Virginia Law

A. Service description. Shared living service means Medicaid coverage of a portion of the total cost of rent, food, and utilities that can be reasonably attributed to a live-in roommate who has no legal responsibility to financially support the individual who is enrolled in the waiver. The types of assistance provided are expected to vary from individual to individual and shall be set out in a detailed, signed, and dated agreement between the individual and roommate. This service shall require the use of a shared living service administrative provider enrolled with DMAS that shall be responsible for directly coordinating the service and directly billing DMAS for reimbursement. Shared living service shall be covered in the FIS, CL, and BI waivers.

B. Criteria and allowable activities.

1. The individual, who shall be at least 18 years of age, shall select his roommate, who shall also be at least 18 years of age, and, together through a person-centered planning process, they shall determine the assistance to be provided by the roommate based on the individual's needs and preferences. The individual shall reside in his own home or in a residence leased by the individual.

2. Reimbursable room and board for the roommate shall be established through the service authorization process per the CMS-approved rate methodology.

3. The individual shall be receiving at least one other waiver service in order to receive Medicaid coverage of shared living service.

4. Allowable activities shall include:

a. Fellowship, which means a close association or communion with friends or equals with whom an individual has shared interests, experiences, and purpose;

b. Safety supports;

c. Limited help with ADLs and IADLs that shall account for no more than 20% of the anticipated roommate time and may include:

(1) Meal preparation;

(2) Light housework;

(3) Medications reminders; and

(4) Routine prompting or intermittent direct assistance with ADLs.

C. Service units and limits. The unit of service shall be a month or may be a partial month for months in which the service begins or ends.

1. The roommate shall complete and pass background checks, including criminal registry checks required by §§ 37.2-416, 37.2-506, and 37.2-607 of the Code of Virginia.

2. The roommate shall successfully meet the training requirements set out in the written supports agreement including CPR training, safety awareness, fire safety and disaster planning, and conflict management and resolution.

3. Shared living service shall not be covered for individuals who are simultaneously receiving group home residential service, sponsored residential service, or supported living residential service.

4. The roommate shall not have the responsibility for providing skill-building or medical services.

5. The roommate shall not be the spouse, parent, grandparent, or guardian of the individual.

6. If the individual is without a roommate for more than 60 calendar days, the administrating agency must submit a termination for services pending the replacement of the roommate.

D. Provider requirements.

1. Providers shall meet the service coverage requirements in this section and the general conditions and requirements for home and community-based participating providers as specified in 12VAC30-122-110 through 12VAC30-122-140.

2. Shared living service administrative providers shall be licensed by DBHDS to provide service to individuals with developmental disabilities and shall manage the administrative aspects of this service, including roommate matching as needed, background checks, training, periodic onsite monitoring, and disbursing funds to the individual.

3. Shared living service administrative providers shall have a current, signed participation agreement with DMAS in order to provide this service. The provider designated in this agreement shall coordinate the shared living service and submit claims directly to DMAS for reimbursement. This shared living service administrative provider shall be reimbursed a flat fee payment for the completion of these duties. DMAS may audit such provider's records for compliance with the requirements in this section.

4. Reimbursement for shared living service shall be based upon compliance with DMAS submission requirements for claims and supporting documentation as may be required as proof of service delivery. Claims that are not supported by the required notes documentation shall be subject to recovery by DMAS of any expenditures that may have been made.

5. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the roommate be unable to render services as needed. This backup plan shall be shared with the administrative provider and support coordinator at the onset of services and updated with the administrative provider and support coordinator as necessary.

6. The administrative provider shall submit monthly claims for shared living service for reimbursement based upon the amount determined through the service authorization process.

E. Service documentation and requirements.

1. The administrative provider shall maintain documentation of the actual rent and submit the documentation with the service authorization request for shared living service.

2. For quality management review and utilization review purposes, the administrative provider shall be required to maintain and present to DMAS, as requested, an agreement that identifies what supports the roommate will provide, and this supports agreement shall be signed by the individual and the roommate. The individual's support coordinator shall retain a copy of this signed, executed agreement in the particular individual's file.

3. The administrative provider shall maintain documentation of the roommate's participation in all required training.

4. The administrative provider shall submit monthly claims for shared living service reimbursement based upon the amount determined through the service authorization process.

5. The administrative provider shall maintain weekly summaries of supports provided by the roommate and signed by the roommate.

6. Documentation of the administrative provider's 90-day face-to-face contact with the individual that includes the status of the individual and resolution of any issues related to service provision. This 90-day face-to-face shall take place in the individual's home. Documentation of the in-person contact and observations shall be provided to the support coordinator quarterly.

7. Provider documentation shall support all claims submitted for DMAS reimbursement. 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.