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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 50. Amount, Duration, and Scope of Medical and Remedial Care Services

12VAC30-50-440. Support coordination/case management services for individuals with intellectual disability.

A. Target Group. Medicaid eligible individuals who have an intellectual disability as defined in § 37.2-100 of the Code of Virginia.

1. An active individual for intellectual disability support coordination/case management shall mean a person for whom there is an individual support plan (ISP) (as defined in 12VAC30-122-20) in effect that requires direct or -related individual-related contacts or communication or activity with the individual, the individual's family or caregiver, service providers, significant others, and others including at least one face-to-face contact with the individual every 90 days. Billing can be submitted for an active individual only for months in which direct or -related individual-related contacts, activity, or communications occur, consistent with the ISP.

2. The unit of service is one month. There shall be no maximum service limits for support coordination/case management services except services for as related to individuals residing in institutions or medical facilities. For these individuals, reimbursement for support coordination/case management shall be limited to 30 days immediately preceding discharge. Support coordination/case management for individuals who reside in an institution may be billed for no more than two predischarge periods within 12 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 § 1915(g)(1) of the Social Security Act (the Act) is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act.

D. Definition of services. Intellectual disability support coordination/case management services to be provided include:

1. Assessment and planning services, to include developing an individual support plan (ISP) as defined on 12VAC30-122-20 and in accordance with the requirements of the Final Rule found at 42 CFR 441.725, which does not include performing medical and psychiatric assessment but does include referral for assessment;

2. Linking the individual to services and supports specified in the ISP;

3. Assisting the individual directly for the purpose of locating, identifying, 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 to use vocational, civic, and recreational services;

6. Making collateral contacts with the individual's significant others to promote implementation of the ISP and community integration;

7. Following up and monitoring to assess ongoing progress and ensuring services are delivered; and

8. Education and counseling that guides the individual and develops a supportive relationship that promotes the ISP.

E. Qualifications of providers:

1. are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Act is invoked to limit Support coordination/case management providers for individuals with intellectual disability shall be limited to the community services boardsally. References to providers in this section shall refer to enrolled community services boards.

2. To qualify as a provider of services enrolled with DMAS for intellectual disability support coordination/case management, the provider of the services shall meet certain criteria. These criteria shall be:

a. The provider shall guarantee that s 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 reimbursement;

c. The provider shall have the administrative and financial management capacity to meet state and federal requirements;

d. The provider have the ability to shall document and maintain individual case records in accordance with state and federal requirements;

e. The provider shall submit the individual support plan in an electronic format in the state DD home and community-based services (HCBS) waiver management system for service authorization and data management for individuals enrolled in any DD HCBS waiver. The provider shall submit evidence to Department of Medical Assistance Services (DMAS) or the Department of Behavioral Health and Developmental Services (DBHDS) in specified format of follow-up and monitoring to assess ongoing progress of the ISP, ensuring services are delivered and health and safety is maintained;

f. The provider shall participate in activities designed to safeguard participants' health and safety in accordance with approved DD HCBS waiver requirements or DBHDS licensing standards; and

g. The provider shall participate in activities designed to assure ongoing compliance by DD HCBS waiver participants' providers of service subject to the Final Rule Settings Requirements found at 42 CFR 441.301(4) and as described in the approved Statewide Transition Plan;

h. The services shall be in accordance with the Virginia State Plan for Medical Assistance; and

i. The provider must be licensed as a developmental disability support coordination/case management agency by the Department of Behavioral Health and Developmental Services.

3. Providers may bill for Medicaid intellectual disability support coordination/case management only when the services are provided by qualified managers support coordinators/case managers. The manager must support coordinator/case manager shall possess a combination of intellectual disability work experience and relevant education that indicates that the incumbent, at entry level, possesses the knowledge, skills, and abilities listed in this subdivision. These must be documented observable in the application form or supporting documentation or observable and documented during the interview (with appropriate supporting documentation).

a. Knowledge of:

(1) The definition and causes of intellectual disability and best practices in supporting individuals who have intellectual disability;

(2) Treatment modalities and intervention techniques, such as positive behavior supports, person-centered practices, independent living skills training, community inclusion/employment skills, supportive guidance, family education, crisis intervention, discharge planning, and support coordination;

(3) Different types of assessments and their uses in service planning;

(4) Individuals' civil and human 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 intellectual disability programs and services;

(7) Effective oral, written, and interpersonal communication principles and techniques;

(8) General principles of documentation; and

(9) The service planning process and the major components of an ISP.

b. Skills in:

(1) Interviewing;

(2) Negotiating with individuals and service providers;

(3) Observing recording and reporting and documenting an individual's 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 and preferences;

(6) Coordinating the provision of services for the individual by diverse public and private providers, generic and natural supports;

(7) Using information from assessments, evaluations, observations, and interviews to develop and revise as needed support plans;

(8) Formulating, writing, and implementing ized consumer individual support plans to promote goal attainment and community integration for individuals with intellectual disability;

(9) Using information from assessment tools, evaluations, observations, and interviews to develop and revise as needed individual support plans (for example to ensure the ISP is implemented appropriately, identify change in status or to determine risk of crisis/hospitalization); and

(10) Identifying community resources and organizations and coordinating resources and activities.

c. Abilities to:

(1) Demonstrate a positive regard for individuals and their families (e.g., treating people as individuals, allowing risk taking, avoiding stereotypes of people with intellectual disability, respecting individual and family privacy, and believing individuals can grow and contribute to their communities);

(2) Be persistent and remain objective;

(3) Work as team member, maintaining effective ter- 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.

F. The state assures that the provision of support coordination/case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act and the Final Rule at 42 CFR 441.301(c)(1)(vi).

1. Enrolled individuals will have free choice of the available providers of support coordination/case management services.

2. Enrolled individuals will have free choice of the providers of other medical care under the State Plan for Medical Assistance.

G. Payments for support coordination/case management services under the does State Plan for Medical Assistance shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from VR460-03-3.1102 § 4, eff. May 1, 1994; amended, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

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