planning with other
agencies and providers involved with the individual;
5. Enhancing community integration by contacting other
entities to arrange community access and involvement, including opportunities
to learn community living skills, and use vocational, civic and recreational
services;
6. Making collateral contacts with the individual's
significant others to promote implementation of the service plan and community
adjustment;
7. Following-up and monitoring to assess ongoing progress
and ensuring services are delivered; and
8. Education and counseling which guides the client and
develops a supportive relationship that promotes the service plan.
E. Qualifications of providers:
1. Services are not comparable in amount, duration, and
scope. Authority of § 1915(g)(1) of the Act is invoked to limit case management
providers for individuals with mental retardation and serious/chronic mental
illness to the Community Services Boards only to enable them to provide
services to serious/chronically mentally ill or mentally retarded individuals
without regard to the requirements of § 1902(a)(10)(B) of the Act.
2. To qualify as a provider of services through DMAS for
rehabilitative mental retardation case management, the provider of the services
must meet certain criteria. These criteria shall be:
a. The provider must guarantee that clients have access to
emergency services on a 24-hour basis;
b. The provider must demonstrate the ability to serve
individuals in need of comprehensive services regardless of the individual's
ability to pay or eligibility for Medicaid reimbursement;
c. The provider must have the administrative and financial
management capacity to meet state and federal requirements;
d. The provider must have the ability to document and
maintain individual case records in accordance with state and federal requirements;
e. The services shall be in accordance with the Virginia
Comprehensive State Plan for Mental Health, Mental Retardation and Substance
Abuse Services; and
f. The provider must be certified as a mental retardation
case management agency by the DMHMRSAS.
3. Providers may bill for Medicaid mental retardation case
management only when the services are provided by qualified mental retardation
case managers. The case manager must possess a combination of mental
retardation work experience or relevant education which indicates that the
individual possesses the following knowledge, skills, and abilities. The
incumbent must have at entry level the following knowledge, skills and
abilities. These must be documented or observable in the application form or supporting
documentation or in the interview (with appropriate documentation).
a. Knowledge of:
(1) The definition, causes and program philosophy of mental
retardation
(2) Treatment modalities and intervention techniques, such
as behavior management, independent living skills training, supportive
counseling, family education, crisis intervention, discharge planning and
service coordination
(3) Different types of assessments and their uses in
program planning
(4) Consumers' rights
(5) Local community resources and service delivery systems,
including support services, eligibility criteria and intake process,
termination criteria and procedures and generic community resources
(6) Types of mental retardation programs and services
(7) Effective oral, written and interpersonal communication
principles and techniques
(8) General principles of record documentation
(9) The service planning process and the major components
of a service plan
b. Skills in:
(1) Interviewing
(2) Negotiating with consumers and service providers
(3) Observing, recording and reporting behaviors
(4) Identifying and documenting a consumer's needs for
resources, services and other assistance
(5) Identifying services within the established service
system to meet the consumer's needs
(6) Coordinating the provision of services by diverse
public and private providers
(7) Using information from assessments, evaluations,
observation and interviews to develop service plans
(8) Formulating, writing and implementing individualized
consumer service plans to promote goal attainment for individuals with mental
retardation;
(9) Using assessment tools
(10) Identifying community resources and organizations and
coordinating resources and activities
c. Abilities to:
(1) Demonstrate a positive regard for consumers and their
families (e.g. treating consumers as individuals, allowing risk taking,
avoiding stereotypes of people with mental retardation, respecting consumers'
and families' privacy, believing consumers can grow)
(2) Be persistent and remain objective
(3) Work as 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) Establish and maintain ongoing supportive relationships
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.
1. Eligible recipients will have free choice of the
providers of case management services.
2. Eligible recipients will have free choice of the
providers of other medical care under the plan.
G. Payments 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.
12VAC30-50-450. Case management services for individuals
with mental retardation and related conditions who are participants in the Home
and Community-Based Care waivers for such individuals. (Repealed.)
A. Target group: Medicaid eligible individuals with mental
retardation and related conditions, or a child under 6 years of age who is at
developmental risk, who have been determined to be eligible for Home and
Community Based Care Waiver Services for persons with mental retardation and
related conditions.
1. An active client for waiver case management shall mean
an individual who receives at least one face-to-face contact every 90 days and
monthly on-going case management interactions. There shall be no maximum
service limits for case management services. Case management services may be
initiated up to 3 months prior to the start of waiver services, unless the
individual is institutionalized.
2. There shall be no maximum service limits for case
management services except case management services for individuals residing in
institutions or medical facilities. For these individuals, reimbursement for
case management shall be limited to thirty days immediately preceding
discharge. Case management for institutionalized individuals may be billed for
no more than two predischarge periods in twelve months.
B. Services will be provided in entire State.
C. Comparability of Services. Services are not comparable
in amount, duration, and scope. Authority of section 1915(g)(1) of the Act is
invoked to provide services without regard to the requirements of section
1902(a)(10)(B) of the Act.
D. Definition of Services. Mental retardation case
management services to be provided include:
1. Assessment and planning services, to include developing
a Consumer Service Plan (does not include performing medical and psychiatric
assessment but does not include referral for such assessment);
2. Linking the individual to services and supports
specified in the consumer service plan;
3. Assisting the individual directly for the purpose of
locating, developing or obtaining needed services and resources;
4. Coordinating services with other agencies and providers
involved with the individual;
5. Enhancing community integration by contacting other
entities to arrange community access and involvement, including opportunities
to learn community living skills, and use vocational, civic and recreational
services;
6. Making collateral contacts with the individual's
significant others to promote implementation of the service plan and community
adjustment; and
7. Following-up and monitoring to assess ongoing progress
and ensuring services are delivered; and
8. Education and counseling which guides the client and
develop a supportive relationship that promotes the service plan.
E. Qualifications of Providers:
1. Services are not comparable in amount, duration, and
scope. Authority of § 1915(g)(1) of the Act is invoked to limit case management
providers for individuals with mental retardation and serious/chronic mental
illness to the Community Services Boards only to enable them to provide
services to seriously or chronically mentally ill or mentally retarded
individuals without regard to the requirements of § 1902(a)(10)(B) of the Act.
2. To qualify as a provider of services through DMAS for
rehabilitative mental retardation case management, the provider of the services
must meet certain criteria. These criteria shall be:
a. The provider must guarantee that clients have access to
emergency services on a 24 hour basis;
b. The provider must demonstrate the ability to serve
individuals in need of comprehensive services regardless of the individuals'
ability to pay or eligibility for Medicaid reimbursement;
c. The provider must have the administrative and financial
management capacity to meet state and federal requirements;
d. The provider must have the ability to document and
maintain individual case records in accordance with state and federal
requirements;
e. The services shall be in accordance with the Virginia
Comprehensive State Plan for Mental Health, Mental Retardation and Substance
Abuse Services; and
f. The provider must be certified as a mental retardation
case management agency by the DMHMRSAS.
3. Providers may bill for Medicaid mental retardation case
management only when the services are provided by qualified mental retardation
case managers. The case manager must possess a combination of mental
retardation work experience or relevant education which indicates that the
individual possesses the following knowledge, skills, and abilities, at the entry
level. These must be documented or observable in the application form or
supporting documentation or in the interview (with appropriate documentation).
a. Knowledge of:
(1) The definition, causes and program philosophy of mental
retardation
(2) Treatment modalities and intervention techniques, such
as behavior management, independent living skills training, supportive
counseling, family education, crisis intervention, discharge planning and
service coordination;
(3) Different types of assessments and their uses in
program planning
(4) Consumers' rights
(5) Local service delivery systems, including support
services
(6) Types of mental retardation programs and services
(7) Effective oral, written and interpersonal communication
principles and techniques
(8) General principles of record documentation
(9) The service planning process and the major components
of a service plan
b. Skills in:
(1) Interviewing
(2) Negotiating with consumers and service providers
(3) Observing, records and reporting behaviors
(4) Identifying and documenting a consumer's needs for
resources, services and other assistance
(5) Identifying services within the established service
system to meet the consumer's needs
(6) Coordinating the provision of services by diverse
public and private providers
(7) Analyzing and planning for the service needs of
mentally retarded persons
(8) Formulating, writing and implementing individualized
consumer service plans to promote goal attainment for individuals with mental
retardation
(9) Using assessment tools.
c. Abilities to:
(1) Demonstrate a positive regard for consumers and their
families (e.g., treating consumers as individuals, allowing risk taking,
avoiding stereotypes of mentally retarded people, respecting consumers' and
families' privacy, believing consumers can grow)
(2) Be persistent and remain objective
(3) Work as team member, maintaining effective inter- and
intra-agency working relationships
(4) Work independently, performing positive duties under
general supervision
(5) Communicate effectively, verbally and in writing
(6) Establish and maintain ongoing supportive
relationships.
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.
1. Eligible recipients will have free choice of the
providers of case management services.
2. Eligible recipients will have free choice of the
providers of other medical care under the plan.
G. Payment for case management services under the plan
shall not duplicate payments made to public agencies or private entities under
other program authorities for this same purpose.
12VAC30-50-455. Support coordination/case management for
individuals with developmental disabilities (DD).
A. Target group. Individuals who have a developmental
disability as defined in § 37.2-100 of the Code of Virginia shall be
eligible for support coordination/case management.
1. An individual receiving DD support coordination/case
management shall mean an individual for whom there is an individual support
plan (ISP) in effect that requires monthly direct or in-person contact,
communication, or activity with the individual and family/caregiver, as
appropriate, service providers, and other authorized representatives including
at least one face-to-face contact between the individual and the support
coordinator/case manager every 90 days. Billing shall be submitted for an
individual only for months in which direct or in-person contact, activity, or
communication occurs and the support coordinator's/case manager's records
document the billed activity. Service providers shall be required to refund
payments made by Medicaid if they fail to maintain adequate documentation to support
billed activities.
2. Individuals who have developmental disabilities as
defined in state law but who are on the DD waiting list for waiver services may
receive support coordination/case management services.
B. Services shall be provided in the entire Commonwealth.
C. Comparability of services. Services shall not be
comparable in amount, duration, and scope. The authority of § 1915(g)(1) of the
Social Security Act is invoked to provide services without regard to the
requirements of § 1902(a)(10)(B) and (C) of the Social Security Act.
D. Definition of services.
1. Developmental disability support coordination/case
management services to be provided shall include:
a. Assessing and planning services, to include developing
an ISP, which does not include performing medical and psychiatric assessment
but does include referral for such assessments;
b. Connecting, joining, arranging, or associating the
individual to or for services and supports specified in the ISP;
c. Assisting the individual directly for the purpose of
locating, developing, or obtaining needed services and resources;
d. Coordinating services and service planning with other
agencies and service providers involved with the individual;
e. Enhancing community integration by contacting other
entities to arrange community access and involvement;
f. Making collateral contacts with the individual to
promote implementation of the ISP and successful community adjustment;
g. Following and monitoring the individual to assess
ongoing progress and ensuring services are delivered; and
h. Educating and counseling that guides the individual and
develops a supportive relationship that promotes the ISP.
2. There shall be no maximum service limits for support
coordination/case management services except for individuals residing in
institutions or medical facilities. For these individuals, reimbursement for
support coordination/case management shall be limited to 90 days pre-discharge
(immediately preceding discharge) from the institution into the community.
While individuals may require re-entry to institutions or medical facilities
for emergencies, discharge planning efforts should be significant to prevent
readmission. For this reason, support coordination/case management may be
billed for only two 90-day pre-discharge periods in a 12-month period.
E. Qualifications of providers.
1. Services shall not be comparable in amount, duration,
and scope. Authority of § 1915(g)(1) of the Social Security Act is hereby
invoked to limit support coordination/case management providers to the
community services boards/behavioral health authorities (CSBs/BHAs). CSBs/BHAs
shall contract with private support coordinators/case managers for this
service. CSBs/BHAs shall have current, signed provider agreements with DMAS and
shall directly bill DMAS for reimbursement.
2. DD support coordinators/case managers shall not be (i)
the direct care staff person, (ii) the immediate supervisor of the direct care
staff person, (iii) otherwise related by business or organization to the direct
care staff person, or (iv) an immediate family member of the direct care staff
person.
3. Parents, spouses, or any family living with the
individual may not provide direct support coordination/case management services
for the individual or spouse of the individual with whom they live or be
employed by a company that provides support coordination/case management for
the individual, spouse, or individual with whom they live.
4. Providers of DD support coordination/case management
services shall meet the following criteria:
a. The provider shall guarantee that individuals have
access to emergency services on a 24-hour basis;
b. The 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;
c. The provider shall have the administrative and financial
management capacity to meet state and federal requirements;
d. The provider shall have the ability to document and
maintain individual case records in accordance with state and federal
requirements; and
e. The provider shall be licensed as a developmental
disability support coordination/case management entity contracted with the CSB.
5. Support coordinators/case managers who provide DD case
management services after September 1, 2016, shall possess a minimum of an
undergraduate degree in a human services field. Support coordinators/case
managers who do not possess a minimum of an undergraduate degree in a human
services field may continue to provide support coordination/case management if
they are employed by an entity with a Medicaid participation agreement to
provide DD case management prior to February 1, 2005, and maintain employment
with the provider under that agreement without interruption.
6. In addition to the requirements in subdivision 5 of this
subsection, the support coordinator/case manager shall possess developmental
disability work experience or relevant education that indicates that the
incumbent at entry level possesses the following knowledge, skills, and
abilities that shall be documented in the employment application form or
supporting documentation or during the job interview. The knowledge, skills,
and abilities shall include:
a. Knowledge of:
(1) The definition, causes, and program philosophy of
developmental disability;
(2) Treatment modalities and intervention techniques, such
as behavior management, independent living skills training, supportive
counseling, family education, crisis intervention, discharge planning, and
service coordination;
(3) Different types of assessments and their uses in
program planning;
(4) Individual rights;
(5) Local community resources and service delivery systems,
including support services, eligibility criteria and intake process,
termination criteria and procedures, and generic community resources;
(6) Types of developmental disability programs and
services;
(7) Effective oral, written, and interpersonal
communication principles and techniques;
(8) General principles of record documentation; and
(9) The service planning process and the major components
of an individual support plan.
b. Skills in:
(1) Interviewing;
(2) Negotiating with individual consumers and service
providers;
(3) Observing, recording, and reporting behaviors;
(4) Identifying and documenting an individual consumer's
needs for resources, services, and other assistance;
(5) Identifying services to meet the individual's needs;
(6) Coordinating the provision of services by diverse
public and private providers;
(7) Analyzing and planning for the service needs of
individuals with developmental disabilities;
(8) Formulating, writing, and implementing individual
support plans to promote goal attainment for individuals with developmental
disabilities;
(9) Successfully using assessment tools; and
(10) Identifying community resources and organizations and
coordinating resources and activities.
c. Ability to:
(1) Demonstrate a positive regard for individuals and their
families (e.g., permitting risk taking, avoiding stereotypes of individuals
with developmental disabilities, respecting individuals' and families' privacy,
believing individuals can grow);
(2) Be persistent and remain objective;
(3) Work as team member, maintaining effective interagency
and intra-agency working relationships;
(4) Work independently, performing position duties under
general supervision;
(5) Communicate effectively, verbally and in writing; and
(6) Establish and maintain ongoing supportive
relationships.
7. Support coordinators/case managers who are employed by an
organization contracted with the CSB/BHA shall receive supervision within the
employing organization. The supervisor of the support coordinator/case manager
shall have at least a master's level degree in a human services field or have
five years of experience in the field working with individuals with
developmental disability as defined in § 37.2-100 of the Code of Virginia, or
both.
8. Support coordinators/case managers who are contracted
with the CSB/BHA shall obtain one hour of documented supervision by the CSB
every three months.
9. A support coordinator/case manager shall complete a
minimum of eight hours of training annually in one or a combination of the
areas described in the knowledge, skills, and abilities in subdivision 6 of
this subsection and shall provide documentation to demonstrate that training is
completed to his supervisor. The documentation shall be maintained by the
supervisor of the support coordinator/case manager for the purposes of
utilization review.
F. The state assures that the provision of support
coordination/case management services shall not restrict an individual's free
choice of providers in violation of § 1902(a)(23) of the Social Security
Act.
1. To provide choice to individuals enrolled in the
Building Independence (BI), Community Living (CL), and Family And Individual
Supports (FIS) waivers, CSB/BHAs shall contract with private support
coordination/case management entities to provide DD support coordination/case
management, except if there are no qualified providers in that CSB/BHA's
catchment area, then the CSB/BHA shall provide services. CSBs/BHAs shall be the
only licensed entities permitted to provide DD support coordination/case
management.
2. Individuals who are eligible for the BI, CL, and FIS
waivers shall have free choice of the providers of support coordination/case
management services within the parameters described in subdivision 1 of this
subsection and as follows:
a. For those individuals that receive intellectual
disability (ID) case management services:
(1) The CSB that serves the individual will be the provider
of support coordination/case management.
(2) The CSB shall provide a choice of support
coordinator/case managers within the CSB.
(3) If the individual or family decides that no choice is
desired in that CSB, the CSB shall afford a choice of another CSB with whom the
responsible CSB has a memorandum of agreement.
(4) At any time, an individual may make a request to change
his support coordinator/case manager.
b. For those individuals who receive DD case management
services:
(1) The CSB that serves the individual will be the provider
of support coordination/case management.
(2) The CSB shall provide a choice of support
coordinator/case managers within the CSB.
(3) If the individual or family decides that no choice is
desired in that CSB, the CSB shall afford a choice of another CSB with whom the
responsible CSB has a memorandum of agreement.
(4) If the individual or family decides not to choose the
responsible CSB or the CSB with whom there is a memorandum of agreement, then
the individual or family will be given a choice of a private provider with whom
the responsible CSB has a contract for support coordination/case management.
(5) At any time, an individual may make a request to change
their support coordinator/case manager.
3. Individuals who are eligible for the BI, CL, and FIS
waivers shall have free choice of the providers of other medical care under the
plan.
4. When the required support coordination/case management
services are contracted out to a private entity, the CSB/BHA shall remain the
responsible provider and only the CSB/BHA may bill DMAS for Medicaid
reimbursement.
G. Payments for support coordination/case management
services under the individual support plan (ISP) shall not duplicate payments
made to public agencies or private entities under other program authorities for
this same or similar purpose.
H. The support coordinator/case manager shall maintain the
following documentation, in either hard copy or electronic format, for a period
of not less than six years from each individual's last date of service or in
the case of a minor child, six years after the minor child's 18th birthday:
1. All assessments and reassessments completed for the
individual, all ISPs for the individual, and every service providers' plan for
supports completed for the individual;
2. All supporting documentation related to any change in
the ISP;
3. All related communication (including dates) with the
individual, family/caregiver, consultants, providers, Department of Behavioral
Health and Developmental Services, Department of Medical Assistance Services,
Department of Social Services, Department for Aging and Rehabilitative
Services, or other related parties;
4. An ongoing log that documents all contacts (including
dates) made by the support coordinator/case manager related to the individual
and family/caregiver; and
5. A copy of the current DMAS-225 form.
I. Individual choice of provider entities. The individual
shall have the option of selecting the provider of his choice from among those
providers meeting the individual's needs. The support coordinator/case manager
shall inform the individual, and family member/caregiver as appropriate, of all
available enrolled waiver service providers in the community in which he
desires services, and he shall have the option of selecting the provider of his
choice from the list of enrolled service providers.
J. Support coordinator/case manager's responsibility for
the Medicaid Long Term Care Communication Form (DMAS-225). It is shall be the
responsibility of the support coordinator/case manager to notify Department of
Medical Assistance Services, Department of Behavioral Health and Developmental
Services, and Department of Social Services, in writing within five business days,
when any of the following circumstances occur:
1. Home and community-based waiver services are
implemented.
2. An individual dies.
3. An individual is discharged or terminated from waiver
services.
4. Any other circumstances (including hospitalization) that
cause home and community-based waiver services to cease or be interrupted for
more than 30 calendar days.
5. A selection by the individual or his family/caregiver,
as appropriate, of a different support coordination/case management provider.
12VAC30-50-490. Case management for individuals with
developmental disabilities, including autism. (Repealed.)
A. Target group. Medicaid-eligible individuals with
related conditions who are six years of age and older and who are on the
waiting list or are receiving services under the Individual and Family
Developmental Disabilities Support (IFDDS) Waiver.
1. An active client for case management shall mean an
individual for whom there is a plan of care that requires regular direct or
client-related contacts or communication or activity with the client, family,
service providers, significant others and others including at least one
face-to-face contact every 90 calendar days. Billing can be submitted for an
active client only for months in which direct or client-related contacts,
activity or communications occur.
2. When an individual applies for the IFDDS Waiver and
there is no available funding (slots), he will be placed on a waitlist until
funding is available. The "Initial Waitlist Plan of Care" is
completed with the case manager and identifies the services anticipated once a
slot is available. Individuals on the waitlist do not have routine case
management services unless there is a documented special service need in the
plan of care. Case managers may make face-to-face contact every 90 calendar
days to monitor the special service need and documentation is required to
support such contact. The case manager will assure the plan of care addresses
the current needs of the individual and will coordinate with DMAS to assure
actual enrollment into the waiver upon slot availability.
3. The unit of service is one month. There shall be no
maximum service limits for case management services except case management
services for individuals residing in institutions or medical facilities. For
these individuals, reimbursement for case management for institutionalized
individuals may be billed for no more than two months in a 12-month cycle.
4. The unit of service is one month. There shall be no
maximum service limits for case management services except case management
services for individuals residing in institutions or medical facilities. For
these individuals, reimbursement for case management for institutionalized
individuals may be billed for no more than two months in a 12-month cycle.
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 Social Security Act (Act) is invoked to
provide services without regard to the requirements of § 1902(a)(10)(B) of the
Act.
D. Definition of services. Case management services will
be provided for Medicaid-eligible individuals with related conditions who are
on the waiting list for or participants in the home and community-based care
IFDDS Waiver. Case management services to be provided include:
1. Assessment and planning services, to include developing
a consumer service plan (does not include performing medical and psychiatric
assessment but does include referral for such assessments);
2. Linking the individual to services and supports
specified in the consumer service plan;
3. Assisting the individual directly for the purpose of
locating, developing, or obtaining needed services and resources;
4. Coordinating services with other agencies and providers involved
with the individual;
5. Enhancing community integration by contacting other
entities to arrange community access and involvement, including opportunities
to learn community living skills and use vocational, civic, and recreational
services;
6. Making collateral contacts with the individual's
significant others to promote implementation of the service plan and community
adjustment;
7. Following up and monitoring to assess ongoing progress
and ensure services are delivered;
8. Education and counseling that guides the individual and
develops a supportive relationship that promotes the service plan; and
9. Benefits counseling.
E. Qualifications of providers. In addition to meeting the
general conditions and requirements for home and community-based care
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
specific provider qualifications are:
1. To qualify as a provider of services through DMAS for
IFDDS Waiver case management, the service provider must meet these criteria:
a. Have the administrative and financial management
capacity to meet state and federal requirements;
b. Have the ability to document and maintain recipient case
records in accordance with state and federal requirements; and
c. Be enrolled as an IFDDS case management agency by DMAS.
2. Providers may bill for Medicaid case management only
when the services are provided by qualified case managers. The case manager
must possess a combination of developmental disability work experience or
relevant education, which indicates that the individual possesses the following
knowledge, skills, and abilities, at the entry level. These must be documented
or observable in the application form or supporting documentation or in the
interview (with appropriate documentation).
a. Knowledge of:
(1) The definition, causes, and program philosophy of
developmental disabilities;
(2) Treatment modalities and intervention techniques, such
as behavior management, independent living skills, training, supportive
counseling, family education, crisis intervention, discharge planning and
service coordination;
(3) Different types of assessments and their uses in
program planning;
(4) Individuals' rights;
(5) Local service delivery systems, including support
services;
(6) Types of developmental disability programs and
services;
(7) Effective oral, written, and interpersonal
communication principles and techniques;
(8) General principles of record documentation; and
(9) The service planning process and the major components
of a service plan.
b. Skills in:
(1) Interviewing;
(2) Negotiating with individuals and service providers;
(3) Observing, recording, and reporting behaviors;
(4) Identifying and documenting an individual's needs for
resources, services, and other assistance;
(5) Identifying services within the established service
system to meet the individual's needs;
(6) Coordinating the provision of services by diverse
public and private providers;
(7) Analyzing and planning for the service needs of
developmentally disabled persons;
(8) Formulating, writing, and implementing
individual-specific service plans to promote goal attainment for recipients
with developmental disabilities; and
(9) Using assessment tools.
c. Abilities to:
(1) Demonstrate a positive regard for individuals and their
families (e.g., allowing risk taking, avoiding stereotypes of developmentally
disabled people, respecting individuals' and families' privacy, believing
individuals can grow);
(2) Be persistent and remain objective;
(3) Work as a team member, maintaining effective inter- and
intra-agency working relationships;
(4) Work independently, performing positive duties under
general supervision;
(5) Communicate effectively, orally and in writing; and
(6) Establish and maintain ongoing supportive
relationships.
3. In addition, case managers who enroll with DMAS to
provide case management services after (insert the effective date of these
regulations) must possess a minimum of an undergraduate degree in a human
services field. Providers who had a Medicaid participation agreement to provide
case management prior to February 1, 2005, and who maintain that agreement
without interruption may continue to provide case management using the KSA
requirements effective prior to February 1, 2005.
4. Case managers who are employed by an organization must
receive supervision within the same organization. Case managers who are
self-employed must obtain one hour of documented supervision every three months
when the case manager has active cases. The individual who provides the
supervision to the case manager must have a master's level degree in a human
services field and/or have five years of satisfactory experience in the field
working with individuals with related conditions as defined in 42 CFR
435.1009. A case management provider cannot supervise another case management
provider.
5. Case managers must complete eight hours of training
annually in one or a combination of the areas described in the knowledge,
skills and abilities (KSA) subdivision. Case managers must have documentation
to demonstrate training is completed. The documentation must be maintained by
the case manager for the purposes of utilization review.
6. Parents, spouses, or any person living with the
individual may not provide direct case management services for their child,
spouse or the individual with whom they live or be employed by a company that
provides case management for their child, spouse, or the individual with whom
they live.
7. A case manager may provide services facilitation
services. In these cases, the case manager must meet all the case management
provider requirements as well as the service facilitation provider
requirements. Individuals and their family/caregivers, as appropriate, have the
right to choose whether the case manager may provide services facilitation or
to have a separate services facilitator and this choice must be clearly
documented in the individual's record. If case managers are not services
facilitation providers, the case manager must assist the individual and his
family/caregiver, as appropriate, to locate an available services facilitator.
8. If the case manager is not serving as the individual's
services facilitator, the case manager may conduct the assessments and
reassessment for CD services if the individual or his family/caregiver, as
appropriate, chooses. The individual's choice must be clearly documented in the
case management record along with which provider is responsible for conducting
the assessments and reassessments required for CD services.
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.
1. Eligible recipients will have free choice of the
providers of case management services.
2. Eligible recipients will have free choice of the
providers of other medical care under the plan.
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.
12VAC30-60-360. Criteria for care in facilities for mentally
retarded persons individuals with developmental disabilities including
intellectual disabilities.
§ 4.0 A. Definitions. The following words and
terms, when used in these criteria this section, shall have the
following meaning meanings, unless the context clearly indicated
indicates otherwise:
"Active treatment" means the same as 42 CFR
483.440(a).
"no assistance" shall mean "No
assistance" means no help is needed.
"Often" means that a behavior occurs two to
three times per month.
""prompting/structuring" shall mean "Prompting/structuring"
means that an individual requires, prior to the functioning, some verbal
direction and/or or some rearrangement, or both, of the
environment is needed.
"Rarely" means that a behavior occurs once a
quarter or less frequently.
"Regularly" means that a behavior occurs once a
week or more frequently.
"Some direct assistance" means that an
individual requires a helper to be present and provide some physical guidance/support
(with or without verbal direction).
"Sometimes" means that a behavior occurs once a
month or less frequently.
"Supervision" means that an individual requires
a helper to be present during the function and provide only verbal direction,
general prompts, or guidance, or all of these.
"supervision" shall mean that a helper must be
present during the function and provide only verbal direction, general prompts,
and/or guidance.
"some direct assistance" shall mean that helper
must be present and provide some physical guidance/support (with or without
verbal direction).
"total care" shall mean "Total
care" means that an individual requires a helper must to
perform all or nearly all of the functions.
"rarely" shall mean that a behavior occurs
quarterly or less.
"sometimes" shall mean that a behavior occurs
once a month or less.
"often" shall mean that a behavior occurs 2-3
times a month.
"regularly" shall mean that a behavior occurs
weekly or more.
§ 4.1 Utilization Control regulations require that
criteria be formulated for guidance for appropriate levels of services.
Traditionally, care for the mentally retarded has been institutionally based;
however, this level of care need not be confined to a specific setting. The
habilitative and health needs of the client are the determining issues.
§ 4.2 The purpose of these regulations is to establish
B. This section establishes standard criteria to measure eligibility
for Medicaid payment for an individual to receive care in facilities.
Medicaid can pay for covers care only when the client individual
is receiving appropriate services and when "active treatment"
is being provided. An individual's need for care must shall meet these
the level of functioning criteria in the VIDES form, referenced in
12VAC30-120-535, before any authorization for payment by Medicaid will be
made for either institutional or waivered rehabilitative services
for the mentally retarded.
§ 4.3 C. Care in facilities for the mentally
retarded individuals with developmental or intellectual disabilities
requires planned programs for of services to address habilitative
needs and/or or health needs, or both, related services
which that exceed the level of room, board, and general
supervision of daily activities.
1. Such cases shall care may be a
combination of habilitative, rehabilitative, and health services directed
toward increasing the functional capacity of the retarded person individual.
Examples of services such care shall include (i) training
in the activities of daily living, (ii) training in task-learning
skills, (iii) learning socially acceptable behaviors, (iv) basic
community living programming, or (v) health care and health maintenance.
2. The overall objective of programming shall be the
attainment of the optimal physical, intellectual, social, or task learning
level which that the person individual can
presently or potentially achieve.
§ 4.4 D. The evaluation and re-evaluation for determination
of the intermediate care facility (ICF) level of care in a facility for the
mentally retarded individuals with development/intellectual disabilities
shall be based on (i) the needs of the person individual, (ii)
the reasonable expectations of the resident's individual's
capabilities, (iii) the appropriateness of programming, whether (iv)
the progress is demonstrated from the training, and, (v)
in an institution, whether the services could reasonably be provided in a less
restrictive environment.
§ 4.5 Patient E. Individual assessment
criteria. The patient individual assessment criteria are
divided into broad categories of needs, or services provided. These must
shall be evaluated in detail to determine the abilities/skills which
skills, abilities, and status that will be the basis for the development
of a plan for care an individual support plan. The evaluation
process will demonstrate shall indicate a need for programming
an array of an individual support plan that addresses the individual's
skills and, abilities, or need for health care services.
These, which have been organized in the seven major
categories set forth in subsection F of this section. Level of
functioning in each category is graded from the most dependent to the least
dependent. In some categories, the dependency status is rated by the degree of
assistance required. In other categories, the dependency is established by the
frequency of a behavior or the ability to perform a given task.
§ 4.6 F. Dependency level. The resident must
meet the indicated dependency level in TWO OR MORE of categories 1
through 7 individual shall demonstrate two or more of the skills or
statuses listed in subdivisions 1 through 7 of this subsection. To
demonstrate a skill or exhibit a status, the individual shall meet the
dependency level described for that skill or status. The questions referenced
in subdivisions 1 through 7 of this subsection to meet a dependency level are
found in Table 1 of this subsection.
1. Health status. To meet this category:
1. a. Two or more questions must be answered
with a 4, OR or
2. b. Question "j" must be answered
"yes."
B. 2. Communication Skills - skills.
To meet this category, three or more questions must be answered with a 3
or a 4.
C. 3. Task Learning Skills - learning
skills. To meet this category, three or more questions must be
answered with a 3 or a 4.
D. 4. Personal Care - care skills.
To meet this category, either:
1. a. Question "a" must be answered
with a 4 or a 5, OR or
2. b. Question "b" must be answered
with a 4 or a 5, OR or
3. c. Questions "c" and "d"
must be answered with a 4 or a 5.
E. Mobility - To 5. Mobility status. To meet
this category any one question must be answered with a 4 or a 5.
F. 6. Behavior - To status. To
meet this category, any one question must be answered with a 3 or a 4.
G. 7. Community Living - To living
skills. To meet this category:
1. a. Any two of the questions "b",
"e", or "g" must be answered with a 4 or a 5, OR;
or
2. b. Three or more questions must be answered
with a 4 or a 5.
§ 4.7. Level of functioning survey.
|
A. HEALTH STATUS Table 1 – Level of Functioning
Survey
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|
1. Health status: How often is nursing care or
nursing supervision by a licensed nurse required for the following?
(Key:1=rarely, 2=sometimes, 3=often, and 4=regularly)
|
|
1. a. Medication administration and/or or
evaluation for effectiveness of a medication regimen?
|
1
|
2
|
3
|
4
|
|
2. b. Direct services: i.e., care for lesions,
dressings, or treatments, (other than shampoos, foot power powder,
etc.)
|
1
|
2
|
3
|
4
|
|
3. c. Seizures control
|
1
|
2
|
3
|
4
|
|
4. d. Teaching diagnosed disease control and
care, including for diabetes
|
1
|
2
|
3
|
4
|
|
5. e. Management of care of diagnosed
circulatory or respiratory problems
|
1
|
2
|
3
|
4
|
|
6. f. Motor disabilities which that
interfere with all activities of Daily Living - Bathing, Dressing,
Mobility, Toileting etc., daily living (i.e. bathing, dressing,
mobility, toileting, etc.)
|
1
|
2
|
3
|
4
|
|
7. g. Observation for choking/aspiration
choking or aspiration while eating, or drinking?
|
1
|
2
|
3
|
4
|
|
8. h. Supervision of use of adaptive equipment,
(i.e., special spoon, braces, etc.)
|
1
|
2
|
3
|
4
|
|
9. i. Observation for nutritional problems
(i.e., undernourishment, swallowing difficulties, obesity)
|
1
|
2
|
3
|
4
|
|
10. j. Is age
55 or older, has a diagnosis of a chronic disease, and has been in an
institution 20 years or more
|
1
|
2
|
3
|
4
|
|
B. COMMUNICATION
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|
Using the 2. Communication skills: How often does
this person: Key 1=regularly, 2=often, 3=sometimes, 4=rarely, how
often does this person
|
|
1. a. Indicate wants by pointing, vocal
noises, or signs?
|
1
|
2
|
3
|
4
|
|
2. b. Use simple words, phrases, short
sentences?
|
1
|
2
|
3
|
4
|
|
3. c. Ask for at least ten 10
things using appropriate names?
|
1
|
2
|
3
|
4
|
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4. d. Understand simple words, phrases or
instructions containing prepositions: i.e., on, in, behind?
|
1
|
2
|
3
|
4
|
|
5. e. Speak in an easily understood manner?
|
1
|
2
|
3
|
4
|
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6. f. Identify self, place of residence, and
significant others?
|
1
|
2
|
3
|
4
|
|
C. TASK LEARNING SKILLS
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|
3. Task learning skills: How often does this person
perform the following activities? (Key: 1=regularly, 2=often,
3=sometimes, 4=rarely)
|
|
1. a. Pay attention to purposeful activities
for 5 five minutes?.
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1
|
2
|
3
|
4
|
|
2. b. Stay with a 3 step three-step
task for more than 15 minutes?.
|
1
|
2
|
3
|
4
|
|
3. c. Tell time to the hour and understand
time intervals? intervals.
|
1
|
2
|
3
|
4
|
|
4. d. Count more than 10 objects? objects.
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1
|
2
|
3
|
4
|
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5. e. Do simple addition, subtraction? subtraction.
|
1
|
2
|
3
|
4
|
|
6. f. Write or print ten words? 10
words.
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1
|
2
|
3
|
4
|
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7. g. Discriminate shapes, sizes, or colors?
colors.
|
1
|
2
|
3
|
4
|
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8. h. Name people or objects when describing pictures?
pictures.
|
1
|
2
|
3
|
4
|
|
9. i. Discriminate between one, many, lot?
and a lot.
|
1
|
2
|
3
|
4
|
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D. PERSONAL and SELF CARE
|
|
4. Personal and self care: With what type of
assistance can this person currently (Key: 1=No Assistance 1=no
assistance, 2=Prompting/Structures 2=prompting/structures, 3=Supervision
3=supervision, 4=Some Direct Assistance 4=some direct
assistance, 5=Total Care) 5=total care)
|
|
1. a. Perform toileting functions: (i.e.,
maintain bladder and bowel continence, clean self, etc.)?
|
1
|
2
|
3
|
4
|
5
|
|
2. b. Perform eating/feeding eating
or feeding functions: (i.e., drinks liquids and eats with
spoon or fork, etc.)?
|
1
|
2
|
3
|
4
|
5
|
|
3. c. Perform bathing function: (i.e.,
bathes, runs bath, dry dries self, etc.)?
|
1
|
2
|
3
|
4
|
5
|
|
4. d. Dress self himself
completely, (i.e., including fastening, putting on clothes,
etc.)?
|
1
|
2
|
3
|
4
|
5
|
|
E. MOBILITY
|
|
5. Mobility: With what type of assistance can this
person currently (Key: 1=No Assistance 1=no assistance, 2=Prompting/Structures
2=prompting/structures, 3=Supervision 3=supervision, 4=Some
Direct Assistance 4=some direct assistance, 5=Total Care) 5=total
care)
|
|
1. a. Move, (i.e., walking,
wheeling) around his environment?
|
1
|
2
|
3
|
4
|
5
|
|
2. b. Rise from lying down to sitting positons
positions, or sits without support?
|
1
|
2
|
3
|
4
|
5
|
|
3. c. Turn and position himself in bed,
or roll over?
|
1
|
2
|
3
|
4
|
5
|
|
F. BEHAVIOR
|
|
6. Behavior: How often does this person (Key:1=Rarely
1=rarely, 2=Sometimes 2=sometimes, 3=Often 3=often,
and 4=Regularly) 4=regularly)
|
|
1. a. Engage in self destructive behavior?
|
1
|
2
|
3
|
4
|
|
2. b. Threaten or do physical violence to
others?
|
1
|
2
|
3
|
4
|
|
3. c. Throw things, damage property, have
temper outbursts?
|
1
|
2
|
3
|
4
|
|
4. d. Respond to others in a socially
unacceptable manner - (without undue anger, frustration, or hostility)?
|
1
|
2
|
3
|
4
|
|
G. COMMUNITY LIVING SKILLS
|
|
7. Community Living Skills: With what type of
assistance can this person currently: (Key:1=No Assistance 1=no
assistance, 2=Prompting/Structures 2=prompting/structures, 3=Supervision
3=supervision, 4=Some Direct Assistance 4=some direct
assistance, 5=Total Care) 5=total care)
|
|
1. a. Prepare simple foods requiring no mixing
or cooking?
|
1
|
2
|
3
|
4
|
5
|
|
2. b. Take care of personal belongings,
and room (excluding vacuuming, ironing, clothes washing/drying washing
and drying, wet mopping)?
|
1
|
2
|
3
|
4
|
5
|
|
3. c. Add coins of various denominations up to
one dollar?
|
1
|
2
|
3
|
4
|
5
|
|
4. d. Use the telephone to call home, doctor,
fire, and police?
|
1
|
2
|
3
|
4
|
5
|
|
5. e. Recognize survival signs/words signs
and words: (i.e., stop, go, traffic lights, police, men, women,
restrooms, danger, etc.)?
|
1
|
2
|
3
|
4
|
5
|
|
6. f. Refrain from exhibiting unacceptable
sexual behavior in public?
|
1
|
2
|
3
|
4
|
5
|
|
7. g. Go around cottage, ward, or building,
without running away, wandering off, or becoming lost?
|
1
|
2
|
3
|
4
|
5
|
|
8. h. Make minor purchases, (i.e.,
candy, soft drink, etc)?
|
1
|
2
|
3
|
4
|
5
|
12VAC30-80-110. Fee-for-service: case management.
A. Targeted case management for high-risk pregnant women
and infants up to two years of age, for community mental health and
intellectual disability services, and for individuals who have applied for or
are participating in the Individual and Family Developmental Disability Support
Waiver program (IFDDS Waiver) shall be reimbursed at the lowest of: state
agency fee schedule, actual charge, or Medicare (Title XVIII) allowances.
B. A. Targeted case management for early
intervention (Part C) children.
1. Targeted case management for children from birth to three
years of age who have developmental delay and who are in need of early
intervention is reimbursed at the lower of the state agency fee schedule or the
actual charge (charge to the general public). The unit of service is monthly
one month. All private and governmental fee-for-service providers are
reimbursed according to the same methodology. The agency's rates are effective
for services on or after October 11, 2011. Rates are published on the agency's
website at www.dmas.virginia.gov.
2. Case management shall not be billed when it is an
integral part of another Medicaid service including, but not limited to,
intensive community treatment services and intensive in-home services for
children and adolescents.
3. 2. Case management defined for another target
group shall not be billed concurrently with this case management service except
for case management services for high risk infants provided under
12VAC30-50-410. Providers of early intervention case management shall
coordinate services with providers of case management services for high risk
infants, pursuant to 12VAC30-50-410, to ensure that services are not
duplicated.
4. 3. Each entity receiving payment for services
as defined in 12VAC30-50-415 shall be required to furnish the following to
DMAS, upon request:
a. Data, by practitioner, on the utilization by Medicaid
beneficiaries of the services included in the unit rate; and
b. Cost information used by practitioner.
5. 4. Future rate updates will be based on
information obtained from the providers. DMAS monitors the provision of
targeted case management through post-payment review (PPR). PPRs ensure that
paid services were (i) rendered appropriately, in accordance with state
and federal laws, regulations, policies, and program
requirements, (ii) provided in a timely manner, and (iii) paid
correctly.
B. Reimbursement for targeted case management for high
risk pregnant women and infants and children.
1. Targeted case management for high risk pregnant women
and infants up to two years of age defined in 12VAC30-50-410 shall be
reimbursed at the lower of the state agency fee schedule or the actual charge
(charge to the general public). The unit of service is one day. All private and
governmental fee-for-service providers are reimbursed according to the same
methodology. The agency's rates were set as of September 10, 2013, and are
effective for services on or after that date. Rates are published on the
agency's website at www.dmas.virginia.gov.
2. Case management may not be billed when it is an integral
part of another Medicaid service.
3. Case management defined for another target group shall
not be billed concurrently with the case management service under this subsection
except for case management for early intervention provided under
12VAC30-50-415. Providers of case management for high risk pregnant women and
infants and children shall coordinate services with providers of early
intervention case management to ensure that services are not duplicated.
4. Each provider receiving payment for the service under
this subsection will be required to furnish the following to the Medicaid
agency, upon request:
a. Data on the hourly utilization of this service furnished
to Medicaid members; and
b. Cost information used by practitioners furnishing this
service.
5. Rate updates will be based on utilization and cost
information obtained from the providers.
C. Reimbursement for targeted case management for
seriously mentally ill adults and emotionally disturbed children and for youth
at risk of serious emotional disturbance.
1. Targeted case management services for seriously mentally
ill adults and emotionally disturbed children defined in 12VAC30-50-420 or for
youth at risk of serious emotional disturbance defined in 12VAC30-50-430 shall
be reimbursed at the lower of the state agency fee schedule or the actual
charge (charge to the general public). The unit of service is one month. All
private and governmental fee-for-service providers are reimbursed according to
the same methodology. The agency's rates were set as of September 10, 2013, and
are effective for services on or after that date. Rates are published on the
agency's website at www.dmas.virginia.gov.
2. Case management for seriously mentally ill adults and
emotionally disturbed children and for youth at risk of serious emotional
disturbance may not be billed when it is an integral part of another Medicaid
service.
3. Case management defined for another target group shall
not be billed concurrently with the case management services under this
subsection.
4. Each provider receiving payment for the services under
this subsection will be required to furnish the following to the Medicaid
agency, upon request:
a. Data on the hourly utilization of these services
furnished to Medicaid members; and
b. Cost information used by the practitioner furnishing
these services.
5. Rate updates will be based on utilization and cost
information obtained from the providers.
D. Reimbursement for targeted case management for
individuals with intellectual disability or developmental disability.
1. Targeted case management for individuals with
intellectual disability defined in 12VAC30-50-440 and individuals with
developmental disabilities defined in 12VAC30-50-450 shall be reimbursed at the
lower of the state agency fee schedule or the actual charge (the charge to the
general public). The unit of service is one month. All private and governmental
fee-for-service providers are reimbursed according to the same methodology. The
agency's rates were set as of July 1, 2016, and are effective for services on
or after that date. Rates are published on the agency's website at
www.dmas.virginia.gov
2. Case management for individuals with intellectual
disability or developmental disability may not be billed when it is an integral
part of another Medicaid service.
3. Case management defined for another target group shall
not be billed concurrently with the case management service under this
subsection.
4. Each provider receiving payment for the service under
this subsection will be required to furnish the following to the Medicaid
agency, upon request:
a. Data on the hourly utilization of this service furnished
to Medicaid members; and
b. Cost information by practitioners furnishing this
service.
5. Rate updates will be based on utilization and cost
information obtained from the providers.
12VAC30-120-501. Definitions.
The following words and terms used in 12VAC30-120-501 et
seq. shall have the following meanings unless the context clearly indicates
otherwise:
"Applicant" means an individual (or his
representative acting on his behalf) who has applied for or is in the process
of applying for and is awaiting a determination of eligibility for admission to
a DD waiver.
"BI" means the Building Independence Waiver as
set out in 12VAC30-120-1500 et seq.
"CL" means the Community Living Waiver as set
out in 12VAC30-120-1000 et seq.
"Comprehensive assessment" means the gathering
of relevant social, psychological, medical, and level of care information by
the support coordinator/case manager and is used as a basis for the development
of the Individual Support Plan.
"DBHDS" means the Department of Behavioral
Health and Developmental Services.
"DD waivers" means the FIS (12VAC30-12-700 et
seq.), CL (12VAC30-120-1000 et seq.), and the BI (12VAC30-120-1500 et seq.)
waivers in the collective.
"Developmental disability" or "DD"
means the same as defined in § 37.2-100 of the Code of Virginia.
"DMAS" means the Department of Medical
Assistance Services.
"Enroll" with respect to an individual means (i)
the local department of social services has determined the individual's
financial eligibility for Medicaid as set out in 12VAC30-120-501 et seq., (ii)
the individual has been determined by the support coordinator/case manager to
meet the functional eligibility requirements in the VIDES form (referenced in
12VAC30-120-535) for the waiver, (iii) the Department of Behavioral Health and
Developmental Services has verified the availability of a waiver slot for the
individual, and (iv) the individual has agreed to accept the waiver slot.
"Family" means, for the purpose of receiving
individual and family/caregiver training services, the unpaid people who live
with or provide care to an individual served on the waiver and may include a
parent, a spouse, children, relatives, a foster family, or in-laws but shall
not include persons who are compensated, by any possible means, to care for the
individual.
"FIS" means the Family and Individual Support Waiver
as set out in 12VAC30-120-700 et. seq.
"Health, safety, and welfare standard" means the
same as defined in 12VAC30-120-1000.
"ICF/IID" means a facility or distinct part of a
facility licensed by DBHDS and meeting the federal certification regulations
for an intermediate care facility for individuals with intellectual
disabilities and individuals with related conditions and that addresses the
total needs of the individuals, which include physical, intellectual, social,
emotional, and habilitation, and provides active treatment as defined in 42 CFR
483.440.
"IDEA" means the Individuals with Disabilities
Education Act (20 USC § 1400 et seq.).
"Individual" means the Commonwealth's citizen,
including a child, who meets the income and resource standards in order to be
eligible for Medicaid-covered services, has a diagnosis of developmental
disability, and is eligible for the BI, CL, or FIS Waiver. The individual may
be a person on the DD waiting list or a person enrolled and receiving waiver
services.
"Levels of support" means the level (1-7) to
which an individual is assigned as a result of the utilization of the SIS®
score and the Virginia Supplemental Questions. The level of support is derived
from a calculation using the SIS® score and correlates to an individual's
needs. The Virginia Supplemental Questions form is completed to gather
additional information regarding the needs of an individual whose SIS®
responses regarding medical or behavioral needs indicate a high level of
support needs. For individuals in Levels 6 and 7, the Virginia Supplemental
Questions may also be used to determine the level of support.
"Positive behavior support" means an applied
science that uses educational methods to expand an individual's behavior
repertoire and systems change methods to redesign an individual's living
environment to enhance the individual's quality of life and minimize his
challenging behaviors.
"Risk assessment" means the same as defined in
12VAC30-120-1000.
"Slot" means an opening or vacancy in waiver
services for an individual.
"Support coordination/case management" means the
same as defined in 12VAC30-50-455 D.
"Support coordinator/case manager" means the
person who provides support coordination/case management services to
individuals enrolled in one of the DD waivers or are listed on the DD waivers
waiting list in accordance with 12VAC30-50-455.
"Supporting documentation" means any written or
electronic materials used to record and verify the individual's support needs,
services provided, and contacts made on behalf of the individual and may
include, but shall not be limited to, the personal profile, individual support
plan, service providers' plans for supports, progress notes, reports, medical
orders, contact logs, attendance logs, and assessments. Supporting
documentation shall be maintained to support claims for all services submitted
to DMAS for reimbursement.
"Support package" means a profile of the mix and
extent of services anticipated to be needed by individuals with similar levels,
needs, and abilities.
"Supports Intensity Scale®" or
"SIS®" means an assessment tool and form that is published
by the American Association on Intellectual and Developmental Disabilities and
administered through a thorough interview process that measures and documents
an individual's practical support requirements in personal, school-related or
work-related, social, behavioral, and medical areas in order to identify and
determine the types and intensity levels of the supports required by that
individual in order to live successfully in the community.
"Tiers of reimbursement" means tiers that are
tied to an individual's level of support, so that providers are reimbursed for
services provided to individuals consistent with that level of support.
"VDSS" means the Virginia Department of Social
Services.
"Waiver Slot Assignment Committee" or
"WSAC" means an impartial body of trained volunteers established for
each locality or region with responsibility for recommending individuals
eligible for a waiver slot according to their urgency of need. All WSACs will
be composed of community members who will not be employees of a CSB or a
private provider of either support coordination/case management or waiver
services. WSAC members will be knowledgeable and have experience in the DD service
system.
12VAC30-120-505. FIS, CL, and BI Waiver establishment, legal
authority, description; waiver population, SIS® requirements.
A. Selected home and community-based waiver services shall
be available through § 1915(c) waivers of the Social Security Act. The
waivers shall be named (i) Family and Individual Supports (FIS), (ii) Community
Living (CL), and (iii) Building Independence (BI) (collectively referred to as
the Developmental Disabilities (DD) Waivers). Under the DD waivers, DMAS has
waived § 1902(a) (10) (B) and (C) of the Social Security Act related to
comparability of services. These services shall be required, appropriate, and
necessary to maintain the individual in the community instead of placement in
institutions.
B. Federal waiver requirements, as established in
§ 1915 of the Social Security Act and 42 CFR 430.25, provide that the
average per capita fiscal year expenditures in the aggregate under the DD
waivers shall not exceed the average per capita expenditures in the aggregate
for the level of care provided in ICFs/IIDs, as defined in 42 CFR 435.1010 and
42 CFR 483.440, under the State Plan for Medical Assistance that would have
been provided had the DD waivers not been granted.
C. DMAS shall be the single state agency pursuant to 42
CFR 431.10 responsible for administrative authority over service authorizations
and delegates the processing of service authorizations and daily operations to
Department of Behavioral Health and Developmental Services. DMAS shall be the
single state agency authority pursuant to 42 CFR 431.10 for payment of claims
for the services covered in the DD waivers and for obtaining federal financial
participation from the Centers for Medicare and Medicaid Services.
D. Individuals, as defined in 12VAC30-120-501, shall have
the right to appeal actions taken by DMAS or its designee, or both, consistent
with 12VAC30-110.
E. Waiver service populations. These waiver services shall
be provided for individuals, including children, with a developmental
disability (DD) as defined in § 37.2-100 of the Code of Virginia and who
have been determined to require the level of care provided in an ICF/IID. Such
services can only be covered if required by the individual to avoid
institutionalization. These services shall be appropriate and necessary to
ensure community integration.
F. The FIS, CL, and BI waivers services shall not be
authorized or reimbursed by DMAS for an individual who resides outside of the
physical boundaries of the Commonwealth. Waiver services shall not be furnished
to individuals who are inpatients of a hospital, nursing facility, ICF/IID, or
inpatient rehabilitation facility. Individuals with DD who are inpatients of
these facilities may receive service coordination/case management services as
described in 12VAC30-50-455. The support coordinator/case manager may recommend
waiver services that would promote the individual's exiting from the
institutional placement; however, these waiver services shall not be provided
until the individual has been enrolled in the waiver.
G. An individual shall not be simultaneously enrolled in
more than one waiver. An individual who has a diagnosis of DD may be on the
waiting list for one of the DD waivers while simultaneously being enrolled in
the Elderly or Disabled with Consumer Direction (EDCD) or the Technology
Assisted waivers if he meets applicable criteria for both.
H. DMAS, or its designee, shall ensure only eligible
individuals receive home and community-based waiver services and shall
terminate the individual from the waiver and such services when the individual
is no longer eligible for the waiver. Termination from the DD waivers shall
occur when either (i) the individual's health and medical needs can no longer
be safely met or (ii) when the individual is no longer eligible.
I. The individual's responses from the combination of the
SIS® and Virginia Supplemental Questions shall determine the
individual's required level of supports and establish the basis for the
individual service plan.
J. No waiver services shall be reimbursed until after both
the provider enrollment process and individual eligibility process have been
completed. No back dated payments shall be made for services that were rendered
before the completion of the provider enrollment process and the individual eligibility
process.
12VAC30-120-514. FIS, CL, and BI Waivers: provider
enrollment, requirements, and termination.
A. No waiver services shall be reimbursed until after the
provider has enrolled with DMAS and the individual eligibility process has been
completed and both the provider (including consumer-directed companions and
assistants) and individual are eligible and enrolled to participate.
Individuals who are enrolled in the DD waivers who chose to employ their own
companions or assistants prior to the completion of the provider enrollment
process shall be responsible for reimbursing such costs themselves. No
backdating of provider enrollment requirements shall be permitted in order for
DMAS to pay for prematurely incurred costs.
B. DMAS or its designee shall be responsible for assuring
continued adherence to provider participation standards. DMAS or its designee
shall conduct ongoing monitoring of compliance with provider participation
standards and applicable laws, regulations, and DMAS policies. A provider's
noncompliance with applicable Medicaid laws, regulations, and DMAS policies and
procedures, as required in the provider's participation agreement, may result
in termination of the provider participation agreement. For DMAS to approve
enrollment of a provider for home and community-based waiver services, the
following standards shall be met:
1. For services that have licensure or certification
requirements, the standards of any state licensure or certification
requirements, or both as applicable;
2. Disclosure of ownership pursuant to 42 CFR 455.104, 42
CFR 455.105, and 42 CFR 455.106; and
3. The ability to document and maintain individual records
in accordance with federal and state requirements.
C. Providers approved for participation shall, at a
minimum, perform the following activities:
1. Screen, on a monthly basis, all new and existing
employees and contractors to determine whether any are excluded from
eligibility for payment from federal healthcare programs, including Medicaid
(i.e., via the U.S. Department of Health and Human Services Office of Inspector
General List of Excluded Individuals or Entities (LEIE) website). Immediately,
upon learning of an exclusion, report in writing to DMAS such exclusion
information to: DMAS, ATTN: Program Integrity/Exclusions, 600 East Broad
Street, Suite 1300, Richmond, VA 23219 or email to
providerexclusion@dmas.virginia.gov.
2. Immediately notify DMAS and DBHDS, in writing, of any
change in the information that the provider previously submitted for the purpose
of the provider agreement to DMAS and DBHDS.
3. Assure the individual's freedom to refuse medical care,
treatment, and services, and document that potential adverse outcomes that may
result from refusal of services were discussed with the individual.
4. Accept referrals for services only when staff is
available to initiate services within 30 calendar days and perform such
services on an ongoing basis.
5. Provide services and supplies for individuals in full
compliance with Title VI of the Civil Rights Act of 1964, as amended (42 USC
§ 2000d et seq.), which prohibits discrimination on the grounds of race,
color, or national origin; the Virginians with Disabilities Act (Title 51.5
(§ 51.5-1 et seq.) of the Code of Virginia); § 504 of the Rehabilitation
Act of 1973, as amended (29 USC § 794), which prohibits discrimination on the
basis of a disability; and the Americans with Disabilities Act, as amended
(42 USC § 12101 et seq.), which provides comprehensive civil rights
protections to individuals with disabilities in the areas of employment, public
accommodations, state and local government services, and telecommunications.
6. Provide services and supplies to individuals of the same
quality and in the same mode of delivery as provided to the general public.
7. Submit reimbursement claims to DMAS for the provision of
covered services and supplies for individuals in amounts not to exceed the
provider's usual and customary charges to the general public and accept as
payment in full the amount established by the DMAS payment methodology from the
individual's authorization date for waiver services.
8. Use program-designated billing forms for submission of
claims for reimbursement.
9. Maintain and retain business and professional records
sufficient to document fully and accurately the nature, scope, and details of
the services provided. Provider documentation that fails to support services
claimed for reimbursement may subject the provider to recovery actions by DMAS
or its designee.
a. Such records shall be retained for at least six years
from the last date of service or as provided by applicable state and federal
laws, whichever period is longer. However, if an audit is initiated within the
required retention period, the records shall be retained until the audit is completed
and every exception resolved. Records of minors shall be kept for at least six
years after such minor has reached the age of 18 years.
b. Policies regarding retention of records shall apply even
if the provider discontinues operation. Providers shall notify DMAS in writing
of storage, location, and procedures for obtaining records for review should
the need arise. The location, agent, or trustee of the provider's records shall
be within the Commonwealth of Virginia.
c. Providers shall maintain an attendance log or similar
document, such as daily progress notes, that indicates the date services were
rendered, type of services rendered, and number of hours or units provided
(including specific time frame) for each service type except for one-time services
such as assistive technology, environmental modifications, transition services,
individual and family caregiver training, electronic home-based services, and
personal emergency response system, where initial documentation to support
claims shall suffice. Such documentation shall be provided to DMAS or its
designee upon request. Documentation shall not be created or modified once an
audit has started.
10. Agree to furnish information on request and in the form
requested to DMAS, DBHDS, the Attorney General of Virginia or his authorized
representatives, federal personnel, and the State Medicaid Fraud Control Unit.
The Commonwealth's right of access to provider premises and records shall
survive any termination of the provider participation agreement. No business or
professional records shall be created or modified by providers, employees, or
any other interested parties, either with or without the provider's knowledge,
once an audit has been initiated.
11. Disclose, as requested by DMAS, all financial, beneficial,
ownership, equity, surety, or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint ventures,
agencies, institutions, or other legal entities providing any form of health
care services to individuals enrolled in Medicaid.
12. Perform criminal history record checks for barrier
crimes in accordance with applicable licensure requirements at § 32.1-162.9:1
or 37.2-416 of the Code of Virginia. If the individual enrolled in the waiver
to be served is a minor child, also perform a search of the VDSS Child
Protective Services Central Registry. The provider shall not be compensated for
services provided to the individual enrolled in the waiver effective on the
date that any of these records checks verifies that he has been convicted of
barrier crimes described in § 32.1-162.9:1 or 37.2-416 (whichever is
applicable to the provider's license) or if he has a finding in the VDSS Child
Protective Services Central Registry.
a. For consumer-directed (CD) services, the CD employee
shall submit to a criminal history records check conducted by the fiscal
employer agent within 30 days of employment. If the individual enrolled in the
waiver is a minor child, the CD employee shall also submit to a search of the
VDSS Child Protective Services Central Registry. The CD employee shall not be
compensated for services provided to the waiver individual effective the date
on which the record check verifies that the CD employee has been convicted of
barrier crimes described in § 37.2-416 of the Code of Virginia or if the CD
employee has a founded complaint confirmed by the VDSS Child Protective
Services Central Registry.
b. The provider or CD employer shall require direct support
professionals or CD employees to notify the employer of all convictions
occurring subsequent to the initial record check. Direct support professionals
or CD employees who refuse to consent to VDSS Child Protective Services
registry checks shall not be eligible for Medicaid reimbursement.
D. Pursuant to Subpart F of 42 CFR Part 431,
12VAC30-20-90, and any other applicable federal or state law or regulation, all
providers shall hold confidential and use for DMAS or DBHDS authorized purposes
only all medical assistance information regarding individuals served. A
provider shall disclose information in his possession only when the information
is used in conjunction with a claim for health benefits or the data are
necessary for purposes directly related to the administration of the State Plan
for Medical Assistance.
E. Change of ownership. When ownership of the provider
changes, the provider shall notify DMAS at least 15 calendar days before the
date of change.
F. For ICF/IID facilities covered by § 1616(e) of the
Social Security Act in which respite care as a home and community-based waiver
service will be provided, the facilities shall be in compliance with applicable
regulatory standards.
G. Suspected abuse or neglect. Pursuant to
§§ 63.2-1509 and 63.2-1606 of the Code of Virginia, if a participating
provider knows or suspects that an individual receiving home and
community-based waiver services is being abused, neglected, or exploited, the
party having knowledge or suspicion of the abuse, neglect, or exploitation
shall report immediately at first knowledge to the local Department for Aging
and Rehabilitative Services, adult protective services or the local department
of social services, child protective services agency; to DMAS; and to the DBHDS
Offices of Licensing and Human Rights, if applicable.
H. Adherence to provider participation agreement, Medicaid
laws, and the DMAS provider manual. In addition to compliance with the general
conditions and requirements, all providers enrolled by DMAS shall adhere to the
requirements outlined in federal and state laws, regulations, their individual
provider participation agreements and in the applicable DMAS provider manual.
I. DMAS may terminate the provider's Medicaid provider
agreement pursuant to § 32.1-325 of the Code of Virginia and as may be
required for federal financial participation. Such provider agreement
terminations shall conform to 12VAC30-10-690 and Part XII (12VAC30-20-500 et
seq.) of 12VAC30-20. DMAS shall not reimburse for services that may be rendered
subsequent to such terminations.
J. Direct marketing. Providers are prohibited from
performing any type of direct marketing activities to Medicaid individuals or
their family/caregivers.
K. Providers shall participate, as may be requested, in
the completion of the DBHDS-approved assessment instruments when the provider
possesses specific, relevant information about the individual enrolled in the
waiver.
L. Felony convictions. A provider who has been convicted
of a felony, or who has otherwise pled guilty to a felony, in Virginia or in
any other of the 50 states, the District of Columbia, or the United States
territories shall, within 30 days of such conviction, notify DMAS of this
conviction and relinquish its provider agreement. Such provider agreement
terminations shall be effective immediately and conform to 12VAC30-10-690.
Providers shall not be reimbursed for services that may be rendered between the
conviction of a felony and the provider's notification to DMAS of the
conviction.
M. Except as otherwise provided by applicable statute or
federal law, the Medicaid provider agreement may be terminated by DMAS at will
on 30 days written notice. The agreement may be terminated immediately if DMAS
determines that the provider poses a threat to the health, safety, or welfare
of any individual enrolled in a DMAS administered program. DMAS may also
immediately terminate a provider's participation agreement if the provider does
not fulfill its obligations as described in the provider participation
agreement. Such action precludes further payment by DMAS for services provided
for individuals subsequent to the date specified in the termination notice.
N. A participating provider may voluntarily terminate his
participation with DMAS by providing 30 days written notification.
O. Fiscal employer/agent, as defined in 12VAC30-120-1000,
requirements. Pursuant to a duly negotiated contract or interagency agreement,
the contractor or entity shall be reimbursed by DMAS to perform certain
employer functions including, but not limited to, payroll and bookkeeping
functions on the part of the individual/employer who is receiving
consumer-directed services.
1. The fiscal employer/agent shall be responsible for
administering payroll services on behalf of the individual enrolled in the
waiver including, but not limited to:
a. Collecting and maintaining citizenship and alien status
employment eligibility information required by the U.S. Department of Homeland
Security;
b. Securing all necessary authorizations and approvals in
accordance with state and federal tax requirements;
c. Deducting and filing state and federal income and
employment taxes and other withholdings;
d. Verifying that assistants' or companions' submitted
timesheets do not exceed the maximum hours prior authorized for individuals
enrolled in the waiver;
e. Processing timesheets for payment;
f. Making all deposits of income taxes, FICA, and other
withholdings according to state and federal requirements; and
g. Distributing biweekly payroll checks to individuals'
companions and assistants.
2. All timesheet discrepancies shall be reported promptly
upon their identification to DMAS for investigation and resolution.
3. The fiscal employer/agent shall maintain records and
information as required by DMAS and state and federal laws and regulations and
make such records available upon DMAS' request in the needed format.
4. The fiscal employer/agent shall establish and operate a
customer service center to respond to individuals' and assistants'/companions'
payroll and related inquiries.
5. The fiscal employer/agent shall maintain confidentiality
of all Medicaid information pursuant to the Health Insurance Portability and
Accountability Act (HIPAA) and DMAS requirements. Should any breaches of
confidential information occur, the fiscal/employer agent shall assume all
liabilities under both state and federal law.
P. Changes to or termination of services. DMAS or its
designee shall have the authority to approve changes to an individual's
individual support plan, based on the recommendations of the support
coordination/case management provider.
1. Service providers shall be responsible for modifying
their plan for supports, with the involvement of the individual enrolled in the
waiver and the individual's family/caregiver, as appropriate, and submitting
such revised plan for supports to the support coordinator/case manager any time
there is a change in the individual's condition or circumstances that may
warrant a change in the amount or type of service rendered.
a. The support coordinator/case manager shall review the
need for a change and may recommend a change to the plan for supports to the
DMAS designee.
b. DBHDS shall approve, deny, or suspend for additional
information, the provider's requested change or changes to the individual's
plan for supports. DBHDS shall communicate its determination to the support
coordinator/case manager within 10 business days of receiving all supporting
documentation regarding the request for change or in the case of an emergency
within three business days of receipt of the request for change.
2. The individual enrolled in the waiver and the
individual's family/caregiver, as appropriate, shall be notified in writing by
the support coordinator/case manager of his right to appeal pursuant to DMAS
client appeals regulations (Part I (12VAC30-110-10 et seq.) of 12VAC30-110) a
decision to reduce, terminate, suspend, or deny services. The support
coordinator/case manager shall submit this written notification to the
individual enrolled in the waiver within 10 business days of the decision. Once
the individual receives the written notification, the clock for filing an
appeal, as set forth in the DMAS client appeals regulations, begins to run.
3. In a nonemergency situation, when a service provider
determines that services to an individual enrolled in the waiver must be
terminated, the service provider shall give the individual and the individual's
family/caregiver, as appropriate, and support coordinator/case manager written
notification of the service provider's intent to discontinue services at least
10 business days in advance of discontinuation of services. The notification
letter shall provide the reasons for the planned termination and the effective
date the service provider will be discontinuing services. The effective date
shall be at least 10 business days from the date of the notification letter.
The individual enrolled in the waiver may pursue services from another enrolled
service provider.
4. In an emergency situation when the health, safety, or
welfare of the individual enrolled in the waiver, other individuals in that
setting, or provider personnel are endangered, the support coordinator/case
manager and DBHDS shall be notified by the service provider prior to
discontinuing services. The 10-business-day prior written notification period
shall not be required. The local department of social services adult protective
services unit or child protective services unit, as appropriate, and the DBHDS
Offices of Licensing and Human Rights shall be notified immediately by the
support coordinator/case manager and the provider when the individual's health,
safety, or welfare may be in danger.
5. The support coordinator/case manager shall have the
responsibility to identify those individuals who no longer meet the level of
functioning criteria or for whom home and community-based waiver services are
no longer an appropriate alternative. In such situations, DMAS or its designee
shall discharge the individuals from the waiver.
a. The support coordinator/case manager shall notify the
individual and family/caregiver, as appropriate, of this determination and the
right to appeal such discharge.
b. The individual shall be given the option to continue his
waiver services pending the final outcome of his appeal. Should the outcome of
the appeal confirm the determination by DMAS or its designee that the
individual should be discharged from the waiver, the individual shall be
responsible for the costs of his waiver services incurred by DMAS during his
appeal.
Q. Documentation requirements for service providers.
1. The need of each individual enrolled in the waiver for
each service shall be clearly set out in the individual support plan (ISP)
containing each service provider's plan for supports.
2. Documentation shall confirm attendance and the
individual's amount of time in services and provide specific information
regarding the individual's response to various settings and supports as agreed
to in the ISP objectives. Observation results shall be available in at least a
daily note. Data shall be collected as described in the ISP, analyzed to
determine if the strategies are effective, summarized, and then clearly
documented in the progress note, task analysis checklist, or support checklist.
3. Service providers shall maintain contemporaneous
documentation for each unit of service delivered, and the documentation shall
correspond with billing. Providers shall maintain separate documentation for
each type of service rendered for an individual. Documentation shall include
all correspondence and contacts related to the individual.
4. A quarterly ISP update shall be conducted. Any update
shall be reviewed by the service provider with the individual, and this written
review shall be dated and submitted to the support coordinator/case manager
with goals, desired outcomes, and support activities, modified as appropriate.
5. Documentation shall be maintained for routine
supervision and oversight of all services provided by direct support
professional staff. All significant contacts shall be documented and dated.
6. A qualified developmental disabilities professional
shall provide supervision of direct support professional staff. Documentation
of supervision shall be completed, signed by the staff person designated to
perform the supervision and oversight, and include the following:
a. Date of contact or observation;
b. Person or persons contacted or observed;
c. A summary about direct support professional staff
performance and service delivery for any monthly contacts and any semi-annual
home visits;
d. Any action planned or taken to correct problems
identified during supervision and oversight; and
e. On a semi-annual basis, the qualified developmental
disabilities professional shall document observations concerning the
individual's satisfaction with service provision.
7. Claims for payment that are not supported by supporting
documentation shall be subject to recovery by DMAS or its designee as a result
of utilization reviews or audits.
R. Providers of services under any of the DD waivers shall
not be the parents (natural, adoptive, foster, or step-parents) of individuals
enrolled in the waiver who are minor children, or the individual's spouse.
Payment shall not be made for services furnished by other family members who
are living under the same roof as the individual receiving services unless
there is objective, written documentation as to why there are no other
providers available to provide the care. Such other family members if approved
to provide services shall meet the same provider requirements as all other
licensed providers.
12VAC30-120-515. General requirements for waivers:
competencies, utilization review, and quality management review (QMR).
A. Core competency requirements for direct support
professionals (DSPs) and their supervisors in programs licensed by DBHDS.
1. Providers shall ensure that DSPs and DSP supervisors
providing services to individuals with developmental disabilities receive
training on the following core competencies:
a. The characteristics of developmental disabilities and
Virginia's DD waivers;
b. Person-centeredness, positive behavioral supports,
effective communication;
c. DBHDS-identified health risks and the appropriate
interventions; and
d. Best practices in the support of individuals with
developmental disabilities.
2. Providers shall ensure that DSPs and DSP supervisors
pass a DBHDS-approved objective, standardized test of skills, knowledge, and
abilities covering the core competencies referenced above prior to providing
direct, reimbursable services in the absence of other qualified staff who have
passed the knowledge-based test and who document oversight of the individual
who has not yet passed the test. Evidence of completed core competency
training, a copy of the DSP completed test, the DBHDS-issued certificate of
completion for supervisors, and documentation of assurances (DMAS Form P242a,
P243a, P245a, or P246a as applicable), shall be retained in the provider record
and subject to review by DBHDS for licensing compliance and by DMAS for quality
management review and financial audit purposes.
3. Providers shall ensure that supervisors of DSPs complete
the competencies checklist (DMAS Form P241a) for each DSP they supervise within
180 days of the DSP passing the DBHDS test with annual updates thereafter.
4. The director of the service provider or the director's
designee shall complete the competencies checklist (DMAS Form P241a) for each
DSP supervisor within 180 days of the DSP supervisor passing the DBHDS test
with annual updates thereafter.
5. The checklist shall be retained in the provider record
and subject to review by DBHDS for licensing compliance and by DMAS for quality
management review and financial audit purposes.
6. Providers shall ensure that all DSPs and DSP supervisors
hired on or after September 1, 2016, shall demonstrate, within 180 days of
hire, the presence of the competencies listed in subsection A of this section
through the administration and passage of the DBHDS-approved objective,
standardized test, which shall be documented in the personnel records of each
staff member and subject to review by DBHDS for licensing compliance and by
DMAS for quality management review and financial audit purposes. Continued
knowledge of the core competencies by DSPs and DSP supervisors shall be
confirmed in accordance with subdivisions 3 and 4 of this subsection.
7. Providers shall ensure that DSP supervisors who were
hired prior to September 1, 2016, shall be in compliance with these competency
training requirements within 120 days of September 1, 2016, through the
administration and passage of the DBHDS-approved objective, standardized test,
which shall be documented in the personnel records of each staff and subject to
review by DBHDS for licensing compliance and by DMAS for quality management
review and financial audit purposes.
8. Providers shall ensure that DSPs who were hired prior to
September 1, 2016, shall be in compliance with these competency training
requirements within 180 days of September 1, 2016, through the administration
and passage of the DBHDS-approved objective, standardized test, which shall be
documented in the personnel records of each staff and subject to review by
DBHDS for licensing compliance and by DMAS for quality management review and
financial audit purposes. Continued knowledge of the core competencies by DSPs
and DSP supervisors shall be confirmed in accordance with subdivisions 3 and 4
of this subsection.
B. Core competency requirements for support
coordinators/case managers. (Reserved.)
C. Core competency requirements for qualified
developmental disabilities professionals (QDDPs). (Reserved.)
D. Advanced core competency requirements for DSPs and DSP
supervisors serving individuals with developmental disabilities with the most
intensive needs.
1. Providers shall ensure that DSPs and DSPs supervisors
supporting individuals identified as having the most intensive needs, as
determined by assignment to Level 5, 6, or 7 (as referenced in 12VAC30-120-570)
based on a completed Supports Intensity Scale® assessment, shall receive
training specific to the individuals' needs and levels.
2. DSPs and DSP supervisors supporting individuals with
extraordinary medical support needs shall receive training on advanced core
competencies in the area of medical supports as established by DBHDS.
3. DSPs and DSP supervisors supporting individuals with
extraordinary behavioral support needs shall receive training on advanced core
competencies in the area of behavioral supports as established by DBHDS.
4. DSPs and DSP supervisors supporting individuals with
autism shall receive training on advanced core competencies in the area of
characteristics of autism as established by DBHDS.
5. Evidence of completed advanced core competency training
through documentation of assurances completed by DSPs and DSP supervisors shall
be retained in the provider record and subject to review by DBHDS for licensing
compliance and by DMAS for quality management review and financial audit
purposes.
6. Providers shall ensure that DSP supervisors complete the
advanced core competencies checklists (DMAS Forms P240a, P244a, and P201)
specific to the needs and levels of the individuals supported for each DSP they
supervise within 180 days of the DSP signing the documentation of assurances
with annual updates thereafter.
7. The director of the provider agency or designee shall
complete the advanced core competencies checklists (DMAS Forms P240a, P244a,
and P201) specific to the needs and level of the individuals supported for each
DSP supervisor within 180 days of the DSP supervisor signing the documentation
of assurances with annual updates thereafter. The checklists shall be retained
in the provider record and subject to review by DBHDS for licensing compliance
and by DMAS for quality management review and financial audit purposes.
8. Providers shall ensure that DSPs and DSP supervisors who
render services to individuals in Level 5, 6, or 7 who were hired prior to
September 1, 2016, shall demonstrate the presence of the advanced core
competencies listed above within 180 days of September 1, 2016, through the
completion of the applicable advanced core competencies checklists based on the
needs and levels of the individuals supported (DMAS Forms P240a, P244a, and
P201), which shall be documented in the personnel records of each staff and
subject to review by DBHDS for licensing compliance and by DMAS for quality
management review and financial audit purposes. Continued knowledge of the
advanced core competencies by DSPs and DSP supervisors shall be confirmed in
accordance with subdivisions 6 and 7 of this subsection.
9. Providers shall ensure that DSPs and DSP Supervisors who
render services to individuals in Level 5, 6, or 7 who are hired on or after
September 1, 2016, shall demonstrate the presence of the advanced core
competencies listed above within 180 days of hire through the completion of the
applicable advanced core competencies checklists based on the needs and levels
of the individuals supported ((DMAS Forms P240a, P244a, and P201), which shall
be documented in the personnel records of each staff and subject to review by
DBHDS for licensing compliance and by DMAS for quality management review and
financial audit purposes. Continued knowledge of the advanced core competencies
by DSPs and DSP supervisors shall be confirmed in accordance with subdivisions
6 and 7 of this subsection.
E. Plan for supports. The plan for supports shall include,
at a minimum, the following elements:
1. The individual's strengths, desired outcomes, goals, and
objectives; required or desired supports or both; and skill-building needs;
2. The individual's support activities to meet the
identified outcomes;
3. The services to be rendered and the schedule for such
services to accomplish the desired outcomes and support activities, a timetable
for the accomplishment of the individual's desired outcomes and support
activities, the estimated duration of the individual's need for services, and
the provider staff responsible for overall coordination and integration of the
services specified in the plan for supports.
F. Reevaluation of service need.
1. The individual support plan (ISP).
a. The ISP shall be collaboratively developed annually by
the support coordinator/case manager with the individual and the individual's
family/caregiver, as appropriate, other service providers, consultants as may
be needed, and other interested parties.
b. The support coordinator/case manager shall be
responsible for continuous monitoring of the appropriateness of the
individual's services and revisions to the ISP as indicated by the changing
needs of the individual. At a minimum, the support coordinator/case manager
shall review the ISP every three months to determine whether the individual's
desired outcomes and support activities are being met and whether any
modifications to the ISP are necessary. The results of such reviews shall be
documented in the individual's record even if no change occurred during the
review period. This documentation shall be provided to DMAS and DBHDS upon
request.
c. Any modification to the amount or type of services in
the ISP shall be service authorized by DMAS or its designee.
d. All requests for increased waiver services by
individuals enrolled in one of the DD waivers shall be reviewed by the support
coordinator/case manager to ensure health, safety, and welfare and for
consistency with cost effectiveness. This assures that an individual's ability
to receive a waiver service is dependent on the finding that the individual
needs the service, based on appropriate assessment criteria and a written plan
for supports, and that services can be safely and cost effectively provided in
the community.
2. Review of level of care.
a. The support coordinator/case manager shall complete a
reassessment annually, at a minimum, in coordination with the individual and
the individual's family/caregiver, as appropriate, and service providers. The
reassessment shall include an update of the level of care and personal profile,
risk assessment, and any other appropriate assessment information. The ISP
shall be revised as appropriate.
b. At least every three years for those individuals who are
16 years of age and older and every two years for those individuals who are
ages birth through 15 years of age, or when the individual's support needs
change significantly (such as a loss of abilities that is expected to last
longer than 30 days), the support coordinator/case manager, with the assistance
of the individual and other appropriate parties who have knowledge of the
individual's circumstances and needs for support, shall request an updated SIS®
assessment and the Virginia Supplemental Questions, as appropriate, or a
DBHDS-approved alternative instrument for children younger than the age of five
years.
c. A medical examination shall be completed for adults
based on need identified by the individual and the individual's
family/caregiver, as appropriate, provider, support coordinator/case manager,
or DBHDS staff. Medical examinations and screenings for children shall be
completed according to the recommended frequency and periodicity of the EPSDT
(42 CFR 440.40 and 12VAC30-50-130) program.
d. A new psychological or other diagnostic evaluation shall
be required whenever the individual's functioning has undergone significant
change (such as an increase or loss of abilities that is expected to last
longer than 30 days) and is no longer reflective of the past evaluation. The
evaluation shall reflect the current diagnosis, adaptive level of functioning,
and presence of a functional delay that arose during the developmental period.
3. The support coordinator/case manager shall monitor the
service providers' plans for supports to ensure that all providers are working
toward the desired outcomes for these individuals.
4. Support coordinators/case managers shall be required to
conduct and document evidence of monthly onsite visits for all individuals
enrolled in the DD waivers who are residing in VDSS-licensed assisted living
facilities or approved adult foster care homes. Support coordinators/case
managers shall conduct and document a minimum of quarterly onsite home visits to
all other individuals.
G. Utilization review and quality management reviews
(QMR).
1. QMR shall be performed by the DMAS Division of Long Term
Care Services or its designee. Utilization review of rendered services
shall be conducted by the DMAS Division of Program Integrity or its designee.
2. DMAS staff shall conduct utilization review of
individual-specific documentation.
3. DMAS shall not reimburse providers for the costs of
participation in social or recreational activities.
12VAC30-120-525. FIS, CL, and BI Waivers: financial
eligibility standards for individuals; criteria for services; waiver assessment
and enrollment.
A. Individuals receiving services under the Family and
Individual Supports (FIS) Waiver (12VAC30-120-700 et seq.), Community Living
(CL) Waiver (12VAC30-120-1000 et seq.), and Building Independence (BI) Waiver
(12VAC30-120-1500 et seq.), shall meet the following Medicaid eligibility
requirements. The Commonwealth shall apply the financial eligibility criteria
contained in the State Plan for Medical Assistance for the categorically needy.
The Commonwealth covers the optional categorically needy groups under 42 CFR
435.211, 42 CFR 435.217, and 42 CFR 435.230.
1. The income level used for 42 CFR 435.211, 42 CFR
435.217, and 42 CFR 435.230 shall be 300% of the current supplemental security
income (SSI) payment standard for one person.
2. Under the DD waivers, the coverage groups authorized
under § 1902(a)(10)(A)(ii)(VI) of the Social Security Act shall be
considered as if they were institutionalized for the purpose of applying
institutional deeming rules. All individuals under the waivers shall meet the
financial and nonfinancial Medicaid eligibility criteria and meet the
institutional level-of-care criteria for an ICF/IID. The deeming rules shall be
applied to waiver eligible individuals as if the individuals were residing in
an ICF/IID or would require that level of care.
3. The Commonwealth shall reduce its payment for home and
community-based waiver services provided to an individual who is eligible for
Medicaid services under 42 CFR 435.217 by that amount of the individual's
total income (including amounts disregarded in determining eligibility) that
remains after allowable deductions for personal maintenance needs, other
dependents, and medical needs have been made, according to the guidelines in 42 CFR
435.735 and § 1915(c)(3) of the Social Security Act as amended by the
Consolidated Omnibus Budget Reconciliation Act of 1986. DMAS shall reduce its
payment for home and community-based waiver services by the amount that remains
after the deductions listed in this subdivision:
a. For individuals to whom § 1924(d) applies and for
whom the Commonwealth waives the requirement for comparability pursuant to §
1902(a)(10)(B), DMAS shall deduct the following in the respective order:
(1) The basic maintenance needs for an individual under the
DD waivers, which shall be equal to 165% of the SSI payment for one person. Due
to expenses of employment, a working individual shall have an additional income
allowance. For an individual employed 20 hours or more per week, earned income
shall be disregarded up to a maximum of both earned and unearned income up to
300% of SSI; for an individual employed at least eight but less than 20 hours
per week, earned income shall be disregarded up to a maximum of both earned and
unearned income up to 200% of SSI. If the individual requires a guardian or
conservator who charges a fee, the fee, not to exceed an amount greater than
5.0% of the individual's total monthly income, shall be added to the
maintenance needs allowance. However, in no case shall the total amount of the
maintenance needs allowance (basic allowance plus earned income allowance plus
guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with only a spouse at home, the
community spousal income allowance determined in accordance with § 1924(d)
of the Social Security Act.
(3) For an individual with a family at home, an additional
amount for the maintenance needs of the family determined in accordance with §
1924(d) of the Social Security Act.
(4) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including Medicare and
other health insurance premiums, deductibles, or coinsurance charges, and
necessary medical or remedial care recognized under state law but not covered under
the State Plan for Medical Assistance.
b. For individuals to whom § 1924(d) does not apply
and for whom the Commonwealth waives the requirement for comparability pursuant
to § 1902(a)(10)(B), DMAS shall deduct the following in the respective
order:
(1) The basic maintenance needs for an individual under the
DD waivers, which is equal to 165% of the SSI payment for one person. Due to
expenses of employment, a working individual shall have an additional income
allowance. For an individual employed 20 hours or more per week, earned income
shall be disregarded up to a maximum of both earned and unearned income up to
300% of SSI; for an individual employed at least eight but less than 20 hours
per week, earned income shall be disregarded up to a maximum of both earned and
unearned income up to 200% of SSI. If the individual requires a guardian or
conservator who charges a fee, the fee, not to exceed an amount greater than
5.0% of the individual's total monthly income, shall be added to the
maintenance needs allowance. However, in no case shall the total amount of the
maintenance needs allowance (basic allowance plus earned income allowance plus
guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with a dependent child or children,
an additional amount for the maintenance needs of the child or children, which
shall be equal to the Title XIX medically needy income standard based on the
number of dependent children.
(3) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including Medicare and
other health insurance premiums, deductibles, or coinsurance charges, and
necessary medical or remedial care recognized under state law but not covered
under the State Plan for Medical Assistance.
B. The following four criteria shall apply to all
individuals who seek these waiver services:
1. The need for the DD waiver services shall arise from an
individual having a diagnosed condition of DD as defined in § 37.2-100 of
the Code of Virginia. Individuals qualifying for the DD waivers services shall
have a demonstrated need for the covered services due to significant functional
limitations in major life activities;
2. Individuals qualifying for the DD waivers services shall
meet the ICF/IID level-of-care criteria as set out in 12VAC30-120-535 et
seq.;
3. The services that are delivered shall be consistent with
the individual support plan, service limits and requirements, and provider
requirements of each service; and
4. Services shall be recommended by the support
coordinator/case manager based on his documentation of the need for each
specific service and as reflected in a current SIS assessment or for children
younger than five years of age, an alternative industry assessment instrument
approved by DBHDS, such as the Early Learning Assessment Profile.
C. Assessment and enrollment.
1. Home and community-based waiver services shall be
considered only for individuals eligible for admission to an ICF/IID due to
their diagnoses of DD. For the support coordinator/case manager to make a
recommendation for the DD waivers services, the services shall be determined to
be an appropriate service alternative to delay or avoid placement in an ICF/IID
or to promote exiting from an ICF/IID or other institutional placement provided
that a viable discharge plan has been developed.
2. The support coordinator/case manager shall confirm
diagnostic and functional eligibility for individuals with input from the
individual and the individual's family/caregiver, as appropriate, and
service/support providers involved in the individual's support prior to DMAS
assuming payment responsibility of home and community-based waiver services.
This shall be accomplished through the completion of the following:
a. The required level-of-care determination through the
Virginia Intellectual Developmental Disabilities Eligibility Survey (VIDES)
appropriate to the individual according to his age, completed no more that six
months prior to waiver enrollment; and
b. A psychological or other evaluation of the individual
that affirms that the individual meets the diagnostic criteria for
developmental disability as defined in § 37.2-100 of the Code of Virginia.
3. The individual who has been found to be eligible for
these services shall be given, by the support coordinator/case manager, his
choice of either institutional placement or receipt of home and community based
waiver services.
4. If the individual chooses home and community-based
waiver services, the support coordinator/case manager shall recommend the
individual for home and community-based waiver services.
5. If the individual selects waiver services and a slot is
available, then the support coordinator/case manager shall enroll the
individual in the waiver. If no slot is available, the support coordinator/case
manager shall place the individual on the DD waivers waiting list consistent
with criteria established for the DD waivers in 12VAC30-120-580, until
such time as a slot becomes available. The CSB/BHA shall only enroll the individual
following electronic confirmation by DBHDS that a slot is available.
a. Once the individual's name has been placed on the DD
waivers waiting list, the support coordinator/case manager shall (i) notify the
individual in writing within 10 business days of his placement on the DD
waiting list and his assigned prioritization level and (ii) offer appeal
rights.
b. The support coordinator/case manager shall document
contact with the individual at least annually while the individual is on the
waiting list to provide the choice between institutional placement and waiver
services.
D. Waiver approval process: authorizing and accessing
services.
1. The support coordinator/case manager shall
electronically submit enrollment information to DBHDS to confirm level-of-care
eligibility once he has determined (i) an individual meets the functional
criteria for these waiver services, (ii) that a slot is available, and
(iii) the individual has chosen waiver services.
2. Once the individual has been notified of an available
waiver slot by the CSB/BHA, the support coordinator/case manager shall submit a
DMAS-225 along with a computer-generated confirmation of level-of-care
eligibility to the local department of social services to determine financial
eligibility for Medicaid and for the waiver program and any patient pay
responsibilities.
3. After the support coordinator/case manager has received
written notification of Medicaid eligibility from the local department of
social services, the support coordinator/case manager shall inform the
individual, submit information to DMAS or its designee to enroll the individual
in the waiver, and permit the development of the individual support plan (ISP).
a. The individual and the individual's family/caregiver, as
appropriate, shall meet with the support coordinator/case manager within 30
calendar days of the waiver enrollment date to discuss the individual's needs
and existing supports, obtain a medical examination (which shall have been
completed no earlier than 12 months prior to the initiation of waiver
services), begin to develop the personal profile, and schedule the
completion of the SIS®.
b. The support coordinator/case manager shall provide the
individual with choice of needed services available in the assigned waiver, alternative
settings, and providers. Once the service providers are chosen, a planning
meeting shall be arranged by the support coordinator/case manager to develop
the ISP based on the individual's assessed needs and the preferences of the
individual and the individual's family/caregiver's, as appropriate.
c. Persons invited by the support coordinator/case manager
to participate in the person-centered planning meeting shall include the
individual, service providers, and others as desired by the individual. During
the person-centered planning meeting, the services to be rendered to
individuals, the frequency of services, the type of service provider or
providers, and a description of the services to be offered are identified and
included in the ISP. The individual enrolled in the waiver, or the
family/caregiver as appropriate, and support coordinator/case manager shall
sign the ISP.
4. The individual, family/caregiver or support
coordinator/case manager shall contact chosen service providers so that
services can be initiated within 30 calendar days of receipt of confirmation of
waiver enrollment. Enrollment occurs once the support coordinator/case manager
submits the DMAS-225 form and the computer-generated confirmation of
level-of-care eligibility to the local department of social services. If the
services are not initiated by the provider within 30 days, the support
coordinator/case manager shall notify the local department of social services
so that re-evaluation of the individual's financial eligibility can be made.
5. In the case of an individual being referred back to a
local department of social services for a redetermination of eligibility and in
order to retain the designated slot, the support coordinator/case manager shall
electronically submit information to DBHDS requesting retention of the
designated slot pending the initiation of services. A copy of the request shall
be provided to the individual and the individual's family/caregiver, as
appropriate. DBHDS shall have the authority to approve the slot-retention
request in 30-day extensions, up to a maximum of four consecutive extensions,
or deny such request to retain the waiver slot for the individual. DBHDS shall
provide an electronic response to the support coordinator/case manager
indicating denial or approval of the slot extension request. DBHDS shall submit
this response to the support coordinator/case manager within 10 working days of
the receipt of the request for extension. The support coordinator/case manager
shall notify the individual in writing of any denial of the slot extension
request and the individual's right to appeal.
6. The service providers, in conjunction with the
individual and the individual's family/caregiver, as appropriate, and the
support coordinator/case manager shall develop a plan for supports for each
service. Each service provider shall submit a copy of his plan to the support
coordinator/case manager. The plan for supports from each service provider
shall be incorporated into the ISP, along with the steps for risk mitigation as
indicated by the risk assessment. The support coordinator/case manager shall
review and ensure the provider-specific plan for supports meet the established
service criteria for the identified needs prior to electronically submitting
these along with the results of the comprehensive assessment and a
recommendation for the final determination of the need for ICF/IID level of
care to DMAS or its designee for service authorization. DMAS or its designee
shall, within 10 working days of receiving all supporting documentation, review
and approve, suspend for more information, or deny the individual service
requests. DMAS or its designee shall communicate electronically to the support
coordinator/case manager whether the recommended services have been approved
and the amounts and types of services authorized or if any services have been
denied. Only waiver services authorized on the ISP by the state-designated
agency or its designee according to DMAS policies shall be reimbursed by DMAS.
7. When the support coordinator/case manager obtains the
DMAS-225 form from a local department of social services, the support
coordinator/case manager shall designate and inform in writing a service
provider to be the collector of patient pay, when applicable. The designated
provider shall monitor monthly the DMAS-designated system for changes in
patient pay obligations and adjust billing, as appropriate, with the change
documented in the record in accordance with DMAS policy. When the designated
collector of patient pay is the consumer-directed personal or respite assistant
or companion, the support coordinator/case manager shall forward a copy of the
DMAS-225 form to the employer of record along with the support
coordinator's/case manager's provider designation. In such cases, the support
coordinator/case manager shall be required to perform the monthly monitoring of
the patient pay system and shall notify the EOR of all changes.
8. DMAS shall not pay for any home and community-based
waiver services delivered prior to the authorization date approved by DMAS or
its designee if service authorization is required.
9. Waiver services shall be approved and authorized by the
DMAS designee only if:
a. The individual is Medicaid eligible as determined by the
local department of social services;
b. The individual, including a child, has a diagnosis of
DD, as defined by § 37.2-100 of the Code of Virginia, and would, in the absence
of waiver services, require the level of care provided in an ICF/IID that would
be reimbursed under the State Plan for Medical Assistance;
c. The individual's ISP is cost effective and can be safely
rendered in the community; and
d. The contents of the providers' plan for supports are
consistent with the ISP requirements, limitation, units, and documentation
requirements of each service.
12VAC30-120-535. FIS, CL, and BI Waivers: level of
functioning standards for waivers eligibility (Virginia Individual
Developmental Disabilities Eligibility Survey (VIDES)).
A. 42 CFR § 441.302 mandates that DMAS ensure that individuals
who are found to be eligible for § 1915(c) of the Social Security Act
waivers demonstrate, at least annually, their need for the level of care
provided in Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF/IID). These waiver services shall be provided for the
individuals diagnosed with a developmental disability, as defined in § 37.2-100
of the Code of Virginia, who have been determined to require the level of care
provided in an ICF/IID:
B. The VIDES assessment tools shall be administered by
support coordinators/case managers.
C. The results of an individual's Virginia Individual
Disabilities Eligibility Survey (VIDES) determination shall be one element of
determining if the individual qualifies for the FIS (12VAC30-120-700 et seq.),
CL (12VAC30-120-1000 et seq.), or BI (12VAC30-120-1500 et seq.) Waiver.
D. The Commonwealth shall use VIDES forms to establish the
level of care required for its DD Waivers.
1. VIDES for infants shall be used for the evaluation of
individuals who are younger than three years of age (DMAS-P235).
2. VIDES for children shall be used for the evaluation of
individuals who are three years of age to 18 years of age (DMAS-P-236).
3. VIDES for adults shall be used for the evaluation of
individuals who are 18 years of age and older (DMAS-P237).
12VAC30-120-545. SIS® requirements; Virginia supplemental
questions, and supports packages.
A. The Supports Intensity Scale (SIS®)
requirements.
1. The SIS® is an assessment tool that evaluates
the practical supports required by individuals to live successfully in their
communities. The SIS® shall be used to assess individuals' patterns
and intensity of needed supports across life activities, such as home living
activities, community living activities, lifelong learning, employment, health
and safety, and social activities, as well as protection and advocacy and
medical and behavioral support needs. It shall be used with the Virginia
supplemental questions to determine individual support levels.
2. The SIS® shall be administered and analyzed
by qualified, trained interviewers designated by DBHDS.
3. The SIS® also assesses what is important to
and important for individuals who are enrolled in a waiver.
B. The Virginia supplemental questions (VSQ) shall
identify individuals who have unique needs falling outside of the needs
captured by the SIS® instrument. It shall also be administered and
analyzed by the same qualified, trained interviewers designated by DBHDS.
C. Establishment of service mix packages. (Reserved.)
12VAC30-120-570. Tiers of reimbursement.
A. Waiver services shall be reimbursed on a prospective,
fee-for-service basis. There shall be no designated formal schedule for annual
cost of living or other adjustments and any adjustments to provider rates shall
be subject to available funding and approval by the General Assembly.
B. There shall be up to four tiers of reimbursement for
some services. The approved reimbursement tier for an individual shall be based
on resultant scores of the SIS® and Virginia supplemental questions.
DBHDS shall verify the scores and levels of the individuals, as appropriate.
C. Levels of supports. The following seven levels of
supports shall be applied by DMAS or its designee in the FIS, CL and BI
waivers: (i) Level 1 means low support needs; (ii) Level 2 means low to
moderate support needs; (iii) Level 3 means moderate support needs plus some
behavior challenges; (iv) Level 4 means moderate to high support needs; (v) Level
5 means maximum support needs; (vi) Level 6 means significant support needs due
to medical challenges; and (vii) Level 7 means significant support needs due to
behavioral challenges.
D. Tiers of reimbursement. There shall be four as follows:
1. Tier 1 shall be used for individuals having Level 1
support needs.
2. Tier 2 shall be used for individuals having Level 2
support needs.
3. Tier 3 shall be used for individuals having either (i)
Level 3 support needs or (ii) Level 4 support needs.
4. Tier 4 shall be used for individuals having (i) Level 5
support needs, (ii) Level 6 support needs, or (iii) Level 7 support needs.
E. Individual-specific support needs, such as the
extraordinary medical or behavioral supports needs of some individuals, may
warrant additional supports as established by criteria in the SIS, and as
described below, in the following service settings: community coaching, group
day services, in-home support services, group home residential services, and
supported living residential services.
1. In these cases, providers and support coordinators/case
managers may submit to the DMAS designee an application for a customized
reimbursement rate exceeding the reimbursement rate, according to the assessed
tier. Application will include, but is not limited to, contact information,
increased staffing supports needed for the individual, the types of service for
which the application is made, increased program oversight needed, behavioral
or medical support needs, and staffing qualifications to address the needs of
the individual.
2. These requests will be reviewed by a team to ensure that
there is documentation of the intense needs of the individual (whether medical,
behavioral, or both) and that the provider has employed staff with higher
qualifications (e.g., direct support professionals with four-year degrees) or
increased the ratio of staff to individual support to 1:1 or, in the case of
services already required to be provided at a 1:1 ratio, a 2:1 ratio.
3. A specialized rate methodology will be used to determine
the customized reimbursement rate for each individual. These methodology
components include wages, employee benefits, productivity assumptions such as
training and supervision time, additional hours related to increased or
specialized staffing supports, and program oversight costs.
4. Denials of customized reimbursement rates may be
appealed.
5. A DMAS designee will review recipients on at least an
annual basis in order to continue to receive or adjust the customized
reimbursement rate.
12VAC30-120-580. Waiting list priorities; assignment
process.
A. There shall be a single, statewide waiting list, called
the DD waiting list, for the DD Waivers. This waiting list shall be created and
maintained by DBHDS.
B. Criteria. In order to be assigned to one of the
categories below, the individual shall meet one of these criteria, as
appropriate:
1. Priority One shall be assigned to individuals determined
to meet one the following criteria and require a waiver service within one
year:
a. An immediate jeopardy exists to the health and safety of
the individual due to the unpaid primary caregiver having a chronic or
long-term physical or psychiatric condition or conditions that significantly
limit the ability of the primary caregiver or caregivers to care for the
individual; there are no other unpaid caregivers available to provide supports.
b. There is immediate risk to the health or safety of the
individual, primary caregiver, or other person living in the home due to either
of the following conditions:
(1) The individual's behavior or behaviors, presenting a
risk to himself or others, cannot be effectively managed by the primary
caregiver or unpaid provider even with support coordinator/case
manager-arranged generic or specialized supports; or
(2) There are physical care needs or medical needs that
cannot be managed by the primary caregiver even with support coordinator/case
manager-arranged generic or specialized supports;
c. The individual lives in an institutional setting and has
a viable discharge plan; or
d. The individual is a young adult who is no longer
eligible for IDEA services and is transitioning to independent living. After
individuals attain 27 years of age, this criterion shall no longer apply.
2. Priority Two shall be assigned to individuals who meet
one of the following criteria and a waiver service will be needed in one to
five years:
a. The health and safety of the individual is likely to be
in future jeopardy due to:
(1) The unpaid primary caregiver or caregivers having a
declining chronic or long-term physical or psychiatric condition or conditions
that significantly limit his ability to care for the individual;
(2) There are no other unpaid caregivers available to
provide supports; and
(3) The individual's skills are declining as a result of
lack of supports;
b. The individual is at risk of losing employment supports;
c. The individual is at risk of losing current housing due
to a lack of adequate supports and services; or
d. The individual has needs or desired outcomes that with adequate
supports will result in a significantly improved quality of life.
3. Priority Three shall be assigned to individuals who meet
one of the following criteria and will need a waiver slot in five years or
longer as long as the current supports and services remain:
a. The individual is receiving a service through another
funding source that meets current needs;
b. The individual is not currently receiving a service but
is likely to need a service in five or more years; or
c. The individual has needs or desired outcomes that with
adequate supports will result in a significantly improved quality of life.
C. Individuals and family/caregivers shall have the right
to appeal the application of the prioritization criteria (in the event that
such application results in a reduction of access to services), emergency
criteria, or reserve criteria to their circumstances pursuant to 12VAC30-110.
All notifications of appeal shall be submitted to DMAS.
D. Slot allocation. Individuals who are in Priority One
category who are determined to be most in need of supports at the time a slot
is available are reviewed by an independent waiver slot assignment committee
for the area in which the slot is available. The individual who has the highest
need as designated by the committee will be recommended for the available
waiver slot. The DMAS designee shall make the final determination for slot
allocation.
E. Emergency access. Eligibility criteria for emergency
access to either the FIS (12VAC30-120-700 et seq.), CL (12VAC30-120-1000 et
seq.), or BI (12VAC30-120-1500 et seq.) waiver.
1. Subject to available funding and a finding of
eligibility under 12VAC30-120-535, individuals shall meet at least one
of the emergency criteria of this subdivision to be eligible for immediate
access to waiver services without consideration to the length of time they have
been waiting to access services. The criteria shall be one of the following:
a. Child protective services has substantiated
abuse/neglect against the primary caregiver and has removed the individual from
the home; or for adults where (i) adult protective services has found that the
individual needs and accepts protective services or (ii) abuse/neglect has not
been founded, but corroborating information from other sources (agencies) indicate
that there is an inherent risk present and there are no other caregivers
available to provide support services to the individual.
b. Death of primary caregiver or lack of alternative
caregiver coupled with the individual's inability to care for himself and
danger to self or others without supports.
2. Requests for emergency slots shall be forwarded by the
CSB/BHA to DBHDS.
a. Emergency slots may be assigned by DBHDS to individuals
until the total number of available emergency slots statewide reaches 10% of
the emergency slots funded for a given fiscal year, or a minimum of three
slots. At that point, the next nonemergency waiver slot that becomes available
at the CSB in receipt of an emergency slot shall be reassigned to the emergency
slot pool in order to ensure emergency slots remain to be assigned to future
emergencies within the Commonwealth's fiscal year.
b. Emergency slots shall also be set aside for those
individuals not previously identified but newly known as needing supports
resulting from an emergent situation.
F. Reserve slots.
1. Reserve slots may be used for transitioning an
individual who, due to documented changes in his support needs, requires a move
from the DD waiver in which he is presently enrolled into another of the DD
waivers to access necessary services.
a. An individual who needs to transition between the DD
waivers shall not be placed on the DD waiting list.
b. A documented change in an individual's assessed needs,
which requires a service or services that is or are not available in the DD
waiver in which the individual is presently enrolled, shall exist for an
individual to be considered for a reserve slot.
c. CSBs shall document and notify DBHDS in writing when an
individual meets the criteria in subdivision 1 b of this subsection within
three business days of knowledge of need. The assignment of reserve slots shall
be managed by DBHDS, which will maintain a chronological list of individuals in
need of a reserve slot in the event that the reserve slot supply is exhausted.
2. The waiver slot belonging to the individual who vacates
one of the DD waivers to utilize the reserve slot to enroll in another DD waiver
shall be assigned to an individual on that CSB's/BHA's part of the statewide
waiting list by DBHDS, after review and recommendations from the local waiver
slot assignment committee.
G. If the individual determines at any time that he no
longer wishes to be on the waiver waiting list, he may contact his support
coordinator/case manager to request removal from the waiting list. The support
coordinator/case manager shall notify DBHDS so that the individual's name can
be removed from the waiting list.
Part VIII
Individual and Family Developmental Disabilities Support Family and
Individual Supports (FIS) Waiver
Article 1
General Requirements
12VAC30-120-700. Definitions.
The following words and terms when used in this part shall
have the following meanings unless the context clearly indicates otherwise:
"Activities of daily living" or "ADL"
means personal care tasks, e.g., bathing, dressing, toileting, transferring,
and eating/feeding. An individual's degree of independence in performing these
activities is a part of determining appropriate level of care and services the
same as defined in 12VAC30-120-1000.
"Appeal" means the process used to challenge
adverse actions regarding services, benefits, and reimbursement provided by
Medicaid pursuant to 12VAC30-110, Eligibility and Appeals, and 12VAC30-20-500
through 12VAC30-20-560 same as defined in 12VAC30-120-1000.
"Assistive technology" means specialized medical
equipment and supplies including those devices, controls, or appliances
specified in the plan of care but not available under the State Plan for
Medical Assistance that enable individuals to increase their abilities to
perform activities of daily living, or to perceive, control, or communicate
with the environment in which they live, or that are necessary to the proper
functioning of the specialized equipment the same as defined in
12VAC30-120-1000.
"Barrier crime" means the same as defined in
12VAC30-120-1000.
"Behavioral health authority" or "BHA"
means the local agency, established by a city or county or a combination of
counties or cities or cities and counties under Chapter 6 (§ 37.2-600 et
seq.) of Title 37.2 of the Code of Virginia, that plans, provides, and
evaluates mental health, intellectual disability, and substance abuse services
in the jurisdiction or jurisdictions it serves same as defined in §
37.2-100 of the Code of Virginia.
"Case management" means services as defined in
12VAC30-50-490.
"Case manager" means the provider of case
management services as defined in 12VAC30-50-490 same as defined in 12VAC30-120-1000.
"Center-based crisis support services" means the
same as defined in 12VAC30-120-1000.
"Centers for Medicare and Medicaid Services" or
"CMS" means the same as defined in 12VAC30-120-1000.
"Challenging behavior" means the same as defined
in 12VAC30-120-1000.
"Centers for Medicare and Medicaid Services" or
"CMS" means the unit of the federal Department of Health and Human
Services that administers the Medicare and Medicaid programs.
"Community-based waiver services" or
"waiver services" means a variety of home and community-based
services paid for by DMAS as authorized under a § 1915(c) waiver designed to
offer individuals an alternative to institutionalization. Individuals may be
preauthorized to receive one or more of these services either solely or in
combination, based on the documented need for the service or services to avoid
ICF/IID placement.
"Community-based crisis supports services" means
the same as defined in 12VAC30-120-1000.
"Community coaching" means the same as defined
in 12VAC30-120-1000.
"Community engagement" means the same as defined
in 12VAC30-120-1000.
"Community services board" or "CSB" means
the local agency, established by a city or county or combination of counties
or cities, or cities and counties, under Chapter 5 (§ 37.2-500 et seq.) of
Title 37.2 of the Code of Virginia, that plans, provides, and evaluates mental
health, intellectual disability, and substance abuse services in the
jurisdiction or jurisdictions it serves same as defined in § 37.2-100 of
the Code of Virginia.
"Companion" means, for the purpose of these
regulations, a person who provides companion services the same as
defined in 12VAC30-120-1000.
"Companion services" means nonmedical care,
supervision, and socialization provided to an adult (age 18 years or older).
The provision of companion services does not entail hands-on care. It is
provided in accordance with a therapeutic goal in the plan of care and is not
purely diversional in nature the same as defined in 12VAC30-120-1000.
"Comprehensive assessment" means the same as
defined in 12VAC30-120-501.
"Consumer-directed employee" or "CD
employee" means, for purposes of these regulations, a person who
provides consumer-directed services, personal care, companion services, or
respite care who is also exempt from workers' compensation the same as
the term "consumer-directed attendant" defined in 12VAC30-120-1000.
"Consumer-directed services" means personal
care, companion services, or respite care services where the individual or his
family/caregiver, as appropriate, is responsible for hiring, training,
supervising, and firing of the employee or employees.
"Consumer-directed (CD) services facilitator"
means the provider enrolled with DMAS who is responsible for management
training and review activities as required by DMAS for consumer-directed
services.
"Crisis stabilization" means direct intervention
for persons with related conditions who are experiencing serious psychiatric or
behavioral challenges, or both, that jeopardize their current community living
situation. This service must provide temporary intensive services and supports
that avert emergency psychiatric hospitalization or institutional placement or
prevent other out-of-home placement. This service shall be designed to
stabilize individuals and strengthen the current living situations so that
individuals may be maintained in the community during and beyond the crisis
period.
"Current functional status" means an
individual's degree of dependency in performing activities of daily living.
"Consumer-direction" means the same as defined
in 12VAC30-120-1000.
"CPR" means cardiopulmonary resuscitation.
"Crisis support services" means the same as
defined in 12VAC30-120-1000.
"DARS" means the Department for Aging and
Rehabilitative Services.
"Date of need" means the date of the initial
eligibility determination assigned to reflect that the individual is
diagnostically and functionally eligible for the waiver and is willing to begin
services within 30 calendar days of the date of need. The date of need shall not
be changed unless the individual is subsequently found to be ineligible, either
functionally or financially, or withdraws his request for services.
"DBHDS" means the Department of Behavioral Health
and Developmental Services.
"DBHDS staff" means employees of DBHDS who provide
technical assistance, conduct service authorizations, and review
individual level of care criteria.
"Developmental disability" or "DD"
means the same as set out in § 37.2-100 of the Code of Virginia.
"Direct marketing" means the same as defined in
12VAC30-120-1000.
"Direct support professionals" or
"DSPs" means the same as defined in 12VAC30-120-1000.
"DMAS" means the Department of Medical Assistance
Services.
"DMAS staff" means DMAS employees who perform
utilization review, preauthorize service type and intensity, and provide
technical assistance persons employed by or contracted with DMAS.
"DSS" means the Department of Social Services.
"Day support" means training in intellectual,
sensory, motor, and affective social development including awareness skills,
sensory stimulation, use of appropriate behaviors and social skills, learning
and problem solving, communication and self-care, physical development,
services and support activities. These services take place outside of the individual's
home/residence.
"Direct marketing" means either (i) conducting
directly or indirectly door-to-door, telephonic, or other "cold call"
marketing of services at residences and provider sites; (ii) mailing directly;
(iii) paying "finders' fees"; (iv) offering financial incentives,
rewards, gifts, or special opportunities to eligible individuals or
family/caregivers as inducements to use the providers' services; (v)
continuous, periodic marketing activities to the same prospective individual or
his family/caregiver, as appropriate, for example, monthly, quarterly, or
annual giveaways as inducements to use the providers' services; or (vi)
engaging in marketing activities that offer potential customers rebates or
discounts in conjunction with the use of the providers' services or other
benefits as a means of influencing the individual's or his family/caregiver's,
as appropriate, use of the providers' services.
"Electronic home-based supports" means the same
as defined in 12VAC30-120-1000.
"Employer of record" or "EOR" means
the same as defined in 12VAC30-120-1000.
"Enroll" means that the individual has been
determined by the IFDDS screening team to meet the eligibility requirements for
the waiver, DBHDS has approved the individual's plan of care and has assigned
an available slot to the individual, and DSS has determined the individual's
Medicaid eligibility for home and community-based services the same as
defined in 12VAC30-120-501.
"Entrepreneurial model" means a small business
employing eight or fewer individuals with disabilities on a shift and may
involve interactions with the public and coworkers with disabilities.
"Environmental modifications" means physical
adaptations to a house, place of residence, primary vehicle or work site, when
the work site modification exceeds reasonable accommodation requirements of the
Americans with Disabilities Act, necessary to ensure individuals' health and
safety or enable functioning with greater independence when the adaptation is
not being used to bring a substandard dwelling up to minimum habitation
standards and is of direct medical or remedial benefit to individuals the
same as defined in 12VAC30-120-1000.
"EPSDT" means the Early Periodic Screening,
Diagnosis and Treatment program administered by DMAS for children under the age
of 21 years according to federal guidelines that prescribe specific preventive
and treatment services for Medicaid-eligible children as defined in
12VAC30-50-130 same as defined in 12VAC30-120-1000.
"Face-to-face visit" means the case manager or
service provider must meet with the individual in person and that the
individual should be engaged in the visit to the maximum extent possible the
same as defined in 12VAC30-120-1000.
"Family" means the same as defined in
12VAC30-120-501.
"Family and Individual Supports Waiver" or
"FIS" means the waiver that supports individuals living with their
families or friends or in their own homes. It will support individuals with
some medical or behavioral needs and will be available to both children and adults.
"Family/caregiver training" means training and
counseling services provided to families or caregivers of individuals receiving
services in the IFDDS Waiver.
"Fiscal employer agent" means an entity
handling employment, payroll, and tax responsibilities on behalf of individuals
who are receiving consumer-directed services the same as defined in
12VAC30-120-1000.
"Freedom of choice" means the same as defined in
§ 1902(a)(23) of the Social Security Act.
"General supports" means the same as defined in
12VAC30-120-1000.
"Group day services" means the same as defined
in 12VAC30-120-1000.
"Group supported employment services" means the
same as defined in 12VAC30-120-1000.
"Habilitation" means services and supports that
help an individual keep, learn, or improve skills and functioning for daily
living.
"Health, safety, and welfare standard" means the
same as defined in 12VAC30-120-1000.
"Home" means, for purposes of the IFDDS Waiver,
an apartment or single family dwelling in which no more than four individuals
who require services live, with the exception of siblings living in the same
dwelling with family. This does not include an assisted living facility or
group home.
"Home and community-based waiver services" means a
variety of home and community-based services reimbursed by DMAS as authorized
under a § 1915(c) waiver designed to offer individuals an alternative to
institutionalization. Individuals may be preauthorized to receive one or more
of these services either solely or in combination, based on the documented need
for the service or services to avoid ICF/IID placement the same as
defined in 12VAC30-120-1000.
"ICF/IID" means a facility or distinct part of a
facility certified as meeting the federal certification regulations for an
Intermediate Care Facility for Individuals with Intellectual Disabilities and
persons with related conditions. These facilities must address the residents'
total needs including physical, intellectual, social, emotional, and
habilitation. An ICF/IID must provide active treatment, as that term is defined
in 42 CFR 483.440(a) the same as defined in 12VAC30-120-1000.
"IDEA" means the federal Individuals with
Disabilities Education Act of 2004, 20 USC § 1400 et seq.
"ID Waiver" means the Intellectual Disability
waiver.
"IFDDS screening team" means the persons
employed by the entity under contract with DMAS who are responsible for
performing level of care screenings for the IFDDS Waiver.
"IFDDS Waiver," "IFDDS," or
"DD" means the Individual and Family Developmental Disabilities
Support Waiver.
"In-home support services" means the same as
defined in 12VAC30-120-1000.
"Individual" means the same as defined in
12VAC30-120-501.
"Individual and family/caregiver training" means
training and counseling services provided to individuals or families or
caregivers of individuals receiving services in the FIS waiver.
"Individual supported employment" means the same
as defined in 12VAC30-120-1000.
"In-home residential support services" means
support provided primarily in the individual's home, which includes training,
assistance, and specialized supervision to enable the individual to maintain or
improve his health; assisting in performing individual care tasks; training in
activities of daily living; training and use of community resources; providing
life skills training; and adapting behavior to community and home-like
environments.
"Individual Support Plan" or "ISP"
means the same as defined in 12VAC30-120-1000.
"Instrumental activities of daily living" or
"IADL" means meal preparation, shopping, housekeeping, laundry, and
money management means the same as defined in 12VAC30-120-1000.
"Intellectual disability" or "ID"
means a disability as defined by the American Association on Intellectual and
Developmental Disabilities (AAIDD) in the Intellectual Disability: Definition,
Classification, and Systems of Supports (11th edition, 2010).
"LDSS" means the local Department of Social
Services.
"Licensed practical nurse" means the same as
defined in 12VAC30-120-1000.
"LMHP" means the same as defined in
12VAC30-50-130.
"LMHP-resident" or "LMHP-R" means the
same as defined in 12VAC30-50-130.
"LMHP-resident in psychology" or LMHP-RP"
means the same as defined in 12VAC30-50-130.
"LMHP-supervisee in social work" or
"LMHP-S" means the same as defined in 12VAC30-50-130.
"Medically necessary" means the same as defined
in 12VAC30-120-1000.
"Participating provider" means an entity that
meets the standards and requirements set forth by DMAS and has a current,
signed provider participation agreement with DMAS the same as defined in
12VAC30-120-1000.
"Pend" means delaying the consideration of an
individual's request for authorization of services until all required
information is received by DMAS or by its authorized agent the same as
defined in 12VAC30-120-1000.
"Person-centered planning" means a process,
directed by the individual or his family/caregiver, as appropriate, intended to
identify the strengths, capacities, preferences, needs and desired outcomes of
the individual the same as defined in 12VAC30-120-1000.
"Personal assistance services" means the same as
defined in 12VAC30-120-1000.
"Personal assistant" means the same as defined
in 12VAC30-120-1000.
"Personal care provider" means a participating
provider that renders services to prevent or reduce inappropriate institutional
care by providing eligible individuals with personal care aides assistants
to provide personal care assistance services.
"Personal care services" means long-term
maintenance or support services necessary to enable individuals to remain in or
return to the community rather than enter an Intermediate Care Facility for
Individuals with Intellectual Disabilities. Personal care services include
assistance with activities of daily living, instrumental activities of daily
living, access to the community, medication or other medical needs, and
monitoring health status and physical condition. This does not include skilled
nursing services with the exception of skilled nursing tasks that may be
delegated in accordance with 18VAC90-20-420 through 18VAC90-20-460.
"Personal emergency response system" or
"PERS" means an electronic device that enables certain individuals
to secure help in an emergency. PERS services are limited to those individuals
who live alone or are alone for significant parts of the day and who have no
regular caregiver for extended periods of time, and who would otherwise require
extensive routine supervision the same as defined in 12VAC30-120-1000.
"Personal profile" means the same as defined in
12VAC30-120-1000.
"Plan of care" means a document developed by the
individual or his family/caregiver, as appropriate, and the individual's case
manager addressing all needs of individuals of home and community-based waiver
services, in all life areas. Supporting documentation developed by waiver
service providers is to be incorporated in the plan of care by the case
manager. Factors to be considered when these plans are developed must include,
but are not limited to, individuals' ages, levels of functioning, and
preferences.
"Plan for supports" means the same as defined in
12VAC30-120-1000.
"Positive behavior support" means the same as
defined in 12VAC30-120-1000.
"Preauthorized" means the service authorization
agent has approved a service for initiation and reimbursement of the service by
the service provider.
"Primary caregiver" means the primary person who
consistently assumes the role of providing direct care and support of the
individual to live successfully in the community without compensation
for such care same as defined in 12VAC30-120-1000.
"Private duty nursing" means the same as defined
in 12VAC30-120-1000.
"Qualified developmental disabilities professional"
or "QDDP" means a professional who (i) possesses at least one year
of documented experience working directly with individuals who have related
conditions; (ii) is one of the following: a doctor of medicine or osteopathy, a
registered nurse, a provider holding at least a bachelor's degree in a
human service field including, but not limited to, sociology, social work,
special education, rehabilitation engineering, counseling or psychology, or a
provider who has documented equivalent qualifications; and (iii) possesses the
required Virginia or national license, registration, or certification in
accordance with his profession, if applicable the same as defined in
12VAC30-120-1000.
"Registered nurse" means the same as defined in
12VAC30-120-1000.
"Related conditions" means those persons who
have autism or who have a severe chronic disability that meets all of the
following conditions identified in 42 CFR 435.1009:
1. It is attributable to:
a. Cerebral palsy or epilepsy; or
b. Any other condition, other than mental illness, found to
be closely related to intellectual disability because this condition results in
impairment of general intellectual functioning or adaptive behavior similar to
that of persons with intellectual disability, and requires treatment or
services similar to those required for these persons.
2. It is manifested before the person reaches age 22 years.
3. It is likely to continue indefinitely.
4. It results in substantial functional limitations in
three or more of the following areas of major life activity:
a. Self-care.
b. Understanding and use of language.
c. Learning.
d. Mobility.
e. Self-direction.
f. Capacity for independent living.
"Respite care services" means services
provided for unpaid caregivers of eligible individuals, who are unable to care
for themselves and are provided on an episodic or routine basis because of the
absence of or need for relief of those unpaid persons who routinely provide the
care the same as defined in 12VAC30-120-1000.
"Respite care provider" means a participating
provider that renders services designed to prevent or reduce inappropriate
institutional care by providing respite care services for unpaid caregivers of
eligible individuals.
"Risk assessment" means the same as defined in
12VAC30-120-1000.
"Routine supports" means the same as defined in
12VAC30-120-1000.
"Safety supports" means the same as
defined in 12VAC30-120-1000.
"Screening" means the process conducted by the
IFDDS screening team to evaluate the medical, nursing, and social needs of
individuals referred for screening and to determine eligibility for an ICF/IID
level of care.
"Service authorization" means the same as defined
in 12VAC30-120-1000.
"Services facilitation" means the same as
defined in 12VAC30-120-1000.
"Services facilitator" means the same as defined
in 12VAC30-120-1000.
"Shared living" means the same as defined in
12VAC30-120-1000.
"Significant change" means the same as defined
in 12VAC30-120-1000.
"Skilled nursing services" means nursing
services (i) listed in the plan of care that do not meet home health criteria,
(ii) required to prevent institutionalization, (iii) not otherwise available
under the State Plan for Medical Assistance, (iv) provided within the scope of
the state's Nursing Act (§ 54.1-3000 et seq. of the Code of Virginia) and
Drug Control Act (§ 54.1-3400 et seq. of the Code of Virginia), and (v)
provided by a registered professional nurse or by a licensed practical nurse
under the supervision of a registered nurse who is licensed to practice in the
state. Skilled nursing services are to be used to provide training,
consultation, nurse delegation as appropriate, and oversight of direct care staff
as appropriate same as defined in 12VAC30-120-1000.
"Slot" means an opening or vacancy of waiver
services for an individual the same as defined in 12VAC30-120-501.
"Specialized supervision" means staff presence
necessary for ongoing or intermittent intervention to ensure an individual's
health and safety.
"State Plan for Medical Assistance" or "the
State Plan" means the document containing the covered groups, covered
services and their limitations, and provider reimbursement methodologies as
provided for under Title XIX of the Social Security Act same as defined
in 12VAC30-120-1000.
"Supporting documentation" means the specific
plan of care developed by the individual and waiver service provider related
solely to the specific tasks required of that service provider. Supporting
documentation helps to comprise the overall plan of care for the individual,
developed by the case manager and the individual.
"Supported employment" means work in settings in
which persons without disabilities are typically employed. It includes training
in specific skills related to paid employment and provision of ongoing or
intermittent assistance and specialized supervision to enable an individual to
maintain paid employment.
"Support coordination/case management" means the
same as defined in 12VAC30-50-455 D.
"Support coordinator/case manager" means the
same as defined in 12VAC30-120-501.
"Supported living residential services" means
the same as defined in 12VAC30-120-1000.
"Supports" means the same as defined in
12VAC30-120-1000.
"Supports Intensity Scale®" or
"SIS®" the same as defined in 12VAC30-120-501.
"Supports level" means" the level (1-7) to
which an individual is assigned as a result of the utilization of the SIS®
score and results of the Virginia Supplemental Questions. The level of
support is derived from a calculation using the SIS® score and the
results of the Virginia Supplemental Questions and correlates to an
individual's support needs.
"Therapeutic consultation" means consultation
provided by members of psychology, social work, rehabilitation engineering,
behavioral analysis, speech therapy, occupational therapy, psychiatry,
psychiatric clinical nursing, therapeutic recreation, or physical therapy or
behavior consultation to assist individuals, parents, family members, in-home
residential support, day support, and any other providers of support services
in implementing a plan of care the same as defined in 12VAC30-120-1000.
"Transition services" means set-up expenses for
individuals who are transitioning from an institution or licensed or certified
provider-operated living arrangement to a living arrangement in a private
residence where the person is directly responsible for his or her own living
expenses provides the service description, criteria, service units and
limitations, and provider requirements for this service the same as
defined in 12VAC30-120-2010.
"VDH" means the Virginia Department of Health.
"Workplace assistance services" means the same
as defined in 12VAC30-120-1000.
12VAC30-120-710. General coverage Covered services
and provider requirements for all home and community-based waiver
Family and Individual Supports (FIS) Waiver services.
A. Waiver service populations. Home and community-based
services shall be available through a § 1915(c) waiver. Coverage shall be
provided under the waiver for individuals six years of age or older with
related conditions as defined in 12VAC30-120-700, including autism, who have
been determined to require the level of care provided in an ICF/IID. The
individual must not have a diagnosis of intellectual disability as defined by
the American Association on Intellectual and Developmental Disabilities
(AAIDD). Intellectual Disability Waiver recipients who are six years of age on
or after October 1, 2002, who are determined to not have a diagnosis of
intellectual disability, and who meet all IFDDS Waiver eligibility criteria,
shall be eligible for and shall transfer to the IFDDS Waiver effective with
their sixth birthday. Psychological evaluations confirming diagnoses must be
completed less than one year prior to the child's sixth birthday. These
recipients transferring from the ID Waiver will automatically be assigned a
slot in the IFDDS Waiver. Such slot shall be in addition to those slots
available through the screening process described in 12VAC30-120-720 B and C.
A. Except for the exclusions outlined in this subsection,
individuals who are enrolled in the Family and Individual Support Waiver may
choose between the agency-directed model of service delivery or the consumer-directed
model for the following services: (i) personal assistance services, (ii)
respite services, and (iii) companion services. The support coordinator/case
manager shall collaborate with the individual, family/caregiver, and other
persons desired by the individual to determine if consumer-directed services
may be appropriate for the individual. Exclusions include instances where:
1. The individual who is enrolled in the waiver is younger
than 18 years of age, except for emancipated minors, or is unable to be the
employer of record and no one else can assume this role in the
consumer-directed model of service delivery;
2. The health, safety, or welfare of the individual
enrolled in the waiver cannot be ensured via the consumer-directed model of service
delivery or a back-up emergency plan cannot be developed; or
3. The individual enrolled in the waiver has medication or
nursing needs or medical/behavioral conditions that cannot be safely met via
the consumer-directed model of service delivery.
B. Covered services.
1. Covered services shall include in-home residential
supports, day support, prevocational services, supported employment, personal
care (both agency-directed and consumer-directed), respite care (both
agency-directed and consumer-directed), assistive technology, environmental
modifications, skilled nursing services, therapeutic consultation, crisis
stabilization, personal emergency response systems (PERS), family/caregiver
training, companion services (both agency-directed and consumer-directed), and
transition services assistive technology, center-based crisis supports
services, community-based crisis supports services, community coaching,
community engagement, companion services (both consumer-directed and
agency-directed), crisis support services, electronic home-based supports,
environmental modifications, group day services, group supported employment,
individual supported employment, in-home support services, individual and
family/caregiver training, personal assistance services (both consumer-directed
and agency-directed), personal emergency response systems (PERS), private duty
nursing, respite services (both consumer-directed and agency-directed),
services facilitation (only for consumer-directed services), shared living,
skilled nursing services, supported living residential, therapeutic
consultation, transition services, and workplace assistance services.
2. These services shall be appropriate and medically
necessary to maintain these individuals in the community. Federal waiver requirements
provide that the average per capita fiscal year expenditures under the waiver
must not exceed the average per capita expenditures for the level of care
provided in ICFs/IID under the State Plan that would have been made had the
waiver not been granted.
3. Under this § 1915(c) waiver, DMAS waives subdivision
(a)(10)(B) of § 1902 of the Social Security Act related to comparability.
C. Eligibility criteria for emergency access to the
waiver.
1. Subject to available funding and a finding of eligibility
under 12VAC30-120-720, individuals must meet at least one of the emergency
criteria of this subdivision to be eligible for immediate access to waiver
services without consideration to the length of time an individual has been
waiting to access services. In the absence of waiver services, the individual
would not be able to remain in his home. The criteria are as follows:
a. The primary caregiver has a serious illness, has been
hospitalized, or has died;
b. The individual has been determined by the DSS to have
been abused or neglected and is in need of immediate waiver services;
c. The individual demonstrates behaviors that present risk
to personal or public safety;
d. The individual presents extreme physical, emotional, or
financial burden at home, and the family or caregiver is unable to continue to
provide care; or
e. The individual lives in an institutional setting and has
a viable discharge plan in place.
2. When emergency slots become available:
a. All individuals who have been found eligible for the
IFDDS Waiver but have not been enrolled shall be notified by either DBHDS or
the individual's case manager.
b. Individuals and their family/caregivers shall be given
30 calendar days to request emergency consideration.
c. An interdisciplinary team of DBHDS professionals shall
evaluate the requests for emergency consideration within 10 calendar days from
the 30-calendar day deadline using the emergency criteria to determine who will
be assigned an emergency slot. If DBHDS receives more requests than the number
of available emergency slots, then the interdisciplinary team will make a
decision on slot allocation based on need as documented in the request for
emergency consideration. A waiting list of emergency cases will not be kept.
D. Appeals. Individual appeals shall be considered pursuant
to 12VAC30-110-10 through 12VAC30-110-370. Provider appeals shall be considered
pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560. 2.
Individuals shall have the right to appeal as set forth in 12VAC30-120-505 D.
C. Core competency requirements for direct support
professionals (DSPs) and their supervisors in programs licensed by DBHDS shall
be the same as those set forth in 12VAC30-120-515 A.
D. Core competency requirements for support
coordinators/case managers. (Reserved.)
E. Core competency requirements for QDDPs. (Reserved.)
F. Advanced core competency requirements for DSPs and DSP
supervisors serving individuals with developmental disabilities with the most
intensive needs shall be the same as those set forth in 12VAC30-120-515 D.
G. Provider enrollment requirements and provider
participation standards shall be the same as those set forth in
12VAC30-120-514.
H. Documentation requirements shall be the same as those
set forth in 12VAC30-120-514 Q.
I. Reevaluation of service need requirements shall be the
same as those set forth in 12VAC30-120-515 F.
J. Utilization review requirements shall be the same
as those set forth in 12VAC30-120-515 G.
12VAC30-120-720. Qualification and eligibility requirements;
intake process. (Repealed.)
A. Individuals receiving services under this waiver must
meet the following requirements. Virginia will apply the financial eligibility
criteria contained in the State Plan for the categorically needy. Virginia has
elected to cover the optional categorically needy groups under 42 CFR 435.121
and 435.217. The income level used for 42 CFR 435.121 and 435.217 is 300% of
the current Supplemental Security Income payment standard for one person.
1. Under this waiver, the coverage groups authorized under
§ 1902(a)(10)(A)(ii)(VI) of the Social Security Act will be considered as if
they were institutionalized for the purpose of applying institutional deeming
rules. All individuals under the waiver must meet the financial and nonfinancial
Medicaid eligibility criteria and meet the institutional level of care
criteria. The deeming rules are applied to waiver eligible individuals as if
the individual were residing in an institution or would require that level of
care.
2. Virginia shall reduce its payment for home and
community-based waiver services provided to an individual who is eligible for
Medicaid services under 42 CFR 435.217 by that amount of the individual's
total income (including amounts disregarded in determining eligibility) that
remains after allowable deductions for personal maintenance needs, deductions
for other dependents, and medical needs have been made, according to the
guidelines in 42 CFR 435.735 and § 1915(c)(3) of the Social Security Act as
amended by the Consolidated Omnibus Budget Reconciliation Act of 1986. DMAS
will reduce its payment for home and community-based waiver services by the
amount that remains after the following deductions:
a. For individuals to whom § 1924(d) applies, and for whom
Virginia waives the requirement for comparability pursuant to § 1902(a)(10)(B),
deduct the following in the respective order:
(1) The basic maintenance needs for an individual, which is
equal to 165% of the SSI payment for one person. Due to expenses of employment,
a working individual shall have an additional income allowance. For an
individual employed 20 hours or more per week, earned income shall be
disregarded up to a maximum of 300% SSI; for an individual employed at least
eight but less than 20 hours per week, earned income shall be disregarded up to
a maximum of 200% of SSI. If the individual requires a guardian or conservator
who charges a fee, the fee, not to exceed an amount greater than 5.0% of the
individual's total monthly income, is added to the maintenance needs allowance.
However, in no case shall the total amount of the maintenance needs allowance
(basic allowance plus earned income allowance plus guardianship fees) for the
individual exceed 300% of SSI.
(2) For an individual with a spouse at home, the community
spousal income allowance determined in accordance with § 1924(d) of the Social
Security Act.
(3) For an individual with a family at home, an additional
amount for the maintenance needs of the family determined in accordance with §
1924(d) of the Social Security Act.
(4) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including Medicare and
other health insurance premiums, deductibles, or coinsurance charges and
necessary medical or remedial care recognized under state law but not covered
under the State Plan.
b. For individuals to whom § 1924(d) does not apply and for
whom Virginia waives the requirement for comparability pursuant to §
1902(a)(10)(B), deduct the following in the respective order:
(1) The basic maintenance needs for an individual, which is
equal to 165% of the SSI payment for one person. Due to expenses of employment,
a working individual shall have an additional income allowance. For an
individual employed 20 hours or more per week, earned income shall be
disregarded up to a maximum of 300% SSI; for an individual employed at least
eight but less than 20 hours per week, earned income shall be disregarded up to
a maximum of 200% of SSI. If the individual requires a guardian or conservator
who charges a fee, the fee, not to exceed an amount greater than 5.0% of the
individual's total monthly income, is added to the maintenance needs allowance.
However, in no case shall the total amount of the maintenance needs allowance
(basic allowance plus earned income allowance plus guardianship fees) for the
individual exceed 300% of SSI.
(2) For an individual with a dependent child or children,
an additional amount for the maintenance needs of the child or children, which
shall be equal to the Title XIX medically needy income standard based on the
number of dependent children.
(3) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including Medicare and
other health insurance premiums, deductibles, or coinsurance charges and
necessary medical or remedial care recognized under state law but not covered
under the State Medical Assistance Plan.
B. Screening.
1. To ensure that Virginia's home and community-based
waiver programs serve only individuals who would otherwise be placed in an
ICF/IID, home and community-based waiver services shall be considered only for
individuals who are eligible for admission to an ICF/IID, absent a diagnosis of
intellectual disability and are age six years or older. Home and
community-based waiver services shall be the critical service that enables the
individual to remain at home rather than being placed in an ICF/IID.
2. To be eligible for IFDDS Waiver services, the individual
must:
a. Be determined to be eligible for the ICF/IID level of
care;
b. Be six years of age or older;
c. Meet the related conditions definition as defined in
42 CFR 435.1009 or be diagnosed with autism; and
d. Not have a diagnosis of intellectual disability as
defined by the American Association on Intellectual and Developmental
Disabilities (AAIDD).
3. A child younger than six years of age shall not be
screened until three months prior to the month of their sixth birthday. A child
younger than six years of age shall not be added to the waiver or the wait list
until the month in which the child's sixth birthday occurs.
4. The IFDDS screening team shall gather relevant medical
and social data and identify all services received by and supports available to
the individual. The IFDDS screening team shall also gather psychological
evaluations or refer the individual to a private or publicly funded
psychologist for evaluation of the cognitive abilities of each screening
applicant.
5. The individual's status as an individual in need of
IFDDS home and community-based care waiver services shall be determined by the
IFDDS screening team after completion of a thorough assessment of the
individual's needs and available supports. Screening for home and
community-based care waiver services by the IFDDS screening team or DBHDS staff
is mandatory before Medicaid will assume payment responsibility of home and
community-based care waiver services.
6. The IFDDS screening team determines the level of care by
applying existing DMAS ICF/IID criteria (12VAC30-130-430).
7. The IFDDS screening team shall explore alternative
settings and services to provide the care needed by the individual with the
individual and his family/caregiver, as appropriate. If placement in an ICF/IID
or a combination of other services is determined to be appropriate, the IFDDS
screening team shall initiate a referral for service to DBHDS. If
Medicaid-funded home and community-based waiver services are determined to be
the critical service to delay or avoid placement in an ICF/IID or promote
exiting from an institutional setting, the IFDDS screening team shall initiate
a referral for service to a case manager of the individual's choice. Referrals
are based on the individual choosing either ICF/IID placement or home and
community-based waiver services.
8. Home and community-based waiver services shall not be
provided to any individual who resides in a nursing facility, an ICF/IID, a
hospital, an adult family care home approved by the DSS, a group home licensed
by DBHDS, or an assisted living facility licensed by the DSS. However, an
individual may be screened for the IFDDS Waiver and placed on the wait list
while residing in one of the aforementioned facilities.
9. The IFDDS screening team must submit the results of the
comprehensive assessment and a recommendation to DBHDS staff for final
determination of ICF/IID level of care and authorization for home and
community-based waiver services.
10. For children receiving ID Waiver services prior to age
six to transfer to the IFDDS Waiver during their sixth year, the individual's
ID Waiver case manager shall submit to DBHDS the child's most recent Level of
Functioning form, the plan of care, and a psychological examination completed
no more than one year prior to transferring. Such documentation must
demonstrate that no diagnosis of intellectual disability exists in order for
this transfer to the IFDDS Waiver to be approved. The case manager shall be
responsible for notifying DBHDS and DSS, via the DMAS-225, when a child transfers
from the ID Waiver to the IFDDS Waiver. Transfers must be completed prior to
the child's seventh birthday.
C. Waiver approval process: available funding.
1. In order to ensure cost effectiveness of the IFDDS
Waiver, the funding available for the waiver is allocated between two budget
levels. The budget is the cost of waiver services only and does not include the
costs of other Medicaid covered services. Other Medicaid services, however,
must be counted toward cost effectiveness of the IFDDS Waiver. All services
available under the waiver are available to both levels.
2. Level one is for individuals whose comprehensive plans
of care cost less than $25,000 per fiscal year. Level two is for individuals
whose plans of care costs are equal to or more than $25,000. There is no
threshold for budget level two; however, if the actual cost of waiver services
exceeds the average annual cost of ICF/IID care for an individual, the
individual's care is case managed by DBHDS staff.
3. Fifty percent of available waiver funds are allocated to
budget level one, and 40% of available waiver funds are allocated to level two
in order to ensure that the waiver is cost effective. The remaining 10% of
available waiver funds is allocated for emergencies as defined in 12VAC30-120-710.
In order to transition an appropriate number of level one slots to emergency
slots, every third level one slot that becomes available will convert to an
emergency slot until the percentage of emergency slots reaches 10%. Half of
emergency slots will be allocated for individuals in institutional settings who
are discharge ready and have a viable discharge plan to transition into the
community within 60 days. If there are no such individuals who choose to
discharge into the community when emergency slots are available for
institutionalized individuals, the emergency slot will be allocated to an
individual residing in the community who meets emergency criteria.
D. Assessment and enrollment.
1. The IFDDS screening team shall determine if an
individual meets the functional criteria within 45 calendar days of receiving
the request for screening from the individual or his family/caregiver, as
appropriate. Once the IFDDS screening team determines that an individual meets
the eligibility criteria for IFDDS Waiver services and the individual has
chosen this service, the IFDDS screening team shall provide the individual with
a list of available case managers. The individual or his family/caregiver, as
appropriate, shall choose a case manager within 10 calendar days of receiving
the list of case managers and the IFDDS screening team shall forward the
screening materials within 10 calendar days of the case manager's selection to
the selected case manager.
2. The case manager shall contact the individual within 10
calendar days of receipt of screening materials. The case manager must meet
face-to-face with the individual and his family/caregiver, as appropriate,
within 30 calendar days to discuss the individual's needs, existing supports
and to develop a preliminary plan of care identifying needed services and
estimating the annual waiver cost of the individual's plan of care. If the
individual's annual waiver services cost is expected to exceed the average
annual cost of ICF/IID care for an individual, the individual's case management
shall be provided by DBHDS.
3. Once the plan of care has been initially developed, the
case manager shall contact DBHDS to request approval of the plan of care and to
enroll the individual in the IFDDS Waiver. DBHDS shall, within 14 calendar days
of receiving all supporting documentation, either approve for Medicaid coverage
or deny for Medicaid coverage the plan of care.
4. Medicaid will not pay for any home and community-based
waiver services delivered prior to the authorization date approved by DMAS. Any
plan of care for home and community-based waiver services must be pre-approved
by DBHDS prior to Medicaid reimbursement for waiver services.
5. The following five criteria shall apply to all IFDDS
Waiver services:
a. Individuals qualifying for IFDDS Waiver services must
have a demonstrated clinical need for the service resulting in significant
functional limitations in major life activities. In order to be eligible, an
individual must be six years of age or older, have a related condition as
defined in these regulations, cannot have a diagnosis of intellectual
disability, and would, in the absence of waiver services, require the level of
care provided in an ICF/IID facility, the cost of which would be reimbursed
under the State Plan;
b. The plan of care and services that are delivered must be
consistent with the Medicaid definition of each service;
c. Services must be approved by the case manager based on a
current functional assessment tool approved by DBHDS or other DBHDS-approved
assessment and demonstrated need for each specific service;
d. Individuals qualifying for IFDDS Waiver services must
meet the ICF/IID level of care criteria; and
e. The individual must be eligible for Medicaid as
determined by the local office of DSS.
6. DBHDS shall only authorize a waiver slot for the
individual if a slot is available. If DBHDS does not have a waiver slot for
this individual, the individual shall be placed on the waiting list until such
time as a waiver slot becomes available for the individual.
7. DBHDS will notify the case manager when a slot is
available for the individual. The case manager shall also notify the local DSS
by submitting a DMAS-225 and IFDDS Level of Care Eligibility form. The case
manager shall inform the individual so that the individual may apply for
Medicaid if necessary and begin choosing waiver service providers for services
listed in the plan of care.
8. The case manager forwards a copy of the completed
DMAS-225 to DBHDS. Upon receipt of the completed DMAS-225, DBHDS shall enroll
the individual into the IFDDS Waiver.
9. Once the individual has been determined to be Medicaid
eligible and enrolled in the waiver, the individual or case manager shall
contact the waiver service providers that the individual or his family/caregiver,
as appropriate, chooses, who shall initiate waiver services within 60 calendar
days. During this time, the individual, case manager, and waiver service
providers shall meet to complete the provider's supporting documentation for
the plan of care, implementing a person-centered planning process. The waiver
service providers shall develop supporting documentation for each waiver
service and shall submit a copy of this documentation to the case manager. If
services are not initiated within 60 calendar days, the case manager must
submit information to DBHDS demonstrating why more time is needed to initiate
services and request in writing a 30-calendar-day extension, up to a maximum of
four consecutive extensions, for the initiation of waiver services. DBHDS must
receive the request for extension letter within the 30-calendar-day extension
period being requested. DBHDS will review the request for extension and make a
determination within 10 calendar days of receiving the request. DBHDS has
authority to approve or deny the 30-calendar-day extension request.
10. The case manager shall monitor the waiver service
providers' supporting documentation to ensure that all providers are working
toward the identified goals of the individual. The case manager shall review
and sign off on the supporting documentation. The case manager shall contact
the preauthorization agent for service authorization of waiver services and
shall notify the waiver service providers when waiver services are approved.
11. The case manager shall contact the individual at a
minimum on a monthly basis and as needed to conduct case management activities
as defined in 12VAC30-50-490. DBHDS shall conduct annual level of care reviews
in which the individual is assessed to ensure continued waiver eligibility.
DBHDS shall review individuals' plans of care and shall review the services
provided by case managers and waiver service providers.
E. Reevaluation of service need and utilization review.
1. The plan of care.
a. The case manager shall develop the plan of care,
implementing a person-centered planning process with the individual, his
family/caregiver, as appropriate, other service providers, and other interested
parties identified by the individual or family/caregiver, based on relevant,
current assessment data. The plan of care development process determines the
services to be provided for individuals, the frequency of services, the type of
service provided, and a description of the services to be offered. All plans of
care written by the case managers must be approved by DBHDS prior to seeking
authorization for services. DMAS is the single state authority responsible for
the supervision of the administration of the home and community-based waiver.
b. The case manager is responsible for continuous monitoring
of the appropriateness of the individual's services by reviewing supporting
documentation and revisions to the plan of care as indicated by the changing
needs of the individual. At a minimum, every three months the case manager
must:
(1) Review the plan of care face-to-face with the
individual and family/caregiver, as appropriate, using a person-centered
planning approach;
(2) Review individual provider quarterly reports to ensure
goals and objectives are being met; and
(3) Determine whether any modifications to the plan of care
are necessary, based upon the needs of the individual.
c. At least once per plan of care year this review must be
performed with the individual present, and his family/caregivers as
appropriate, in the individual's home environment.
d. DBHDS staff shall review the plan of care every 12
months or more frequently as required to assure proper utilization of services.
Any modification to the amount or type of services in the plan of care must be
approved by DBHDS.
2. Annual reassessment.
a. The case manager or DBHDS, if DBHDS is acting as the
individual's case manager, shall complete an annual comprehensive reassessment,
in coordination with the individual, family/caregiver, and service providers.
If warranted, the case manager will coordinate a medical examination and a
psychological evaluation for every waiver individual. The reassessment,
completed in a person-centered planning manner, must include an update of the
assessment instrument and any other appropriate assessment data.
b. A medical examination must be completed for adults 18
years of age and older based on need identified by the individual, his
family/caregiver, as appropriate, providers, the case manager, or DBHDS staff.
Medical examinations for children must be completed according to the
recommended frequency and periodicity of the EPSDT program.
c. A psychological evaluation or standardized developmental
assessment for children older than six years of age and adults must reflect the
current psychological status (diagnosis), adaptive level of functioning, and
cognitive abilities. A new psychological evaluation is required whenever the
individual's functioning has undergone significant change and the current
evaluation no longer reflects the individual's current psychological status.
3. Documentation required.
a. The case management provider must maintain the following
documentation for review by the DBHDS staff for each waiver individual:
(1) All assessment summaries and all plans of care
completed for the individual are maintained for a period of not less than six
years;
(2) All supporting documentation from any provider
rendering waiver services for the individual;
(3) All supporting documentation related to any change in
the plan of care;
(4) All related communication with the individual, his
family/caregiver, as appropriate, providers, consultants, DBHDS, DMAS, DSS,
DARS, or other related parties;
(5) An ongoing log documenting all contacts related to the
individual made by the case manager that relate to the individual;
(6) The individual's most recent, completed level of
functioning;
(7) Psychologicals;
(8) Communications with DBHDS;
(9) Documentation of rejection or refusal of services and
potential outcomes resulting from the refusal of services communicated to the individual;
and
(10) DMAS-225.
b. The waiver service providers must maintain the following
documentation for review by the DMAS or DBHDS staff for each waiver individual:
(1) All supporting documentation developed for that
individual and maintained for a period of not less than six years;
(2) An attendance log documenting the date and times
services were rendered and the amount and the type of services rendered;
(3) Appropriate progress notes reflecting the individual's
status and, as appropriate, progress toward the identified goals on the
supporting documentation;
(4) All communication relating to the individual. Any
documentation or communication must be dated and signed by the provider;
(5) Service authorization decisions;
(6) Plans of care specific to the service being provided;
and
(7) Assessments/reassessments as required for the service
being provided.
12VAC30-120-730. General requirements for home and
community-based participating providers. (Repealed.)
A. Providers approved for participation shall, at a
minimum, perform the following activities:
1. Immediately notify DMAS, in writing, of any change in
the information that the provider previously submitted to DMAS.
2. Assure freedom of choice for individuals seeking
services from any institution, pharmacy, practitioner, or other provider
qualified to perform the service or services required and participating in the
Medicaid Program at the time the service or services were performed.
3. Assure the individual's freedom to reject medical care,
treatment, and services, and document that potential adverse outcomes that may
result from refusal of services were discussed with the individual.
4. Accept referrals for services only when staff is
available to initiate services within 30 calendar days and perform such
services on an ongoing basis.
5. Provide services and supplies for individuals in full
compliance with Title VI of the Civil Rights Act of 1964, as amended (42 USC §
2000d et seq.), which prohibits discrimination on the grounds of race, color,
or national origin; the Virginians with Disabilities Act (Title 51.5
(§ 51.5-1 et seq.) of the Code of Virginia); § 504 of the Rehabilitation
Act of 1973, as amended (29 USC § 794), which prohibits discrimination on the
basis of a disability; and the Americans with Disabilities Act, as amended
(42 USC § 12101 et seq.), which provides comprehensive civil rights
protections to individuals with disabilities in the areas of employment, public
accommodations, state and local government services, and telecommunications.
6. Provide services and supplies to individuals of the same
quality and in the same mode of delivery as provided to the general public.
7. Submit charges to DMAS for the provision of services and
supplies for individuals in amounts not to exceed the provider's usual and
customary charges to the general public and accept as payment in full the
amount established by DMAS from the individual's authorization date for waiver
services.
8. Use program-designated billing forms for submission of
charges.
9. Maintain and retain business and professional records
sufficient to document fully and accurately the nature, scope, and details of
the care provided.
a. Such records shall be retained for at least six years
from the last date of service or as provided by applicable state and federal
laws, whichever period is longer. However, if an audit is initiated within the
required retention period, the records shall be retained until the audit is
completed and every exception resolved. Records of minors shall be kept for at least
six years after such minor has reached the age of 18 years.
b. Policies regarding retention of records shall apply even
if the provider discontinues operation. DMAS shall be notified in writing of
storage, location, and procedures for obtaining records for review should the
need arise. The location, agent, or trustee shall be within the Commonwealth of
Virginia.
c. An attendance log or similar document must be maintained
that indicates the date services were rendered, type of services rendered, and
number of hours/units provided (including specific time frame).
10. Consistent with 12VAC30-120-1040, agree to furnish
information on request and in the form requested to DMAS, DBHDS, the Attorney
General of Virginia or his authorized representatives, federal personnel, and
the State Medicaid Fraud Control Unit. The Commonwealth's right of access to
provider premises and records shall survive any termination of the provider
participation agreement.
11. Disclose, as requested by DMAS, all financial,
beneficial, ownership, equity, surety, or other interests in any and all firms,
corporations, partnerships, associations, business enterprises, joint ventures,
agencies, institutions, or other legal entities providing any form of health
care services to individuals enrolled in Medicaid.
B. Pursuant to 42 CFR Part 431, Subpart F, 12VAC30-20-90,
and any other applicable federal or state law, all providers shall hold
confidential and use for DMAS or DBHDS authorized purposes only all medical
assistance information regarding individuals served. A provider shall disclose
information in his possession only when the information is used in conjunction
with a claim for health benefits or the data are necessary for the functioning
of DMAS in conjunction with the cited laws. DMAS shall not disclose medical
information to the public.
C. Change of ownership. When ownership of the provider
changes, the provider must notify DMAS at least 15 calendar days before the
date of change.
D. For (ICF/IID) facilities covered by § 1616(e) of the
Social Security Act in which respite care as a home and community-based waiver
service will be provided, the facilities shall be in compliance with applicable
standards that meet the requirements for board and care facilities. Health and
safety standards shall be monitored through the DBHDS' licensure standards or
through DSS-approved standards for adult foster care providers.
E. Suspected abuse or neglect. Pursuant to
§§ 63.2-1509 and 63.2-1606 of the Code of Virginia, if a participating
provider knows or suspects that a home and community-based waiver service
individual is being abused, neglected, or exploited, the party having knowledge
or suspicion of the abuse, neglect, or exploitation shall report this
immediately from first knowledge to the local DARS adult or DSS child
protective services agency, as applicable, as well as to DMAS, and, if
applicable, to DBHDS Offices of Licensing and Human Rights.
F. Adherence to provider participation agreement and the
DMAS provider manual. In addition to compliance with the general conditions and
requirements, all providers enrolled by DMAS shall adhere to the conditions of
participation outlined in their individual provider participation agreements
and in the DMAS provider manual.
G. DMAS may terminate the provider's Medicaid provider
agreement pursuant to § 32.1-325 of the Code of Virginia and as may be
required for federal financial participation. Such provider agreement
terminations shall conform to 12VAC30-10-690 and Part XII (12VAC30-20-500 et
seq.) of 12VAC30-20. DMAS shall not reimburse for services that may be rendered
subsequent to such terminations.
H. Direct marketing. Providers are prohibited from
performing any type of direct marketing activities to Medicaid individuals or
their family/caregivers.
12VAC30-120-735. Enrollment and voluntary or involuntary
disenrollment of consumer-directed services.
A. Enrollment.
1. Individuals who are enrolled in the FIS waiver may
choose between the agency-directed model of service delivery or the
consumer-directed model of service delivery, or a combination of both, when
DMAS makes the consumer-directed model available for care. The only services
provided in this waiver that permit the consumer-directed model of service
delivery shall be (i) personal assistance services, (ii) respite services, or
(iii) companion services for which an individual is eligible. An individual
enrolled in the waiver shall not be able to choose consumer-directed services
if any of the following conditions exists:
a. The individual enrolled in the waiver is younger than 18
years of age except for emancipated minors or is unable to be the employer of
record and no one else can assume the role of EOR;
b. The health, safety, or welfare of the individual
enrolled in the waiver cannot be ensured or a back-up emergency plan cannot be
developed; or
c. The individual enrolled in the waiver has medication or
skilled nursing needs or medical/behavioral conditions that cannot be safely
met via the consumer-directed model of service delivery.
2. The support coordinator/case manager shall make a
determination if subdivision 1 a, 1 b, or 1 c of this subsection apply.
Individuals shall have the right to appeal, pursuant to 12VAC30-110, the
decision if they are denied their choice of the consumer-directed service
delivery model based on items described in subdivision 1 a, 1 b, or 1 c of this
subsection.
B. Either voluntary or involuntary disenrollment of the
individual from consumer-directed services may occur. In either voluntary or
involuntary situations, the individual who is enrolled in the waiver shall be
permitted to select an agency from which to receive his personal assistance,
respite, or companion services. If the individual refuses to make his own
selection, then either the support coordinator/case manager or the services
facilitator shall make the choice for him.
1. An individual who has chosen consumer-direction may
choose, at any time, to change to the agency-directed services model as long as
he continues to qualify for personal assistance, respite, or companion
services. The services facilitator or support coordinator/case manager, as
appropriate, shall assist the individual with the change of services from
consumer-directed to agency-directed.
2. The services facilitator or support coordinator/case
manager, as appropriate, shall initiate involuntary disenrollment from
consumer-direction of the individual who is enrolled in the waiver when any of
the following conditions occur:
a. The health, safety, or welfare of the individual enrolled
in the waiver is at risk;
b. The individual or EOR, as appropriate, demonstrates
consistent inability to hire and retain an assistant or companion; or
c. The individual or EOR, as appropriate, is consistently
unable to manage the assistant or companion, as may be demonstrated by, but not
limited to, a pattern of serious discrepancies with timesheets.
3. Prior to involuntary disenrollment, the services
facilitator or support coordinator/case manager, as appropriate, shall:
a. Verify that essential training has been provided to the
individual or EOR, as appropriate, to improve the problem condition or
conditions;
b. Document in the individual's record the conditions
creating the necessity for the involuntary disenrollment and actions taken by
the services facilitator or support coordinator/case manager, as appropriate;
c. Discuss with the individual or the EOR, as appropriate,
the agency-directed option that is available and the actions needed to arrange
for such services while providing a list of potential providers; and
d. Provide written notice to
the individual and EOR, as appropriate, of the right to appeal, pursuant to
12VAC30-110, such involuntary termination of consumer direction. Except in
emergency situations in which the health or safety of the individual is at
serious risk, such notice shall be given at least 10 business days prior to the
effective date of the termination of consumer direction. In cases of an
emergency situation, notice of the right to appeal shall be given to the
individual but the requirement to provide notice at least 10 business days in
advance shall not apply.
4. If the services facilitator initiates the involuntary
disenrollment from consumer-direction, then he shall inform the support
coordinator/case manager.
12VAC30-120-740. Participation standards for home and
community-based waiver services participating providers. (Repealed.)
A. Requests for participation. Requests will be screened
to determine whether the provider applicant meets the basic requirements for
participation.
B. Provider participation standards. For DMAS to approve
provider participation agreements with home and community-based waiver
providers, the following standards shall be met:
1. For services that have licensure and certification
requirements, licensure and certification requirements pursuant to 42 CFR
441.352.
2. Disclosure of ownership pursuant to 42 CFR 455.104 and
455.105.
3. The ability to document and maintain individual case
records in accordance with state and federal requirements.
C. Adherence to provider participation agreements and
special participation conditions. In addition to compliance with the general
conditions and requirements, all providers enrolled by DMAS shall adhere to the
conditions of participation outlined in their provider participation
agreements.
D. Individual choice of provider entities. The individual
will have the option of selecting the provider of his choice. The case manager
must inform the individual of all available waiver service providers in the
community in which he desires services, and he shall have the option of
selecting the provider of his choice.
E. Review of provider participation standards and renewal
of provider participation agreements. DMAS is responsible for assuring
continued adherence to provider participation standards. DMAS shall conduct
ongoing monitoring of compliance with provider participation standards and DMAS
policies and recertify each provider for agreement renewal with DMAS to provide
home and community-based waiver services. A provider's noncompliance with DMAS
policies and procedures, as required in the provider's participation agreement,
may result in a written request from DMAS for a corrective action plan that
details the steps the provider must take and the length of time permitted to achieve
full compliance with the plan to correct the deficiencies that have been cited.
F. Termination of provider participation. A participating
provider may voluntarily terminate his participation in Medicaid by providing
30 calendar days' written notification. DMAS may terminate at will a provider's
participation agreement on 30 calendar days' written notice as specified in the
DMAS participation agreement. DMAS may also immediately terminate a provider's
participation agreement if the provider is no longer eligible to participate in
the program as determined by DMAS. Such action precludes further payment by
DMAS for services provided for individuals subsequent to the date specified in
the termination notice.
G. Appeals of adverse actions. A provider shall have the
right to appeal adverse action taken by DMAS or its agent or DBHDS' decisions
regarding the Medicaid IFDDS waiver. Provider appeals shall be considered
pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.
H. Termination of a provider participation agreement upon
conviction of a felony. Section 32.1-325 D 2 of the Code of Virginia mandates
that "any such Medicaid agreement or contract shall terminate upon
conviction of the provider of a felony." A provider convicted of a felony
in Virginia or in any other of the 50 states or Washington, D.C., must, within
30 days, notify the Medicaid Program of this conviction and relinquish its
provider agreement. In addition, termination of a provider participation
agreement will occur as may be required for federal financial participation.
I. Case manager's responsibility for the Medicaid Long
Term Care Communication Form (DMAS-225). It is the responsibility of the case
manager to notify DMAS, DBHDS, and DSS, in writing, when any of the following
circumstances occur:
1. Home and community-based waiver services are
implemented.
2. An individual dies.
3. An individual is discharged or terminated from services.
4. Any other circumstances (including hospitalization) that
cause home and community-based waiver services to cease or be interrupted for
more than 30 calendar days.
5. A selection by the individual or his family/caregiver,
as appropriate, of a different case management provider.
J. Changes or termination of care. It is the DBHDS staff's
responsibility to authorize any changes to supporting documentation of an
individual's plan of care based on the recommendations of the case manager.
Waiver service providers are responsible for modifying the supporting
documentation with the involvement of the individual or his family/caregiver,
as appropriate. The provider shall submit the supporting documentation to the
case manager any time there is a change in the individual's condition or
circumstances that may warrant a change in the amount or type of service
rendered. The case manager shall review the need for a change and shall sign
the supporting documentation if he agrees to the changes. The case manager
shall submit the revised supporting documentation to the DBHDS staff to receive
approval for that change. DMAS or its agent or DBHDS has the final authority to
approve or deny the requested change to individual's supporting documentation.
DBHDS shall notify the individual or his family/caregiver, as appropriate, in
writing of the right to appeal the decision or decisions to reduce, terminate,
suspend, or deny services pursuant to DMAS client appeals regulations,
12VAC30-110, Eligibility and Appeals.
1. Nonemergency termination of home and community-based
waiver services by the participating provider. The participating provider shall
give the individual, his family/caregiver, as appropriate, and case manager 10
calendar days' written notification of the intent to terminate services. The
notification letter shall provide the reasons for and effective date of the
termination. The effective date of services termination shall be at least 10
calendar days from the date of the termination notification letter.
2. Emergency termination of home and community-based waiver
services by the participating provider. In an emergency situation when the
health and safety of the individual or provider is endangered, the case manager
and DBHDS must be notified prior to termination. The 10-day written
notification period shall not be required. When appropriate, the local DSS adult
protective services or child protective services agency must be notified
immediately. DBHDS Offices of Licensing and Human Rights must also be notified
as required under the provider's license.
3. The DMAS termination of eligibility to receive home and community-based
waiver services. DMAS shall have the ultimate responsibility for assuring
appropriate placement of the individual in home and community-based waiver
services and the authority to terminate such services to the individual for the
following reasons:
a. The home and community-based waiver service is not the
critical alternative to prevent or delay institutional (ICF/IID) placement;
b. The individual no longer meets the institutional level
of care criteria;
c. The individual's environment does not provide for his
health, safety, and welfare; or
d. An appropriate and cost-effective plan of care cannot be
developed.
4. In the case of termination of home and community-based
waiver services by DMAS staff:
a. Individuals shall be notified of their appeal rights by
DMAS pursuant to 12VAC30-110.
b. Individuals identified by the case manager who no longer
meet the level of care criteria or for whom home and community-based waiver
services are no longer appropriate must be referred by the case manager to DMAS
for review.
Article 2
Covered Services and Limitations and Related Provider Requirements
12VAC30-120-750. In-home residential support services, supported
living residential.
A. In-home support services.
1. Service description. In-home residential support
services shall be based primarily in the individual's home. The service shall
be designed to enable individuals enrolled in the IFDDS Waiver to be maintained
in their homes and shall include: (i) training in or engagement and interaction
with functional skills and appropriate behavior related to an individual's
health and safety, personal care, activities of daily living and use of
community resources; (ii) assistance with medication management and monitoring
the individual's health, nutrition, and physical condition (iii) life skills
training; (iv) cognitive rehabilitation; (v) assistance with personal care
activities of daily living and use of community resources; and (vi) specialized
supervision to ensure the individual's health and safety. Service providers
shall be reimbursed only for the amount and type of in-home residential support
services included in the individual's approved plan of care. In-home
residential support services shall not be authorized in the plan of care unless
the individual requires these services and these services exceed services
provided by the family or other caregiver. Services are not provided by paid
staff of the in-home residential services provider for a continuous 24-hour
period. The service description shall be the same as that set forth in
12VAC30-120-1028 A.
1. This service must be provided on an individual-specific
basis according to the plan of care, supporting documentation, and service
setting requirements.
2. Individuals may have in-home residential, personal care,
and respite care in their plans of care but cannot receive these services
simultaneously.
3. Room and board and general supervision shall not be
components of this service.
4. This service shall not be used solely to provide routine
or emergency respite care for the parent or parents or other unpaid caregivers
with whom the individual lives.
B. 2. Criteria.
1. All individuals must meet the following criteria in
order for Medicaid to reimburse providers for in-home residential support
services. The individual must meet the eligibility requirements for this waiver
service as defined. The individual shall have a demonstrated need for supports
to be provided by staff who are paid by the in-home residential support
provider.
2. A functional assessment must be conducted to evaluate
each individual in his home environment and community settings.
3. Routine supervision/oversight of direct care staff. To
provide additional assurance for the protection or preservation of an
individual's health and safety, there are specific requirements for the
supervision and oversight of direct care staff providing in-home residential
support as outlined below. For all in-home residential support services
provided under a DBHDS license or Rehabilitation Accreditation Commission
accreditation:
a. An employee of the provider, typically by position, must
be formally designated as the supervisor of each direct care staff person
providing in-home residential support services.
b. The supervisor must have and document at least one supervisory
contact with each direct care staff person per month regarding service delivery
and direct care staff performance.
c. The supervisor must observe each direct care staff
person delivering services at least semi-annually. Staff performance, service delivery
in accordance with the plan of care, and evaluation of and evidence of the
individual's satisfaction with service delivery by direct care staff must be
documented.
d. The supervisor must complete and document at least one
monthly contact with the individual or his family/caregiver, as appropriate,
regarding satisfaction with services delivered by each direct care staff
person.
4. The in-home residential support supporting documentation
must indicate the necessary amount and type of activities required by the
individual, the schedule of in-home residential support services, the total
number of hours per day, and the total number of hours per week of in-home
residential support. A formal, written behavioral program is required to
address behaviors, including self-injury, aggression or self-stimulation.
5. Medicaid reimbursement is available only for in-home
residential support services provided when the individual is present and when a
qualified provider is providing the services. The criteria shall be the
same as those set forth in 12VAC30-120-1028 B.
C. 3. Service units and service limitations. In-home
residential supports shall be reimbursed on an hourly basis for time the
in-home residential support direct care staff is working directly with the individual.
Total monthly billing cannot exceed the total hours authorized in the plan of
care. The provider must maintain documentation of the date, times, the services
that were provided, and specific circumstances preventing the provision of any
scheduled services. The service units and service limits shall be the
same as those set forth in 12VAC30-120-1028 C.
4. Allowable activities shall be the same as those set
forth in 12VAC30-120-1028 D.
5. Provider requirements shall be the same as those set
forth in 12VAC30-120-1028 E.
D. Provider requirements. In addition to meeting the
general conditions and requirements for home and community-based waiver
services participating providers as specified in 12VAC30-120-730 and
12VAC30-120-740, each in-home residential support service provider must be
licensed by DBHDS as a provider of supportive residential services or have
Rehabilitation Accreditation Commission accreditation. The provider must also
have training in the characteristics of individuals with related conditions and
appropriate interventions, strategies, and support methods for individuals with
related conditions and functional limitations.
1. For DBHDS licensed programs, a plan of care and ongoing
documentation of service delivery must be consistent with licensing
regulations.
2. Documentation must confirm attendance and the
individual's amount of time in services and provide specific information
regarding the individual's response to various settings and supports as agreed
to in the supporting documentation objectives. Assessment results must be
available in at least a daily note or a weekly summary. Data must be collected
as described in the plan of care, analyzed, summarized, and then clearly
addressed in the regular supporting documentation.
3. The supporting documentation must be reviewed by the
provider with the individual, and this written review submitted to the case
manager, at least semi-annually with goals, objectives, and activities modified
as appropriate.
4. Documentation must be maintained for routine supervision
and oversight of all in-home residential support direct care staff. All
significant contacts described in this section must be documented. A qualified
developmental disabilities professional must provide supervision of direct
service staff.
5. Documentation of supervision must be completed, signed
by the staff person designated to perform the supervision and oversight, and
include the following:
a. Date of contact or observation;
b. Person or persons contacted or observed;
c. A summary about direct care staff performance and
service delivery for monthly contacts and semi-annual home visits;
d. Semi-annual observation documentation must also address
individual satisfaction with service provision;
e. Any action planned or taken to correct problems
identified during supervision and oversight; and
f. Copy of the most recently completed DMAS-225 form. The
provider must clearly document efforts to obtain the completed DMAS-225 form
from the case manager.
B. Supported living residential.
1. Description. The service description shall be the same
as set forth in 12VAC30-120-1036 A 1.
2. Criteria. The criteria shall be the same as those set
forth in 12VAC30-120-1036 A 2.
3. Units and limits. Service units and limits shall be the
same as those set forth in 12VAC30-120-1036 A 3.
4. Provider requirements. Provider requirements shall be
the same as those set forth in 12VAC30-120-1036 A 4.
12VAC30-120-751. [Reserved] Shared living.
A. Service description. The service description shall be
the same as that set forth in subdivision 1 of 12VAC30-120-1034.
B. Criteria for covered services. The criteria shall be
the same as those set forth in subdivision 2 of 12VAC30-120-1034.
C. Allowable activities. Allowable activities shall be the
same as those set forth in subdivision 3 of 12VAC30-120-1034.
D. Covered services units and limits. Service units and
limits shall be the same as those set forth in subdivision 4 of
12VAC30-120-1034.
E. Provider requirements. Provider requirements shall be
the same as those set forth in subdivision 5 of 12VAC30-120-1034 and
subdivision 17 of 12VAC30-120-1560.
12VAC30-120-752. Day support Group day services.
A. Service description. Day support services shall include
a variety of training, assistance, support, and specialized supervision offered
in a setting (other than the home or individual residence), which allows peer
interactions and community integration for the acquisition, retention, or
improvement of self-help, socialization, and adaptive skills. When services are
provided through alternative payment sources, the plan of care shall not
authorize them as a waiver funded expenditure. Service providers are reimbursed
only for the amount and type of day support services included in the
individual's approved plan of care based on the setting, intensity, and
duration of the service to be delivered. This does not include prevocational
services. The service description shall be the same as that set forth in
subdivision 1 of 12VAC30-120-1026.
B. Criteria. For day support services, the individual must
demonstrate the need for functional training, assistance, and specialized
supervision offered in settings other than the individual's own residence that
allow an opportunity for being productive and contributing members of communities.
In addition, day support services will be available for individuals who can
benefit from supported employment services, but who need the services as an
appropriate alternative or in addition to supported employment services. The
criteria shall be the same as those set forth in subdivision 2 of
12VAC30-120-1026.
1. A functional assessment must be conducted by the
provider to evaluate each individual in his home environment and community
settings.
2. Types and levels of day support. The amount and type of day
support included in the individual's plan of care is determined according
to the services required for that individual. There are two types of day
support: center-based, which is provided primarily at one location/building, or
noncenter-based, which is provided primarily in community settings. Both types
of day support may be provided at either intensive or regular levels. To be
authorized at the intensive level, the individual must meet at least one of the
following criteria: (i) requires physical assistance to meet the basic personal
care needs (toileting, feeding, etc.); (ii) has extensive disability-related
difficulties and requires additional, ongoing support to fully participate in
programming and to accomplish his service goals; or (iii) requires extensive
constant supervision to reduce or eliminate behaviors that preclude full
participation in the program. A formal, written behavioral program is required
to address behaviors such as, but not limited to, withdrawal, self-injury,
aggression, or self-stimulation.
C. Allowable activities shall be the same as those set
forth in subdivision 3 of 12VAC30-120-1026.
C. D. Service units and service limitations. Day
support cannot be regularly or temporarily provided in an individual's home or
other residential setting (e.g., due to inclement weather or individual's
illness) without prior written approval from DBHDS. Noncenter-based day
support services must be separate and distinguishable from both in-home
residential support services and personal care services. There must be separate
supporting documentation for each service and each must be clearly
differentiated in documentation and corresponding billing. The supporting
documentation must provide an estimate of the amount of day support required by
the individual. The maximum is 780 units per plan of care year. If this service
is used in combination with prevocational or supported employment services the
combined total units for these services cannot exceed 780 units per plan of
care year. Transportation shall not be billable as a day support service. The
service units and limits shall be the same as those set forth in subdivision 4
of 12VAC30-120-1026.
1. One unit shall be 1 to 3.99 hours of service a day.
2. Two units are 4 to 6.99 hours of service a day.
3. Three units are 7 or more hours of service a day.
Services shall normally be furnished four or more hours
per day on a regularly scheduled basis for one or more days per week unless
provided as an adjunct to other day activities included in an individual's plan
of care.
D. E. Provider requirements. In addition to
meeting the general conditions and requirements for home and community-based
waiver services participating providers as specified in 12VAC30-120-730 and
12VAC30-120-740, day support providers must meet the following requirements:
Provider requirements shall be the same as those set forth in subdivision 5
of 12VAC30-120-1026 and 12VAC30-120-501 et seq.
1. For DBHDS programs licensed as day support programs, the
plan of care, supporting documentation, and ongoing documentation must be
consistent with licensing regulations. For programs accredited by
Rehabilitation Accreditation Commission as day support programs, there must be
supporting documentation that contains, at a minimum, the following elements:
a. The individual's strengths, desired outcomes, required
or desired supports and training needs;
b. The individual's goals and, for a training goal, a
sequence of measurable objectives to meet the above identified outcomes;
c. Services to be rendered and the frequency of services to
accomplish the above goals and objectives;
d. All entities that will provide the services specified in
the statement of services;
e. A timetable for the accomplishment of the individual's
goals and objectives;
f. The estimated duration of the individual's needs for
services; and
g. The entities responsible for the overall coordination
and integration of the services specified in the plan of care.
2. Documentation must confirm the individual's attendance,
the amount of the individual's time in services, and provide specific
information regarding the individual's response to various settings and
supports as agreed to in the supporting documentation objectives. Assessment
results must be available in at least a daily note or a weekly summary.
a. The provider must review the supporting documentation
with the individual or his family/caregiver, as appropriate, and this written
review submitted to the case manager at least semi-annually with goals,
objectives, and activities modified as appropriate. For the annual review and
anytime the supporting documentation is modified, the revised supporting
documentation must be reviewed with the individual or his family/caregiver, as
appropriate.
b. An attendance log or similar document must be maintained
that indicates the date, type of services rendered, and the number of hours and
units provided (including specific time frame).
c. Documentation must indicate whether the services were
center-based or noncenter-based and regular or intensive level.
d. If intensive day support services are requested, in
order to verify which of these criteria the individual met, documentation must
be present in the individual's record to indicate the specific supports and the
reasons they are needed. For reauthorization of intensive day support services,
there must be clear documentation of the ongoing needs and associated staff
supports.
e. In instances where day support staff are required to
ride with the individual to and from day support, the day support staff time
may be billed as day support, provided that the billing for this time does not
exceed 25% of the total time spent in the day support activity for that day.
Documentation must be maintained to verify that billing for day support staff
coverage during transportation does not exceed 25% of the total time spent in
the day support for that day.
f. Copy of the most recently completed DMAS-225 form. The
provider must clearly document efforts to obtain the completed DMAS-225 form
from the case manager.
3. Supervision of direct service staff must be provided by
a qualified developmental disabilities professional.
12VAC30-120-753. Prevocational services. (Repealed.)
A. Service description. Prevocational services are
services aimed at preparing an individual for paid or unpaid employment, but
are not job-task oriented. Prevocational services are provided for individuals
who are not expected to be able to join the general work force without supports
or to participate in a transitional, sheltered workshop within one year of
beginning waiver services (excluding supported employment services or
programs). Activities included in this service are not primarily directed at
teaching specific job skills but at underlying rehabilitative goals such as
accepting supervision, attendance, task completion, problem solving, and
safety.
B. Criteria. In order to qualify for prevocational
services, the individual shall have a demonstrated need for support in skills
that are aimed toward preparation for paid employment that may be offered in a
variety of community settings.
C. Service units and service limitations. Billing is for
one unit of service. This service is limited to 780 units per plan of care
year. If this service is used in combination with day support or supported
employment services, the combined total units for these services cannot exceed
780 units per plan of care year. Prevocational services may be provided in
center or noncenter-based settings. There must be documentation about whether
prevocational services are available in vocational rehabilitation agencies
through § 110 of the Rehabilitation Act of 1973 or through the Individuals with
Disabilities Education Act (IDEA). When services are provided through these
sources to the individual, they will not be authorized as a waiver service.
Prevocational services may only be provided when the individual's compensation
is less than 50% of the minimum wage.
1. One unit shall be 1 to 3.99 hours of service a day.
2. Two units are 4 to 6.99 hours of service a day.
3. Three units are 7 or more hours of service a day.
Services shall normally be furnished four or more hours
per day on a regularly scheduled basis for one or more days per week unless
provided as an adjunct to other day activities included in an individual's plan
of care.
D. Provider requirements. In addition to meeting the
general conditions and requirements for home and community-based services
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
prevocational services providers must also meet the following requirements:
1. The prevocational services provider must be a vendor of
extended employment services, long-term employment services, or supported
employment services for DARS, or be licensed by DBHDS as a day support services
provider. Providers must ensure and document that persons providing
prevocational services have training in the characteristics of related
conditions, appropriate interventions, training strategies, and support methods
for individuals with related conditions and functional limitations.
2. Required documentation in the individual's record. The
provider must maintain a record for each individual receiving prevocational
services. At a minimum, the record must contain the following:
a. A functional assessment conducted by the provider to
evaluate each individual in the prevocational environment and community
settings.
b. A plan of care containing, at a minimum, the following
elements (DBHDS licensing regulations require the following for plans of care):
(1) The individual's needs and preferences;
(2) Relevant psychological, behavioral, medical,
rehabilitation, and nursing needs as indicated by the assessment;
(3) Individualized strategies including the intensity of
services needed;
(4) A communication plan for individuals with communication
barriers including language barriers; and
(5) The behavior treatment plan, if applicable.
3. The plan of care must be reviewed by the provider
quarterly, annually, and more often as needed, modified as appropriate, and
with written results of these reviews submitted to the case manager. For the
annual review and in cases where the plan of care is modified, the plan of care
must be reviewed with the individual or his family/caregiver, as appropriate.
4. Documentation must confirm the individual's attendance,
amount of time spent in services, type of services rendered, and provide
specific information about the individual's response to various settings and
supports as agreed to in the plan of care.
5. In instances where prevocational staff are required to
ride with the individual to and from prevocational services, the prevocational
staff time may be billed for prevocational services, provided that the billing
for this time does not exceed 25% of the total time spent in prevocational
services for that day. Documentation must be maintained to verify that billing
for prevocational staff coverage during transportation does not exceed 25% of
the total time spending the prevocational services for that day.
6. A copy of the most recently completed DMAS-225. The
provider must clearly document efforts to obtain the completed DMAS-225 from
the case manager.
12VAC30-120-754. Supported Group supported
employment services; individual supported employment; workplace assistance
services.
A. Service description Group supported
employment.
1. Service description. The service description shall be
the same as set forth in 12VAC30-120-1035 A.
1. Supported employment services shall include training in
specific skills related to paid employment and provision of ongoing or
intermittent assistance or specialized training to enable an individual to
maintain paid employment. Each supporting documentation must confirm whether
supported employment services are available to the individual in vocational
rehabilitation agencies through the Rehabilitation Act of 1973 or in special
education services through 20 USC § 1401 of the Individuals with Disabilities
Education Act (IDEA). Providers of these DARS and IDEA services cannot be
reimbursed by Medicaid with the IFDDS Waiver funds. Waiver service providers
are reimbursed only for the amount and type of habilitation services included
in the individual's approved plan of care based on the intensity and duration
of the service delivered. Reimbursement shall be limited to actual
interventions by the provider of supported employment, not for the amount of
time the recipient is in the supported employment environment.
2. Supported employment may be provided in one of two
models. Individual supported employment is defined as intermittent support,
usually provided one on one by a job coach for an individual in a supported
employment position. Group supported employment is defined as continuous
support provided by staff for eight or fewer individuals with disabilities in
an enclave, work crew, or bench work/entrepreneurial model. The individual's
assessment and plan of care must clearly reflect the individual's need for
training and supports.
B. 2. Criteria for receipt of services. The
criteria shall be the same as set forth in 12VAC30-120-1035 B.
1 Only job development tasks that specifically include the
individual are allowable job search activities under the IFDDS FIS
Waiver supported employment and only after determining this service is not
available from DARS or IDEA.
2 In order to qualify for these services, the individual
shall have a demonstrated need for training, specialized supervision, or
assistance in paid employment and for whom competitive employment at or above
the minimum wage is unlikely without this support and who, because of the
disability, needs ongoing support, including supervision, training and
transportation to perform in a work setting.
3. A functional assessment must be conducted to evaluate
each individual in his work environment and related community settings.
4. The supporting documentation must document the amount of
supported employment required by the individual. Service providers are
reimbursed only for the amount and type of supported employment included in the
plan of care based on the intensity and duration of the service delivered.
3. Allowable activities shall be the same as those set
forth in 12VAC30-120-1035 C.
C. 4. Service units and service limitations shall
be the same as set forth in 12VAC30-120-1035 D.
1 Supported employment for individual job placement is
provided in one-hour units. This service is limited to 40 hours per week. The
unit of service shall be one hour. Services shall not exceed 66 hours per week.
The 66-hour weekly limit may include a combination of the following: group supported
employment services, individual supported employment, community engagement,
community coaching, workplace assistance services, and group day services.
2. Group models of supported employment (enclaves, work
crews, bench work, and entrepreneurial model of supported employment) will be
billed according to the DMAS fee schedule.
3 Supported employment services are limited to 780 units
per plan of care year. If used in combination with prevocational and day
support services, the combined total units for these services cannot exceed 780
units, or its equivalent under the DMAS fee schedule, per plan of care year.
4. For the individual job placement model, reimbursement
will be limited to actual documented interventions or collateral contacts by
the provider, not the amount of time the individual is in the supported
employment situation.
D Provider 5. Group supported employment provider
requirements. In addition to meeting the general conditions and requirements
for home and community-based care participating providers as specified in
12VAC30-120-730 and 12VAC30-120-740, supported employment providers must meet
the following requirements: The provider requirements shall be the same
as set forth in 12VAC30-120-1035 E.
1. Supported employment services shall be provided by
agencies that are programs certified by the Rehabilitation Accreditation
Commission to provide supported employment services or are DARS vendors of
supported employment services.
2. Individual ineligibility for supported employment services
through DARS or IDEA must be documented in the individual's record, as
applicable. If the individual is ineligible to receive services through IDEA,
documentation is required only for lack of DARS funding. Acceptable
documentation would include a copy of a letter from DARS or the local school
system or a record of a telephone call (name, date, person contacted)
documented in the case manager's case notes, Consumer Profile/Social assessment
or on the supported employment supporting documentation. Unless the
individual's circumstances change, the original verification may be forwarded
into the current record or repeated on the supporting documentation or revised
Social Assessment on an annual basis.
3. Supporting documentation and ongoing documentation
consistent with licensing regulations, if a DBHDS licensed program.
4. For non-DBHDS programs certified as supported employment
programs, there must be supporting documentation that contains, at a minimum,
the following elements:
a. The individual's strengths, desired outcomes,
required/desired supports, and training needs;
b. The individual's goals and, for a training goal, a
sequence of measurable objectives to meet the above identified outcomes;
c. Services to be rendered and the frequency of services to
accomplish the above goals and objectives;
d. All entities that will provide the services specified in
the statement of services;
e. A timetable for the accomplishment of the individual's
goals and objectives;
f. The estimated duration of the individual's needs for
services; and
g. Entities responsible for the overall coordination and
integration of the services specified in the plan of care.
5. Documentation must confirm the individual's attendance,
the amount of time the individual spent in services, and must provide specific
information regarding the individual's response to various settings and
supports as agreed to in the supporting documentation objectives. Assessment
results should be available in at least a daily note or weekly summary.
6. The provider must review the supporting documentation
with the individual, and this written review submitted to the case manager, at
least semi-annually, with goals, objectives, and activities modified as
appropriate. For the annual review and in cases where the plan of care is
modified, the plan of care must be reviewed with the individual or his
family/caregiver, as appropriate.
7. In instances where supported employment staff are
required to ride with the individual to and from supported employment activities,
the supported employment staff time may be billed as supported employment
provided that the billing for this time does not exceed 25% of the total time
spent in supported employment for that day. Documentation must be maintained to
verify that billing supported employment staff coverage during transportation
does not exceed 25% of the total time spent in supported employment for that
day.
8. There must be a copy of the completed DMAS-225 form in
the record. Providers must clearly document efforts to obtain the DMAS-225 form
from the case manager.
B. Individual supported employment services.
1. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1035 A.
2. Criteria for receipt of services. The criteria shall be
the same as those set forth in 12VAC30-120-1035 B.
3. Allowable activities. The allowable activities shall be
the same as those set forth in 12VAC30-120-1035 C.
4. Service units and service limitations. The service units
and limitations shall be the same as those set forth in 12VAC30-120-1035 D.
5. Provider requirements. The provider requirements shall
be the same as those set forth in 12VAC30-120-501 et seq. and 12VAC30-120-1035
E.
C. Workplace assistance services.
1. Service description. The service description shall be
the same as set forth in 12VAC30-120-1039 A.
2. Service criteria. The service criteria shall be the same
as those set forth in 12VAC30-120-1039 B.
3. Allowable activities. The allowable activities shall be
the same as those set forth in 12VAC30-120-1039 C.
4. Service units and service limitations. Service units and
limits shall be the same as those set forth in 12VAC30-120-1039 D.
5. Provider requirements. Provider requirements shall be
the same as those set forth in 12VAC30-120-501 et seq. and 12VAC30-120-1039 E.
12VAC30-120-756. Therapeutic consultation.
A. Service description. Therapeutic consultation provides
expertise, training, and technical assistance in any of the following specialty
areas to assist family members, caregivers, and service providers in supporting
the individual. The specialty areas include the following: psychology, social
work, occupational therapy, physical therapy, therapeutic recreation,
rehabilitation, psychiatry, psychiatric clinical nursing, behavioral
consultation, and speech/language therapy. These services may be provided,
based on the individual's plan of care, for those individuals for whom
specialized consultation is clinically necessary to enable their utilization of
waiver services and who have additional challenges restricting their ability to
function in the community. Therapeutic consultation services may be provided in
the individual's home, in other appropriate community settings, and in
conjunction with another waiver service. These services are intended to
facilitate implementation of the individual's desired outcomes as identified in
the individual's plan of care. Therapeutic consultation service providers are
reimbursed according to the amount and type of service authorized in the plan of
care based on an hourly fee for service. The service description shall
be the same as that set forth in 12VAC30-120-1037 A.
B. Criteria. In order to qualify for these services, the
individual shall have a demonstrated need for consultation in any of these
services. Documented need must indicate that the plan of care cannot be
implemented effectively and efficiently without such consultation from this
service. The criteria shall be the same as those set forth in
12VAC30-120-1037 B.
1. The individual's plan of care must clearly reflect the
individual's needs, as documented in the social assessment, for specialized
consultation provided to family/caregivers and providers in order to implement
the plan of care effectively.
2. Therapeutic consultation services may not include direct
therapy provided to individuals receiving waiver services, or monitoring
activities, and may not duplicate the activities of other services that are
available to the individual through the State Plan of Medical Assistance.
C. Service units and service limitations limits.
The unit of service shall equal one hour Service units and limits
shall be the same as those set forth in 12VAC30-120-1037 C.
The services must be explicitly detailed in the supporting
documentation. Travel time, written preparation, and telephone communication
are in-kind expenses within this service and are not billable as separate
items.
Therapeutic consultation may not be billed solely for
purposes of monitoring. Therapeutic consultations shall be available to individuals
who are receiving at least one other waiver service and case management
services.
D. Allowable activities. Allowable activities shall be the
same as those set forth in 12VAC30-120-1037 D.
D. E. Provider requirements. In addition to
meeting the general conditions and requirements for home and community-based
care participating providers as specified in 12VAC30-120-730 and
12VAC30-120-740, professionals rendering therapeutic consultation services,
including behavior consultation services, shall meet all applicable state
licensure or certification requirements. Persons providing rehabilitation
consultation shall be rehabilitation engineers or certified rehabilitation
specialists. Behavioral consultation may be performed by professionals
based on the professional's knowledge, skills, and abilities as defined by
DMAS. Provider requirements shall be the same as those set forth in
12VAC30-120-1037 E.
1. Supporting documentation for therapeutic consultation.
The following information is required in the supporting documentation:
a. Identifying information: individual's name and Medicaid
number; provider name and provider number; responsible person and telephone
number; effective dates for supporting documentation; and semi-annual review
dates, if applicable;
b. Targeted objectives, time frames, and expected outcomes;
c. Specific consultation activities; and
d. A written support plan detailing the interventions or
support strategies.
2. Monthly and contact notes shall include:
a. Summary of consultative activities for the month;
b. Dates, locations, and times of service delivery;
c. Supporting documentation objectives addressed;
d. Specific details of the activities conducted;
e. Services delivered as planned or modified; and
f. Effectiveness of the strategies and individuals' and
caregivers' satisfaction with service.
3. Semi-annual reviews are required by the service provider
if consultation extends three months or longer, are to be forwarded to the case
manager, and must include:
a. Activities related to the therapeutic consultation
supporting documentation;
b. Individual status and satisfaction with services; and
c. Consultation outcomes and effectiveness of support plan.
4. If consultation services extend less than three months,
the provider must forward monthly contact notes or a summary of them to the
case manager for the semi-annual review.
5. A written support plan, detailing the interventions and
strategies for providers, family, or caregivers to use to better support the
individual in the service.
6. A final disposition summary must be forwarded to the
case manager within 30 calendar days following the end of this service and must
include:
a. Strategies utilized;
b. Objectives met;
c. Unresolved issues; and
d. Consultant recommendations.
12VAC30-120-758. Environmental modifications (EM).
A. Service description. Environmental modifications shall
be defined as those physical adaptations to the individual's primary home or
primary vehicle used by the individual documented in the individual's plan of
care, that are necessary to ensure the health, welfare, and safety of the
individual, or that enable the individual to function with greater independence
in the primary home and, without which, the individual would require
institutionalization. Such adaptations may include the installation of ramps
and grab-bars, widening of doorways, modification of bathroom facilities, or
installation of specialized electrical and plumbing systems that are necessary
to accommodate the medical equipment and supplies that are necessary for the
welfare of the individual. Excluded are those adaptations or
improvements to the home that are of general utility and are not of direct
medical or remedial benefit to the individual, such as carpeting, roof repairs,
central air conditioning, etc. Adaptations that add to the total square footage
of the home shall be excluded from this benefit, except when necessary to
complete an adaptation, as determined by DMAS or its designated agent. All
services shall be provided in the individual's primary home in accordance with
applicable state or local building codes. All modifications must be authorized
by the service authorization agent. Modifications may be made to a vehicle if
it is the primary vehicle being used by the individual. This service does not
include the purchase of vehicles. The service description shall be the
same as set forth in 12VAC30-120-1025 B 1.
B. Criteria. In order to qualify for these services, the
individual must have a demonstrated need for equipment or modifications of a
remedial or medical benefit offered in an individual's primary home, primary
vehicle used by the individual, community activity setting, or day program to
specifically improve the individual's personal functioning. This service shall
encompass those items not otherwise covered in the State Plan for Medical
Assistance or through another program. Environmental modifications shall be
covered in the least expensive, most cost-effective manner. For
enrollees in the Elderly or Disabled with Consumer Direction (EDCD) waiver
(12VAC30-120-900 through 12VAC30-120-980), environmental modification services
shall be available only to those EDCD enrollees who are also enrolled in the
Money Follows the Person demonstration. The criteria shall be the same
as those set forth in 12VAC30-120-1025 B 2.
C. Service units and service limitations. Environmental
modifications shall be available to individuals who are receiving case
management services. To receive environmental modifications in the EDCD waiver,
the individual must be receiving at least one other waiver service. To receive
environmental modifications in the IFDDS waiver, the individual must be
receiving case management services and at least one other waiver service. A
maximum limit of $5,000 may be reimbursed per plan of care or calendar year, as
appropriate to the waiver in which the individual is enrolled. Costs for
environmental modifications shall not be carried over from year to year. All
environmental modifications must be authorized by the service authorization
agent prior to billing. Modifications shall not be used to bring a substandard
dwelling up to minimum habitation standards. Also excluded are modifications
that are reasonable accommodation requirements of the Americans with
Disabilities Act, the Virginians with Disabilities Act, and the Rehabilitation
Act. Case managers or transition coordinators must, upon completion of each
modification, meet face-to-face with the individual and his family/caregiver,
as appropriate, to ensure that the modification is completed satisfactorily and
is able to be used by the individual. The service units and limits shall
be the same as those set forth in 12VAC30-120-1025 B 3.
D. Provider requirements. In addition to meeting the
general conditions and requirements for home and community-based waiver
services participating providers as specified in 12VAC30-120-160,
12VAC30-120-730, 12VAC30-120-740, and 12VAC30-120-930, as appropriate,
environmental modifications must be provided in accordance with all applicable
state or local building codes by contractors who have a provider agreement with
DMAS. Providers may not be spouses or parents of the individual. Modifications
must be completed within the plan of care or the calendar year in which the
modification was authorized, as appropriate to the waiver in which the
individual is enrolled. Provider requirements shall be the same as those
set forth in 12VAC30-120-1025 B 4.
12VAC30-120-759. [Reserved] Services facilitation.
A. Covered services; limits on covered services. Services
facilitation and consumer-directed service model. Service description.
Individuals enrolled in the waiver may be approved to select the
consumer-directed (CD) model of service delivery, absent any of the specified
conditions that precludes such a choice, and may also receive support from a
services facilitator. This shall be a separate waiver service to be used in
conjunction with consumer-directed personal assistance, respite, or companion
services and shall not be covered for an individual absent one of these
consumer-directed services.
1. Services facilitators shall train individuals enrolled
in the waiver, family/caregiver, or EOR, as appropriate, to direct (such as
select, hire, train, supervise, and authorize timesheets of) their own
assistants who are rendering personal assistance, respite services, and
companion services.
2. The services facilitator shall assess the individual's
particular needs for a requested consumer-directed service, assist in the
development of the plan for supports, provide management training for the
individual or the EOR, as appropriate, on his responsibilities as employer, and
provide ongoing support of the consumer-directed model of services. The service
authorization for receipt of consumer directed services shall be based on the
approved plan for supports.
3. The services facilitator shall make an initial
comprehensive home visit to collaborate with the individual and the
individual's family/caregiver, as appropriate, to identify the individual's
needs, assist in the development of the plan for supports with the individual
and the individual's family/caregiver, as appropriate, and provide employer
management training to the individual and the family/caregiver, as appropriate,
on his responsibilities as an employer, and provide ongoing support of the
consumer-directed model of services. Individuals or EORs who are unable to
receive employer management training at the time of the initial visit shall
receive management training within seven days of the initial visit.
a. The initial comprehensive home visit shall be completed
only once upon the individual's entry into the consumer-directed model of
service regardless of the number or type of consumer-directed services that an
individual requests.
b. If an individual changes services facilitators, the new
services facilitator shall complete a reassessment visit in lieu of a
comprehensive visit.
c. The employer management training shall be completed
before the individual or EOR may hire an assistant who is to be reimbursed by DMAS.
d. After the initial visit, the services facilitator shall
continue to monitor the individual's plan for supports quarterly (i.e., every
90 days) and more often as needed. If consumer-directed respite services are
provided, the services facilitator shall review the utilization of
consumer-directed respite services either every six months or upon the use of
240 respite services hours, whichever comes first.
4. A face-to-face meeting shall occur between the services
facilitator and the individual at least every six months to reassess the
individual's needs and to ensure appropriateness of any consumer-directed
services received by the individual. During these visits with the individual,
the services facilitator shall observe, evaluate, and consult with the
individual, EOR, and the individual's family/caregiver, as appropriate, for the
purpose of documenting the adequacy and appropriateness of consumer-directed
services with regard to the individual's current functioning and cognitive
status, medical needs, and social needs. The services facilitator's written
summary of the visit shall include, but shall not necessarily be limited to:
a. Discussion with the individual and EOR or
family/caregiver, as appropriate, whether the particular consumer directed
service is adequate to meet the individual's needs;
b. Any suspected abuse, neglect, or exploitation and to
whom it was reported;
c. Any special tasks performed by the assistant/companion
and the assistant's/companion's qualifications to perform these tasks;
d. Individual's and EOR's or family/caregiver's, as
appropriate, satisfaction with the assistant's/companion's service;
e. Any hospitalization or change in medical condition,
functioning, or cognitive status;
f. The presence or absence of the assistant/companion in
the home during the services facilitator's visit; and
g. Any other services received and the amount.
5. The services facilitator, during routine visits, shall
also review and verify timesheets as needed to ensure that the number of hours
approved in the plan for supports is not exceeded. If discrepancies are
identified, the services facilitator shall discuss these with the individual or
the EOR to resolve discrepancies and shall notify the fiscal/employer agent. If
an individual is consistently identified as having discrepancies in his
timesheets, the services facilitator shall contact the support coordinator/case
manager to resolve the situation. Failure to review and verify timesheets and
maintain documentation of such reviews shall subject the provider to recovery
of payments made by DMAS in accordance with 12VAC30-80-130.
6. The services facilitator shall maintain a record of each
individual containing elements as set out in 12VAC30-120-770.
7. The services facilitator shall be available during
standard business hours to the individual or EOR by telephone.
8. If a services facilitator is not selected by the individual,
the individual or the family/caregiver serving as the EOR shall perform all of
the duties and meet all of the requirements, including documentation
requirements, identified for services facilitation. However, the individual or
family/caregiver shall not be reimbursed by DMAS for performing these duties or
meeting these requirements.
9. If an individual enrolled in consumer-directed services
has a lapse in services facilitator duties for more than 90 consecutive days,
and the individual or family/caregiver is not willing or able to assume the
service facilitation duties, then the support coordinator/case manager shall
notify DMAS or its designated service authorization contractor and the
consumer-directed services shall be discontinued once the required 10 days
notice of this change has been observed. The individual whose consumer-directed
services have been discontinued shall have the right to appeal this
discontinuation action pursuant to 12VAC30-110. The individual shall be given
his choice of an agency for the alternative personal care, respite, or
companion services that he was previously obtaining through consumer direction.
10. The consumer-directed services facilitator, who is to
be reimbursed by DMAS, shall not be the individual enrolled in the waiver, the
individual's support coordinator/case manager, a direct service provider, the
individual's spouse, a parent, including stepparents and legal guardians, of
the individual who is a minor child, or the EOR who is employing the
assistant/companion.
11. The services facilitator shall document what
constitutes the individual's back-up plan in case the assistant/companion does
not report for work as expected or terminates employment without prior notice.
12. Should the assistant/companion not report for work or
terminate his employment without notice, then the services facilitator shall,
upon the individual's or EOR's request, provide management training to ensure
that the individual or the EOR is able to recruit and employ a new
assistant/companion.
13. The limits and requirements for individuals' selection
of consumer directed services shall be as follows:
a. In order to be approved to use the consumer-directed
model of services, the individual enrolled in the waiver, or if the individual
is unable, the designated EOR, shall have the capability to hire, train, and
fire his own assistants/companions and supervise the assistants'/companions'
performance. Support coordinators/case managers shall document in the
individual support plan the individual's choice for the consumer-directed model
and whether or not the individual chooses services facilitation. The support
coordinator/case manager shall document in this individual's record that the
individual can serve as the EOR or if there is a need for another person to
serve as the EOR on behalf of the individual.
b. An individual enrolled in the waiver who is younger than
18 years of age shall be required to have an adult responsible for functioning
in the capacity of an EOR.
c. Specific employer duties shall include checking
references of assistants/companions, determining that assistants/companions
meet specified qualifications, timely and accurate completion of hiring
packets, training the assistants/companions, supervising
assistants'/companions' performance, and submitting complete and accurate
timesheets to the fiscal/employer agent on a consistent and timely basis.
B. Participation standards for provision of services;
providers' requirements.
1. To be enrolled as a Medicaid CD services facilitator and
maintain provider status, the services facilitator provider shall have
sufficient resources to perform the required activities, including the ability
to maintain and retain business and professional records sufficient to document
fully and accurately the nature, scope, and details of the services provided.
All CD services facilitators, whether employed by or contracted with a DMAS
enrolled services facilitator provider, shall meet all of the qualifications
set out in this subsection. To be enrolled, the services facilitator shall also
meet the combination of work experience and relevant education set out in this
subsection that indicate the possession of the specific knowledge, skills, and
abilities to perform this function. The services facilitator shall maintain a
record of each individual containing elements as set out in this section.
a. If the services facilitator is not an RN, then, within
30 days from the start of such services, the services facilitator shall inform
the primary health care provider for the individual enrolled in the waiver that
consumer-directed services are being provided and request skilled nursing or
other consultation as needed by the individual. Prior to contacting the primary
health care provider, the services facilitator shall obtain the individual's
written consent to make such contact or contacts. All such contacts and
consultations shall be documented in the individual's medical record. Failure
to document such contacts and consultations shall be subject to DMAS' recovery
of payments made.
b. Prior to enrollment by DMAS as a consumer-directed
services facilitator, applicants shall possess, at a minimum, either (i) an
associate's degree from an accredited college in a health or human services
field or be a registered nurse currently licensed to practice in the
Commonwealth and two years of satisfactory direct care experience supporting
individuals with disabilities or older adults or children or (ii) a bachelor's
degree in a non-health or human services field and a minimum of three years of
satisfactory direct care experience supporting individuals with disabilities or
older adults or children.
c. All consumer-directed services facilitators, shall:
(1) Have a satisfactory work record as evidenced by two
references from prior job experiences from any human services work; such
references shall not include any evidence of abuse, neglect, or exploitation of
the elderly, persons with disabilities, or children;
(2) Submit to a criminal background check within 15 days of
employment. The results of such check shall contain no record of conviction of
barrier crimes as set forth in § 32.1-162.9:1 of the Code of Virginia. Proof
that the criminal record check was conducted shall be maintained in the record
of the services facilitator. In accordance with 12VAC30-80-130, DMAS shall not
reimburse the provider for any services provided by a services facilitator who
has been convicted of committing a barrier crime as set forth in § 32.1-162.9:1
of the Code of Virginia;
(3) Submit to a search of the DSS Child Protective Services
Central Registry yielding no founded complaint; and
(4) Not be debarred, suspended, or otherwise excluded from
participating in federal health care programs, as listed on the federal List of
Excluded Individuals/Entities (LEIE) database at https://exclusions.oig.hhs.gov.
d. The services facilitator shall not be compensated for
services provided to the waiver individual after the initial or a subsequent
background check verifies that the services facilitator (i) has been convicted
of a barrier crime described in § 32.1-162.9:1 of the Code of Virginia;
(ii) has a founded complaint confirmed by the DSS Child Protective Services
Central Registry; or (iii) is found to be listed on the LEIE.
e. All consumer-directed services facilitators providers
and staff employed by consumer-directed services facilitator providers to
function as a consumer-directed services facilitator shall complete the
DMAS-approved consumer-directed services facilitator training and pass the
corresponding competency assessment with a score of at least 80% prior to being
approved as a consumer-directed services facilitator or being reimbursed for
working with waiver individuals. The competency assessment and all corresponding
competency assessments shall be kept in the employee's record.
f. Failure to complete the competency assessment within the
90-day time limit and meet all other requirements shall result in a retraction
of Medicaid payment or the termination of the provider agreement, or both.
g. As a component of the renewal of the provider agreement,
all consumer-directed services facilitators shall take and pass the competency
assessment every five years and achieve a score of at least 80%.
h. The consumer-directed services facilitator shall have
access to a computer with secure Internet access that meets the requirements of
45 CFR Part 164 for the electronic exchange of information. Electronic exchange
of information shall include, for example, checking individual eligibility,
submission of service authorizations, submission of information to the fiscal
employer agent, and billing for services.
i. All consumer-directed services facilitators shall
possess a demonstrable combination of work experience and relevant education
that indicates possession of the following knowledge, skills, and abilities.
Such knowledge, skills, and abilities shall be documented on the application
form, found in supporting documentation, or be observed during the job
interview. Observations during the interview shall be documented. The
knowledge, skills, and abilities include:
(1) Knowledge of:
(a) Types of functional limitations and health problems
that may occur in individuals with intellectual disability or individuals with
other developmental disabilities, as well as strategies to reduce limitations
and health problems;
(b) Physical assistance that may be required by individuals
with developmental disabilities, such as transferring, bathing techniques,
bowel and bladder care, and the approximate time those activities normally
take;
(c) Equipment and environmental modifications that may be
required by individuals with developmental disabilities that reduce the need
for human help and improve safety;
(d) Various long-term care program requirements, including
nursing home and ICF/IID placement criteria; Medicaid waiver services; and
other federal, state, and local resources that provide personal assistance,
respite, and companion services;
(e) DD Waivers requirements, as well as the administrative
duties for which the services facilitator will be responsible;
(f) Conducting assessments (including environmental,
psychosocial, health, and functional factors) and their uses in service
planning;
(g) Interviewing techniques;
(h) The individual's right to make decisions about, direct
the provisions of, and control his consumer-directed personal assistance,
companion, and respite services, including hiring, training, managing,
approving timesheets, and firing an assistant/companion;
(i) The principles of human behavior and interpersonal
relationships; and
(j) General principles of record documentation.
(2) Skills in:
(a) Negotiating with individuals and the individual's
family/caregivers, as appropriate, and service providers;
(b) Assessing, supporting, observing, recording, and
reporting behaviors;
(c) Identifying, developing, or providing services to
individuals with developmental disabilities; and
(d) Identifying services within the established services
system to meet the individual's needs.
(3) Abilities to:
(a) Report findings of the assessment or onsite visit,
either in writing or an alternative format, for individuals who have visual
impairments;
(b) Demonstrate a positive regard for individuals and their
families;
(c) Be persistent and remain objective;
(d) Work independently, performing position duties under
general supervision;
(e) Communicate effectively, orally and in writing; and
(f) Develop a rapport and communicate with individuals of
diverse cultural backgrounds.
2. The services facilitator's record about the individual
shall contain:
a. Documentation of all employer management training
provided to the individual enrolled in the waiver and the EOR, as appropriate,
including the individual's or the EOR's, as appropriate, receipt of training on
his responsibility for the accuracy and timeliness of the
assistant's/companion's timesheets; and
b. All documents signed by the individual enrolled in the
waiver or the EOR, as appropriate, which acknowledge their legal
responsibilities as the employer.
12VAC30-120-760. Skilled nursing services; private duty
nursing services.
A. Service description. Skilled nursing services shall be
provided for individuals with serious medical conditions and complex health
care needs who require specific skilled nursing services that cannot be
provided by non-nursing personnel. Skilled nursing may be provided in the home
or other community setting. It may include consultation and training for other
providers.
B. Criteria. In order to qualify for these services, the
individual must have demonstrated complex health care needs that require
specific skilled nursing services ordered by a physician and that cannot be
otherwise accessed under the Title XIX State Plan for Medical Assistance. The
individual's plan of care must stipulate that this service is necessary in
order to prevent institutionalization and is not available under the State Plan
for Medical Assistance.
C. Service units and service limitations. Skilled nursing
services to be rendered by either registered or licensed practical nurses are
provided in 15-minute units. Services must be explicitly detailed in the CSP
and must be specifically ordered by a physician.
D. Provider requirements. Skilled nursing services shall
be provided by a DMAS-enrolled home care organization provider or a home health
provider, or licensed registered nurse or a licensed practical nurse under the
supervision of a licensed registered nurse who is contracted or employed by a
DBHDS licensed day support, respite, or residential provider. In addition to
meeting the general conditions and requirements for home and community-based
waiver participating providers as specified in 12VAC30-120-730 and
12VAC30-120-740, in order to be enrolled as a skilled nursing provider, the
provider must:
1. If a home health agency, be certified by the VDH for
Medicaid participation and have a current DMAS provider participation agreement
for private duty nursing;
2. Demonstrate a prior successful health care delivery
business or practice;
3. Operate from a business office; and
4. If community services boards or behavioral health
authority employ or subcontract with and directly supervise a registered nurse
(RN) or a licensed practical nurse (LPN) with a current and valid license
issued by the Virginia State Board of Nursing, the RN or LPN must have at least
two years of related clinical nursing experience that may include work in an
acute care hospital, public health clinic, home health agency, or nursing home.
A. Skilled nursing services.
1. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1031 A 1.
2. Services criteria. The criteria shall be the same as
that set forth in 12VAC30-120-1031 A 2.
3. Allowable activities. Allowable activities shall be the
same as that set forth in 12VAC30-120-1031 A 3.
4. Skilled nursing services units and limits. Service units
and limits shall be the same as that set forth in 12VAC30-120-1031 A 4.
5. Skilled nursing services provider requirements. Provider
requirements shall be the same as that set forth in 12VAC30-120-1031 A 5.
B. Private duty nursing
services.
1. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1031 B 1.
2. Private duty nursing services criteria. The criteria
shall be the same as those set forth in 12VAC30-120-1031 B 2.
3. Private duty nursing services allowable activities.
Allowable activities shall be the same as those set forth in 12VAC30-120-1031 B
3.
4. Private duty nursing services service units and limits.
Service units and limits shall be the same as those set forth in
12VAC30-120-1031 B 4.
5. Private duty nursing services provider requirements.
Provider requirements shall be the same as those set forth in 12VAC30-120-1031
B 5.
12VAC30-120-761. [Reserved] Community engagement;
community coaching; community guide.
A. Community engagement.
1. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1022 A 1.
2. Community engagement criteria. Criteria shall be the
same as those set forth in 12VAC30-120-1022 A 2.
3. Community engagement allowable activities. Allowable
activities shall be the same as those set forth in 12VAC30-120-1022 A 3.
4. Community engagement service units and service limits.
Service units and limits shall be the same as those set forth in
12VAC30-120-1022 A 4.
5. Community engagement provider requirements. Provider
requirements shall be the same as those set forth in 12VAC30-120-1022 A 5 and
12VAC30-120-1065 A.
B. Community coaching.
1. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1022 B 1.
2. Criteria. The criteria shall be the same as those set
forth in 12VAC30-120-1022 B 2.
3. Allowable activities. The allowable activities shall be
the same as those set forth in 12VAC30-120-1022 B 3.
4. Service units and service limits. The service units and
limits shall be the same as those set forth in 12VAC30-120-1022 B 4.
5. Provider requirements. The provider requirements shall
be the same as those set forth in 12VAC30-120-1022 B 5 and 12VAC30-120-1065 B.
C. Community guide. (Reserved.)
12VAC30-120-762. Assistive technology (AT).
A. Service description. Assistive technology (AT) is available
to recipients who are receiving at least one other waiver service and may be
provided in a residential or nonresidential setting. AT is the specialized
medical equipment and supplies, including those devices, controls, or
appliances, specified in the plan of care, but not available under the State
Plan for Medical Assistance, that enable individuals to increase their
abilities to perform activities of daily living, or to perceive, control, or
communicate with the environment in which they live. This service also includes
items necessary for life support, ancillary supplies, and equipment necessary
to the proper functioning of such items. The service description is the
same as set forth in 12VAC30-120-1021 A.
B. Criteria. In order to qualify for these services, the
individual must have a demonstrated need for equipment or modification for
remedial or direct medical benefit primarily in an individual's primary home,
primary vehicle used by the individual, community activity setting, or day
program to specifically serve to improve the individual's personal functioning.
This shall encompass those items not otherwise covered under the State Plan for
Medical Assistance. Assistive technology shall be covered in the least
expensive, most cost-effective manner. For enrollees in the Elderly or Disabled
with Consumer Direction (EDCD) waiver (12VAC30-120-900 through
12VAC30-120-980), assistive technology services shall be available only to
those EDCD enrollees who are also enrolled in the Money Follows the Person demonstration.
The criteria are the same as set forth in 12VAC30-120-1021 A 1.
C. Service units and service limitations. AT is available
to individuals receiving at least one other waiver service and may be provided
in the individual's home or community setting. A maximum limit of $5,000 may be
reimbursed per plan of care year or the calendar year, as appropriate to the
waiver in which the individual is enrolled or calendar year, as
appropriate to the waiver being received. Costs for assistive technology cannot
be carried over from year to year and must be preauthorized each plan of care
year. AT will not be approved for purposes of convenience of the
caregiver/provider or restraint of the individual. Service units and
limitations are the same as those set forth in 12VAC30-120-1021 A 2.
An independent, professional consultation must be obtained
from qualified professionals who are knowledgeable of that item for each AT
request prior to approval by the prior authorization agent, and may include
training on such AT by the qualified professional. All AT must be authorized by
the service authorization agent prior to billing. Also excluded are
modifications that are reasonable accommodation requirements of the Americans
with Disabilities Act, the Virginians with Disabilities Act, and the
Rehabilitation Act.
D. Provider Service requirements. In
addition to meeting the general conditions and requirements for home and
community-based care participating providers as specified in 12VAC30-120-160,
12VAC30-120-730, 12VAC30-120-740, and 12VAC30-120-930, AT shall be provided by
providers having a current provider participation agreement with DMAS as
durable medical equipment and supply providers. Independent, professional
consultants include speech/language therapists, physical therapists,
occupational therapists, physicians, behavioral therapists, certified
rehabilitation specialists, or rehabilitation engineers. Service
requirements are the same as those set forth in 12VAC30-120-1021 A 3.
Providers that supply AT for an individual may not perform
assessment/consultation, write specifications, or inspect the AT for that
individual. Providers of services may not be spouses or parents of the
individual.
AT must be delivered within the plan of care year, or
within a year from the start date of the authorization, as appropriate to the
waiver, in which the individual is enrolled.
E. Provider requirements. Provider requirements are the
same as those set forth in 12VAC30-120-1021 A 4 and 12VAC30-120-1061 A and B.
12VAC30-120-764. Crisis stabilization services support
services (such as prevention, intervention, stabilization); center-based crisis
supports; community-based crisis supports.
A. Service description. Crisis stabilization services
involve direct interventions that provide temporary, intensive services and
supports that avert emergency, psychiatric hospitalization or institutional
placement of individuals who are experiencing serious psychiatric or behavioral
problems that jeopardize their current community living situation. Crisis
stabilization services shall include, as appropriate, neuropsychological,
psychiatric, psychological and other functional assessments and stabilization
techniques, medication management and monitoring, behavior assessment and
support, and intensive care coordination with other agencies and providers.
This service is designed to stabilize the individual and strengthen the current
living situation so that the individual remains in the community during and
beyond the crisis period.
These services shall be provided to:
1. Assist planning and delivery of services and supports to
enable the individual to remain in the community;
2. Train family members, other care givers, and service
providers in supports to maintain the individual in the community; and
3. Provide temporary crisis supervision to ensure the
safety of the individual and others.
B. Criteria.
1. In order to receive crisis stabilization services, the
individual must meet at least one of the following criteria:
a. The individual is experiencing marked reduction in
psychiatric, adaptive, or behavioral functioning;
b. The individual is experiencing extreme increase in
emotional distress;
c. The individual needs continuous intervention to maintain
stability; or
d. The individual is causing harm to self or others.
2. The individual must be at risk of at least one of the
following:
a. Psychiatric hospitalization;
b. Emergency ICF/IID placement;
c. Disruption of community status (living arrangement, day
placement, or school); or
d. Causing harm to self or others.
C. Service units and service limitations. Crisis
stabilization services must be authorized following a documented face-to-face
assessment conducted by a qualified developmental disabilities professional
(QDDP).
1. The unit for each component of the service is one hour.
Each service may be authorized in 15-day increments, but no more than 60
calendar days in a plan of care year may be used. The actual service units per
episode shall be based on the documented clinical needs of the individuals
being served. Extension of services beyond the 15-day limit per authorization
must be authorized following a documented face-to-face reassessment conducted
by a qualified professional as described in subsection D of this section.
2. Crisis stabilization services may be provided directly
in the following settings (the following examples are not exclusive):
a. The home of an individual who lives with family or other
primary caregiver or caregivers;
b. The home of an individual who lives independently or
semi-independently to augment any current services and support;
c. A day program or setting to augment current services and
supports; or
d. A respite care setting to augment current services and
supports.
3. Crisis supervision may be provided as a component of
this service only if clinical or behavioral interventions allowed under this
service are also provided during the authorized period. Crisis supervision must
be provided one-on-one and face-to-face with the individual. Crisis
supervision, if provided as a part of this service, shall be billed separately
in hourly service units.
4. Crisis stabilization services shall not be used for
continuous long-term care. Room and board and general supervision are not
components of this service.
5. If appropriate, the assessment and any reassessments
shall be conducted jointly with a licensed mental health professional or other
appropriate professional or professionals.
D. Provider requirements. In addition to the general
conditions and requirements for home and community-based waiver services
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
the following crisis stabilization provider requirements apply:
1. Crisis stabilization services shall be provided by
entities licensed by DBHDS as a provider of outpatient, residential, supportive
in-home services, or day support services. The provider must employ or utilize
qualified licensed mental health professionals or other qualified personnel
competent to provide crisis stabilization and related activities for
individuals with related conditions who require crisis stabilization services.
Supervision of direct service staff must be provided by a QDDP. Crisis
supervision providers must be licensed by DBHDS as providers of residential
services, supportive in-home services, or day support services.
2. Crisis stabilization supporting documentation must be
developed (or revised, in the case of a request for an extension) and submitted
to the case manager for authorization within 72 hours of the face-to-face
assessment or reassessment.
3. Documentation indicating the dates and times of crisis
stabilization services, the amount and type of service provided, and specific
information about the individual's response to the services and supports as
agreed to in the supporting documentation must be recorded in the individual's
record.
4. Documentation of provider qualifications must be
maintained for review by DMAS staff. This service shall be designed to
stabilize the individual and strengthen the current semi-independent living
situation, or situation with family or other primary care givers, so the
individual can be maintained during and beyond the crisis period.
A. Service description.
1. Crisis support services. The service definition shall be
the same as that set forth in 12VAC30-120-1024 A 1.
a. Crisis prevention. The service description shall be the
same as that set forth in 12VAC30-120-1024 A 1 a.
b. Crisis intervention. The service definition shall be the
same as that set forth in 12VAC30-120 A 1 b.
c. Crisis stabilization. The service description shall be
the same as that set forth in 12VAC30-120-1024 A 1 c.
2. Center-based crisis supports. The service definition
shall be the same as set forth in 12VAC30-120-1024 A 2.
3. Community-based crisis supports. The service definition
shall be the same as set forth in 12VAC30-120-1024 A 3.
B. Criteria.
1. Crisis support services. The criteria shall be the same
as those set forth in 12VAC30-120-1024 B 1.
2. Center-based crisis supports. The criteria shall be the
same as those set forth in 12VAC30-120-1024 B 2.
3. Community-based crisis supports. The criteria shall be
the same as those set forth in 12VAC30-120-1024 B 3.
C. Allowable activities.
1. Crisis support services. Allowable activities shall be
the same as those set forth in 12VAC30-120-1024 C 1 and C 2.
2. Center-based crisis supports. Allowable activities shall
be the same as those set forth in 12VAC30-120-1024 C 3.
3. Community-based crisis supports. Allowable activities
shall be the same as those set forth in 12VAC30-120-1024 C 4.
D. Service units and service limitations.
1. Crisis support services.
Service units and limits shall be the same as those set forth in
12VAC30-120-1024 D 1.
2. Center-based crisis
supports. Service units and limits shall be the same as those set forth in
12VAC30-120-1024 D 2.
3. Community-based crisis supports. Service units and
limits shall be the same as those set forth in 12VAC30-120-1024 D 3.
E. Provider requirements. Provider requirements shall be
the same as those set forth in 12VAC30-120-1024 E and 12VAC30-120-1063.
12VAC30-120-766. Personal care and respite care assistance,
services, and companion services.
A. Service description. Services may be provided
either through an agency-directed or consumer-directed model.
1. Personal care services means services offered to
individuals in their homes and communities to enable an individual to maintain
the health status and functional skills necessary to live in the community or
participate in community activities. Personal care services substitute for the
absence, loss, diminution, or impairment of a physical, behavioral, or
cognitive function. This service shall provide care to individuals with
activities of daily living (eating, drinking, personal hygiene, toileting,
transferring and bowel/bladder control), instrumental activities of daily
living (IADL), access to the community, monitoring of self-medication or other
medical needs, and the monitoring of health status or physical condition. In
order to receive personal care services, the individual must require assistance
with their ADLs.
When specified in the plan of care, personal care services
may include assistance with IADL. Assistance with IADL must be essential to the
health and welfare of the individual, rather than the individual's
family/caregiver.
An additional component to personal care is work or
school-related personal care. This allows the personal care provider to
provide assistance and supports for individuals in the workplace and for those
individuals attending postsecondary educational institutions. Workplace or
school supports through the IFDDS Waiver are not provided if they are services
that should be provided by DARS, under IDEA, or if they are an employer's
responsibility under the Americans with Disabilities Act, the Virginians with
Disabilities Act, or § 504 of the Rehabilitation Act. Work-related personal
care services cannot duplicate services provided under supported employment.
2. Respite care means services provided for unpaid
caregivers of eligible individuals who are unable to care for themselves that
are provided on an episodic or routine basis because of the absence of or need
for relief of those unpaid persons who routinely provide the care.
A. Personal assistance services.
1. Service description. The service description for
personal assistance services shall be the same as that set forth in
12VAC30-120-1029 B.
2. Criteria. The criteria for personal assistance services
shall be the same as those set forth in 12VAC30-120-1029 C.
3. Allowable activities. Allowable activities for personal
assistance services are the same as those set forth in 12VAC30-120-1029 C 3.
4. Service units and service limitations. Service units and
service limitations for personal assistance are the same as those set forth in
12VAC30-120-1029 D.
5. Provider requirements. Provider requirements for
personal assistance are the same as those set forth in 12VAC30-120-1029 E and
12VAC30-120-1059.
B. Criteria. Respite services.
1. In order to qualify for personal care services, the
individual must demonstrate a need in activities of daily living, reminders to
take medication, or other medical needs, or monitoring health status or
physical condition. Service description. The service description shall
be the same as that set forth in 12VAC30-120-1032 B.
2. In order to qualify for respite care, individuals must
have an unpaid primary caregiver who requires temporary relief to avoid
institutionalization of the individual. The criteria for respite
services shall be the same as those set forth in 12VAC30-120-1032 C.
3. Individuals choosing the consumer-directed option must
receive support from a CD services facilitator and meet requirements for
consumer direction as described in 12VAC30-120-770. Allowable activities
for respite services shall be the same as those set forth in 12VAC30-120-1032
D.
4. Service units and service limitations. Service units and
service limitations for respite services shall be the same as those set forth
in 12VAC30-120-1032 E.
5. Provider requirements for respite services shall be the
same as those set forth in 12VAC30-120-1032 F and 12VAC30-120-1059.
C. Service units and service limitations.
1. The unit of service is one hour.
2. Effective July 1, 2011, respite care services are
limited to a maximum of 480 hours per year. Individuals who are receiving
services through both the agency-directed and consumer-directed models cannot
exceed 480 hours per year combined.
3. Individuals may have personal care, respite care, and
in-home residential support services in their plan of care but cannot receive
in-home residential supports and personal care or respite care services at the
same time.
4. Each individual receiving personal care services must
have a back-up plan in case the personal care aide or consumer-directed (CD)
employee does not show up for work as expected or terminates employment without
prior notice.
5. Individuals must need assistance with ADLs in order to
receive IADL care through personal care services.
6. Individuals shall be permitted to share personal care
service hours with one other individual (receiving waiver services) who lives
in the same home.
7. This service does not include skilled nursing services
with the exception of skilled nursing tasks that may be delegated in accordance
with 18VAC90-20-420 through 18VAC90-20-460.
D. Provider requirements. In addition to meeting the
general conditions and requirements for home and community-based care
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
personal and respite care providers must meet the following provider
requirements:
1. Services shall be provided by:
a. For the agency-directed model, a DMAS enrolled personal
care/respite care provider or by a DBHDS-licensed residential supportive
in-home provider. All personal care aides must pass an objective standardized
test of knowledge, skills, and abilities approved by DBHDS and administered
according to DBHDS' defined procedures. Providers must demonstrate a prior
successful health care delivery business and operate from a business office.
b. For the consumer-directed model, a service facilitation
provider meeting the requirements found in 12VAC30-120-770.
2. For DBHDS-licensed providers, a residential supervisor
shall provide ongoing supervision for all personal care aides
For DMAS-enrolled personal care/respite care providers, the
provider must employ or subcontract with and directly supervise an RN who will
provide ongoing supervision of all aides. The supervising RN must be currently
licensed to practice in the Commonwealth and have at least two years of related
clinical nursing experience that may include work in an acute care hospital,
public health clinic, home health agency, ICF/IID, or nursing facility.
3.The RN supervisor or case manager/services facilitator
must make a home visit to conduct an initial assessment prior to the start of
care for all individuals requesting services. The RN supervisor or case
manager/service facilitator must also perform any subsequent reassessments or
changes to the supporting documentation. Under the consumer-directed model, the
initial comprehensive visit is done only once upon the individual's entry into
the service. If an individual served under the waiver changes CD services
facilitation agencies, the new CD services facilitation provider must bill for
a reassessment in lieu of a comprehensive visit.
4. The RN supervisor or case manager/services facilitator
must make supervisory visits as often as needed to ensure both quality and
appropriateness of services.
a. For personal care the minimum frequency of these visits
is every 30 to 90 calendar days depending on individual needs. For respite care
offered on a routine basis, the minimum frequency of these visits is every 30
to 90 calendar days under the agency-directed model and every six months or
upon the use of 240 respite care hours (whichever comes first) under the
consumer-directed model.
b. Under the agency-directed model, when respite care services
are not received on a routine basis, but are episodic in nature, the RN is not
required to conduct a supervisory visit every 30 to 90 calendar days. Instead,
the RN supervisor must conduct the initial home visit with the respite care
aide immediately preceding the start of care and make a second home visit
within the respite care period.
c. When respite care services are routine in nature and
offered in conjunction with personal care, the 30-day to 90-day supervisory
visit conducted for personal care may serve as the RN supervisor or case
manager/service facilitator visit for respite care. However, the RN supervisor
or case manager/services facilitator must document supervision of respite care
separately. For this purpose, the same record can be used with a separate
section for respite care documentation.
5. Under the agency-directed model, the supervisor shall
identify any gaps in the aide's ability to provide services as identified in
the individual's plan of care and provide training as indicated based on
continuing evaluations of the aide's performance and the individual's needs.
6. The supervising RN or case manager/services facilitator
must maintain current documentation. This may be done as a summary and must
note:
a. Whether personal and respite care services continue to
be appropriate;
b. Whether the supporting documentation is adequate to meet
the individual's needs or if changes are indicated in the supporting
documentation;
c. Any special tasks performed by the aide/CD employee and
the aide's/CD employee's qualifications to perform these tasks;
d. Individual's satisfaction with the service;
e. Any hospitalization or change in the individual's
medical condition or functioning status;
f. Other services received and their amount; and
g. The presence or absence of the aide in the home during
the RN's visit.
7. Qualification of aides/CD employees. Each aide/CD
employee must:
a. Be 18 years of age or older and possess a valid social
security number;
b. For the agency-directed model, be able to read and write
English to the degree necessary to perform the tasks required. For the
consumer-directed model, possess basic math, reading and writing skills;
c. Have the required skills to perform services as
specified in the individual's plan of care;
d. Not be the parents of individuals who are minors, or the
individual's spouse. Payment will not be made for services furnished by other
family members living under the same roof as the individual receiving services
unless there is objective written documentation as to why there are no other
providers available to provide the care. Family members who are approved to be
reimbursed for providing this service must meet the qualifications. In
addition, under the consumer-directed model, family/caregivers acting as the
employer on behalf of the individual may not also be the CD employee;
e. Additional aide requirements under the agency-directed
model:
(1) Complete an appropriate aide training curriculum
consistent with DMAS standards. Prior to assigning an aide to an individual,
the provider must ensure that the aide has satisfactorily completed a training
program consistent with DMAS standards. DMAS requirements may be met in any of
the following ways:
(a) Registration as a certified nurse aide (DMAS-enrolled
personal care/respite care providers);
(b) Graduation from an approved educational curriculum that
offers certificates qualifying the student as a nursing assistant, geriatric
assistant or home health aide (DMAS-enrolled personal care/respite care
providers);
(c) Completion of provider-offered training that is
consistent with the basic course outline approved by DMAS (DMAS-enrolled
personal care/respite care providers);
(d) Completion and passing of the DBHDS standardized test
(DBHDS-licensed providers);
(2) Have a satisfactory work record as evidenced by two
references from prior job experiences, including no evidence of possible abuse,
neglect, or exploitation of aged or incapacitated adults or children; and
(3) Be evaluated in his job performance by the supervisor.
f. Additional CD employee requirements under the
consumer-directed model:
(1) Submit to a criminal records check and, if the
individual is a minor, the child protective services registry. The employee
will not be compensated for services provided to the individual if the records
check verifies the employee has been convicted of crimes described in §
37.2-314 of the Code of Virginia or if the employee has a complaint confirmed
by the DSS child protective services registry;
(2) Be willing to attend training at the request of the
individual or his family/caregiver, as appropriate;
(3) Understand and agree to comply with the DMAS
consumer-directed services requirements; and
(4) Receive an annual TB screening.
8. Provider inability to render services and substitution
of aides (agency-directed model). When an aide is absent, the provider may
either obtain another aide, obtain a substitute aide from another provider if
the lapse in coverage is to be less than two weeks in duration, or transfer the
individual's services to another provider.
9. Retention, hiring, and substitution of employees
(consumer-directed model). Upon the individual's request, the CD services
facilitator shall provide the individual or his family/caregiver, as
appropriate, with a list of consumer-directed employees on the
consumer-directed employee registry that may provide temporary assistance until
the employee returns or the individual or his family/caregiver, as appropriate,
is able to select and hire a new employee. If an individual or his
family/caregiver, as appropriate, is consistently unable to hire and retain an
employee to provide consumer-directed services, the services facilitator must
contact the case manager and DBHDS to transfer the individual, at the choice of
the individual or his family/caregiver, as appropriate, to a provider that
provides Medicaid-funded agency-directed personal care or respite care
services. The CD services facilitator will make arrangements with the case
manager to have the individual transferred.
10. Required documentation in individuals' records. The
provider must maintain all records of each individual receiving services. Under
the agency-directed model, these records must be separated from those of other
nonwaiver services, such as home health services. At a minimum these records
must contain:
a. The most recently updated plan of care and supporting
documentation, all provider documentation, and all DMAS-225 forms;
b. Initial assessment by the RN supervisory nurse or case
manager/services facilitator completed prior to or on the date services are
initiated, subsequent reassessments, and changes to the supporting
documentation by the RN supervisory nurse or case manager/services facilitator;
c. Nurses' or case manager/services facilitator summarizing
notes recorded and dated during any contacts with the aide or CD employee and
during supervisory visits to the individual's home;
d. All correspondence to the individual, to DBHDS, and to
DMAS;
e. Contacts made with family, physicians, DBHDS, DMAS,
formal and informal service providers, and all professionals concerning the
individual;
f. Under the agency-directed model, all aide records. The
aide record must contain:
(1) The specific services delivered to the individual by
the aide and the individual's responses;
(2) The aide's arrival and departure times;
(3) The aide's weekly comments or observations about the
individual to include observations of the individual's physical and emotional
condition, daily activities, and responses to services rendered;
(4) The aide's and individual's weekly signatures to verify
that services during that week have been rendered;
(5) Signatures, times, and dates; these signatures, times,
and dates shall not be placed on the aide record prior to the last date of the
week that the services are delivered; and
(6) Copies of all aide records; these records shall be
subject to review by state and federal Medicaid representatives.
g. Additional documentation requirements under the
consumer-directed model:
(1) All management training provided to the individuals or
their family caregivers, as appropriate, including responsibility for the
accuracy of the timesheets.
(2) All documents signed by the individual or his
family/caregivers, as appropriate, that acknowledge the responsibilities of the
services.
C. Companion services.
1. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1023 A.
2. Criteria. The criteria shall be the same as those set
forth in 12VAC30-120-1023 B.
3. Service units and service limitations. The service units
and limits shall be the same as those set forth in 12VAC30-120-1023 C.
4. Provider requirements. The provider requirements shall
be the same as those set forth in 12VAC30-120-1023 D and 12VAC30-120-1059.
12VAC30-120-770. Consumer-directed model of service
delivery.
A. Criteria.
1. The IFDDS FIS Waiver has three services,
companion, personal care, and respite services, that may be provided through a
consumer-directed model.
2. Individuals who are eligible for consumer-directed services
must have the capability to hire, train, and fire their consumer-directed
employees and supervise the employee's work performance. If an individual is
unable to direct his own care or is younger than 18 years of age, a
family/caregiver may serve as the employer on behalf of the individual.
3. Responsibilities as employer. The individual, or if the
individual is unable, then a family/caregiver, is the employer in this service
and is responsible for hiring, training, supervising, and firing employees.
Specific duties include checking references of employees, determining that
employees meet basic qualifications, training employees, supervising the
employees' performance, and submitting timesheets to the fiscal agent on a
consistent and timely basis. The individual or his family/caregiver, as
appropriate, must have an emergency back-up plan in case the employee does not
show up for work.
4. DMAS shall contract for the services of a fiscal agent for
consumer-directed personal care, companion, and respite care services. The
fiscal agent will be paid by DMAS to perform certain tasks as an agent for the
individual/employer who is receiving consumer-directed services. The fiscal
agent will handle responsibilities for the individual for employment taxes. The
fiscal agent will seek and obtain all necessary authorizations and approvals of
the Internal Revenue Services in order to fulfill all of these duties.
5. Individuals choosing consumer-directed services must
receive support from a CD services facilitator. Services facilitators assist
the individual or his family/caregiver, as appropriate, as they become
employers for consumer-directed services. This function includes providing the
individual or his family/caregiver, as appropriate, with management training,
review and explanation of the Employee Management Manual, and routine visits to
monitor the employment process. The CD services facilitator assists the
individual/employer with employer issues as they arise. The services
facilitator meeting the stated qualifications may also complete the
assessments, reassessments, and related supporting documentation necessary for
consumer-directed services if the individual or his family/caregiver, as
appropriate, chooses for the CD services facilitator to perform these tasks
rather than the case manager. Services facilitation services are provided on an
as-needed basis as determined by the individual, family/caregiver, and CD
services facilitator. This must be documented in the supporting documentation
for consumer-directed services and the services facilitation provider bills
accordingly. If an individual enrolled in consumer-directed services has a
lapse in consumer-directed services for more than 60 consecutive calendar days,
the case manager shall notify DBHDS so that consumer-directed services may be
discontinued and the option given to change to agency-directed services.
B. Provider qualifications. In addition to meeting the
general conditions and requirements for home and community-based care
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
services facilitators providers must meet the following qualifications:
1. To be enrolled as a Medicaid CD services facilitation
provider and maintain provider status, the CD services facilitation provider
must operate from a business office and have sufficient qualified staff who
will function as CD services facilitators to perform the service facilitation
and support activities as required. It is preferred that the employee of the CD
services facilitation provider possess a minimum of an undergraduate degree in
a human services field or be a registered nurse currently licensed to practice
in the Commonwealth. In addition, it is preferable that the CD services
facilitator has two years of satisfactory experience in the human services
field working with individuals with related conditions.
2. The CD services facilitator must possess a combination of
work experience and relevant education that indicates possession of the
following knowledge, skills, and abilities. Such knowledge, skills, and
abilities must be documented on the application form, found in supporting
documentation, or be observed during the job interview. Observations during the
interview must be documented. The knowledge, skills, and abilities include:
a. Knowledge of:
(1) Various long-term care program requirements, including
nursing home, ICF/IID, and assisted living facility placement criteria,
Medicaid waiver services, and other federal, state, and local resources that
provide personal care services;
(2) DMAS consumer-directed services requirements, and the
administrative duties for which the individual will be responsible;
(3) Interviewing techniques;
(4) The individual's right to make decisions about, direct the
provisions of, and control his consumer-directed services, including hiring,
training, managing, approving time sheets, and firing an employee;
(5) The principles of human behavior and interpersonal
relationships; and
(6) General principles of record documentation.
(7) For CD services facilitators who also conduct assessments
and reassessments, the following is also required. Knowledge of:
(a) Types of functional limitations and health problems that
are common to different disability types and the aging process as well as strategies
to reduce limitations and health problems;
(b) Physical assistance typically required by people with
developmental disabilities, such as transferring, bathing techniques, bowel and
bladder care, and the approximate time those activities normally take;
(c) Equipment and environmental modifications commonly used
and required by people with developmental disabilities that reduces the need
for human help and improves safety; and
(d) Conducting assessments (including environmental,
psychosocial, health, and functional factors) and their uses in care planning.
b. Skills in:
(1) Negotiating with individuals or their family/caregivers,
as appropriate, and service providers;
(2) Observing, recording, and reporting behaviors;
(3) Identifying, developing, or providing services to persons
with developmental disabilities; and
(4) Identifying services within the established services
system to meet the individual's needs.
c. Abilities to:
(1) Report findings of the assessment or onsite visit, either
in writing or an alternative format for persons who have visual impairments;
(2) Demonstrate a positive regard for individuals and their
families;
(3) Be persistent and remain objective;
(4) Work independently, performing position duties under
general supervision;
(5) Communicate effectively, orally and in writing;
(6) Develop a rapport and communicate with different types of
persons from diverse cultural backgrounds; and
(7) Interview.
3. If the CD services facilitator is not an RN, the CD
services facilitator must inform the primary health care provider that services
are being provided and request skilled nursing or other consultation as needed.
4. Initiation of services and service monitoring.
a. If the services facilitator has responsibility for
individual assessments and reassessments, these must be conducted as specified
in 12VAC30-120-766 and 12VAC30-120-776.
b. Management training.
(1) The CD services facilitation provider must make an initial
visit with the individual or his family/caregiver, as appropriate, to provide
management training. The initial management training is done only once upon the
individual's entry into the service. If an individual served under the waiver
changes CD services facilitation providers, the new CD services facilitator
must bill for a regular management training in lieu of initial management
training.
(2) After the initial visit, two routine visits must occur
within 60 days of the initiation of care or the initial visit to monitor the
employment process.
(3) For personal care services, the CD services facilitation
provider will continue to monitor on an as needed basis, not to exceed a
maximum of one routine visit every 30 calendar days but no less than the
minimum of one routine visit every 90 calendar days per individual. After the initial
visit, the CD services facilitator will periodically review the utilization of
companion services at a minimum of every six months and for respite services,
either every six months or upon the use of 300 respite care hours, whichever
comes first.
5. The CD services facilitator must be available to the
individual or his family/caregiver, as appropriate, by telephone during normal
business hours, have voice mail capability, and return phone calls within 24
hours or have an approved back-up CD services facilitator.
6. The CD services fiscal contractor for DMAS must submit a
criminal record check within 15 calendar days of employment pertaining to the
consumer-directed employees on behalf of the individual or family/caregiver and
report findings of the criminal record check to the individual or his
family/caregiver, as appropriate.
7. The CD services facilitator shall verify bi-weekly
timesheets signed by the individual or his family caregiver, as appropriate,
and the employee to ensure that the number of plan of care approved hours are
not exceeded. If discrepancies are identified, the CD services facilitator must
contact the individual to resolve discrepancies and must notify the fiscal
agent. If an individual is consistently being identified as having discrepancies
in his timesheets, the CD services facilitator must contact the case manager to
resolve the situation.
8. Consumer-directed employee registry. The CD services
facilitator must maintain a consumer-directed employee registry, updated on an
ongoing basis.
9. Required documentation in individuals' records. CD services
facilitators responsible for individual assessment and reassessment must
maintain records as described in 12VAC30-120-766 and 12VAC30-120-776. For CD
services facilitators conducting management training, the following
documentation is required in the individual's record:
a. All copies of the plan of care, all supporting
documentation related to consumer-directed services, and all DMAS-225 forms.
b. CD services facilitator's notes recorded and dated at the
time of service delivery.
c. All correspondence to the individual, to others concerning
the individual, and to DMAS and DBHDS.
d. All training provided to the consumer-directed employees on
behalf of the individual or his family/caregiver, as appropriate.
e. All management training provided to the individuals or his
family/caregivers, as appropriate, including the responsibility for the
accuracy of the timesheets.
f. All documents signed by the individual or his
family/caregiver, as appropriate, that acknowledge the responsibilities of the
services.
12VAC30-120-773. [Reserved] Electronic-based home
supports (EBHS).
A. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1025 A 1.
B. Criteria. The criteria shall be the same as those set
forth in 12VAC30-120-1025 A 2.
C. Service limits and service limitations. The service
limits and units shall be the same as those set forth in 12VAC30-120-1025 A 3.
D. Provider requirements. The provider requirements shall
be the same as those set forth in 12VAC30-120-1025 A 4.
12VAC30-120-774. Personal emergency response system (PERS).
A. Service description. PERS is a service that monitors
individual safety in the home and provides access to emergency assistance for medical
or environmental emergencies through the provision of a two-way voice
communication system that dials a 24-hour response or monitoring center upon
activation and via the individual's home telephone line. PERS may also include
medication monitoring devices. The service description shall be the same
as set forth in 12VAC30-120-1030 A 1.
B. Criteria. PERS may be authorized when there is no one
else is in the home who is competent or continuously available to call for help
in an emergency. The criteria shall be the same as set forth in
12VAC30-120-1030 A 2.
C. Service units and service limitations. Service units
and limits shall be the same as set forth in 12VAC30-120-1030 A 3.
1. A unit of service shall include administrative costs,
time, labor, and supplies associated with the installation, maintenance,
monitoring, and adjustments of the PERS. A unit of service is one-month rental
price set by DMAS. The one-time installation of the unit includes installation,
account activation, individual and caregiver instruction, and removal of PERS
equipment.
2. PERS services must be capable of being activated by a
remote wireless device and be connected to the individual's telephone line. The
PERS console unit must provide hands-free voice-to-voice communication with the
response center. The activating device must be waterproof, automatically
transmit to the response center an activator low battery alert signal prior to
the battery losing power, and be able to be worn by the individual.
3. PERS cannot be used as a substitute for providing
adequate supervision of the individual.
D. Provider requirements. In addition to meeting the
general conditions and requirements for home and community-based care
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
providers must also meet the following requirements: Provider
requirements shall be the same as those set forth in 12VAC30-120-1030 A 4 and
12VAC30-120-1560 P.
1. A PERS provider is a certified home health or personal
care agency, a durable medical equipment provider, a hospital, or a PERS
manufacturer that has the ability to provide PERS equipment, direct services
(i.e., installation, equipment maintenance, and service calls), and PERS
monitoring.
2. The PERS provider must provide an emergency response
center staff with fully trained operators who are capable of receiving signals
for help from an individual's PERS equipment 24 hours a day, 365, or 366 as
appropriate, days per year; of determining whether an emergency exists; and of
notifying an emergency response organization or an emergency responder that the
PERS individual needs emergency help.
3. A PERS provider must comply with all applicable Virginia
statutes, all applicable regulations of DMAS, and all other governmental
agencies having jurisdiction over the services to be performed.
4. The PERS provider has the primary responsibility to
furnish, install, maintain, test, and service the PERS equipment, as required
to keep it fully operational. The provider shall replace or repair the PERS
device within 24 hours of the individual's notification of a malfunction of the
console unit, activating devices, or medication-monitoring unit while the
original equipment is being repaired.
5. The PERS provider must properly install all PERS
equipment into the functioning telephone line of an individual receiving PERS
and must furnish all supplies necessary to ensure that the system is installed
and working properly.
6. The PERS installation includes local seize line
circuitry, which guarantees that the unit will have priority over the telephone
connected to the console unit should the phone be off the hook or in use when
the unit is activated.
7. A PERS provider must maintain all installed PERS
equipment in proper working order.
8. A PERS provider must maintain a data record for each
individual receiving PERS at no additional cost to DMAS. The record must
document all of the following:
a. Delivery date and installation date of the PERS;
b. The signature of the individual or his family/caregiver,
as appropriate, verifying receipt of PERS device;
c. Verification by a test that the PERS device is
operational, monthly or more frequently as needed;
d. Updated and current individual responder and contact
information, as provided by the individual or the individual's care provider,
or case manager; and
e. A case log documenting the individual's utilization of
the system and contacts and communications with the individual or his
family/caregiver, as appropriate, case manager, or responder.
9. The PERS provider must have back-up monitoring capacity
in case the primary system cannot handle incoming emergency signals.
10. Standards for PERS equipment. All PERS equipment must
be approved by the Federal Communications Commission and meet the Underwriters'
Laboratories, Inc. (UL) safety standard Number 1635 for Digital Alarm
Communicator System Units and Number 1637, which is the UL safety standard for
home health care signaling equipment. The UL listing mark on the equipment will
be accepted as evidence of the equipment's compliance with such standard. The
PERS device must be automatically reset by the response center after each
activation ensuring that subsequent signals can be transmitted without
requiring manual reset by the individual.
11. A PERS provider must furnish education, data, and
ongoing assistance to DBHDS and case managers to familiarize staff with the
service, allow for ongoing evaluation and refinement of the program, and must
instruct the individual, his family/caregiver, as appropriate, and responders in
the use of the PERS service.
12. The emergency response activator must be activated
either by breath, by touch, or by some other means, and must be usable by
persons who have visual or hearing impairments or physical disabilities. The
emergency response communicator must be capable of operating without external
power during a power failure at the individual's home for a minimum period of
24 hours and automatically transmit a low battery alert signal to the response
center if the back-up battery is low. The emergency response console unit must
also be able to self-disconnect and redial the back-up monitoring site without
the individual resetting the system in the event it cannot get its signal
accepted at the response center.
13. Monitoring agencies must be capable of continuously
monitoring and responding to emergencies under all conditions, including power
failures and mechanical malfunctions. It is the PERS provider's responsibility
to ensure that the monitoring agency and the agency's equipment meets the following
requirements. The monitoring agency must be capable of simultaneously
responding to multiple signals for help from multiple individuals' PERS
equipment. The monitoring agency's equipment must include the following:
a. A primary receiver and a back-up receiver, which must be
independent and interchangeable;
b. A back-up information retrieval system;
c. A clock printer, which must print out the time and date
of the emergency signal, the PERS individual's identification code, and the
emergency code that indicates whether the signal is active, passive, or a
responder test;
d. A back-up power supply;
e. A separate telephone service;
f. A toll free number to be used by the PERS equipment in
order to contact the primary or back-up response center; and
g. A telephone line monitor, which must give visual and
audible signals when the incoming telephone line is disconnected for more than
10 seconds.
14. The monitoring agency must maintain detailed technical
and operations manuals that describe PERS elements, including the installation,
functioning, and testing of PERS equipment; emergency response protocols; and
recordkeeping and reporting procedures.
15. The PERS provider shall document and furnish within 30
calendar days of the action taken a written report to the case manager for each
emergency signal that results in action being taken on behalf of the
individual. This excludes test signals or activations made in error.
16. The PERS provider is prohibited from performing any
type of direct marketing activities.
12VAC30-120-775. [Reserved] Transition services.
Transition services shall be consistent with the
requirements and limits set out in 12VAC30-120-1038, 12VAC30-120-2000, and
12VAC30-120-2010.
12VAC30-120-776. Companion services. (Repealed.)
A. Service description. Companion services is a covered
service when its purpose is to supervise or monitor those individuals who
require the physical presence of an aide to ensure their safety during times
when no other supportive people are available. This service may be provided
either through an agency-directed or a consumer-directed model.
B. Criteria.
1. The inclusion of companion services in the plan of care
is appropriate only when the individual cannot be left alone at any time due to
mental or severe physical incapacitation. This includes individuals who cannot
use a phone to call for help due to a physical or neurological disability.
Individuals may receive companion services due to their inability to call for
help if PERS is not appropriate for them.
2. Individuals having a current, uncontrolled medical
condition making them unable to call for help during a rapid deterioration may
be approved for companion services if there is documentation that the
individual has had recurring attacks during the two-month period prior to the
authorization of companion services. Companion services shall not be covered if
required only because the individual does not have a telephone in the home or
because the individual does not speak English.
3. There must be a clear and present danger to the
individual as a result of being left unsupervised. Companion services cannot be
authorized for individuals whose only need for companion services is for
assistance exiting the home in the event of an emergency.
4. Individuals choosing the consumer-directed option must
receive support from a CD services facilitator and meet requirements for
consumer direction as described in 12VAC30-120-770.
C. Service units and service limitations.
1. The amount of companion service time included in the
plan of care must be no more than is necessary to prevent the physical
deterioration or injury to the individual. In no event may the amount of time
relegated solely to companion service on the plan of care exceed eight hours
per day.
2. A companion cannot provide supervision to individuals on
ventilators, requiring continuous tube feedings, or requiring suctioning of
their airways.
3. Companion services will be authorized for family members
to sleep either during the day or during the night when the individual cannot
be left alone at any time due to the individual's severe agitation or
physically wandering behavior. Companion services must be necessary to ensure
the individual's safety if the individual cannot be left unsupervised due to
health and safety concerns.
4. Companion services may be authorized when no one else is
in the home is competent to call for help in an emergency.
D. Provider requirements. In addition to meeting the
general conditions and requirements for home and community-based care
participating providers as specified in 12VAC30-120-730 and 12VAC30-120-740,
companion service providers must meet the following requirements:
1. Companion services providers shall include:
a. For the agency-directed model: companion providers
include DBHDS-licensed residential services providers; DBHDS-licensed
supportive, in-home residential service providers; DBHDS-licensed day support
service providers; DBHDS-licensed respite service providers; and DMAS-enrolled
personal care/respite care providers.
b. For the consumer-directed model: a services facilitator
must meet the requirements found in 12VAC30-120-770.
2. Companion qualifications. Companions must meet the
following requirements:
a. Be at least 18 years of age;
b. Possess basic math skills and English reading and
writing skills, to the degree necessary to perform the tasks required;
c. Be capable of following a plan of care with minimal
supervision;
d. Submit to a criminal history record check and if
providing services to a minor, submit to a record check under the State's Child
Protective Services Registry. The companion will not be compensated for
services provided to the individual if the records check verifies the companion
has been convicted of crimes described in § 37.2-416 of the Code of Virginia;
e. Possess a valid social security number; and
f. Have the required skills to perform services as
specified in the individual's plan of care.
g. Additional CD employee requirements under the
consumer-directed model:
(1) Be willing to attend training at the request of the
individual or his family/caregiver, as appropriate;
(2) Understand and agree to comply with the DMAS
consumer-directed services requirements; and
(3) Receive an annual TB screening.
3. Companions may not be the individual's spouse. Other
family members living under the same roof as the individual being served may
not provide companion services unless there is objective, written documentation
as to why there are no other providers available to provide the services.
Companion services shall not be provided by adult foster care/family care
providers or any other paid caregivers.
4. Family members who are reimbursed to provide companion
services must meet the companion qualifications.
5. For the agency-directed model, companions are employees
of entities that enroll with DMAS to provide companion services. Providers are
required to have a companion services supervisor to monitor companion services.
The supervisor must be an LPN, or an RN, have a current license or
certification to practice in the Commonwealth, and have at least one year of
experience working with individuals with related conditions; or must have a
bachelor's degree in a human services field and at least one year of experience
working with individuals with related conditions.
6. Retention, hiring, and substitution of companions
(consumer-directed model). Upon the individual's request, the CD services
facilitator shall provide the individual or his family/caregiver, as
appropriate, with a list of potential consumer-directed employees on the
consumer-directed employee registry that may provide temporary assistance until
the companion returns or the individual or his family/caregiver as,
appropriate, is able to select and hire a new companion. If an individual or
his family/caregiver, as appropriate, is consistently unable to hire and retain
a companion to provide consumer-directed services, the CD services facilitator
must contact the case manager and DBHDS to transfer the individual, at the
choice of the individual or his family/caregiver, as appropriate, to a provider
that provides Medicaid-funded agency-directed companion services. The CD
services facilitator will make arrangements with the case manager to have the
individual transferred.
7. The provider or case manager/services facilitator must
conduct an initial home visit prior to initiating companion services to
document the efficacy and appropriateness of services and to establish a plan
of care for the individual. Under the agency-directed model, the provider must provide
follow-up home visits quarterly or as often as needed to monitor the provision
of services. Under the consumer-directed model, the case manager/services
facilitator will periodically review the utilization of companion services at a
minimum of every six months or more often as needed. The individual must be
reassessed for services every six months.
8. Required documentation. The provider or case
manager/services facilitator must maintain a record of each individual
receiving companion services. At a minimum these records must contain the
following:
a. An initial assessment completed prior to or on the date
services are initiated and subsequent reassessments and changes to the
supporting documentation.
b. The supporting documentation must be reviewed by the
provider or case manager/services facilitator quarterly under the
agency-directed model, semiannually under the consumer-directed model,
annually, and more often, as needed, modified as appropriate, and the written
results of these reviews submitted to the case manager. For the annual review
and in cases where the supporting documentation is modified, the plan of care
must be reviewed with the individual or his family/caregiver, as appropriate.
c. All correspondence to the individual, family/caregiver,
case manager, DBHDS, and DMAS.
d. Contacts made with family/caregiver, physicians, formal
and informal service providers, and all professionals concerning the
individual.
e. The companion services supervisor or case
manager/service facilitator must document in the individual's record a summary
note following significant contacts with the companion and quarterly or
semiannual home visits with the individual. This summary must include the
following at a minimum:
(1) Whether companion services continue to be appropriate;
(2) Whether the plan is adequate to meet the individual's
needs or changes are indicated in the plan;
(3) The individual's satisfaction with the service; and
(4) The presence or absence of the companion during the
visit.
f. A copy of the most recently completed DMAS-225 form. The
provider must clearly document efforts to obtain the completed DMAS-225 form
from the case manager.
g. Additional documentation requirements under the
consumer-directed model:
(1) All training provided to the companion on behalf of the
individual or his family/caregiver, as appropriate.
(2) All management training provided to the individual or
his family/caregiver, as appropriate, including responsibility for the accuracy
of the timesheets.
(3) All documents signed by the individual or his
family/caregiver, as appropriate, that acknowledge the responsibilities of the
services.
h. Under the agency-directed model, all companion records.
The companion record must contain the following:
(1) The specific services delivered to the individual by
the companion, dated the day of service delivery, and the individual's
response;
(2) The companion's arrival and departure times;
(3) The companion's weekly comments or observations about
the individual to include observations of the individual's physical and
emotional condition, daily activities, and responses to services rendered; and
(4) The weekly signatures of the companion and the
individual or his family/caregiver, as appropriate, recorded on the last day of
service delivery for any given week to verify that companion services during
that week have been rendered.
12VAC30-120-777. [Reserved] Companion services (both
consumer-directed and agency-directed).
A. Service description. The service description shall be
the same as that set forth in 12VAC30-120-1023 A.
B. Criteria. The criteria shall be the same as those set
forth in 12VAC30-120-1023 B.
C. Service units and service limitations. The service
units and service limitations shall be the same as those set forth in
12VAC30-120-1023 C.
D. Provider requirements. The provider requirements shall
be the same as those set forth in 12VAC30-120-1023 D and 12VAC30-120-1059.
12VAC30-120-779. [Reserved] Individual and
family/caregiver training.
A. Service description. This service provides training and
counseling services to individuals, families, or caregivers of individuals
enrolled in the waiver including participation in education opportunities
designed to improve the family's or caregiver's ability to care for and support
the individual enrolled in the waiver. This service shall also provide
educational opportunities for the individual to better understand his
disability and increase his self-determination and self-advocacy.
B. Criteria. Any individuals who are enrolled in this
waiver and their family/caregivers, as appropriate, may participate in this
service. DMAS shall cover this service as authorized by the individual's plan
for supports.
C. Service units and limits.
1. This service may be authorized for up to 80 hours per
ISP year.
2. Travel and room and board expenses shall not be covered.
D. Provider requirements.
1. Providers shall have a signed, current provider
participation agreement with DMAS in order to be reimbursed for providing
individual and family/caregiver training.
2. Providers shall have the necessary licensure or
certification as required for their profession (i.e., RNs shall have a current
license to practice nursing in the Commonwealth or hold a multistate licensure
privilege).
3. This service shall be provided by enrolled provider
entities with expertise in, experience in, or demonstrated knowledge of the
training topic set out in the plan for supports.
4. This service may be provided through seminars and
conferences organized by the enrolled provider entities.
5. This service may also be provided by individual
practitioners who have experience in or demonstrated knowledge of the training
topics. This may include psychologists, teachers or educators, social workers,
medical personnel, personal care providers, therapists, and providers of other
services such as day and residential supports.
6. Qualified provider types include:
a. Staff of home health agencies;
b. Staff of community developmental disabilities services
agencies;
c. Staff of developmental disabilities residential
providers;
d. Staff of community mental health centers;
e. Staff of public health agencies, hospitals, clinics, or
other agencies/organizations; and
f. Individual practitioners including licensed or certified
personnel such as RNs, LPNs, psychologists, speech/language therapists,
occupational therapists, physical therapists, licensed clinical social workers,
licensed behavior analysts, and persons with other education, training, or
experience directly related to the specified needs of the individual as set out
in the ISP.
12VAC30-120-782. Payment for services.
A. All shared living, supported living residential,
in-home supports, group day services, community engagement, community coaching,
workplace assistance services, personal assistance (both agency-directed and
consumer-directed), respite services (both agency directed and consumer
directed), skilled nursing, private duty nursing, therapeutic consultation,
center-based crisis support services, community-based crisis support services,
crisis support services, PERS, environmental modifications, assistive
technology, companion (both agency-directed and consumer-directed), individual
and family/caregiver training, consumer-directed services facilitation, and
transition services provided in this waiver shall be reimbursed consistent with
DMAS service limits and payment amounts as set out in the fee schedule.
B. Reimbursement rates for individual supported employment
shall be the same as set by the Department for Aging and Rehabilitative
Services for the same services. Reimbursement rates for group supported
employment shall be as set by DMAS.
C. All EHBS, AT, and EM covered procedure codes provided
in the FIS Waiver shall be reimbursed as a service limit of one. The
maximum Medicaid funded expenditure per individual for all AT and EM covered
procedure codes (combined total of AT and EM items and labor related to these
items) shall be $5,000 each for AT and $5,000 for EM per calendar year. The
maximum expenditure for EHBS shall be $5,000 per calendar year. No additional
provider mark-ups shall be permitted.
D. Duplication of services.
1. DMAS shall not duplicate services that are required as a
reasonable accommodation as a part of the Americans with Disabilities Act (42
USC §§ 12131 through 12165), the Rehabilitation Act of 1973, the Virginians
with Disabilities Act, or any other applicable statute.
2. Payment for services under the ISP shall not
duplicate payments made to public agencies or private entities under other
program authorities for this same purpose.
3. Payment for services under the ISP shall not be made for
services that are duplicative of each other.
4. Payments for services shall only be provided as set out
in the individual's' ISP.
Part X
Intellectual Disability Community Living (CL) Waiver
Article 1
Definitions and General Requirements
12VAC30-120-1000. Definitions.
"AAIDD" means the American Association on
Intellectual and Developmental Disabilities.
"Activities of daily living" or "ADLs"
means personal care tasks, e.g., bathing, dressing, toileting, transferring,
and eating/feeding. An individual's degree of independence in performing these
activities is a part of determining appropriate level of care and service
needs.
"ADA" means the Americans with Disabilities Act
pursuant to 42 USC § 12101 et seq.
"Agency-directed model" means a model of service
delivery where an agency is responsible for providing direct support staff, for
maintaining individuals' records, and for scheduling the dates and times of the
direct support staff's presence in the individuals' homes.
"Appeal" means the process used to challenge
actions regarding services, benefits, and reimbursement provided by Medicaid
pursuant to 12VAC30-110 and 12VAC30-20-500 through 12VAC30-20-560.
"Applicant" means a person (or his representative
acting on his behalf) who has applied for or is in the process of applying for
and is awaiting a determination of eligibility for admission to a home and
community-based waiver or is on the waiver waiting list waiting for a slot to
become available.
"Assistive technology" or "AT" means
specialized medical equipment and supplies, including those devices, controls,
or appliances specified in the Individual Support Plan but not available under
the State Plan for Medical Assistance, which enable individuals to increase
their abilities to perform ADLs, or to perceive, control, or communicate with
the environment in which they live, or that are necessary to the proper
functioning of the specialized equipment.
"Barrier crime" means those crimes listed in
§§ 32.1-162.9:1, 37.2-314, 37.2-416, 37.2-506, 37.2-607, and
63.2-1719 of the Code of Virginia.
"Behavioral health authority" or "BHA"
means the local agency, established by a city or county under § 37.2-600
same as defined in § 37.2-600 of the Code of Virginia that
plans, provides, and evaluates mental health, intellectual disability (ID), and
substance abuse services in the locality that it serves.
"Behavioral specialist" means a person who
possesses any of the following credentials: (i) endorsement by the Partnership
for People with Disabilities at Virginia Commonwealth University as a positive
behavioral supports facilitator; (ii) board certification as a behavior analyst
(BCBA) or board certification as an associate behavior analyst (BCABA) as required
by § 54.1-2957.16 of the Code of Virginia; or (iii) licensure by the
Commonwealth as either a psychologist, a licensed professional counselor (LPC),
a licensed clinical social worker (LCSW), or a psychiatric clinical nurse
specialist.
"Case management" means the assessing and
planning of services; linking the individual to services and supports
identified in the Individual Support Plan; assisting the individual directly
for the purpose of locating, developing, or obtaining needed services and
resources; coordinating services and service planning with other agencies and
providers involved with the individual; enhancing community integration; making
collateral contacts to promote the implementation of the Individual Support
Plan and community integration; monitoring to assess ongoing progress and
ensuring services are delivered; and education and counseling that guides the
individual and develops a supportive relationship that promotes the Individual
Support Plan.
"Case manager" means the person who provides
case management services on behalf of the community services board or
behavioral health authority, as either an employee or a contractor, possessing
a combination of (ID) work experience and relevant education that indicates
that the individual possesses the knowledge, skills, and abilities as
established by DMAS in 12VAC30-50-450 delivers the support
coordination/case management services set out in 12VAC30-50-455.
"Center-based crisis support services" means
crisis prevention and stabilization in a crisis therapeutic home using planned
and emergency admissions. They are designed for those individuals who need
ongoing crisis supports.
"Centers for Medicare and Medicaid Services" or
"CMS" means the unit of the federal Department of Health and Human
Services that administers the Medicare and Medicaid programs.
"Challenging behavior" means culturally abnormal
behaviors of such intensity, frequency, and duration that the physical safety
of the individual or others is placed in serious jeopardy or that the behavior
limits access to ordinary community facilities. These behaviors include
withdrawal, self-injury, injury to others, aggression, or self-stimulation.
"CMS" means the Centers for Medicare and
Medicaid Services, which is the unit of the federal Department of Health and
Human Services that administers the Medicare and Medicaid programs.
"Community-based crisis support services" means
services to individuals who are experiencing crisis events putting them at risk
for homelessness, incarceration, hospitalization, or danger to themselves or
others. This service shall provide ongoing supports to individuals in their
homes and in community settings.
"Community coaching" means a service designed
for individuals who need one-to-one support in order to develop a specific
skill to address barriers preventing that individual from participating in the
community engagement services.
"Community engagement" means services that
support and foster individuals' abilities to acquire, retain, or improve skills
necessary to build positive social behavior, interpersonal competence, greater
independence, employability, and personal choice necessary to access typical
activities and functions of community life such as those chosen by the general
population.
"Community Living Waiver" or "CL
Waiver" means the waiver set out in 12VAC30-120-1000 et seq.
"Community services board" or "CSB" means
the local agency, established by a city or county or combination of counties
or cities under Chapter 5 (§ 37.2-500 et seq.) of Title 37.2 of the Code
of Virginia, that plans, provides, and evaluates mental health, ID, and
substance abuse services in the jurisdiction or jurisdictions it serves same
as defined in § 37.2-100 of the Code of Virginia.
"Companion" means a person who provides companion
services for compensation by DMAS.
"Companion services" means nonmedical care,
support, and socialization provided to an adult (ages 18 years and over). The
provision of companion services does not entail routine hands-on care.
It is provided in accordance with a therapeutic outcome goal in
the Individual Support Plan and is not purely diversional in nature.
"Complex behavioral needs" means conditions
requiring exceptional supports in order to respond to the individual's
significant safety risk to self or others and documented by the Supports
Intensity Scale® (SIS®) Virginia Supplemental Risk
Assessment form (2010) as described in 12VAC30-120-1012.
"Complex medical needs" means conditions requiring
exceptional supports in order to respond to the individual's significant health
or medical needs requiring frequent hands-on care and medical oversight and
documented by the Supports Intensity Scale (SIS) Virginia Supplemental Risk
Assessment form (2010) as described in 12VAC30-120-1012.
"Comprehensive assessment" means the gathering of
relevant social, psychological, medical, and level of care information by the
case manager and is used as a basis for the development of the Individual
Support Plan.
"Congregate residential support" or
"CRS" means those supports in which the residential support
services provider renders primary care (room, board, general supervision) and
residential support services to the individual in the form of continuous (up to
24 hours per day) services performed by paid staff who shall be physically
present in the home. These supports may be provided individually or
simultaneously to more than one individual living in that home, depending on
the required support. These supports are typically provided to an individual
living (i) in a group home, (ii) in the home of the ID Waiver services provider
(such as adult foster care or sponsored residential), or (iii) in an apartment
or other home setting.
"Consumer-directed model" means a model of
service delivery for which the individual or the individual's employer of
record, as appropriate, is responsible for hiring, training, supervising, and
firing of the person or persons who render the direct support or services
reimbursed by DMAS
"Crisis stabilization" means direct intervention
to individuals with ID who are experiencing serious psychiatric or behavioral
challenges that jeopardize their current community living situation, by
providing temporary intensive services and supports that avert emergency
psychiatric hospitalization or institutional placement or prevent other
out-of-home placement. This service shall be designed to stabilize the
individual and strengthen the current living situation so the individual can be
supported in the community during and beyond the crisis period.
"Consumer-directed attendant" or "CD
attendant" means a person who provides via the consumer-directed model of
services, person assistance services, companion services, or respite services,
or any combination of these three services, and who is also exempt from
workers' compensation.
"Consumer direction" means a model of service
delivery for which the individual or the individual's employer of record, as
appropriate, is responsible for hiring, training, supervising, and firing of
the person or persons who render the direct support or services reimbursed by
DMAS.
"Crisis support services" means intensive
supports by trained and, where applicable, licensed staff in crisis prevention,
crisis intervention, and crisis stabilization to an individual who is
experiencing an episodic behavioral or psychiatric event in the community that
has the potential to jeopardize the current community living situation.
"DARS" means the Department for Aging and
Rehabilitative Services.
"DBHDS" means the Department of Behavioral Health
and Developmental Services.
"DBHDS staff" means persons employed by or
contracted with DBHDS.
"Developmental disability" or "DD"
means the same as defined in § 37.2-100 of the Code of Virginia.
"Direct marketing" means either (i) conducting
directly or indirectly door-to-door, telephonic, or other "cold call"
marketing of services at residences and provider sites; (ii) mailing directly;
(iii) paying "finder's fees"; (iv) offering financial incentives,
rewards, gifts, or special opportunities to eligible individuals and the
individual's family/caregivers, as appropriate, as inducements to use the
provider's services; (v) continuous, periodic marketing activities to the same
prospective individual and the individual's family/caregiver, for example,
monthly, quarterly, or annual giveaways as inducements to use the provider's
services; or (vi) engaging in marketing activities that offer potential customers
rebates or discounts in conjunction with the use of the provider's services or
other benefits as a means of influencing the individual's and the individual's
family/caregivers use of the provider's services.
"Direct support professional" or "DSP"
means staff members identified by the provider as having the primary role of
assisting an individual on a day-to-day basis with routine personal care needs,
social support, and physical assistance in a wide range of daily living
activities so that the individual can lead a self-directed life in his own
community.
"DMAS" means the Department of Medical Assistance
Services.
"DMAS staff" means persons employed by or
contracted with DMAS.
"Day support" means services that promote skill
building and provide supports (assistance) and safety supports for the
acquisition, retention, or improvement of self-help, socialization, and
adaptive skills, which typically take place outside the home in which the
individual resides. Day support services shall focus on enabling the individual
to attain or maintain his highest potential level of functioning.
"Developmental risk" means the presence before,
during, or after an individual's birth, of conditions typically identified as
related to the occurrence of a developmental disability and for which no
specific developmental disability is identifiable through existing diagnostic
and evaluative criteria.
"Direct marketing" means either (i) conducting
directly or indirectly door-to-door, telephonic, or other "cold call"
marketing of services at residences and provider sites; (ii) mailing directly;
(iii) paying "finders' fees"; (iv) offering financial incentives,
rewards, gifts, or special opportunities to eligible individuals and the
individual's family/caregivers, as appropriate, as inducements to use the
providers' services; (v) continuous, periodic marketing activities to the same
prospective individual and the individual's family/caregiver, as appropriate -
for example, monthly, quarterly, or annual giveaways as inducements to use the
providers' services; or (vi) engaging in marketing activities that offer
potential customers rebates or discounts in conjunction with the use of the
providers' services or other benefits as a means of influencing the
individual's and the individual's family/caregivers, as appropriate, use of the
providers' services.
"DSS" means the Virginia Department of Social
Services.
"Electronic home-based supports" or
"EHBS" means goods and services based on current technology, such as
Smart Home©, and includes purchasing electronic devices, software,
services, and supplies not otherwise covered through other benefits in the CL
Waiver or through the State Plan for Medical Assistance that allows individuals
to use technology in their residences to achieve greater independence and
self-determination and reduce the need for human intervention.
"Employer of record" or "EOR" means the
person who performs the functions of the employer in the consumer directed
model of service delivery. The EOR may be the individual enrolled in the
waiver, or a family member, a caregiver, or another designated
person, as appropriate, when the individual is unable to perform the
employer functions.
"Enroll" means that the individual has been
determined by the case manager to meet the level of functioning requirements
for the ID Waiver and DBHDS has verified the availability of an ID Waiver slot
for that individual. Financial eligibility determinations and enrollment in
Medicaid are set out in 12VAC30-120-1010 the same as defined in
12VAC30-120-501.
"Entrepreneurial model" means a small business
employing a shift of eight or fewer individuals who have disabilities and
usually involves interactions with the public and coworkers who do not have
disabilities.
"Environmental modifications" or "EM"
means physical adaptations to a primary place of residence the
individual's home or primary vehicle, or work site (when the work site
modification exceeds reasonable accommodation requirements of the Americans
with Disabilities Act) that are necessary to ensure the individual's health
and safety welfare or enable functioning with greater
independence when the adaptation is not being used to bring a substandard
dwelling up to minimum habitation standards. Such EM shall be of direct medical
or remedial benefit to the individual.
"EPSDT" means the Early and Periodic
Screening, Diagnosis and Treatment program administered by DMAS for children
under the age of 21 years according to federal guidelines (that
prescribe preventive and treatment services for Medicaid eligible children) as
defined in 12VAC30-50-130.
"ES service authorization" means the process of
approving an individual, by either DMAS or its designated service authorization
contractor, for the purpose of receiving exceptional supports. ES service
authorization shall be obtained before exceptional supports to the individual
are rendered.
"Exceptional reimbursement rate" or
"exceptional rate" means a rate of reimbursement for congregate
residential supports paid to providers who qualify to receive the exceptional
rate set out in 12VAC30-120-1062.
"Exceptional supports" or "exceptional support
services" means a qualifying level of supports, as more fully described in
12VAC30-120-1012, that are medically necessary for individuals with complex
medical or behavioral needs, or both, to safely reside in a community setting.
The need for exceptional supports is demonstrated when the funding required to
meet the individual's needs has been expended on a consistent basis by providers
in the past 90 days for medical or behavioral supports, or both, over and above
the current maximum allowable CRS rate in order to support the individual in a
manner that ensures his health and safety.
"Face-to-face visit" means an in-person meeting
between the support coordinator/case manager and individual, and
family/caregiver, as appropriate, for the purpose of assessing the individual's
status and determining satisfaction with services, including the need for
additional services and supports.
"Fiscal employer/agent" means a state agency or
other entity as determined by DMAS to meet the requirements of 42 CFR
441.484 and the Virginia Public Procurement Act (Chapter 43 (§ 2.2-4300 et
seq.) of Title 2.2 of the Code of Virginia).
"Freedom of choice" means the right afforded an
individual who is determined to require a level of care specified in a waiver
to choose (i) either institutional or home and community-based services
provided there are available CMS-allocated and state-funded slots; (ii) providers
of services; and (iii) waiver services as may be limited by medical necessity
same as defined in § 1902(a)(23) of the Social Security Act.
"General supports" means staff presence to
ensure that appropriate action is taken in an emergency or an unanticipated
event and includes (i) awake staff during nighttime hours; (ii) routine bed
checks; (iii) oversight of unstructured activities; (iv) asleep staff at night
on premises for security or safety reasons, or both; or (v) on-call staff.
"Group day services" means services for the
individual to acquire, retain, or improve skills of self-help, socialization,
community integration, employability and adaptation via opportunities for peer
interactions, community integration, and enhancement of social networks.
"Group home residential services" means
skill-building, routine supports, general supports, and safety supports that
are provided primarily in a licensed residence that enable the individual to
acquire, retain, or improve skills necessary to successfully live in the
community.
"Group supported employment services" means
continuous support provided by staff in a naturally occurring place of
employment to groups of two to eight individuals with developmental
disabilities and involves interactions with the public and coworkers who do not
have developmental disabilities.
"Health planning region" or "HPR"
means the federally designated geographical area within which health care needs
assessment and planning takes place, and within which health care resource development
is reviewed.
"Health, safety, and welfare standard" means the
standard that is applied when an individual who is enrolled in a DD waiver
requests additional waiver services. It is the standard applied to ensure that
an individual's right to receive a waiver service is dependent on a finding
that the individual needs the service, based on appropriate assessment criteria
and a written, approved individual plan for supports, and that services
can be safely provided in the community.
"Home and community-based waiver services" or
"waiver services" means the range of community services approved by
the CMS, pursuant to § 1915(c) of the Social Security Act, to be offered to
persons as an alternative to institutionalization.
"IDOLS" means Intellectual Disability Online
System.
"In-home residential support services" means
support provided in a private residence by a DBHDS-licensed residential
provider to an individual enrolled in the waiver to include: (i) skill building
and supports and safety supports to enable individuals to maintain or improve
their health; (ii) developing skills in daily living; (iii) safely using
community resources; (iv) being included in the life of the community and home;
(v) developing relationships; and (vi) participating as citizens of the
community. In-home residential support services shall not replace the primary
care provided to the individual by his family and caregiver but shall be
supplemental to it.
"ICF/IID" means a facility or distinct part of a
facility licensed by DBHDS and meeting the federal certification regulations
for an intermediate care facility for individuals with intellectual
disabilities and individuals with related conditions and that addresses the
total needs of the individuals, which include physical, intellectual, social,
emotional, and habilitation, and provides active treatment as defined in 42 CFR
483.440.
"Incremental step-down provisions" means procedures
normally found in plans for supports in which an individual's supports are
gradually altered or reduced based upon progress towards meeting the goals of
the individual's behavior plan.
"Individual" means the person receiving the
services or evaluations established in this chapter the same as defined
in 12VAC30-120-501.
"Individual supported employment" means
one-on-one ongoing supports that enable individuals for whom competitive
employment at or above the minimum wage is unlikely absent the provision of
supports to work in an integrated setting.
"Individual Support Plan" or "ISP" means
a comprehensive, person-centered plan that sets out the supports and
actions to be taken during the year by each service provider, as detailed in the
each service provider's Plan for Supports, which are part of the ISP,
to achieve desired outcomes. The Individual Support Plan shall be developed collaboratively
by the individual enrolled in the waiver, the individual's family/caregiver, as
appropriate, other service providers such as the case manager,
the support coordinator/case manager, and other interested parties chosen by
the individual, and shall contain the DMAS-approved ISP components
essential information, what is important to the individual on a day-to-day
basis and in the future, and what is important for the individual to be healthy
and safe as reflected in the Plan for Supports. The Individual Support
Plan is known as the Consumer Service Plan in the Day Support Waiver.
"In-home support services" means residential
services that take place in the individual's home, family home, or community
settings that typically supplement the primary care provided by the individual,
family, or other unpaid caregiver and are designed to ensure the health, safety
and welfare of the individual.
"Instrumental activities of daily living" or
"IADLs" means tasks complex skills needed to successfully
live independently such as meal preparation, shopping, housekeeping,
laundry, and money management.
"Intellectual disability" or "ID"
means a disability as defined by the American Association on Intellectual and
Developmental Disabilities (AAIDD) in the Intellectual Disability: Definition,
Classification, and Systems of Supports (11th edition, 2010).
"ICF/IID" means a facility or distinct part of a
facility certified by the Virginia Department of Health as meeting the federal
certification regulations for an intermediate care facility for individuals
with intellectual disability and persons with related conditions and that
addresses the total needs of the residents, which include physical,
intellectual, social, emotional, and habilitation providing active treatment as
defined in 42 CFR 435.1010 and 42 CFR 483.440.
"Licensed practical nurse" or "LPN" means
a person who is licensed or holds multi-state licensure privilege pursuant to
Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia to
practice practical nursing as defined in § 54.1-3000 of the Code of
Virginia.
"LMHP" means a licensed mental health
professional as defined in 12VAC35-105-20.
"LMHP-resident" means the same as defined in
12VAC30-50-130.
"LMHP-RP" means the same as defined in
12VAC30-50-130.
"LMHP-supervisee" means the same as defined in
12VAC30-50-130.
"Medicaid Long-Term Care Communication Form" or
"DMAS-225" means the form used by the case support
coordinator/case manager to report information about changes in an
individual's situation.
"Medically necessary" means an item or service
provided for the diagnosis or treatment of an individual's condition consistent
with community standards of medical practice as determined by DMAS and in
accordance with Medicaid policy.
"Parent" or "parents" means a person or
persons who is or are biologically or naturally related, a foster parent, or an
adoptive parent to the individual enrolled in the waiver.
"Participating provider" means an entity that meets
the standards and requirements set forth by DMAS and has a current, signed
provider participation agreement with DMAS.
"Pend" means delaying the consideration of an
individual's request for authorization of services until all required
information is received by DBHDS DMAS or its designee.
"Person-centered planning" means a fundamental
process that focuses on what is important to and for an individual and on
the needs and preferences of the individual to create an Individual Support
Plan that shall contain essential information, a personal profile, and
desired outcomes of the individual to be accomplished through waiver services
and included in the providers' Plans for Supports.
"Personal assistance services" means assistance
direct support with ADLs, IADLs, access to the community, monitoring
of self-administration of medication or other medical needs, and the
monitoring of health status and physical condition or work or post-secondary
school related personal assistance.
"Personal assistant" means a person who provides
personal assistance services employed by a provider agency.
"Personal emergency response system" or
"PERS" means an electronic device and monitoring service that enable
certain individuals at high risk of institutionalization to secure help in an
emergency. PERS services shall be limited to those individuals who live
alone or are alone for significant parts of the day and who have no regular
caregiver for extended periods of time and who would otherwise require extensive
routine supervision.
"Personal profile" means a point-in-time synopsis
of what an individual enrolled in the waiver wants to maintain, change, or
improve in his life and shall be completed by the individual and another
person, such as his case manager support coordinator/case manager
or family/caregiver, chosen by the individual to help him plan before the
annual planning meeting where it is discussed and finalized.
"Plan for Supports" means each service provider's
plan for supporting the individual enrolled in the waiver in achieving his
desired outcomes and facilitating the individual's health and safety. The Plan
for Supports is one component of the Individual Support Plan. The Plan for
Supports is referred to as an Individual Service Plan in the Day Support and
Individual and Family with Developmental Disability Services (IFDDS) Waivers.
"Prevocational services" means services aimed at
preparing an individual enrolled in the waiver for paid or unpaid employment.
The services do not include activities that are specifically job-task oriented
but focus on concepts such as accepting supervision, attendance at work, task
completion, problem solving, and safety. Compensation for the individual, if
provided, shall be less than 50% of the minimum wage.
"Positive behavior support" means an applied
science that uses educational methods to expand an individual's behavior
repertoire and systems, change methods to redesign an individual's living
environment to enhance the individual's quality of life, and minimize his
challenging behaviors.
"Primary caregiver" means the primary person who
consistently assumes the role of providing direct care and support of without
compensation for such care to the individual enrolled in the waiver to
enable him to live successfully in the community without compensation
for providing such care.
"Private duty nursing services" means individual
and continuous nursing care to individuals that may be provided, concurrently
with other services, due to the medical nature of supports required by
individuals who have a serious medical condition or complex health care needs,
or both, and that has been certified by a physician as medically necessary to
enable the individual to remain at home rather than in a hospital, nursing
facility, or ICF/IID.
"Progressive condition" means disease or health
condition that gets worse over time, resulting in general decline in health or
function, including aging.
"Qualified developmental disabilities
professional" or "QDDP" means a professional who (i) possesses
at least one year of documented experience working directly with individuals
who have developmental disabilities; (ii) is one of the following: a doctor of
medicine or osteopathy, a registered nurse, a provider holding at least a
bachelor's degree in a human service field including, but not limited to,
sociology, social work, special education, rehabilitation engineering,
counseling, or psychology, or a provider who has documented equivalent
qualifications; and (iii) possesses the required Virginia or national license,
registration, or certification in accordance with his profession, if
applicable.
"Qualified mental retardation professional" or
"QMRP" for the purposes of the ID Waiver means the same as defined at
12VAC35-105-20.
"Qualifying individual" means an individual who has
received an ES service authorization from DMAS or its service authorization
contractor to receive exceptional supports.
"Registered nurse" or "RN" means a person
who is licensed or holds multi-state licensure privilege pursuant to Chapter 30
(§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia to practice
professional nursing.
"Residential support services" means support
provided in the individual's home by a DBHDS-licensed residential provider or a
VDSS-approved provider of adult foster care services. This service is one in
which skill-building, supports, and safety supports are routinely provided to
enable individuals to maintain or improve their health, to develop skills in
daily living and safely use community resources, to be included in the
community and home, to develop relationships, and to participate as citizens in
the community.
"Respite services" means services provided to
individuals who are unable to care for themselves, furnished on a short-term
basis because of the absence or need for relief of those unpaid persons
normally providing the care temporary, substitute care that is normally
provided by the family or other unpaid, primary caregiver who resides in the
same home as the individual. Services shall be provided on a short-term
basis due to the emergency absence of or need for routine or periodic relief of
the primary caregiver.
"Review committee" means DBHDS staff, including a
trained SIS® specialist approved by DBHDS, a behavior specialist, a
registered nurse, and a master's level social worker, and other staff as may be
otherwise constituted by DBHDS, who will evaluate and make a determination
about applications for the congregate residential support services and CRS
exceptional reimbursement rate for compliance with regulatory requirements.
"Risk assessment" means an assessment that is
completed by the case manager support coordinator/case manager to
determine areas of high risk of danger to the individual or others based on the
individual's serious medical or behavioral factors. The required risk
assessment for the ID Waiver each waiver shall be found in the
state-designated assessment form which may be supplemented with other
information. The risk assessment shall be used to plan risk mitigating supports
for the individual in the Individual Support Plan.
"Routine supports" means supports that assist
the individual with daily activities.
"Safety supports" means specialized
assistance that is required to assure the health and welfare of an
individual ensure an individual's health and safety.
"Service authorization" means the process
approving by either DMAS or its designated service authorization contractor,
for the purpose of DMAS' reimbursement, the service for the individual before
it is rendered.
"Service authorization" means the process to
approve specific services for an enrolled Medicaid individual by a DMAS service
authorization designee prior to service delivery and reimbursement in order to
validate that the service requested is medically necessary and meets DMAS
requirements for reimbursement. Service authorization does not guarantee
payment for the service.
"Services facilitation" means a service that
assists the individual or the individual's family/caregiver, or EOR, as
appropriate, in arranging for, directing, and managing services provided
through the consumer-directed model of service delivery.
"Services facilitator" means the DMAS-enrolled
provider who is responsible for supporting the individual or the individual's
family/caregiver, or EOR, as appropriate, by collaborating with the case
manager to ensure the development and monitoring of the CD Services Plan for
Supports, providing employee management training, and completing ongoing review
activities as required by DMAS for consumer-directed companion, personal
assistance, and respite services.
"Services facilitator" means a DMAS-enrolled
provider or DMAS-designated entity or one who is employed by or contracts with
a DMAS-enrolled services facilitator, who is responsible for supporting the individual
or EOR, as appropriate, by ensuring the development and monitoring of the Plan
for Supports for consumer-directed model of services, providing employee
management training, and completing ongoing review activities as required by
the DMAS-approved consumer-directed model of services. "Services
facilitator" shall be deemed to mean the same thing as
"consumer-directed services facilitator."
"Shared living" means an arrangement in which a
roommate resides in the same household as the individual receiving waiver
services and provides an agreed-upon, limited amount of supports. In exchange
for providing the agreed-upon support, a portion of the total cost of rent,
food, and utilities that can be reasonably attributed to the live-in roommate
is reimbursed to the individual.
"Significant change" means, but shall not be
limited to, includes a change in an individual's condition that is
expected to last longer than 30 calendar days but shall not include short-term
changes that resolve with or without intervention, a short-term acute illness
or episodic event, or a well-established, predictive, cyclical pattern of
clinical signs and symptoms associated with a previously diagnosed condition
where an appropriate course of treatment is in progress.
"Skill building supports" means those supports
that help the individual gain new skills and abilities and was previously
called training.
"Skilled nursing services" means both skilled
and hands-on care, as rendered by either a licensed RN or LPN, of either a
supportive or health-related nature and may include, but shall not be limited
to, all skilled nursing care as ordered by the attending physician and
documented on the Plan for Supports, assistance with ADLs, administration of
medications or other medical needs, and monitoring of the health status and
physical condition of the individual enrolled in the waiver. nursing
services (i) listed in the plan of care that do not meet home health criteria,
(ii) required to prevent institutionalization, (iii) not otherwise available
under the State Plan for Medical Assistance, (iv) provided within the scope of
§ 54.1-3000 et seq. of the Code of Virginia and the Drug Control Act (§
54.1-3400 et seq. of the Code of Virginia), and (v) provided by a registered
nurse or by a licensed practical nurse under the supervision of a registered
nurse who is licensed to practice in the state. Skilled nursing services are to
be used to provide training, consultation, nurse delegation as appropriate, and
oversight of direct care staff as appropriate.
"Slot" means an opening or vacancy in waiver
services for an individual.
"Sponsored residential services" means
residential services that consist of skill-building, routine supports, general
supports, and safety supports provided in the homes of families or persons
(sponsors) providing supports under the supervision of a DBHDS-licensed provider
that enable an individual to acquire, retain, or improve the self-help,
socialization, and adaptive skills necessary to reside successfully in home and
community settings.
"State Plan for Medical Assistance" or
"Plan" means the Commonwealth's legal document approved by CMS
identifying the covered groups, covered services and their limitations, and
provider reimbursement methodologies as provided for under Title XIX of the
Social Security Act.
"Support coordination/case management" means the
same as defined in 12VAC30-50-455 D.
"Support coordinator/case manager" means the
person who provides support coordination/case management services to an
individual in accordance with 12VAC30-50-455.
"Supports" means paid and nonpaid assistance that
promotes the accomplishment of an individual's desired outcomes. There shall be
three four types of supports: (i) routine supports that assist
the individual in daily activities; (ii) skill building supports that to
help the individual gain new abilities; and (iii) safety supports that
are required to assure the individual's health and safety; and (iv) general
supports that provide general oversight.
"Supported employment" means paid supports
provided in work settings in which persons without disabilities are typically
employed. Paid supports include skill-building supports related to paid
employment, ongoing or intermittent routine supports, and safety supports to
enable an individual with ID to maintain paid employment.
"Supported living residential services" means a
service taking place in an apartment setting operated by a DBHDS-licensed
provider that consist of skill-building, routine supports, general supports,
and safety supports that enable the individual to acquire, retain, or improve
self-help, socialization, and adaptive skills necessary to successfully live in
home and community settings.
"Support plan" means the report of
recommendations resulting from a therapeutic consultation.
"Supports Intensity Scale®" or "SIS®"
means a tool, developed by the American Association on Intellectual and
Developmental Disabilities that measures the intensity of an individual's
support needs for the purpose of assessment, planning, and aligning resources
to enhance personal independence and productivity the same as defined in
12VAC30-120-501.
"Therapeutic consultation" means covered
services designed to assist the individual and the individual's
family/caregiver, as appropriate, with assessments, plan design, and teaching
for the purpose of assisting the individual enrolled in the waiver professional
consultation provided by members of psychology, social work, rehabilitation
engineering, behavioral analysis, speech therapy, occupational therapy,
psychiatry, psychiatric clinical nursing, therapeutic recreation, physical
therapy, or behavior consultation disciplines that are designed to assist
individuals, parents, family members, and any other providers of support
services with implementing the Individual Support Plan.
"Therapeutic consultation plan" means the report
of recommendations resulting from a therapeutic consultation.
"Transition services" means set-up expenses the
same as defined in 12VAC30-120-2010.
"VDSS" means the Virginia Department of Social
Services.
"Workplace assistance services" means supports
provided to an individual who has completed job development and has completed
or nearly completed job placement training (i.e., supported employment) but
requires more than typical job coach services to maintain stabilization in
their employment.
12VAC30-120-1005. Waiver description and legal authority
service population and provider requirements.
A. Home and community-based waiver services shall be
available through a § 1915(c) waiver of the Social Security Act. Under
this waiver, DMAS has waived § 1902(a) (10) (B) and (C) of the Social
Security Act related to comparability of services. These services shall be
appropriate and necessary to maintain the individual in the community.
B. Federal waiver requirements, as established in
§ 1915 of the Social Security Act and 42 CFR 430.25, provide that the
average per capita fiscal year expenditures in the aggregate under this waiver
shall not exceed the average per capita expenditures for the level of care
provided in an ICF/ID, as defined in 42 CFR 435.1010 and 42 CFR 483.440, under
the State Plan that would have been provided had the waiver not been granted.
C. DMAS shall be the single state agency authority
pursuant to 42 CFR 431.10 responsible for the processing and payment of claims
for the services covered in this waiver and for obtaining federal financial
participation from CMS. The Department of Behavioral Health and Developmental
Services (DBHDS) shall be responsible for the daily administrative supervision
of the ID Waiver in accordance with the interagency agreement between DMAS and
DBHDS.
D. Any of the services covered under the authority of this
waiver shall be required in order for the individual to avoid
institutionalization.
E. A. Waiver service populations. These waiver
services shall be provided for the following individuals who have been
determined to require the level of care provided in an ICF/ID ICF/IID:
1. Individuals with ID; or DD.
2. Individuals younger than the age of six who are at
developmental risk. At the age of six years, these individuals must have
a diagnosis of ID to continue to receive these home and community-based waiver
services.
Individuals enrolled in the waiver who attain the age of
six years of age, who are determined not to have a diagnosis of ID, and who
meet all Individual and Family Developmental Disability Support (IFDDS) Waiver
eligibility criteria, shall be eligible to apply for transfer to the IFDDS
Waiver for the period of time up to their seventh birthday. Psychological
evaluations or standardized development assessments confirming individuals'
diagnoses must be completed less than one year prior to transferring to the
IFDDS Waiver. These individuals transferring from the ID Waiver will be assigned
a slot in the IFDDS Waiver, if one is available. The case manager shall submit
the current Level of Functioning Survey, Individual Support Plan, and
psychological evaluation (or standardized developmental assessment for children
under six years of age) to DMAS for review. Upon determination by DMAS that the
individual is appropriate for transfer to the IFDDS Waiver and there is a slot
available for the child, the ID case manager shall provide the family with a
list of IFDDS Waiver case managers. The ID case manager shall work with the
selected IFDDS Waiver case manager to determine an appropriate transfer date
and shall submit a DMAS-225 to the local department of social services. The ID
Waiver slot shall be held by the CSB until the child has successfully
transitioned to the IFDDS Waiver. Once the child's transition into the IFDDS
Waiver is complete, the CSB shall reallocate the ID slot to another individual
on the waiting list.
F. ID services shall not be offered or provided to an
individual who resides outside of the physical boundaries of the United States
or the Commonwealth. Waiver services shall not be furnished to individuals who
are inpatients of a hospital, nursing facility, ICF/ID, or inpatient
rehabilitation facility. Individuals with ID who are inpatients of these
facilities may receive case management services as described in 12VAC30-50-450.
The case manager may recommend waiver services that would promote exiting from
the institutional placement; however, these waiver services shall not be provided
until the individual has exited the institution.
G. An individual shall not be simultaneously enrolled in
more than one waiver.
H. DMAS shall be responsible for assuring appropriate
placement of the individual in home and community-based waiver services and
shall have the authority to terminate such services for the individual who no
longer qualifies for the waiver. Termination from this waiver shall occur when
the individual's health and medical needs can no longer be safely met by waiver
services in the community.
I. No waiver services shall be reimbursed until after both
the provider enrollment process and individual eligibility process have been
completed.
B. Core competency requirements for direct support
professionals (DSPs) and their supervisors in programs licensed by DBHDS shall
be the same as those set forth in 12VAC30-120-515 A.
C. Core competency requirements for support
coordinators/case managers. (Reserved.)
D. Core competency requirements for QDDPs. (Reserved.)
E. Advanced core competency requirements for DSPs and DSP
supervisors serving individuals with developmental disabilities with the most
intensive needs as identified by assignment to levels 5, 6, or 7 shall be the
same as those set forth in 12VAC30-120-515 D.
F. Provider enrollment requirements shall be the same as
those set forth in 12VAC30-120-514.
G. Documentation requirements shall be the same as those
set forth in 12VAC30-120-514 Q.
H. Reevaluation of service need requirements shall be the
same as those set forth in 12VAC30-120-515 F.
I. Utilization review requirements shall be the same as
those set forth in 12VAC30-120-515 G.
12VAC30-120-1010. Individual eligibility requirements. (Repealed.)
A. Individuals receiving services under this waiver must
meet the following Medicaid eligibility requirements. The Commonwealth shall
apply the financial eligibility criteria contained in the State Plan for the
categorically needy. The Commonwealth covers the optional categorically needy
groups under 42 CFR 435.211, 42 CFR 435.217, and 42 CFR 435.230.
1. The income level used for 42 CFR 435.211, 42 CFR
435.217 and 42 CFR 435.230 shall be 300% of the current Supplemental Security
Income (SSI) payment standard for one person.
2. Under this waiver, the coverage groups authorized under
§ 1902(a)(10)(A)(ii)(VI) of the Social Security Act shall be considered as
if they were institutionalized for the purpose of applying institutional
deeming rules. All individuals under the waiver must meet the financial and
nonfinancial Medicaid eligibility criteria and meet the institutional
level-of-care criteria. The deeming rules shall be applied to waiver eligible
individuals as if the individuals were residing in an institution or would
require that level of care.
3. The Commonwealth shall reduce its payment for home and
community-based waiver services provided to an individual who is eligible for
Medicaid services under 42 CFR 435.217 by that amount of the individual's
total income (including amounts disregarded in determining eligibility) that
remains after allowable deductions for personal maintenance needs, other
dependents, and medical needs have been made, according to the guidelines in 42
CFR 435.735 and § 1915(c)(3) of the Social Security Act as amended by the
Consolidated Omnibus Budget Reconciliation Act of 1986. DMAS shall reduce its
payment for home and community-based waiver services by the amount that remains
after the deductions listed in this subdivision:
a. For individuals to whom § 1924(d) applies and for
whom the Commonwealth waives the requirement for comparability pursuant to §
1902(a)(10)(B), DMAS shall deduct the following in the respective order:
(1) The basic maintenance needs for an individual under
this waiver, which shall be equal to 165% of the SSI payment for one person. As
of January 1, 2002, due to expenses of employment, a working individual shall
have an additional income allowance. For an individual employed 20 hours or
more per week, earned income shall be disregarded up to a maximum of both
earned and unearned income up to 300% SSI; for an individual employed at least
eight but less than 20 hours per week, earned income shall be disregarded up to
a maximum of both earned and unearned income up to 200% of SSI. If the
individual requires a guardian or conservator who charges a fee, the fee, not
to exceed an amount greater than 5.0% of the individual's total monthly income,
is added to the maintenance needs allowance. However, in no case shall the
total amount of the maintenance needs allowance (basic allowance plus earned income
allowance plus guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with only a spouse at home, the
community spousal income allowance determined in accordance with § 1924(d)
of the Social Security Act.
(3) For an individual with a family at home, an additional
amount for the maintenance needs of the family determined in accordance with §
1924(d) of the Social Security Act.
(4) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including Medicare and
other health insurance premiums, deductibles or coinsurance charges, and
necessary medical or remedial care recognized under state law but not covered
under the plan.
b. For individuals to whom § 1924(d) does not apply
and for whom the Commonwealth waives the requirement for comparability pursuant
to § 1902(a)(10)(B), DMAS shall deduct the following in the respective
order:
(1) The basic maintenance needs for an individual under
this waiver, which is equal to 165% of the SSI payment for one person. As of
January 1, 2002, due to expenses of employment, a working individual shall have
an additional income allowance. For an individual employed 20 hours or more per
week, earned income shall be disregarded up to a maximum of both earned and
unearned income up to 300% SSI; for an individual employed at least eight but
less than 20 hours per week, earned income shall be disregarded up to a maximum
of both earned and unearned income up to 200% of SSI. If the individual
requires a guardian or conservator who charges a fee, the fee, not to exceed an
amount greater than 5.0% of the individual's total monthly income, is added to
the maintenance needs allowance. However, in no case shall the total amount of
the maintenance needs allowance (basic allowance plus earned income allowance
plus guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with a dependent child or children,
an additional amount for the maintenance needs of the child or children, which
shall be equal to the Title XIX medically needy income standard based on the
number of dependent children.
(3) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including Medicare and
other health insurance premiums, deductibles or coinsurance charges, and
necessary medical or remedial care recognized under state law but not covered
under the State Plan for Medical Assistance.
B. The following four criteria shall apply to all
individuals who have ID who seek these waiver services:
1. Individuals qualifying for ID Waiver services shall have
a demonstrated need for the service due to significant functional limitations
in major life activities. The need for these waiver services shall arise from
either (i) an individual having a diagnosed condition of ID or (ii) a child
younger than six years of age being at developmental risk of significant
functional limitations in major life activities;
2. Individuals qualifying for ID Waiver services shall meet
the ICF/ID level-of-care criteria;
3. The Individual Support Plan and services that are
delivered shall be consistent with the Medicaid definition of each service; and
4. Services shall be recommended by the case manager based
on his documentation of the need for each specific service as reflected in a
current assessment using a DBHDS-approved SIS instrument, or for children
younger than five years of age, an alternative industry assessment instrument,
such as the Early Learning Assessment Profile, and authorized by DBHDS.
C. Assessment and enrollment.
1. To ensure that Virginia's home and community-based
waiver programs serve only individuals who would otherwise be placed in an
ICF/ID, home and community-based waiver services shall be considered only for
individuals who are eligible for admission to an ICF/ID due to their diagnoses
of ID, or individuals who are younger than six years of age and who are at
developmental risk. For the case manager to make a recommendation for waiver
services, ID Waiver services must be determined to be an appropriate service
alternative to delay or avoid placement in an ICF/ID, or to promote exiting
from an ICF/ID or other institutional placement.
2. The case manager shall recommend the individual for home
and community-based waiver services after determining diagnostic and functional
eligibility. This determination shall be mandatory before DMAS assumes payment
responsibility of home and community-based waiver services and shall include:
a. The required level-of-care determination by applying the
existing DMAS ICF/ID criteria (Part VI (12VAC30-130-430 et seq.) of the Amount,
Duration and Scope of Selected Services Regulation) to be completed no more
than six months prior to enrollment. The case manager determines whether the
individual meets the ICF/ID criteria with input from the individual and the
individual's family/caregiver, as appropriate, and service and support
providers involved in the individual's support; and
b. A psychological evaluation or standardized developmental
assessment for children who are younger than six years of age that reflects the
current psychological status (diagnosis), current cognitive abilities, and
current adaptive level of the individual's functioning.
3. The case manager shall provide the individual and the
individual's family/caregiver, as appropriate, with the choice of ID Waiver
services or ICF/ID placement.
4. The case manager shall enroll the individual in the ID
Waiver or, if no slot is available, place the individual on the waiting list.
The CSB shall only enroll the individual following electronic confirmation by
DBHDS that a slot is available. If no slot is available, then the individual's
name shall be placed on either the urgent or nonurgent statewide waiting list,
consistent with criteria established in this waiver in 12VAC30-120-1088, until
such time as a slot becomes available. Once the individual's name has been
placed on either the urgent or nonurgent waiting list, the case manager shall
notify the individual in writing within 10 business days of his placement on
either list and offer appeal rights. The case manager shall contact the
individual and the individual's family/caregiver, as appropriate, at least
annually while the individual is on the waiting list to provide the choice
between institutional placement and waiver services.
D. Waiver approval process: authorizing and accessing
services.
1. Once the case manager has determined an individual meets
the functional criteria for ID Waiver services, has determined that a slot is
available, and that the individual has chosen ID Waiver services, the case
manager shall submit enrollment information via the IDOLS to DBHDS to confirm
level-of-care eligibility.
2. Once the individual has been enrolled by the CSB, the
case manager will submit a DMAS-225 along with a computer-generated
confirmation of level-of-care eligibility to the local department of social
services to determine financial eligibility for the waiver program and any
patient pay responsibilities.
3. After the case manager has received written notification
of Medicaid eligibility by the local departments of social services, the case
manager shall so inform the individual and the individual's family/caregiver,
as appropriate, to permit the development of the Individual Support Plan.
a. The individual and the individual's family/caregiver, as
appropriate, shall meet with the case manager within 30 calendar days of waiver
enrollment to discuss the individual's needs and existing supports, complete
the DBHDS-approved assessment, obtain a medical examination completed no
earlier than 12 months prior to the initiation of waiver services, begin to
develop the Personal Profile, and complete all designated assessments, such as
the Supports Intensity Scale (SIS), deemed necessary to establish and document
the needed services.
b. The case manager shall provide the individual and the
individual's family/caregiver, as appropriate, with choice of needed services
available under the ID Waiver, alternative settings, and providers. Once the
service providers are chosen, a planning meeting shall be arranged by the case
manager to develop the person-centered Individual Support Plan based on the
assessment of needs as reflected in the level of care and DBHDS-approved
functional assessment instruments and the preferences of the individual and the
individual's family/caregiver's, as appropriate.
c. Participants invited to participate in the
person-centered planning meeting shall include the individual, case manager,
service providers, the individual's family/caregiver, as appropriate, and
others desired by the individual. The Individual Support Plan development
process identifies the services to be rendered to individuals, the frequency of
services, the type of service provider or providers, and a description of the
services to be offered. The individual enrolled in the waiver, or the
family/caregiver as appropriate, and case manager must sign the ISP.
4. The individual or case manager shall contact chosen
service providers so that services can be initiated within 30 calendar days of
enrollment. The service providers in conjunction with the individual and the
individual's family/caregiver, as appropriate, and the case manager shall
develop Plans for Supports for each service. A copy of these plans shall be
submitted to the case manager. The case manager shall review and ensure the
Plan for Supports meets the established service criteria for the identified
needs prior to submitting to the state-designated agency or its contractor for
service authorization. Only ID Waiver services authorized on the Individual
Support Plan by the state-designated agency or its contractor according to DMAS
policies may be reimbursed by DMAS. The Plan for Supports from each waiver
service provider shall be incorporated into the Individual Support Plan along
with the steps for risk mitigation as indicated by the risk assessment.
5. When the case manager obtains the DMAS-225 form from a
local department of social services, the case manager shall designate and
inform in writing a service provider to be the collector of patient pay when
applicable. The designated provider shall monthly monitor the DMAS-designated
system for changes in patient pay obligations and adjust billing, as appropriate,
with the change documented in the record in accordance with DMAS policy. When
the designated collector of patient pay is the consumer-directed personal or
respite assistant or companion, the case manager shall forward a copy of the
DMAS-225 form to the EOR along with the case manager's designation described in
12VAC30-120-1060 S 2 a (6). In such cases, the case manager shall be required
to perform the monthly monitoring of the patient pay system and shall notify
the EOR of all changes.
6. The case manager shall submit the results of the
comprehensive assessment and a recommendation to DBHDS staff for final
determination of ICF/ID level of care and authorization for community-based
services. The state-designated agency or its contractor shall, within 10
working days of receiving all supporting documentation, review and approve,
pend for more information, or deny the individual service requests. The
state-designated agency or its contractor shall communicate in writing to the
case manager whether the recommended services have been approved and the
amounts and type of services authorized or if any services have been denied.
Medicaid shall not pay for any home and community-based waiver services
delivered prior to the authorization date approved by the state-designated
agency or its contractor if service authorization is required.
7. ID Waiver services may be recommended by the case
manager only if:
a. The individual is Medicaid eligible as determined by the
local departments of social services;
b. The individual has a diagnosis of ID as defined by the
American Association on Intellectual and Developmental Disabilities, or is a
child under the age of six at developmental risk, and who would in the absence
of waiver services require the level of care provided in an ICF/ID the cost of
which would be reimbursed under the Plan; and
c. The contents of the Plans for Support are consistent
with the Medicaid definition of each service.
8. All Individual Support Plans shall be subject to final
approval by DMAS. DMAS is the single state agency authority responsible for the
supervision of the administration of the ID Waiver.
9. If services are not initiated by the provider within 30
days of receipt of enrollment confirmation from DBHDS, the case manager shall
notify the local department of social services so that a re-evaluation of
eligibility as a noninstitutionalized individual can be made.
10. In the case of an individual enrolled in the waiver
being referred back to a local department of social services for a
redetermination of eligibility and in order to retain the designated slot, the
case manager shall submit information to DBHDS via IDOLS requesting retention
of the designated slot pending the initiation of services. A copy of the
request shall be provided to the individual and the individual's
family/caregiver, as appropriate. DBHDS shall have the authority to approve the
slot-retention request in 30-day extensions, up to a maximum of four
consecutive extensions, or deny such request to retain the waiver slot for that
individual. DBHDS shall provide a response to the case manager via IDOLS
indicating denial or approval of the slot extension request. DBHDS shall submit
this response within 10 working days of the receipt of the request for
extension and include the individual's right to appeal its decision.
E. Reevaluation of service need.
1. The Individual Support Plan.
a. The Individual Support Plan, as defined herein, shall be
collaboratively developed annually by the case manager with the individual and
the individual's family/caregiver, as appropriate, other service providers,
consultants, and other interested parties based on relevant, current assessment
data.
b. The case manager shall be responsible for continuous
monitoring of the appropriateness of the individual's services and revisions to
the Individual Support Plan as indicated by the changing needs of the
individual. At a minimum, the case manager must review the Individual Support
Plan every three months to determine whether the individual's desired outcomes
and support activities are being met and whether any modifications to the
Individual Support Plan are necessary.
c. Any modification to the amount or type of services in
the Individual Support Plan shall be prior authorized by the state-designated
agency or its contractor.
d. All requests for increased waiver services by
individuals enrolled in the waiver shall be reviewed under the health, safety,
and welfare standard and for consistency with cost effectiveness. This standard
assures that an individual's ability to receive a waiver service is dependent
on the finding that the individual needs the service, based on appropriate
assessment criteria and a written Plan for Supports, and that services can
safely and cost effectively be provided in the community.
2. Review of level of care.
a. The case manager shall complete a reassessment annually
in coordination with the individual and the individual's family/caregiver, as
appropriate, and service providers. The reassessment shall include an update of
the level of care and Personal Profile, risk assessment, and any other
appropriate assessment information. The Individual Support Plan shall be
revised as appropriate.
b. At