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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
10/28/2021

12VAC30-50-470. Case management for recipients of auxiliary grants.

A. Target group. Recipients of optional state supplements (auxiliary grants) as defined in 12VAC30-40-350 (Attachment 2.6 B), who reside in licensed adult care residences.

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 Act is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act.

D. Definition of services. The case management services will provide assessment, service location, coordination and monitoring for aged, blind and disabled individuals who are applying for or receiving an optional state supplement (auxiliary grant) to pay the cost of residential or assisted living care in a licensed adult care residence in order to facilitate access to and receipt of the most appropriate placement. In addition, the case management services will provide for periodic reassessment to determine whether the placement continues to meet the needs of the recipient of optional state supplement (auxiliary grant) and to arrange for transfer to a more appropriate placement or arrange for supplemental services as the needs of the individual change.

E. Qualifications of providers. A qualified case manager for recipients of auxiliary grants must be a qualified employee of a human service agency as required in § 63.1-25.1 of the Code of Virginia. To qualify as a provider of case management for auxiliary grant recipients, the human service agency:

1. Must employ or contract for case managers who have experience or have been trained in establishing, and in periodically reviewing and revising, individual community care plans and in the provision of case management services to elderly persons and to disabled adults;

2. Must have signed an agreement with the Department of Medical Assistance Services to deliver case management services to aged, blind and disabled recipients of optional state supplements (auxiliary grants);

3. Shall have written procedures for assuring the quality of case management services; and

4. Must ensure that claims are submitted for payment only when the services were performed by case managers meeting these qualifications. The case manager must possess a combination of work experience in human services or health care and relevant education which indicates that the individual possesses the following knowledge, skills, and abilities at entry level. These must be documented on the job application form or supporting documentation.

a. Knowledge of:

(1) Aging;

(2) The impact of disabilities and illnesses on elderly and nonelderly persons;

(3) Conducting client assessments (including psychosocial, health and functional factors) and their uses in care planning;

(4) Interviewing techniques;

(5) Consumers' rights;

(6) Local human and health service delivery systems, including support services and public benefits eligibility requirements;

(7) The principles of human behavior and interpersonal relationships;

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

(9) General principles of record documentation; and

(10) Service planning process and the major components of a service plan.

b. Skills in:

(1) Negotiating with consumers and service providers;

(2) Observing, recording and reporting behaviors;

(3) Identifying and documenting a consumer's needs for resources, services and other assistance;

(4) Identifying services within the established services system to meet the consumer's needs;

(5) Coordinating the provision of services by diverse public and private providers; and

(6) Analyzing and planning for the service needs of elderly or disabled persons.

c. Abilities to:

(1) Demonstrate a positive regard for consumers and their families;

(2) Be persistent and remain objective;

(3) Work as a 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) Develop a rapport and communicate with different types of persons from diverse cultural backgrounds; and

(7) Interview.

d. Individuals meeting all the above qualifications shall be considered a qualified case manager; however, it is preferred that the case manager possess a minimum of an undergraduate degree in a human services field, or be a licensed nurse. In addition, it is preferable that the case manager have two years of experience in the human services field working with the aged or disabled.

e. To obtain DMAS payment, the case management provider must maintain in a resident's record a copy of the resident's assessment, plan of care, all reassessments, and documentation of all contacts, including but not limited to face-to-face contacts with the resident, made in regard to the resident.

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.

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.

H. Payment for case management services is limited to no more than one visit during each calendar quarter. In order to bill for case management services during a calendar quarter, the case manager must comply with the documentation requirements of subdivision E 4 e of this section and have documented contact with the resident during that quarter.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-03-3.1102 § 7, eff. June 1, 1994; amended, Virginia Register Volume 12, Issue 12, eff. April 4, 1996.

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