Virginia Law

A. Medicaid-funded long-term services and supports (LTSS) may be provided in either home and community-based or institutional-based settings. To receive LTSS, the individual's condition shall first be evaluated using the designated assessment instrument, the Uniform Assessment Instrument (UAI), and other DMAS-designated forms. LTSS screening teams shall also use the DMAS-designated forms (DMAS-96 and DMAS-97), and if selecting nursing facility placement, the DMAS-95 Level I. If screening must be completed and if indicated by the DMAS-95 Level I results, the individual shall be referred to DBHDS for completion of the DMAS-95 Level II evaluation and determination prior to admission to the nursing facility. For private duty nursing services under the Commonwealth Coordinated Care (CCC) Plus waiver, the DMAS-108 (adult), or the DMAS-109 (pediatric), shall be used to document needs.

1. An individual's need for LTSS shall meet the established criteria (12VAC30-60-303) before any authorization for reimbursement by Medicaid or its designee is made for LTSS.

2. Appropriate home and community-based services shall be evaluated as an option for long-term services and supports prior to consideration of nursing facility placement.

B. The evaluation shall be the LTSS screening as designated in § 32.1-330 of the Code of Virginia, which, if eligible, shall preauthorize a continuum of LTSS covered by Medicaid. These LTSS screenings shall be conducted face to face.

1. Such LTSS screenings, using the UAI, shall be conducted by teams of representatives of (i) acute care hospitals for individuals (adults and children) who are inpatients; (ii) local departments of social services and local health departments, known in this part as CBTs, for adults and children residing in the community and who are not inpatients; (iii) a DMAS designee for adults and children residing in the community or hospital inpatients who cannot be screened by the LTSS screening team within 30 days of the request date; and (iv) nursing facility LTSS screening teams for individuals receiving skilled or rehabilitative nursing services that are not covered by Medicaid in an institutional setting following discharge from an acute care hospital. Hospitals, CBTs, and DMAS designees shall be contracted with DMAS or authorized by DMAS to perform this activity and be reimbursed by DMAS.

2. All LTSS screenings shall be comprehensive, accurate, standardized, and reproducible evaluations of individual functional capacities, medical or nursing needs, and whether the individual is at risk for institutional placement within 30 days of the LTSS screening.

C. Individuals shall not be required to be financially eligible for receipt of Medicaid or have submitted an application for Medicaid in order to be screened for LTSS for admission to either an NF or home and community-based services.

D. Pursuant to § 32.1-330 of the Code of Virginia, every individual who applies for or requests Medicaid community or institutional long-term services and supports shall be screened prior to admission to such community or institutional LTSS to determine the individual's need for long-term services and supports, including nursing facility services.

E. Special circumstances.

1. Private pay individuals who seek admission to a Virginia nursing facility shall not be required to have an LTSS screening in order to be admitted to the NF.

2. Individuals who reside out of state and seek direct admission to a Virginia nursing facility shall not be required to have an LTSS screening. Individuals who need an LTSS screening for HCBS waiver or PACE programs and request the LTSS screening shall be screened by the CBT serving the locality in which the individual resides once the individual has relocated to the Commonwealth.

3. Individuals who are inpatients in an out-of-state hospital, in-state or out-of-state veteran's hospital, or in-state or out-of-state military hospital and seek direct admission to a Virginia NF shall not be required to have an LTSS screening. Individuals who need an LTSS screening for HCBS waiver or PACE programs and request the LTSS screening shall be referred, upon discharge from one of the identified facilities, to the CBT serving the locality in which the individual resides once the individual has relocated to the Commonwealth.

4. Individuals who are patients or residents of a state owned or operated facility and seek direct admission to a Virginia NF shall not be required to have an LTSS screening. Individuals who need an LTSS screening for HCBS waiver or PACE and request the LTSS screening shall be referred, upon discharge from the facility, to the CBT serving the locality in which the individual resides.

5. An LTSS screening shall not be required for enrollment in Medicaid hospice services as set out in 12VAC30-50-270 or home health services as set out in 12VAC30-50-160.

F. Failure to comply with DMAS requirements, including competency and training requirements applicable to staff, may result in retraction of Medicaid payments.