Documents Incorporated by Reference (12VAC30-120)

Chapter 120. Waivered Services

12VAC30-120-10. (Repealed.)

Historical Notes

Derived from VR460-04.8.4 §§ 1 to 6, eff. September 1, 1991; amended, Virginia Register Volume 19, Issue 8, eff. February 1, 2003; Volume 19, Issue 18, eff. July 1, 2003; repealed, Virginia Register Volume 22, Issue 10, eff. February 22, 2006.

Part I
(Repealed)

12VAC30-120-61. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 16, Issue 18, eff. July 1, 2000; amended, Virginia Register Volume 23, Issue 16, eff. July 1, 2007; repealed, Virginia Register Volume 25, Issue 8, eff. February 5, 2009.

12VAC30-120-62. (Repealed.)

Historical Notes

12VAC30-120-63. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 16, Issue 18, eff. July 1, 2000; repealed, Virginia Register Volume 25, Issue 8, eff. February 5, 2009.

12VAC30-120-64. (Repealed.)

Historical Notes

12VAC30-120-65. (Repealed.)

Historical Notes

12VAC30-120-66. (Repealed.)

Historical Notes

12VAC30-120-67. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 16, Issue 18, eff. July 1, 2000; repealed, Virginia Register Volume 25, Issue 8, eff. February 5, 2009.

12VAC30-120-68. (Repealed.)

Historical Notes

Part II
Home and Community-Based Services for Technology Assisted Individual (Repealed)

12VAC30-120-70. (Repealed.)

Home and Community-Based Services for Technology Assisted Individual (Repealed)

Historical Notes

Derived from VR460-04-8.5 § 1, eff. June 22, 1991; amended, Virginia Register Volume 13, Issue 22, eff. August 20, 1997; Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-80. (Repealed.)

Historical Notes

Derived from VR460-04-8.5 § 2, eff. June 22, 1991; amended, Virginia Register Volume 13, Issue 22, eff. August 20, 1997; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-90. (Repealed.)

Historical Notes

Derived from VR460-04-8.5 § 3, eff. June 22, 1991; amended, Virginia Register Volume 13, Issue 22, eff. August 20, 1997; Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-100. (Repealed.)

Historical Notes

Derived from VR460-04-8.5 § 4, eff. June 22, 1991; amended, Virginia Register Volume 13, Issue 22, eff. August 20, 1997; Volume 24, Issue 26, eff. October 15, 2008; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-110. (Repealed.)

Historical Notes

Derived from VR460-04-8.5 § 5, eff. June 22, 1991; amended, Virginia Register Volume 13, Issue 22, eff. August 20, 1997; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-115. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 13, Issue 22, eff. August 20, 1997; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-120. (Repealed.)

Historical Notes

Derived from VR460-04-8.5 § 6, eff. June 22, 1991; amended, Virginia Register Volume 13, Issue 22, eff. August 20, 1997; repealed, Virginia Register Volume 30, Issue 12, eff. March 13, 2014.

12VAC30-120-130. (Repealed.)

Historical Notes

Derived from VR460-04-8.5 § 7, eff. June 22, 1991; repealed, Virginia Register Volume 13, Issue 22, eff. August 20, 1997.

Part III
Home and Community-Based Services for Individuals with Acquired Immunodeficiency Syndrome (Aids) and Aids-Related Complex (Repealed)

12VAC30-120-140. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 1, eff. February 1, 1991; amended, Virginia Register Volume 20, Issue 11, eff. March 11, 2004; Volume 25, Issue 14, eff. April 15, 2009; Errata, 25:16 VA.R. 2978 April 13, 2009; amended, Virginia Register Volume 25, Issue 20, eff. July 9, 2009; Errata, 25:23 VA.R. 4262 July 20, 2009; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-150. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 2, eff. February 1, 1991; amended, Virginia Register Volume 20, Issue 11, eff. March 11, 2004; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-160. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 3, eff. February 1, 1991; amended, Virginia Register Volume 20, Issue 11, eff. March 11, 2004; Volume 27, Issue 3, eff. November 10, 2010; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-165. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 20, Issue 11, eff. March 11, 2004; amended, Virginia Register Volume 27, Issue 19, eff. July 1, 2011; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013; Errata, 30:2 VA.R. 274 September 23, 2013.

12VAC30-120-170. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 4, eff. February 1, 1991; amended, Virginia Register Volume 20, Issue 11, eff. March 11, 2004; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-180. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 5, eff. February 1, 1991; amended, Virginia Register Volume 20, Issue 11, eff. March 11, 2004; amended, Volume 27, Issue 19, eff. July 1, 2011; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-190. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 6, eff. February 1, 1991; amended, Virginia Register Volume 20, Issue 11, eff. March 11, 2004; amended, Volume 27, Issue 19, eff. July 1, 2011; repealed, Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-195. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 20, Issue 11, eff. March 11, 2004; amended, Virginia Register Volume 26, Issue 4, eff. January 1, 2010; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-200. (Repealed.)

Historical Notes

Derived from VR460-04-8.11 § 7, eff. February 1, 1991; repealed, Virginia Register Volume 20, Issue 11, eff. March 11, 2004.

12VAC30-120-201. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 20, Issue 11, eff. March 11, 2004; repealed, Virginia Register Volume 29, Issue 18, eff. June 20, 2013.

12VAC30-120-210. (Repealed.)

Historical Notes

Derived from VR460-04-8.12 § 1, eff. January 1, 1992; amended, Virginia Register Volume 10, Issue 13, eff. April 20, 1994; Virginia Register Volume 14, Issue 7, eff. January 22, 1998; Errata, 14:11 VA.R. 1869 February 16, 1998; repealed, Virginia Register Volume 18, Issue 26, eff. October 16, 2002.

Part IV
Mental Retardation Waiver (Repealed)

12VAC30-120-211. (Repealed.)

Mental Retardation Waiver (Repealed)

Historical Notes

Derived from Virginia Register Volume 18, Issue 26, eff. October 16, 2002; amended, Virginia Register Volume 22, Issue 19, eff. June 28, 2006; Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 29, Issue 20, eff. July 4, 2013.

12VAC30-120-213. (Repealed.)

Historical Notes

12VAC30-120-215. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 18, Issue 26, eff. October 16, 2002; amended, Virginia Register Volume 22, Issue 19, eff. June 28, 2006; Volume 22, Issue 24, eff. September 6, 2006; repealed, Virginia Register Volume 29, Issue 20, eff. July 4, 2013.

12VAC30-120-217. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 18, Issue 26, eff. October 16, 2002; amended, Virginia Register Volume 22, Issue 19, eff. June 28, 2006; repealed, Virginia Register Volume 29, Issue 20, eff. July 4, 2013.

12VAC30-120-219. (Repealed.)

Historical Notes

12VAC30-120-220. (Repealed.)

Historical Notes

Derived from VR460-04-8.12 § 2, eff. January 1, 1992; amended, Virginia Register Volume 10, Issue 13, eff. April 20, 1994; Virginia Register Volume 14, Issue 7, eff. January 22, 1998; repealed, Virginia Register Volume 18, Issue 26 eff. October 16, 2002.

12VAC30-120-221. (Repealed.)

Historical Notes

12VAC30-120-223. (Repealed.)

Historical Notes

12VAC30-120-225. (Repealed.)

Historical Notes

12VAC30-120-227. (Repealed.)

Historical Notes

12VAC30-120-229. (Repealed.)

Historical Notes

12VAC30-120-230. (Repealed.)

Historical Notes

Derived from VR460-04-8.12 § 3, eff. January 1, 1992; amended, Virginia Register Volume 10, Issue 13, eff. April 20, 1994; Virginia Register Volume 14, Issue 7, eff. January 22, 1998; Errata, 14:11 VA.R. 1869, 1870 February 16, 1998; repealed, Virginia Register Volume 18, Issue 26, eff. October 16, 2002.

12VAC30-120-231. (Repealed.)

Historical Notes

12VAC30-120-233. (Repealed.)

Historical Notes

12VAC30-120-235. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 18, Issue 26, eff. October 16, 2002; repealed, Virginia Register Volume 29, Issue 20, eff. July 4, 2013.

12VAC30-120-237. (Repealed.)

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

12VAC30-120-240. (Repealed.)

Historical Notes

Derived from VR460-04-8.12 § 4, eff. January 1, 1992; amended, Virginia Register Volume 10, Issue 13, eff. April 20, 1994; Virginia Register Volume 14, Issue 7, eff. January 22, 1998; Errata, 14:11 VA. R. 1870 February 16, 1998; repealed, Virginia Register Volume 18, Issue 26, eff. October 16, 2002.

12VAC30-120-241. (Repealed.)

Historical Notes

12VAC30-120-243. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 18, Issue 26, eff. October 16, 2002; repealed, Virginia Register Volume 22, Issue 19, eff. June 28, 2006.

12VAC30-120-245. (Repealed.)

Historical Notes

12VAC30-120-247. (Repealed.)

Historical Notes

12VAC30-120-249. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 18, Issue 26, eff. October 16, 2002; Errata, 19:3 VA.R. 549 October 2, 2002; amended, Virginia Register Volume 22, Issue 19, eff. June 28, 2006; repealed, Virginia Register Volume 29, Issue 20, eff. July 4, 2013.

12VAC30-120-250. (Repealed.)

Historical Notes

Derived from VR460-04-8.12 § 5, eff. January 1, 1992; amended, Virginia Register Volume 10, Issue 13, eff. April 20, 1994; Virginia Register Volume 14, Issue 7, eff. January 22, 1998; Errata, 14:11 VA.R. 1870 Febraury 16, 1998; repealed, Virginia Register Volume 18, Issue 26, eff. October 16, 2002.

Part V
Medallion (Repealed)

12VAC30-120-260. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 1, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-270. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 2, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-280. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 3, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 22, Issue 8, eff. April 3, 2006; Volume 22, Issue 26, eff. November 20, 2006; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-290. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 4, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 21, Issue 11, eff. March 10, 2005; Volume 22, Issue 26, eff. November 20, 2006; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-300. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 5, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 19, Issue 23, eff. August 27, 2003; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-310. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 6, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 21, Issue 11, eff. March 10, 2005; Volume 22, Issue 26, eff. November 20, 2006; Volume 26, Issue 8, eff. January 21, 2010; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-320. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 7, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 21, Issue 11, eff. March 10, 2005; Volume 22, Issue 26, eff. November 20, 2006; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-330. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 8, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-340. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 9, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

12VAC30-120-350. (Repealed.)

Historical Notes

Derived from VR460-04-8.14 § 10, eff. July 1, 1993; amended, Virginia Register Volume 12, Issue 16, eff. June 1, 1996; Volume 21, Issue 11, eff. March 10, 2005; repealed, Virginia Register Volume 30, Issue 12, eff. March 28, 2014.

Part VI
Medallion Mandatory Managed Care

12VAC30-120-360. Definitions.

The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise. All other words and terms used in this part shall comply with the definitions in the contract and those identified 42 CFR 438.2:

"Adverse benefit determination" means, consistent with 42 CFR 438.400, (i) the denial or limited authorization of a requested service; (ii) the failure to take action or timely take action on a request for service; (iii) the reduction, suspension, or termination of a previously authorized service; (iv) the denial in whole or in part of a payment for a covered service; (v) the failure to provide services within the timeframes required by the state, or for a resident of a rural exception area with only one MCO, the denial of a member's request to exercise his right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; (vi) the denial of a member's request to dispute a financial liability; or (vii) the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Appeal" when applicable to a member means a request to DMAS to review an MCO's internal appeal decision to uphold the contractor's adverse benefit determination. For members, an appeal may only be requested after exhaustion of the MCO's one step internal appeal process. Member appeals to DMAS will be conducted in accordance with regulations at 42 CFR 431 Subpart E and 12VAC 30-110-10 through 12VAC 30-110-370.

"Appeal" when applicable to an appeal by a provider means a request to DMAS to review an MCO's reconsideration decision. For providers, an appeal may only be requested after exhaustion of the MCO's reconsideration process. Provider appeals to DMAS will be conducted in accordance with the requirements set forth in § 2.2-4000 et seq. of the Code of Virginia and 12VAC 30-20-500 et seq.

"Covered services" means Medicaid services as defined in the State Plan for Medical Assistance.

"Day" means calendar day unless otherwise stated.

"Disenrollment" means the process of changing enrollment from one managed care organization (MCO) plan to another MCO, if applicable.

"DMAS" means the Department of Medical Assistance Services.

"Eligible person" means any person eligible for Virginia Medicaid in accordance with the State Plan for Medical Assistance under Title XIX of the Social Security Act.

"Emergency services" means those health care services that are rendered by participating or nonparticipating providers after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, 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 (i) placing the client's health in serious jeopardy; (ii) with respect to a pregnant woman, placing the health of the woman or her unborn child in serious jeopardy; (iii) serious impairment to bodily functions; or (iv) serious dysfunction of any bodily organ or part.

"Exclude" means the removal of a member from the Medallion mandatory managed care program on a temporary or permanent basis.

"External quality review organization" or "EQRO" means an organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality reviews, other external quality review related activities as set forth in 42 CFR 438.358, or both.

"Grievance" means, in accordance with 42 CFR 438.400, an expression of dissatisfaction about any matter other than an "adverse benefit determination." Possible subjects for grievances include the quality of care or services provided; aspects of interpersonal relationships, such as rudeness of a provider or employee; or failure to respect the member's rights.

"Health care professional" means a provider as defined in 42 CFR 438.2.

"Individual" means a person who is eligible for Medicaid who is not yet undergoing enrollment for mandatory managed care and who is not enrolled in a mandatory managed care organization.

"Internal appeal" means a request to the MCO by a member or by a member's authorized representative or provider acting on behalf of the member and with the member's written consent for review of a contractor's adverse benefit determination, as defined in 42 CFR 438.400. The internal appeal is the only level of appeal with the MCO and must be exhausted by a member or deemed exhausted according to 42 CFR 438.408(c)(3) before the member may initiate a state fair hearing with DMAS.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIP), as defined by § 38.2-5800 of the Code of Virginia. Any health maintenance organization as defined in § 38.2-4300 of the Code of Virginia or health carrier that offers preferred provider contracts or policies as defined in § 38.2-3407 of the Code of Virginia or preferred provider subscription contracts as defined in § 38.2-4209 of the Code of Virginia shall be deemed to be offering one or more MCHIPs. For the purposes of this definition, the prohibition of balance billing by a provider shall not be deemed a benefit payment differential incentive for covered persons to use providers who are directly or indirectly managed by, owned by, under contract with, or employed by the health carrier. A single managed care health insurance plan may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan shall encompass only one provider network or set of provider networks.

Additionally, and in accordance with 42 CFR 438.2, "managed care organization" or "MCO" means an entity that has qualified to provide the services covered in the Medallion program to qualifying Medallion members as accessible in terms of timeliness, amount, duration, and scope as those services are to other Medicaid members within the area served, and that meets the solvency standards of 42 CFR 438.116.

"Mandatory managed care program" means the same as set forth in 42 CFR 438.54(b) and (d).

"Member" means a person eligible for Medicaid or Family Access to Medical Insurance Security who has been assigned to a Medicaid MCO.

"Network provider" means doctors, hospitals, or other health care providers who participate or contract with an MCO contractor and as a result agree to accept a mutually agreed upon sum or fee schedule as payment in full for covered services that are rendered to eligible participants.

"Newborn enrollment period" means the period from the child's date of birth plus the next two calendar months.

"PCP of record" means a primary care physician of record with whom the recipient has an established history, and such history is documented in the individual's records.

"Reconsideration" means a provider's request to the MCO for review of an adverse benefit determination. The MCO's reconsideration decision is a prerequisite to a provider's filing of an appeal, as provided for in 12VAC 30-20-500 through 12VAC 30-20-560, to DMAS Appeals Division.

"Rural exception" means a rural area designated in the § 1915(b) managed care waiver, pursuant to § 1932(a)(3)(B) of the Social Security Act and 42 CFR 438.52(b) and recognized by the Centers for Medicare and Medicaid Services, wherein qualifying mandatory managed care members are mandated to enroll in the one available contracted MCO.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 6, eff. January 7, 1998; Volume 14, Issue 18, eff. July 1, 1998; Volume 15, Issue 18, eff. July 1, 1999; Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 29, Issue 2, eff. October 25, 2012; Volume 30, Issue 6, eff. January 2, 2014; Volume 30, Issue 7, eff. January 2, 2014; Volume 30, Issue 12, eff. March 28, 2014; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

12VAC30-120-370. Medallion mandatory managed care members.

A. DMAS shall determine enrollment in Medallion mandatory managed care.

1. Medicaid eligible persons not meeting the exclusion criteria set out in subsection B of this section shall participate in the Medallion mandatory managed care program. Enrollment in Medallion mandatory managed care shall not be a guarantee of continuing eligibility for services and benefits under the Virginia Medical Assistance Services Program.

2. DMAS reserves the right to exclude from participation in the Medallion mandatory managed care program any member who has been consistently noncompliant with the policies and procedures of managed care or who is threatening to providers, MCOs, or DMAS. There must be sufficient documentation from various providers, the MCO, and DMAS of these noncompliance issues and any attempts at resolution. Members excluded from Medallion mandatory managed care through this provision may appeal the decision to DMAS.

B. The following individuals shall be excluded (as defined in 12VAC 30-120-360 and the § 1915(b) managed care waiver) from participating in Medallion mandatory managed care. Individuals excluded from Medallion mandatory managed care shall include the following:

1. Individuals who are inpatients in state mental hospitals;

2. Individuals who are approved by DMAS as inpatients in long-stay hospitals, nursing facilities, or intermediate care facilities for individuals with intellectual disabilities;

3. Individuals who are placed on spend-down, which is the process of reducing countable income by deducting incurred medical expenses for medically needy individuals, as determined in the State Plan for Medical Assistance;

4. Individuals who are participating in the family planning waiver;

5. Prior to April 1, 2019, individuals younger than 21 years of age who are approved for DMAS residential facility Level C programs as defined in 12VAC 30-130-860;

6. Individuals, other than students, who permanently live outside their area of residence, which is the member's address in the Medicaid eligibility file, for greater than 60 consecutive days except those individuals placed there for medically necessary services funded by the MCO;

7. Individuals who receive hospice services in accordance with DMAS criteria;

8. Individuals with insurance purchased through the Health Insurance Premium Payment Program (HIPP);

9. Individuals requesting exclusion who are inpatients in hospitals, other than those listed in subdivisions 1 and 2 of this subsection, at the scheduled time of MCO enrollment or who are scheduled for inpatient hospital stay or surgery within 30 calendar days of the MCO enrollment effective date. The exclusion shall remain effective until the first day of the month following discharge. This exclusion reason shall not apply to members admitted to the hospital while already enrolled in a department-contracted MCO;

10. Individuals who request exclusion during assignment to an MCO or within a time set by DMAS from the effective date of their MCO enrollment, who have been diagnosed with a terminal condition and who have a life expectancy of six months or less. The individual's physician must certify the life expectancy;

11. Individuals who have an eligibility period that is less than three months;

12. Individuals who have an eligibility period that is only retroactive; and

13. Children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program established pursuant to Chapter 50 (§ 38.2-5000 et seq.) of Title 38.2 of the Code of Virginia.

C. Members enrolled with an MCO who subsequently meet one or more of the criteria of subsection B of this section during MCO enrollment shall be excluded from MCO participation as determined by DMAS. .

D. Individuals who are enrolled in localities that qualify for the rural exception may meet exclusion criteria if their PCP of record, as defined in 12VAC 30-120-360, cannot or will not participate with the one MCO in the locality. Individual requests to be excluded from MCO participation in localities meeting the qualification for the rural exception must be made to DMAS for consideration on a case-by-case basis. Members enrolled in MCO rural exception areas shall not have open enrollment periods and shall not be afforded the 90-day window after initial enrollment during which they may make a health plan or program change.

Individuals excluded from Medallion mandatory managed care enrollment shall receive Medicaid services under the current fee-for-service system. When individuals no longer meet the criteria for exclusion, they shall be required to enroll in the appropriate managed care program.

E. Medallion mandatory managed care plans shall be offered to individuals, and individuals shall be enrolled in those plans. DMAS has sole responsibility for determining enrollment in the contractor's plan. DMAS utilizes an independent enrollment broker under contract to DMAS to assist members with making plan choices after initial preassignment and during open enrollment. An enrollment broker is an independent contractor that enrolls individuals in the contractor's plan and is responsible for the operation and documentation of a toll-free individual service helpline.

F. Members shall be enrolled as follows:

1. All eligible individuals, except those meeting one of the exclusions in subsection B of this section, shall be enrolled in Medallion mandatory managed care.

2. Individuals shall receive a Medicaid card from DMAS and shall be provided authorized medical care in accordance with DMAS procedures after Medicaid eligibility has been determined to exist.

3. Once individuals are enrolled in Medicaid, they will receive a letter indicating that they may select one of the contracted MCOs. These letters shall indicate an assigned MCO, determined as provided in subsection G of this section, in which the member will be enrolled if he does not make a selection within a period specified by DMAS of not less than 30 days. Members who are enrolled in one mandatory MCO program who immediately become eligible for another mandatory MCO program are able to maintain consistent enrollment with the member's currently assigned MCO if available. These members will receive a notification letter including information regarding their ability to change health plans under the new program.

4. Any newborn whose mother is enrolled with an MCO at the time of birth shall be considered a member of that same MCO for the newborn enrollment period.

a. This requirement does not preclude the member, once the member is assigned a Medicaid identification number, from disenrolling from one MCO to enrolling with another in accordance with subdivision H 1 of this section.

b. The newborn's continued enrollment with the MCO is not contingent upon the mother's enrollment. Additionally, if the MCO's contract is terminated in whole or in part, the MCO shall continue newborn coverage if the child is born while the contract is active until the newborn receives a Medicaid number or for the newborn enrollment period, whichever timeframe is earlier. Newborns who remain eligible for participation in Medallion mandatory managed care will be reenrolled in an MCO through the assignment process upon receiving a Medicaid identification number.

c. Any newborn whose mother is enrolled in an MCO at the time of birth shall receive a Medicaid identification number prior to the end of the newborn enrollment period in order to maintain the newborn's enrollment in an MCO.

5. Individuals who lose then regain eligibility for Medallion mandatory managed care within 60 days will be reenrolled into their previous MCO without going through assignment and selection.

G. Individuals who do not select an MCO as described in subdivision F 3 of this section shall be assigned to an MCO as follows:

1. Individuals are assigned through a system algorithm based upon the member's history with a contracted MCO.

2. Individuals not assigned pursuant to subdivision 1 of this subsection shall be assigned to the MCO of another family member if applicable.

3. Individuals who live in rural exception areas as defined in 12VAC 30-120-360 shall enroll with the one available MCO. These individuals shall receive an assignment notification for enrollment into the MCO. Individuals in rural exception areas who are assigned to the one MCO may request exclusion from MCO participation if their PCP of record, as defined in 12VAC 30-120-360, cannot or will not participate with the one MCO in the locality. Individual requests to be excluded from MCO participation in rural exception localities must be made to DMAS for consideration on a case-by-case basis.

4. All other individuals shall be assigned to an MCO on a basis of approximately equal number by MCO in each locality.

5. All eligible members are automatically assigned to a contracted MCO in their localities. Members are allowed 90 days after the effective date of initial enrollment to change to another MCO that participates in the geographic area where the member lives. Members residing in localities qualifying for a rural exception shall not be afforded the 90-day window after initial enrollment during which they may make a health plan or program change.

6. DMAS shall have the discretion to use an alternate strategy for enrollment or transition of enrollment from the method described in this section for expansions, retractions, or changes to member populations, geographical areas, procurements, or any or all of these; such alternate strategy shall comply with federal waiver requirements. "Retractions" means the departure of an enrolled managed care organization from any one or more localities as provided in this section.

H. Following the member's initial enrollment into an MCO, the member shall be restricted to the MCO until the next open enrollment period, unless appropriately disenrolled or excluded by the department, as defined in 12VAC 30-120-360.

1. During the first 90 days of enrollment in an initial MCO, a member may disenroll from that MCO to enroll into another MCO for any reason. Such disenrollment shall be effective no later than the first day of the second month after the month in which the member requests disenrollment.

2. During the remainder of the enrollment period, the member may only disenroll from one MCO into another MCO upon determination by DMAS that good cause exists as determined under subsection J of this section.

I. The department shall conduct an annual open enrollment for all Medallion mandatory managed care members with the exception of those members who live in a designated rural exception area. The open enrollment period shall be the 60 days before the end of the enrollment period. Prior to the open enrollment period, DMAS will inform the member of the opportunity to remain with the current MCO or change to another MCO, without cause, for the following year. Enrollment selections will be effective on the first day of the next month following the open enrollment period. Members who do not make a choice during the open enrollment period will remain with their current MCO selection.

J. Disenrollment for cause may be requested at any time and the disenrollment reasons shall be in accordance with 42 CFR 438.56 (d)(2)(v).

1. The request may be made orally or in writing to DMAS and shall cite the reason or reasons why the member wishes to disenroll. Cause for disenrollment shall be in accordance with 42 CFR 438.56(d)(2), which includes the following reasons:

a. A member's desire to seek services from a federally qualified health center that is not under contract with the member's current MCO, and the member requests a change to another MCO that subcontracts with the desired federally qualified health center;

b. Performance or nonperformance of service to the member by an MCO or one or more of its network providers that is deemed by the DMAS external quality review organizations to be below the generally accepted community practice of health care. This may include poor quality care;

c. Lack of access to a primary care physician or necessary specialty services covered under the State Plan or lack of access to network providers experienced in dealing with the member's health care needs;

d. A member has a combination of complex medical factors that, in the sole discretion of DMAS, would be better served under another contracted MCO;

e. The member moves out of the MCO's service area;

f. The MCO does not, because of moral or religious objections, cover the service the member seeks; or

g. The member needs related services to be performed at the same time; not all related services are available within the network, and the member's primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk.

2. DMAS shall determine whether cause exists for disenrollment. Written responses shall be provided within a timeframe set by department policy; however, the effective date of an approved disenrollment shall be no later than the first day of the second month following the month in which the member files the request in compliance with 42 CFR 438.56.

3. Cause for disenrollment shall be deemed to exist and the disenrollment shall be granted if DMAS fails to take final action on a valid request prior to the first day of the second month after the request.

4. The DMAS determination concerning cause for disenrollment may be appealed by the member in accordance with the DMAS client appeals process at 12VAC 30-110-10 through 12VAC 30-110-370.

5. The current MCO shall provide within two working days of a request from DMAS information necessary to determine cause.

6. Members enrolled with an MCO who subsequently meet one or more of the exclusions in subsection B of this section during MCO enrollment shall be excluded from Medallion as determined appropriate by DMAS.

K. In accordance with 42 CFR 438.3(q)(5) and 42 CFR 438.56(c)(2), a member has the right to disenroll from the contractor's plan without cause at the following times:

1. During the 90 days following the date of the member's initial enrollment into the MCO or during the 90 days following the date DMAS sends the member notice of that enrollment, whichever is later.

2. At least once every 12 months thereafter.

3. Upon automatic reenrollment under subsection G of this section if the temporary loss of Medicaid eligibility has caused the beneficiary to miss the annual disenrollment opportunity.

4. When DMAS imposes the intermediate sanction specified in 42 CFR 438.702(a)(4).

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 6, eff. January 7, 1998; Volume 14, Issue 18, eff. July 1, 1998; Volume 15, Issue 18, eff. July 1, 1999; Errata, 15:19 VA.R. 2502 June 7, 1999; amended, Virginia Register Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 22, Issue 8, eff. eff. April 3, 2006; Volume 25, Issue 11, eff. March 4, 2009; Volume 30, Issue 6, eff. January 2, 2014; Volume 30, Issue 7, eff. January 2, 2014; Volume 30, Issue 12, eff. March 28, 2014; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

12VAC30-120-380. Medallion MCO responsibilities.

A. The MCO shall provide, at a minimum, all medically necessary covered services provided under the State Plan for Medical Assistance and further defined by written federal and state regulations, the Medallion contract, policies, and instructions, except as otherwise modified or excluded in this part.

1. Nonemergency services provided by hospital emergency departments shall be covered by MCOs in accordance with rates negotiated between the MCOs and the hospital emergency departments.

2. Services that shall be provided outside the MCO network shall include those services identified and defined by the contract between DMAS and the MCO. Services reimbursed by DMAS include dental and orthodontic services for children younger than 21 years of age, dental services for others as described in 12VAC30-50-190, and school health services.

3. The MCOs shall pay for emergency services and family planning services and supplies whether such services are provided inside or outside the MCO network.

B. Early and periodic screening, diagnostic, and treatment (EPSDT) services shall be covered by the MCO and defined by the contract between DMAS and the MCO. The MCO shall have the authority to determine the provider of service for EPSDT screenings.

C. The MCOs shall report data to DMAS under the contract requirements, which may include data reports, report cards for members, and ad hoc quality studies performed by the MCO or third parties.

D. Documentation requirements.

1. The MCO shall comply with the records retention requirements as outlined in the contract. The MCO shall furnish such required information to DMAS, the Attorney General of Virginia or his authorized representatives, or the State Medicaid Fraud Control Unit on request and in the form requested.

2. Each MCO shall comply with the member rights and protections stipulated in the contract and as identified in 42 CFR 438 Subpart C.

E. The MCO shall comply with the contract and 42 CFR 438 Subparts E and H to ensure that the health care provided to its members meets all applicable federal and state mandates, community standards for quality, and standards developed pursuant to the DMAS managed care quality program.

F. The MCOs shall promptly provide or arrange for the provision of all required services as specified in the contract between the Commonwealth and the MCO. Medical evaluations shall be available within 48 hours for urgent care and within 30 days for routine care. On-call clinicians shall be available 24 hours per day, seven days per week.

G. The MCOs shall meet the standards specified in 42 CFR 438, Subpart D by DMAS for sufficiency of provider networks as specified in the contract between the Commonwealth and the MCO.

H. Each MCO and its subcontractors shall have in place and follow written policies and procedures for processing requests for initial and continuing authorizations of service. Each MCO and its subcontractors shall ensure that any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease. Each MCO and its subcontractors shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.

I. In accordance with 42 CFR 447.50 through 42 CFR 447.90, MCOs shall not impose any cost sharing obligations on members except as set forth in 12VAC 30-20-150 and 12VAC 30-20-160.

J. An MCO may not prohibit or otherwise restrict a health care professional acting within the lawful scope of practice from advising or advocating on behalf of a member who is his patient in accordance with 42 CFR 438.102.

K. An MCO that would otherwise be required to reimburse for or provide coverage of a counseling or referral service is not required to do so if the MCO objects to the service on moral or religious grounds and furnishes information about the service it does not cover in accordance with 42 CFR 438.102.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 6, eff. January 7, 1998; Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 22, Issue 23, eff. August 23, 2006; Volume 25, Issue 11, eff. March 4, 2009; Volume 26, Issue 8, eff. January 21, 2010; Volume 30, Issue 7, eff. January 2, 2014Volume 31, Issue 9, eff. February 13, 2015; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

12VAC30-120-385. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 14, Issue 18, eff. July 1, 1998; repealed, Virginia Register Volume 19, Issue 3, eff. December 1, 2002.

12VAC30-120-390. Payment rate for MCOs.

The payment rate to MCOs that participate in the Medallion mandatory managed care program shall be set by negotiated contracts and in accordance with 42 CFR 438.4 through 42 CFR 438.8 and other pertinent federal regulations.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, 2019.

12VAC30-120-395. Preauthorized, emergency, and post-stabilization services and payment rate for care provided by out-of-network providers.

The MCOs shall pay for preauthorized, emergency, and post-stabilization services to members in compliance with the contract and 42 CFR 438.114. Preauthorized, emergency, and post-stabilization services provided to a managed care member by a provider or facility not participating in the MCO's network will be reimbursed according to the current Medicaid fee schedule. This reimbursement shall be considered payment in full to the provider or facility of emergency services.

Statutory Authority

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

Historical Notes

12VAC30-120-400. Quality control and utilization review.

A. DMAS shall rigorously monitor the quality of care provided by the MCOs. DMAS and the MCOs shall comply with (i) the contract; (ii) 42 CFR 438 Subpart E, entitled Quality Measurement and Improvement: External Quality Review; and (iii) the MCO standards identified in 42 CFR 438 Subpart D, entitled MCO, PIHP, and PAHP Standards. DMAS shall monitor the MCOs to determine their compliance with the contract, 42 CFR Subpart A, and all other relevant sections of 42 CFR Part 438 (Managed Care) as follows:

1. If the MCO fails substantially to provide the medically necessary items and services required under law or under the contract to be provided to an enrolled recipient and the failure has adversely affected or has substantial likelihood of adversely affecting the individual.

2. If the MCO engages in any practice that discriminates against individuals on the basis of their health status or requirements for health care services, including expulsion or refusal to reenroll an individual, or any practice that could reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by § 1903(m) of the Social Security Act (42 USC § 1396(m)) by eligible individuals whose medical conditions or histories indicate a need for substantial future medical services.

3. If the MCO misrepresents or falsifies information that it furnishes, under § 1903(m) of the Social Security Act (42 USC § 1396b(m)) to CMS, DMAS, an individual, or any other entity.

4. If the MCO fails to comply with the requirements of 42 CFR 417.479(d) through 42 CFR 417.479(g) relating to physician incentive plans or fails to submit to DMAS its physician incentive plans as required or requested in 42 CFR 434.70.

5. If the MCO imposes on members premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program.

B. DMAS shall ensure that data on performance and patient results are collected.

C. DMAS shall ensure that quality outcomes information is provided to MCOs. DMAS shall ensure that changes that are determined to be needed as a result of quality control or utilization review are made.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 5, eff. January 1, 1998; Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

12VAC30-120-410. Sanctions.

A. If DMAS determines that an MCO is not in compliance with applicable state or federal laws or regulations (including the requirements of or pursuant to § 1932(e)(1) of the Social Security Act (the Act), 12VAC 30-120-380, or 42 CFR 438 Subpart I) or the MCO contract, DMAS may impose sanctions on the MCO pursuant to § 1932(e) of the Act and this section. The sanctions may include:

1. Limiting enrollments in the MCO by freezing voluntary member enrollments;

2. Freezing DMAS assignment of members to the MCO;

3. Limiting MCO enrollment to specific areas;

4. Denying, withholding, or retracting payments to the MCO;

5. Terminating the MCO's contract as provided in § 1932(e)(4) of the Act;

6. Civil monetary penalties as specified in 42 CFR 438.704; and

7. Appointment of temporary management for an MCO as provided in 42 CFR 438.706.

B. In the case of an MCO that has repeatedly failed to meet the requirements of §§ 1903(m) and 1932(e) of the Social Security Act, DMAS shall, regardless of what other sanctions are imposed, impose the following sanctions:

1. Appoint a temporary manager to:

a. Oversee the operation of the Medicaid managed care organization upon a finding by DMAS that there is continued egregious behavior by the organization or there is a substantial risk to the health of members; or

b. Ensure the health of the organization's members if there is a need for temporary management while (i) there is an orderly termination or reorganization of the organization or (ii) improvements are made to remedy the violations found under subsection A of this section. Temporary management under this subdivision may not be terminated until DMAS has determined that the MCO has the capability to ensure that the violations shall not recur.

2. Permit members who are enrolled with the MCO to disenroll without cause. If this sanction is imposed, DMAS shall be responsible for notifying such members of the right to disenroll.

C. Prior to terminating a contract as permitted under § 1932(e)(4) of the Act, DMAS shall provide the MCO with a hearing. DMAS shall not provide an MCO with a predetermination hearing before the appointment of a temporary manager under subdivision B 1 of this section.

D. Prior to imposing any sanction other than termination of the MCO's contract, DMAS shall provide the MCO with notice, develop procedures with which the MCO must comply to eliminate specific sanctions, and provide such other due process protections as the Commonwealth may provide.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 18, eff. July 1, 1998; Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

12VAC30-120-420. Member grievances and appeals.

A. The MCOs shall comply with (i) the Grievance and Appeal System as identified in 42 CFR 438 Subpart F, (ii) the Enrollee Rights and Protections requirements in 42 CFR 438 Subpart C, (iii) the Medallion contract between DMAS and the MCO, and (iv) any other applicable state or federal statutory or regulatory requirements.

B. MCOs shall at (i) the initiation of new member enrollment, (ii) the initiation of new provider or subcontractor contracts, or (iii) the request of the member, provide to every member the information described in 42 CFR 438.10(g) concerning grievance and appeal rights and procedures.

C. Disputes between the MCO and the member concerning any aspect of service delivery, including medical necessity and specialist referral, shall be resolved through a verbal or written grievance or appeals process operated by the MCO or through the DMAS appeals process. A provider or other representative who has the member's written consent may act on behalf of a member in the MCO grievance or appeals or the DMAS appeals process.

1. The member, provider, or representative acting on behalf of the member with the member's written consent may file an oral or written grievance or internal appeal with the MCO. The MCO must accept grievances filed at any time. Internal appeal requests must be submitted within 60 days from the date of the notice of adverse benefit determination. Oral requests for internal appeals must be followed up in writing by the member, provider, or the representative acting on behalf of the member with the member's consent, unless the request is for an expedited internal appeal.

2. The member must exhaust the MCO's internal appeals process before appealing to the DMAS Appeals Division. The member may also file a written request for a standard or expedited internal appeal of the MCO's adverse benefit determination with the DMAS Appeals Division within 120 days of the member's receipt of the MCO's internal appeal decision, in accordance with 42 CFR 431 Subpart E; 42 CFR Part 438 Subpart F; and 12VAC 30-110-10 through 12VAC 30-110-370.

3. As specified in 12VAC 30-110-100, pending the resolution of a grievance, internal appeal, or appeal filed by a member or his representative (including a provider acting on behalf of the member) prior to the effective date of the adverse benefit determination, coverage shall not be terminated or reduced for the member for any reason that is the subject of the grievance or appeal.

4. The MCO shall ensure that neither the individuals nor agents, nor a subordinate of any such individual, who makes decisions on grievances and internal appeals were involved in any previous level of review or decision making. Additionally, where the reason for the grievance or internal appeal involves clinical issues or relates to a denial of a request for an expedited appeal, or where the appeal is based on a lack of medical necessity, the MCO shall ensure that the decision makers are health care professionals with the appropriate clinical expertise in treating the member's condition or disease.

5. The MCO shall provide the member and any representative a reasonable opportunity in person and in writing to present evidence and testimony and to make legal and factual arguments in accordance with 42 CFR 438.406(b)(4). The MCO shall inform the member of the limited time available for this sufficiently in advance of the resolution timeframe for appeals in accordance with 42 CFR 438.406(b)(4).

6. The MCO shall provide the member and any representative the member's case file, including medical records, and any new or additional evidence considered, relied upon, or generated by the MCO in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals in accordance with 42 CFR 438.406(b)(5).

D. The MCO shall develop written materials describing the grievance or appeals system and its procedures and operation.

E. The MCO shall maintain a recordkeeping, reporting, and tracking system for complaints, grievances, and appeals that complies with the Medallion contract between DMAS and the MCO. The system shall include a copy of the original complaint, grievance, or internal appeal; the decision; the nature of the decision; and data on the number of internal appeals filed, the average time to resolve internal appeals, and the total number of internal appeals open as of the reporting date. This system shall distinguish Medicaid from commercial members if the MCO does not have a separate system for Medicaid members.

F. At the time of enrollment and at the time of any adverse benefit determination, the MCO shall notify the member in writing that:

1. An adverse benefit determination may be resolved through a system of grievances and appeals, first within the MCO and then through the DMAS client appeals process;

2. Members have the right to request an expedited internal appeal;

3. Members shall exhaust their internal appeals with the MCO before being given the right to appeal to DMAS; and

4. The MCO shall promptly provide grievance or appeal forms, reasonable assistance, and written procedures to members who wish to register written grievances or appeals, including auxiliary aids and services upon request such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.

G. The MCO shall issue grievance or internal appeal decisions as defined by 42 CFR 438.408 and the contract between DMAS and the MCO. Oral grievance decisions are not required to be in writing.

H. The MCO shall issue standard internal appeal decisions within 30 days from the date of initial receipt of the internal appeal in accordance with 42 CFR 438.408 and as defined by the Medallion contract between DMAS and the MCO. This timeframe may be extended by up to 14 days under the requirements of 42 CFR 438.408. The internal appeal decision shall be in writing and shall include the following:

1. The decision reached, the results, and the date of the decision reached by the MCO;

2. The reasons for the decision;

3. The policies or procedures that provide the basis for the decision;

4. For internal appeals not resolved wholly in favor of the member:

a. A clear explanation of further appeal rights and a timeframe for filing an internal appeal; and

b. The right to continue to receive benefits in accordance with 42 CFR 438.420 pending a hearing and how to request continuation of benefits.

The member may be held liable for the cost of those benefits if the hearing decision upholds the contractor's adverse benefit determination.

I. An expedited appeal decision shall be issued as expeditiously as the member's condition requires and within 72 hours from receipt of the internal appeal request in cases of medical emergencies in which delay could result in death or serious injury to a member. Extensions to these timeframes shall be allowed in accordance with 42 CFR 438.408 and as defined by the Medallion contract between DMAS and the MCO. Written confirmation of the decision shall promptly follow the verbal notice of the expedited decision.

J. If the MCO fails to adhere to the internal appeals notice and timing requirements of this section, the member is deemed to have exhausted the MCO's internal appeals process and may file an internal appeal with DMAS.

K. Any adverse benefit determination upheld in whole or in part by the internal appeal decision issued by the MCO may be appealed by the member to DMAS in accordance with the DMAS appeals regulations at 12VAC 30-110-10 through 12VAC 30-110-370. DMAS shall conduct an evidentiary hearing in accordance with the Client Appeals regulations at 12VAC 30-110-10 through 12VAC 30-110-370 and shall not base any appealed decision on the record established by any internal appeal decision of the MCO. The MCO shall comply with the DMAS appeal decision. The DMAS decision in these matters shall be final and shall not be subject to appeal by the MCO.

L. The MCO shall provide information necessary for any DMAS appeal within timeframes established by DMAS.

Statutory Authority

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

Historical Notes

12VAC30-120-430. Provider grievances, reconsiderations, and appeals.

A. The MCOs shall comply with the requirements of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia), the provider appeals regulations at 12VAC 30-20-500 through 12VAC 30-20-560, the Medallion contract between DMAS and the MCO, and any other applicable state or federal statutory or regulatory requirements.

B. The MCOs shall have a grievance system established to respond to grievances made by network providers. Network provider grievances are not appealable to the DMAS Appeals Division.

C. MCOs shall, at the initiation of new network provider contracts, provide to every network provider the information described in this section concerning grievance, reconsideration, and appeal rights and procedures.

D. Disputes between the MCO and the network provider concerning any aspect of reimbursement shall be resolved through a verbal or written grievance or reconsideration process operated by the MCO or through the DMAS appeals process. A network provider or representative that is authorized by the network provider may act on behalf of a network provider in the MCO grievance or reconsideration or the DMAS appeals process.

E. Disputes arising solely from the MCO's denial or termination of a provider's enrollment in the MCO's network are not appealable to the DMAS Appeals Division.

F. If a network provider has rendered services to a member and has been denied authorization or reimbursement for the services or has received reduced authorization or reimbursement, that provider may request a reconsideration of the denied or reduced authorization or reimbursement. Before appealing to DMAS, network providers must first exhaust all MCO reconsideration processes. The MCO's final denial letter must include a statement that the provider has exhausted its reconsideration rights with the MCO and that the next level of appeal is with DMAS. The final denial letter must include the appeal rights to DMAS in accordance with the provider appeals regulations at 12VAC 30-20-500 through 12VAC 30-20-560.

G. All network provider appeals to DMAS must be submitted to the DMAS Appeals Division in writing and within 30 days of the MCO's last date of denial.

H. The MCO shall provide information necessary for any DMAS appeal within timeframes established by DMAS.

I. The MCO shall comply with the DMAS appeal decision. A DMAS appeal decision is not appealable by the MCO.

J. The MCO shall maintain a recordkeeping, reporting, and tracking system for complaints, grievances, and reconsiderations that complies with the Medallion contract between DMAS and the MCO. The system shall include a copy of the original complaint, grievance, or reconsideration; the decision; the nature of the decision; and data on the number of reconsiderations filed, the average time to resolve reconsiderations, and the total number of reconsiderations open as of the reporting date.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 12, Issue 9, eff. January 1, 1996; reserved, Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended Virginia Register Volume 35, Issue 14, eff. April 18, 2019.

12VAC30-120-440. [Reserved].

Historical Notes

Reserved, Virginia Register Volume 13, Issue 5, eff. January 1, 1997.

Part VII
Commonwealth Coordinated Care Plus Program

12VAC30-120-450. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 12, Issue 20, eff. August 1, 1996; repealed, Virginia Register Volume 29, Issue 25, eff. September 26, 2013.

12VAC30-120-460. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 12, Issue 20, eff. August 1, 1996; repealed, Virginia Register Volume 29, Issue 25, eff. September 26, 2013.

12VAC30-120-470. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 12, Issue 20, eff. August 1, 1996; repealed, Virginia Register Volume 29, Issue 25, eff. September 26, 2013.

12VAC30-120-480. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 12, Issue 20, eff. August 1, 1996; repealed, Virginia Register Volume 29, Issue 25, eff. September 26, 2013.

12VAC30-120-490. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 14, Issue 18, eff. July 1, 1998; amended, Virginia Register Volume 19, Issue 18, eff. July 1, 2003; repealed, Virginia Register Volume 22, Issue 10, eff. February 22, 2006.

12VAC30-120-600. Definitions.

The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:

"Adverse action" means the denial, suspension, or reduction in services or the denial or retraction, in whole or in part, of payment for a service that has already been rendered.

"Adverse benefit determination" means, consistent with 42 CFR 438.400, any of the following: (i) the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; (ii) the reduction, suspension, or termination of a previously authorized service; (iii) the denial, in whole or in part, of payment for a service; (iv) the failure to provide services in a timely manner, as defined by the state; (v) the failure of an MCO, PIHP, or PAHP to act within the timeframes provided in 42 CFR 438.408(b)(1) and 42 CFR 438.408(b)(2) regarding the standard resolution of grievances and appeals; (vi) for a resident of a rural area with only one MCO, the denial of an enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the network; or (vii) the denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.

"Appellant" means an applicant for or recipient of Medicaid benefits who seeks to challenge an adverse benefit determination taken by the participating plan, subcontractor, service provider, or DMAS regarding eligibility for services and payment determinations.

"Authorized representative" means the same as set forth in 12VAC 30-110-1380 and 12VAC 30-110-1390.

"Centers for Medicare and Medicaid Services" or "CMS" means the federal agency of the U.S. Department of Health and Human Services that is responsible for the administration of Titles XVIII, XIX, and XXI of the Social Security Act.

"Commonwealth Coordinated Care Plus program" or "CCC Plus" means the department's mandatory integrated care initiative for certain qualifying individuals, including dual eligible individuals and individuals receiving long-term services and supports (LTSS). The CCC Plus program includes individuals who receive services through nursing facility (NF) care or from the four home and community-based services (HCBS) § 1915(c) waivers .

"Continuity of care period" means a set period of time during which the MCO shall ensure a seamless transition from Medicaid FFS, or from another MCO, for all members upon enrollment into a plan.

"Contractor" means a managed care health plan selected by DMAS and contracted to participate in the CCC Plus program.

"Covered services" means the set of required services offered by the participating plan.

"Department of Medical Assistance Services," "department," or "DMAS" means the Virginia Department of Medical Assistance Services, the single state agency for the Medicaid program in Virginia that is responsible for implementation and oversight of CCC Plus.

"Disenrollment" means the process of changing enrollment from one participating plan to another participating plan or the process of being excluded from CCC Plus by the department as described in 12VAC 30-120-610.

"Division" or "Appeals Division" means the Appeals Division of the Department of Medical Assistance Services.

"Dual eligible" means a Medicare member who receives Medicare Parts A, B, and D benefits and also receives full Medicaid benefits.

"Effective date" means the date on which a participating plan's coverage begins for a member.

"Enrollment" means assignment of an individual to a health plan by the department in accordance with the terms of the contract with the participating plan. This does not include attaining eligibility for the Medicaid program.

"Enrollment broker" means an independent contractor that enrolls individuals in the contractor's plan and is responsible for the operation and documentation of a toll-free individual service helpline. The responsibilities of the enrollment broker include individual education and MCO enrollment and assistance with and tracking of individuals' complaints and their resolutions and may include individual marketing and outreach.

"Enrollment period" means the time that a member is actually enrolled in a participating plan.

"External appeal" means an appeal, subsequent to the participating plan internal appeal or reconsideration decision, to the state fair hearing process (for a member appeal) or informal appeals process (for a provider appeal).

"Fee-for-service" or "FFS" means the traditional health care payment system in which physicians and other providers receive a payment for each service they provide.

"Final decision" means a written determination by a department hearing officer from an appeal of an internal appeal decision that is binding on the department, unless modified during or after the judicial process.

"Handbook" means a document prepared by the MCO and provided to the member that is consistent with the requirements of 42 CFR 438.10 and the CCC Plus contract and includes information about all the services covered by that plan.

"Hearing officer" means an impartial decision maker who conducts evidentiary state fair hearings for member appeals on behalf of the department.

"Internal appeal" means an oral or a written request to the MCO by a member, a member's authorized representative, or a provider acting on behalf of the member and with the member's written consent for review of a contractor's adverse benefit determination. The internal appeal is the only level of appeal with the MCO and must be exhausted by a member or deemed exhausted according to 42 CFR 438.408(c)(3) before the member may initiate a state fair hearing.

"Long-term services and supports" or "LTSS" means a variety of services and supports that (i) help elderly s members and s members with disabilities who need assistance to perform activities of daily living and instrumental activities of daily living to improve the quality of their lives and (ii) are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities.

"MCO" means a health plan selected to participate in Virginia's CCC Plus program. "MCO" means the same as "participating plan."

"Medicaid" means the program of medical assistance benefits under Title XIX of the Social Security Act.

"Medically complex" means those who have a complex medical or behavioral health condition and a functional impairment or an intellectual or developmental disability.

"Medically necessary" or "medical necessity" means an item or service provided for the diagnosis or treatment of an enrollee's condition consistent with standards of medical practice and in accordance with Virginia Medicaid policy (12VAC 30-130-600 et seq.) or EPSDT criteria, for those younger than 21 years of age, in accordance with 42 CFR 441 Subpart B (§§ 50 through 62), 42 CFR 438.210, and 42 CFR 440.230.

"Medicare" means Title XVIII of the Social Security Act, the federal health insurance program for people age 65 years or older, people younger than 65 years of age who have certain disabilities, and people with end stage renal disease or amyotrophic lateral sclerosis.

"Member" means an individual who has enrolled in a participating plan to receive services under CCC plus.

"Member appeal" means a member's request for review of an adverse benefit determination.

"Network provider" means a doctor, hospital, or other health care provider that participates or contracts with a participating plan and, as a result, agrees to accept a mutually-agreed upon payment amount or fee schedule as payment in full for covered services that are rendered to eligible s members.

"Nursing facility" means any skilled nursing facility, skilled care facility, intermediate care facility, nursing care facility, or nursing facility, whether freestanding or a portion of a freestanding medical care facility, that is certified for participation as a Medicare or Medicaid provider, or both, pursuant to Title XVIII and Title XIX of the Social Security Act, as amended, and § 32.1-137 of the Code of Virginia.

"Open enrollment" means the timeframe in which members are permitted to change from one MCO to another without cause.

"Participating plan" means the same as "MCO."

"Previously authorized" means, in relation to continuation of benefits, as described in 42 CFR 438.420, a prior approved course of treatment.

"Primary care provider" means a practitioner who provides preventive and primary medical care and certifies service authorizations and referrals for medically necessary specialty services. Primary care providers may include pediatricians, family and general practitioners, internists, obstetricians or gynecologists, geriatricians, specialists who perform primary care functions (such as surgeons), and clinics, including local health departments, federally qualified health centers, and rural health clinics.

"Program of All-Inclusive Care for the Elderly" or "PACE" means the program in which the PACE provider provides the entire spectrum of health services (preventive, primary, and acute) and long-term services and supports to its s members without limit as to duration or cost of services pursuant to 12VAC30-50-320 et seq.

"Provider appeal" means an appeal to the department filed by a Medicaid-enrolled or network service provider that has already provided a service to a member and has received an adverse reconsideration decision regarding service authorization, payment, or audit result.

"Reconsideration" means a provider's request to the MCO for review of an adverse action related to service authorization or payment. The MCO's reconsideration decision is a prerequisite to a provider's filing of an appeal to the Appeals Division.

"Remand" means the return of a case by the department's hearing officer to the MCO for further review, evaluation, and action.

"Reverse" means to overturn the MCO's internal appeal decision and to direct that the MCO fully approve the amount, duration, and scope of requested services.

"Social Security Act" means the federal act, codified through Chapter 7 of Title 42 of the United States Code, that established social insurance programs including Medicare and Medicaid.

"State fair hearing" means the DMAS evidentiary hearing as administered by the Appeals Division. A state fair hearing is conducted by a department hearing officer to allow a member the opportunity to present the member's concerns with or objections to the participating plan's internal appeal decision.

"Subcontractor" means an entity that has contracted with the contractor to perform part of the responsibilities within the CCC Plus program. All subcontractors shall be approved by DMAS.

"Sustain" means to uphold the MCO's appeal decision.

"Withdraw" means a written request from the member or the 's member's authorized representative for the department to terminate the member appeal.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-610. CCC Plus mandatory managed care members enrollment process.

A. The following individuals shall be enrolled in CCC Plus per the CCC Plus § 1915(b) waiver:

1. Dual eligible individuals with Medicare A or B coverage and full Medicaid coverage.

2. Non-dual eligible individuals who receive long-term services and supports through an institution, the CCC Plus waiver , Building Independence waiver, Community Living waiver, and Family and Individual Supports waiver.

Those enrolled in the Building Independence, Community Living, and Family and Individual Supports waivers will continue to receive their LTSS including LTSS related transportation services through Medicaid fee-for-service.

3. All individuals classified as aged, blind, or disabled (ABD) without Medicare and not receiving LTSS.

4. Individuals who qualify for and enroll under Medicaid expansion who have been identified as medically complex.

B. The following individuals shall be excluded from enrollment in CCC Plus:

1. Individuals enrolled in another DMAS managed care program (e.g., Medallion, FAMIS, and FAMIS MOMS).

2. Individuals enrolled in a PACE program.

3. Newborns whose mothers are CCC Plus members on their date of birth.

4. Individuals who are in limited coverage groups, such as:

a. Dual eligible individuals without full Medicaid benefits, such as:

(1) Qualified Medicare beneficiaries;

(2) Special low-income Medicare beneficiaries;

(3) Qualified disabled working individuals; or

(4) Qualifying individuals for whom Medicaid pays the Part B premium.

b. Individuals enrolled in Plan First who do not meet eligibility criteria for Medicaid expansion.

5. Individuals enrolled in a Medicaid-approved hospice program at the time of enrollment. However, if an individual enters a hospice program while enrolled in CCC Plus, the member will remain enrolled in CCC Plus.

6. Individuals who live on Tangier Island.

7. Individuals younger than 21 years of age who are approved for DMAS psychiatric residential treatment center (RTC) Level C programs as defined in 12VAC 30-130-860. Any individual admitted to an RTC Level C program for behavioral health services will be temporarily excluded from CCC Plus until after they are discharged. RTC Level C services may be transitioned to the CCC Plus program in the future.

8. Individuals with end stage renal disease (ESRD) and in fee-for-service at the time of enrollment will be automatically enrolled into CCC Plus but may request to be disenrolled and remain in fee-for-service. The department will exclude these individuals if requested by the member within the first 90 days of CCC Plus enrollment. However, a member who does not request an extension within the first 90 days of CCC Plus enrollment or who develops ESRD while enrolled in CCC Plus will remain in CCC Plus.

9. Individuals who are institutionalized in certain state and private intermediate care facility for individuals with intellectual disabilities (ICF/IID) and mental health facilities as specified in the CCC Plus contract. "Intermediate care facility for individuals with intellectual disabilities" or "ICF/IID" means a facility licensed by the Department of Behavioral Health and Developmental Services in which care is provided to intellectually disabled individuals who are not in need of skilled nursing care, but who need more intensive training and supervision than would be available in a rooming home, boarding home, or group home. Such facilities must comply with Title XIX standards, provide health or rehabilitative services, and provide active treatment to members toward the achievement of a more independent level of functioning.

10. Individuals who are patients at nursing facilities operated by the Veterans Administration.

11. Individuals participating in the CMS Independence at Home (IAH) demonstration. However, IAH individuals may enroll in CCC Plus if they choose to disenroll from IAH.

12. Certain individuals in out-of-state placements as specified in the CCC Plus contract.

13. Individuals placed on spenddown. However, spenddown individuals are included if they are residing in a nursing home.

14. Incarcerated individuals. Individuals on house arrest are not considered incarcerated.

15. All children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program, established pursuant to Chapter 50 of Title 38.2 (§ 38.2-5000 et seq.) of the Code of Virginia, who shall maintain enrollment in Medicaid fee-for-service.

16. Individuals who have any insurance purchased through the Health Insurance Premium Payment (HIPP) program, as defined in 12VAC 30-20-205 and 12VAC 30-20-210.

17. Individuals who are included in the Medicaid expansion population, but are not identified as medically complex. These individuals are covered through the Medallion program.

C. Enrollment in CCC Plus will be mandatory for eligible individuals. The department shall have sole authority and responsibility for the enrollment of individuals into the CCC Plus program and for excluding members from CCC Plus.

D. There shall be no retroactive enrollment for CCC Plus.

E. The MCO shall notify the member of enrollment in the MCO's plan through a letter submitted simultaneously with the handbook. Upon disenrollment from the plan, the MCO shall notify the member through a disenrollment notice that coverage in the MCO's plan will no longer be effective.

F. The department reserves the right to revise the CCC Plus intelligent default assignment methodology (as described in subsection I of this section) as needed based upon DMAS sole discretion.

G. Eligible individuals as defined in subsection A of this section shall be enrolled in a CCC Plus contracted health plan through a CCC Plus intelligent assignment methodology as defined by DMAS in the CCC Plus contract.

1. The member will be, at a minimum, notified of the 's member's assigned MCO, right to select another CCC Plus MCO operating in the 's member's locality, CCC Plus service begin date, and instructions for the individual or the individual's designee to contact DMAS or its enrollment broker to either:

a. Accept the assigned MCO; or

b. Select a different CCC Plus MCO that is operating in the individual's locality.

2. If an individual does not contact DMAS or its enrollment broker to accept the assigned MCO or select a different CCC Plus MCO operating in the individual's locality, the individual shall be enrolled into the assigned MCO.

3. For the initial 90 calendar days following the effective date of CCC Plus enrollment, the member will be permitted to disenroll from one MCO and enroll in another without cause. This 90-day timeframe applies only to the 's member's initial start date of enrollment in CCC Plus; it does not reset or apply to any subsequent enrollment periods. After the initial 90-day period following the initial enrollment date, the member may not disenroll without cause until the next annual open enrollment period.

4. Open enrollment is a period of time when individuals are able to change from one MCO to another without cause.

a. Open enrollment will occur at least once every 12 months per 42 CFR 438.56(c)(2) and 42 CFR 438.56(f)(1). The open enrollment will occur during October through December with any changes to take effect the following January 1. For individuals not participating in Medicaid expansion, open enrollment will occur from October 1 to December 18 for a January 1 effective date. Individuals participating through Medicaid expansion will have an open enrollment period from November 1 to December 18 for a January 1 effective date.

b. Within 60 days prior to the open enrollment effective date, the department will inform members of the opportunity to remain with the current plan or change to another plan without cause. Those individuals who do not choose a new MCO during the open enrollment period shall remain in their current MCO until their next open enrollment effective date.

H. DMAS shall utilize an intelligent default assignment process to assign eligible individuals, other than the ABD populations described in subdivision A 5 of this section, to a CCC Plus MCO contracted to operate in their locality. If none of the criteria used in the intelligent default assignment process applies to an individual, the individual will be randomly assigned to a CCC Plus MCO operating in the individual's locality. The intelligent default assignment process will, at a minimum, take into account:

1. The individual's previous Medicare and Medicaid MCO enrollment within the past two months if known at the time of assignment, the expansion member's child's Medicaid MCO enrollment; and

2. Which MCO the individual's current providers are contracted with. This may include the nursing facility an individual is residing in at the time of assignment, adult day health care for CCC Plus Waiver enrolled members, and an individual's private duty nursing provider.

I. Consistent with 42 CFR 438.56(d), DMAS must permit a member to disenroll at any time for cause.

1. A member may disenroll from the 's member's current plan for the following reasons:

a. The member moves out of the MCO's service area;

b. The MCO does not, because of moral or religious objections, cover the service the member seeks;

c. The member needs related services (e.g., a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the provider network; and the 's member's primary care provider or another provider determines that receiving the services separately would subject the individual to unnecessary risk;

d. The member would have to change residential, institutional, or employment supports provider based on that provider's change in status from an in-network to an out-of-network provider with the MCO and, as a result, the member would experience a disruption in residence or employment; and

e. Other reasons as determined by DMAS, including poor quality of care, lack of access to services covered under this MCO, or lack of access to providers experienced in dealing with the 's member's care needs.

2. The 's member's request to change from one plan to another outside of open enrollment, or for cause request, may be submitted orally or in writing to the department as provided for in 42 CFR 438.56(d)(1) and cite the reasons why the member wishes to disenroll from one plan and enroll in another. The department will review the request in accordance with cause for disenrollment criteria defined in 42 CFR 438.56(d)(2). The department will respond to "for cause" requests, in writing, within 15 business days of the department's receipt of the request. In accordance with 42 CFR 438.56(e)(2), if the department fails to make a determination by the first day of the second month following the month in which the member files the request, the disenrollment request shall be considered approved and effective on the date of approval. Members who are dissatisfied with the department's determination of the 's member's request to disenroll from one plan and enroll in another for cause shall have the right to appeal through the state fair hearing process in 12VAC 30-110.

J. CCC Plus eligible individuals who have been previously enrolled with a CCC Plus MCO and who regain eligibility for the CCC Plus program within 60 calendar days of the effective date of exclusion or disenrollment will be reassigned to the same MCO whenever possible and without going through the selection or assignment process.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-615. CCC Plus providers; Medicaid enrollment process.

A. All individuals and entities who provide services of any type to CCC Plus members, including health care providers; pharmacies; ordering, referring, and prescribing providers; and providers who do not participate in Medicaid fee-for-service shall abide by all CCC Plus contract requirements regarding Provider Enrollment, pursuant to the 21st Century Cures Act (P.L. 114-255).

B. Each provider shall be screened and enrolled with DMAS through the DMAS provider enrollment system by December 1, 2019. The MCO shall ensure that all providers are registered in the DMAS provider enrollment system prior to contracting with the provider.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-620. MCO responsibilities; sanctions.

A. The MCO and any of its subcontractors shall abide by all CCC Plus contract requirements, including:

1. The MCO shall provide medically necessary covered services in accordance with the CCC Plus contract.

a. Each MCO and its subcontractors shall have in place and follow written policies and procedures for processing requests for initial and continuing authorizations of service. Each MCO and its subcontractors shall ensure that any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease. Each MCO and its subcontractors shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.

b. In accordance with § 1932(f) of the Social Security Act (42 USC § 1396a-2), the contractor shall pay all in-network and out-of-network providers (including Native American health care providers) on a timely basis, consistent with the claims payment procedure described in 42 CFR 447.45 and 42 CFR 447.46 and § 1902(a)(37) of the Social Security Act, upon receipt of all clean claims, for covered services rendered to covered members who are enrolled with the contractor at the time the service was delivered. The MCO may deny claims in whole or in part for not meeting payment criteria established by the MCO.

c. Utilization review and audit. MCOs may perform utilization reviews and audits on their network providers. As a result of such a review or audit, an overpayment may be determined.

2. The MCO shall report data to DMAS per CCC Plus contract requirements, which includes data, claims reports, and quality studies performed by the MCO.

3. The MCO shall maintain records, including written policies and procedures, as required by the CCC Plus contract.

4. The MCO shall furnish such required information to DMAS, the Attorney General of Virginia or the Attorney General's authorized representative, or the State Medicaid Fraud Control Unit upon request and in the form requested.

5. The MCO shall meet standards specified in the CCC Plus contract for sufficiency of provider networks. In accordance with § 1915(b)(4) of the Social Security Act, 42 CFR 431.51, and 42 CFR 438.12b(1), the MCO does not have to contract with any willing provider.

6. The MCO shall conduct monthly checks to screen providers for exclusion.

7. The MCO shall require its providers and subcontractors to fully comply with federal requirements for disclosure of ownership and control, business transactions, and information for persons convicted of crimes against federal related health care programs, including Medicare, Medicaid, and CHIP programs, as described in 42 CFR 455 Subpart B.

8. In accordance with 42 CFR 447.50 through 42 CFR 447.60, the MCO shall not impose any cost sharing obligations on members except as set forth in 12VAC 30-20-150 and 12VAC 30-20-160 .

B. Sanctions shall be the same as those set forth in the CCC Plus contract.

C. As provided in 42 CFR 438.210(a)(5)(i), the MCO's medical necessity criteria shall not be more restrictive than the department's criteria.

D. The MCO's coverage rules for contract covered services shall also ensure compliance with federal EPSDT coverage requirements for members younger than 21 years of age.

E. The MCO shall provide services at least in equal amount, duration, and scope as available under the Medicaid fee-for-service program and as described in Attachment 5 of the CCC Plus contract.

F. The MCO shall not apply any financial requirement or treatment limitation to behavioral health benefits, including mental health or addiction, recovery and treatment benefits, in any classification (inpatient, out-patient, emergency, and pharmacy) that is more restrictive than the predominant financial requirement or treatment limitation of that type applied to substantially all medical/surgical benefits in the same classification furnished to members.

G. The MCO shall provide behavioral health benefits to the member in every classification in which medical/surgical benefits are provided.

H. The MCO shall not place any limitation on behavioral health benefits that is more restrictive than limits in place under fee-for-service Medicaid.

I. The MCO may cover, in addition to services covered under the state plan, any service necessary for compliance with the requirements for parity in mental health and substance abuse benefits in 42 CFR 438 Subpart K.

J. If a member of the MCO is provided behavioral health benefits in any classification of benefits (inpatient, outpatient, emergency care, or prescription drugs), the behavioral health benefits must be provided to the member in every classification in which medical/surgical benefits are provided.

K. The MCO shall not impose an aggregate lifetime dollar limit on any behavioral health benefit regardless of classification.

L. The MCO may not impose non-quantitative treatment limits (NQTL) for behavioral health benefits in any classification (inpatient, out-patient, emergency care, or prescription drugs) unless, under the policies and procedures of the MCO as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to behavioral health benefits in the classification are comparable to and are applied no more stringently than the processes, strategies, evidentiary standards, or other factors used in applying the limitation for medical/surgical benefits in the classification.

M. The MCO shall provide documentation necessary to establish and demonstrate compliance with mental health parity requirements in 42 CFR 438 Subpart K, regarding the provision of behavioral health benefits.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-625. Continuity of care.

The MCO shall ensure continuity of care for each member upon enrollment into the member's plan. During the time period set forth in this section, the MCO shall maintain the member's current providers at the Medicaid FFS rate and honor service authorizations (SAs) issued prior to enrollment for the specified time period. The continuity of care period is as follows:

1. Within the first 30 calendar days of a member's enrollment, the MCO shall allow a member to maintain the member's current providers, including out-of-network providers. The MCO shall extend this timeframe as necessary to ensure continuity of care pending the provider contracting with the MCO or the member's safe and effective transition to a contracted provider. DMAS has sole discretion to extend the continuity of care period timeframe.

2. The MCO shall reimburse nursing facilities and specialized care services (described in 12VAC 30-60-40, 12VAC 30-60-320, and 12VAC 30-60-340) no less than the Medicaid established per diem rate for Medicaid covered days, using the DMAS methodologies, unless the MCO and the provider mutually agree to an alternative payment methodology or value-based payment arrangement; however, the rate paid shall not be less than the current Medicaid fee-for-service rate.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-630. Covered services.

A. The MCO shall, at a minimum, provide all medically necessary Medicaid covered services required under the state plan (12VAC30-50-10 through 12VAC30-50-310, 12VAC30-50-410 through 12VAC30-50-430, and 12VAC30-50-470 through 12VAC30-50-580) and Elderly and Disabled with Consumer Direction waiver regulations (12VAC 30-120-924 and 12VAC 30-120-927) and the Technology Assisted waiver regulations (12VAC 30-120-1720) and, effective January 1, 2018, community mental health services (12VAC30-50-130 and 12VAC30-50-226).

B. The following services are not covered by the MCO and shall be provided through fee-for-service outside the CCC Plus MCO contract:

1. Dental services (12VAC30-50-190);

2. School health services (12VAC30-50-130);

3. Preadmission screening (12VAC 30-60-303);

4. Individual and Developmental Disability Support waiver services (12VAC 30-120-700 et seq.);

5. Intellectual Disability Waiver (12VAC 30-120-1000 et seq.); or

6. Day Support Waiver (12VAC 30-120-1500 et seq.).

C. The Program of All-Inclusive Care for the Elderly, or PACE, is not available to CCC Plus members.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-635. Payment rates for MCOs.

A. The payment rate to MCOs shall be set by negotiated contracts and in accordance with 42 CFR 438.6 Subpart A through 42 CFR 438.8 and other pertinent federal regulations.

B. In accordance with § 1932(b)(2)(D) of the Social Security Act and State Medicaid Director Letter 06-010, the contractor shall pay noncontracted providers for emergency services no more than the amount that would have been paid if the service had been provided under the state's FFS Medicaid program. The contractor shall reimburse out-of-network providers and providers of emergent or urgent care, as defined by 42 CFR 424.101 and 42 CFR 405.400 respectively, at the Medicaid FFS payment level for that service.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-640. State fair hearing process.

A. Notwithstanding the provisions of 12VAC 30-110-10 through 12VAC 30-110-370, this section through 12VAC 30-120-690 govern state fair hearings for individuals enrolled in CCC Plus.

B. The Appeals Division maintains an appeals and fair hearings system for members (referred to as "appellants" once the appeal process has begun) to challenge appeal decisions rendered by the MCO in response to member appeals of adverse benefit determinations related to Medicaid services. Exhaustion of the MCO's appeals process is a prerequisite to requesting a state fair hearing with the department. Appellants who meet the criteria for a state fair hearing shall be entitled to a state fair hearing before a department hearing officer.

C. The MCO shall conduct an internal appeal , pursuant to 42 CFR Part 431 Subpart E and 42 CFR Part 438 Subpart F, and issue a written decision that includes its findings and information regarding the appellant's right to file an appeal with DMAS for a state fair hearing for Medicaid appeals.

D. Members must be notified in writing of the MCO's internal appeals process in accordance with 42 CFR 438.400 et seq.:

1. With the handbook; and

2. Upon receipt of a notice of adverse benefit determination from the MCO.

E. Members must be notified in writing of their right to an external appeal to DMAS upon receipt of the MCO's final internal appeal decision.

F. An appellant shall have the right to representation by an attorney or an authorized representative at the internal appeal and external appeal before DMAS. An authorized representative may be designated to represent the appellant, pursuant to 12VAC 30-110-60, 12VAC 30-110-1380, and 12VAC 30-110-1390, at the internal appeal and external appeal before DMAS.

G. Any communication from a member or the 's member's authorized representative that expresses the 's member's desire to present his case to a reviewing authority shall constitute an appeal request.

1. This communication should explain the basis for the appeal of the MCO's internal appeal decision.

2. The appellant or the appellant's authorized representative may examine witnesses, documents, or both; provide testimony; submit evidence; and advance relevant arguments during the state fair hearing.

H. After the MCO's internal appeal process has been exhausted, an appellant may request a state fair hearing by filing an appeal with the Appeals Division via regular mail, fax transmission, telephone, email, in person, or through other commonly available electronic means.

I. Expedited appeals referenced in subsection K of this section may be filed by telephone or any of the methods set forth in subsection H of this section.

J. The appellant member has the right to have his benefits continued during the MCO's appeal or the state fair hearing.

1. All of the following requirements must be met in order for benefits to be continued during the MCO and state fair hearing appeals:

a. The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;

b. The services were ordered by an authorized provider;

c. The original period covered by the initial authorization has not expired; and

d. The member requests that the benefits be continued.

2. For continuation of benefits for an internal appeal with the MCO, the member or authorized representative must file the appeal before the effective date of the adverse benefit determination or within 10 calendar days of the mail date of the MCO's notice of the adverse benefit determination.

3. For continuation of benefits for a state fair hearing, the member or authorized representative must file the appeal within 10 calendar days of the mail date of the MCO's final appeal decision.

4. The MCO shall also continue benefits for members who initiate a state fair hearing directly because of deemed exhaustion of appeals processes due to failure of the MCO to adhere to the notice and timing requirements in 42 CFR 438.408.

5. If the final resolution of the appeal or state fair hearing is adverse to the member, that is, upholds the MCO's adverse benefit determination, the MCO may recover the costs of services furnished to the member while the appeal and the state fair hearing was pending, to the extent they were furnished solely because of the pending appeal.

K. The MCO and the department shall maintain an expedited process for appeals when an appellant's treating provider indicates in making the request on the 's member's behalf or supporting the 's member's request that taking the time for a standard resolution could seriously jeopardize the 's member's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

1. Resolution of an expedited appeal shall be no longer than 72 hours after the MCO receives the appeal.

2. Members must exhaust the MCO's internal appeals processes prior to filing an expedited appeal request with the department with the exception of those with members who gain direct access to state fair hearings because of deemed exhaustion of appeals processes with the MCO pursuant to 42 CFR 438.402(c)(1)(i)(A).

3. The MCO and the department may extend the timeframes for resolution of an expedited appeal by up to 14 calendar days if the member or the 's member's authorized representative requests the extension, or if the MCO or the department shows that there is a need for additional information and how the delay is in the 's member's best interest.

4. Requirements following extension. If the MCO extends the timeframes not at the request of the member, it shall complete the following:

a. Promptly notify the member of the reason for an extension and provide the date the extension expires; and

b. Resolve the appeal as expeditiously as the 's member's health condition requires and no later than the date the extension expires.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-650. Appeal timeframes.

A. Appeals to the Medicaid state fair hearing process must be filed with the Appeals Division within 120 days of the date of the MCO's final internal appeal decision.

B. It is presumed that appellants will receive the MCO's final internal appeal decision five days after the MCO mails it unless the appellant shows that the appellant did not receive the notice within the five-day period.

C. A request for a state fair hearing on the grounds that the MCO has not acted with reasonable promptness in response to an internal appeal request may be filed at any time until the MCO has acted.

D. The date of filing shall be the date the internal appeal request is received by the MCO, the date the state fair hearing request is received by the Appeals Division, or the postmark date if the state fair hearing request is sent by regular mail.

E. In computing any time period under this chapter, the day of the act or event from which the designated period of time begins to run shall be excluded and the last day included. If a time limit would expire on a Saturday, Sunday, or state or federal holiday, it shall be extended until the next regular business day.

F. DMAS shall take final administrative action within 90 days from the date the member filed an MCO appeal, not including the number of days the member took to subsequently file for a state fair hearing.

G. Exceptions to standard appeal resolution timeframes. Decisions may be issued beyond the standard appeal resolution timeframes when the appellant or the appellant's authorized representative requests or causes a delay. Decisions may also be issued beyond the standard appeal resolution timeframe when any of the following circumstances exist:

1. The appellant or authorized representative requests to reschedule or continue the state fair hearing;

2. The appellant or authorized representative provides good cause for failing to keep a scheduled state fair hearing appointment, and the Appeals Division reschedules the state fair hearing;

3. Inclement weather, unanticipated system outage, or the department's closure prevents the hearing officer's ability to work;

4. Following a state fair hearing, the hearing officer orders an independent medical assessment as described in 12VAC 30-120-670 H 1;

5. The hearing officer leaves the state fair hearing record open after the state fair hearing in order to receive additional evidence or argument from the appellant;

6. The hearing officer receives additional evidence from a person other than the appellant or the appellant's authorized representative, and the appellant requests to comment on such evidence in writing or to have the state fair hearing reconvened to respond to such evidence; or

7. The Appeals Division determines that there is a need for additional information and documents how the delay is in the appellant's best interest.

H. For delays requested or caused by an appellant or the appellant's authorized representative, the delay date for the decision will be calculated as follows:

1. If an appellant or authorized representative requests or causes a delay within 30 days of the request for a state fair hearing, the 90-day time limit will be extended by the number of days from the date when the first state fair hearing was scheduled until the date to which the state fair hearing is rescheduled.

2. If an appellant or authorized representative requests or causes a delay within 31 to 60 days of the request for a state fair hearing, the 90-day time limit will be extended by 1.5 times the number of days from the date when the first state fair hearing was scheduled until the date to which the state fair hearing is rescheduled.

3. If an appellant or authorized representative requests or causes a delay within 61 to 90 days of the request for a state fair hearing, the 90-day time limit will be extended by two times the number of days from the date when the first state fair hearing was scheduled until the date to which the state fair hearing is rescheduled.

I. Post state fair hearing delays requested or caused by an appellant or authorized representative (e.g., requests for the record to be left open) will result in a day-for-day delay for the decision date. The department shall provide the appellant and authorized representative with written notice of the reason for the decision delay and the delayed decision date, if applicable.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-660. Pre state fair hearing decisions.

A. If the Appeals Division determines that any of the conditions as described in this subsection exist, a state fair hearing will not be held and the appeal process shall be terminated.

1. A request for appeal may be invalidated if:

a. It was not filed within the time limit imposed by 12VAC 30-120-650; or

b. The individual who filed the appeal ("filer") is not the appellant or parent of a minor appellant, and the Appeals Division sends a letter to the filer requesting proof of the filer's authority to appeal on behalf of the appellant; and

(1) The filer did not reply within 10 calendar days to the request for authorization to represent the appellant ; or

(2) The filer replied within 10 calendar days of the request, and the Appeals Division determined that the authorization submitted was insufficient to allow the filer to represent the appellant under the provisions of 12VAC 30-120-640.

2. A request for appeal may be administratively dismissed if:

a. The MCO's internal appeals process was not exhausted prior to the member's request for a state fair hearing;

b. The issue of the appeal is not related to the MCO's final internal appeal decision;

c. The adverse benefit determination being appealed was not taken by the MCO; or

d. The sole issue is a federal or state law requiring an automatic change adversely affecting some or all beneficiaries.

3. An appeal case may be closed if:

a. The Appeals Division schedules a state fair hearing and sends a written schedule letter notifying the appellant or the appellant's authorized representative of the date, time, and location of the state fair hearing; the appellant or the appellant's authorized representative fails to appear at the scheduled state fair hearing; and the Appeals Division sends a letter to the appellant for an explanation as to why he failed to appear; and

(1) The appellant did not reply within 10 calendar days to the request for an explanation that met good cause criteria ; or

(2) The appellant replied within 10 calendar days of the request, and the Appeals Division determined that the reply did not meet good cause criteria.

b. The Appeals Division sends a written schedule letter requesting that the appellant or the appellant's authorized representative provide a telephone number at which he can be reached for a telephonic state fair hearing, and the appellant or the appellant's authorized representative failed to respond within 10 calendar days to the request for a telephone number at which he could be reached for a telephonic state fair hearing.

c. The appellant or the appellant's authorized representative withdraws the appeal request. If the appeal request is withdrawn orally, the Appeals Division shall (i) record the individual's statement and telephonic signature and (ii) send the affected individual written confirmation via regular mail or electronic notification, in accordance with the individual's election.

d. The MCO approves the full amount, duration, and scope of services requested.

e. The evidence in the record shows that the MCO's decision was clearly in error and that the case should be fully resolved in the appellant's favor.

B. Remand to the MCO. If the hearing officer determines from the record, without conducting a state fair hearing, that the case might be resolved in the appellant's favor if the MCO obtains and develops additional information, documentation, or verification, the hearing officer may remand the case to the MCO for action consistent with the hearing officer's written instructions pursuant to 12VAC 30-110-210 D.

C. A letter shall be sent to the appellant or the appellant's authorized representative that explains the determination made on the appeal.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-670. State fair hearing process and final decision.

A. All state fair hearings shall be conducted de novo per 12VAC 30-110-220. As such, no deference will be given to the entity that made the adverse action being appealed.

B. All state fair hearings must be scheduled at a reasonable time, date, and place, and the appellant and the appellant's authorized representative shall be notified in writing prior to the hearing.

1. The state fair hearing location will be determined by the Appeals Division.

2. A state fair hearing may be rescheduled at the appellant's request no more than twice unless compelling reasons exist, which shall be determined by the department hearing officer.

3. Rescheduling the state fair hearing at the appellant's request will result in automatic waiver of the 90-day deadline for resolution of the appeal. The delay date for the decision will be calculated as set forth in 12VAC 30-120-650 H and I.

C. The state fair hearing shall be conducted by a department hearing officer. The hearing officer shall review the complete record for all MCO decisions that are properly appealed; conduct informal, fact-gathering state fair hearings; evaluate evidence presented; research the issues; and render a written final decision.

D. Subject to the requirements of all applicable federal and state laws regarding privacy, confidentiality, disclosure, and personally identifiable information, the appeal record shall be made accessible to the appellant and the appellant's authorized representative at a convenient place and time before the date of the state fair hearing, as well as during the state fair hearing. The appellant and the appellant's authorized representative may examine the content of the appellant's case file and all documents and records the department will rely on at the state fair hearing except those records excluded by law.

E. Appellants who require the attendance of witnesses or the production of records, memoranda, papers, and other documents at the state fair hearing may request in writing the issuance of a subpoena. The request must be received by the department at least 10 business days before the scheduled state fair hearing. Such request shall (i) include the witness's or respondent's name, home and work addresses, and county or city of work and residence and (ii) identify the sheriff's office that will serve the subpoena.

F. The hearing officer shall conduct the state fair hearing; decide on questions of evidence, procedure, and law; question witnesses; and assure that the state fair hearing remains relevant to the issue being appealed. The hearing officer shall control the conduct of the state fair hearing and decide who may participate in or observe the state fair hearing.

G. State fair hearings shall be conducted in an informal, impartial manner. The appellant and the appellant's authorized representative shall have the right to bring witnesses, establish all pertinent facts and circumstances, present an argument without undue interference, and question or refute the testimony or evidence, including the opportunity to confront and cross-examine agency representatives.

H. The rules of evidence shall not strictly apply. All relevant, nonrepetitive evidence may be admitted, but the probative weight of the evidence will be evaluated by the hearing officer.

I. The hearing officer may leave the state fair hearing record open for a specified period of time after the state fair hearing in order to receive additional evidence or argument from the appellant and the appellant's authorized representative.

1. At the appellant's option, the hearing officer may order an independent medical assessment when the appeal involves medical issues, such as a diagnosis, an examining physician's report, or a medical review team's decision, and the hearing officer determines that it is necessary to have an assessment by someone other than the person or team who made the original decision (e.g., to obtain more detailed medical findings about the impairments, to obtain technical or specialized medical information, or to resolve conflicts or differences in medical findings or assessments in the existing evidence). A medical assessment ordered pursuant to this chapter shall be at the department's expense, shall not extend any of the timeframes specified in this chapter, shall not disrupt the continuation of benefits, and shall become part of the record.

2. The hearing officer may receive evidence that was not presented by either party if the record indicates that such evidence exists, and the appellant or the appellant's authorized representative requests to submit it or requests that the hearing officer secure it.

3. If the hearing officer receives additional evidence from an entity other than the appellant or the appellant's authorized representative, the hearing officer shall send a copy of such evidence to the appellant and the appellant's authorized representative and give the appellant or the appellant's authorized representative the opportunity to comment on such evidence in writing or to have the state fair hearing reconvened to respond to such evidence.

4. Any additional evidence received will become a part of the state fair hearing record, but the hearing officer must determine whether or not it will be used in making the final decision.

J. After conducting the state fair hearing, reviewing the record, and deciding questions of law, the hearing officer shall issue a written final decision. The hearing officer's final decision shall be considered as the department's final administrative action pursuant to 42 CFR 431.244(f). The final decision shall include:

1. Identification of the issue;

2. Relevant facts, to include a description of the procedural development of the case;

3. Conclusions of law, regulations, and policy that relate to the issue;

4. Discussions, analysis of the accuracy of the MCO's appeal decision, conclusions, and hearing officer's decision;

5. Further action, if any, to be taken by the MCOs to implement the hearing officer's decision;

6. The deadline date by which further action must be taken; and

7. A cover letter informing the appellant and the appellant's authorized representative of the hearing officer's decision. The letter must indicate that the hearing officer's decision is final, and that the final decision may be appealed directly to circuit court.

K. A copy of the state fair hearing record shall be forwarded to the appellant and the appellant's authorized representative with the final decision.

L. An appellant who disagrees with the hearing officer's final decision described in this section may seek judicial review pursuant to the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) and Rules of the Supreme Court of Virginia, Part Two A. Written instructions for requesting judicial review must be provided to the appellant or the appellant's authorized representative with the hearing officer's decision, and upon request by the appellant or authorized representative.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021; amended, Virginia Register Volume 40, Issue 22, eff. August 1, 2024.

12VAC30-120-680. Appeals Division records.

A. No person shall take from the department's custody any original record, paper, document, or exhibit that has been certified to the Appeals Division except as the Appeals Division Director or the director's designee authorizes, or as may be necessary to furnish or transmit copies for other official purposes.

B. Information in the appellant's record can be released only to the appellant, the appellant's authorized representative, the MCO, other entities for official purposes, and other persons named in a release of information authorization signed by an appellant or the appellant's authorized representative.

C. The fees to be charged and collected for any copy of Appeals Division records will be in accordance with Virginia's Freedom of Information Act (§ 2.2-3700 et seq. of the Code of Virginia) or other controlling law.

D. When copies are requested from records in the Appeals Division's custody, the required fee shall be waived if the copies are requested in connection with a member's own appeal.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-690. Provider appeals.

A. The Appeals Division maintains an appeal process for network and Medicaid-enrolled providers of Medicaid services that have rendered services to members and are requesting to challenge an MCO's reconsideration decision regarding an adverse action affecting service authorization or payment. The MCO's internal reconsideration process is a prerequisite to filing for an external appeal to the department's provider appeal process. The appeal process is available to network and Medicaid-enrolled providers that (i) have rendered services and have been denied payment in whole or part for Medicaid covered services; (ii) have rendered services and have been denied authorization for the services; and (iii) have received a notice of program reimbursement or overpayment demand from the department or its contractors. Providers that have had their enrollment in the MCO's network denied or terminated by the MCO do not have the right to an external appeal with the Appeals Division.

B. Department provider appeals shall be conducted in accordance with the department's provider appeal regulations (12VAC 30-20-500 et seq.), § 32.1-325 et seq. of the Code of Virginia, and the Virginia Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia).

C. The department's external appeal decision shall be binding upon the MCO and not subject to further appeal by the MCO.

D. If the provider is successful in its appeal of a reimbursement issue, then the MCO shall reimburse the provider for the appealed issue.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

Part VIII
Individual and Family Developmental Disabilities Support Waiver

Article 1
General Requirements [Repealed]

12VAC30-120-700. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 19, Issue 25, eff. October 1, 2003; Volume 23, Issue 20, eff. July 11, 2007; Volume 25, Issue 20, eff. July 9, 2009; Volume 30, Issue 14, April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-710. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 19, Issue 25, eff. October 1, 2003; Volume 23, Issue 20, eff. July 11, 2007; Volume 25, Issue 20, eff. July 9, 2009; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-720. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 19, Issue 25, eff. October 1, 2003; Volume 22, Issue 24, eff. September 6, 2006; Volume 23, Issue 20, eff. July 11, 2007; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-730. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Volume 27, Issue 3, eff. November 10, 2010; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-740. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

Article 2
Covered Services and Limitations and Related Provider Requirements

12VAC30-120-750. (Repealed.)

Historical Notes

12VAC30-120-751. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-752. (Repealed.)

Historical Notes

12VAC30-120-753. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 23, Issue 20, eff. July 11, 2007; amended, Virginia Register Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-754. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Volume 25, Issue 20, eff. July 9, 2009; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-755. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-756. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Errata, 23:24 VA.R. 4080 August 6, 2007; amended, Virginia Register Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-757. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-758. (Repealed.)

Historical Notes

12VAC30-120-759. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-760. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Volume 30, Issue 7, eff. January 2, 2014; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-761. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-762. (Repealed.)

Historical Notes

12VAC30-120-763. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-764. (Repealed.)

Historical Notes

12VAC30-120-765. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-766. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; amended, Volume 27, Issue 19, eff. July 1, 2011; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-767. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-768. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; repealed, Virginia Register Volume 23, Issue 20, eff. July 11, 2007.

12VAC30-120-769. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-770. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; Errata, 17:21 VA.R. 3124 July 2, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Volume 25, Issue 20, eff. July 9, 2009; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-771. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-772. (Repealed.)

Historical Notes

12VAC30-120-773. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-774. (Repealed.)

Historical Notes

12VAC30-120-775. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-776. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; Errata, 17:21 VA.R. 3124 July 2, 2001; amended, Virginia Register Volume 23, Issue 20, eff. July 11, 2007; Volume 30, Issue 14, eff. April 10, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-777. (Repealed.)

Historical Notes

Previously reserved; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-780. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; repealed, Virginia Register Volume 23, Issue 20, eff. July 11, 2007.

12VAC30-120-790. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 17, Issue 18, eff. July 1, 2001; repealed, Virginia Register Volume 23, Issue 20, eff. July 11, 2007.

Part IX
Commonwealth Coordinated Care Plus Waiver

12VAC30-120-900. 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 "ADLs" means personal care tasks such as bathing, dressing, toileting, transferring, and eating or feeding. An individual's degree of independence in performing these activities is a part of determining appropriate level of care and service needs.

"Adult" means an individual who is 21 years of age or older.

"Adult day health care" or "ADHC" means a program licensed by the Virginia Department of Social Services (VDSS) as an adult day care center (ADCC) and authorized as a Medicaid-enrolled provider meeting home and community-based services (HCBS) settings rules that provides a variety of health, therapeutic, and social services designed to meet the specialized needs of those waiver individuals who are elderly or who have a disability and who are at risk of placement in a nursing facility (NF). ADHC can also refer to the center where this service is provided.

"Adult protective services" or "APS" means the same as defined in § 63.2-100 of the Code of Virginia.

"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 for personal and respite care.

"Agency provider" means a public or private organization or entity that holds a Medicaid provider agreement and furnishes services to individuals using its own employees or subcontractors.

"Annually" means a period of time covering 365 consecutive calendar days or 366 consecutive days in the case of leap years.

"Appeal" means the process used to challenge actions regarding services, benefits, and reimbursement provided by Medicaid pursuant to 12VAC 30-110 and 12VAC 30-20-500 through 12VAC 30-20-570.

"Applicant" means an individual or representative on the individual's behalf who has applied for or is in the process of applying for and is awaiting a determination of eligibility for admission to the CCC Plus Program Waiver.

"Assess" means to evaluate an applicant's or an individual's condition, including functional status (i.e., an individual's degree of dependence in performing ADLs or IADLs), current medical status, psychosocial history, and environment. Information is collected from the applicant or individual, applicant's or individual's representative, family, and medical professionals as well as the assessor's observation of the applicant or individual.

"Assessment" means one or more processes that are used to obtain information about an individual, including the individual's condition, personal goals and preferences, functional limitations, health status, financial status, and other factors that are relevant to the determination of eligibility for service. An assessment is required for the authorization of and provision of services and for the development of the plan of care.

"Assistive technology" or "AT" 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 (i) enable individuals to increase their abilities to perform ADLs or IADLs and to perceive, control, or communicate with the environment in which the individuals live or (ii) are necessary to the proper functioning of the specialized equipment.

"Backup caregiver" means a secondary person who assumes the role of providing direct care to and support of the waiver individual in instances of emergencies and in the absence of the primary caregiver who is unable to care for the individual. The backup caregiver shall perform the duties needed by the waiver individual without compensation and shall be trained in the skilled needs and technologies required by the waiver individual. The backup caregiver shall be identified in the waiver individual's records.

"Backup plan" means a secondary network of supports to perform the duties needed by the waiver individual to ensure the individual's health, safety, and welfare should the paid caregiver be unable to provide such services. All waiver individuals are required to have a backup plan prior to initiation of services and ongoing, which shall be documented in the waiver individual's records. Those listed in the backup plan shall be trained in the skilled needs and technologies required by the waiver individual.

"Barrier crime" means those crimes as defined at § 19.2-392.02 of the Code of Virginia that would prohibit either the employment or the continuation of employment if a person is found, through a Virginia State Police criminal record check, to have been convicted of such a crime.

"Care coordinator" means a professional from one of the state's contracted managed care organizations who assists assigned individuals enrolled in the CCC Plus integrated care initiative using a team-based, person-centered approach to effectively manage an individual's medical, social, and behavioral conditions.

"CMS" means the Centers for Medicare and Medicaid Services, which is the unit of the U.S. Department of Health and Human Services that administers the Medicare and Medicaid programs.

"Child protective services" or "CPS" means the same as defined in § 63.2-100 of the Code of Virginia.

"Cognitive impairment" means a severe deficit in mental capability that affects a waiver individual's areas of functioning such as thought processes, problem solving, judgment, memory, or comprehension that interferes with such things as reality orientation, ability to care for self, ability to recognize danger to self or others, or impulse control.

"Commonwealth Coordinated Care Plus Program" or "CCC Plus" means the DMAS mandatory integrated care initiative for certain qualifying Medicaid members, including members who are dually eligible for Medicare and Medicaid and members receiving long-term services and supports (LTSS). The CCC Plus Program includes members who receive services through nursing facility (NF) care, specialized care NF, or long-stay hospitals, or from one of the four DMAS home and community-based services (HCBS) § 1915(c) waivers. Not all individuals in the CCC Plus Program will qualify for the CCC Plus Waiver.

"Community-based team" or "CBT" means the same as defined in 12VAC 30-60-301.

"Congregate living arrangement" means a living arrangement in which three or fewer waiver individuals live in the same household and share receipt of health care services from the same provider.

"Congregate PDN" means skilled in-home nursing provided to three or fewer waiver individuals in the individuals' primary residence or a group setting.

"Consumer-directed attendant" means a person who provides, via the consumer-directed model of services, personal care or respite care, or any combination of these two services, and who is also exempt from workers' compensation.

"Consumer-directed" or "CD" means the 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 attendant or attendants who render the services that are reimbursed by DMAS.

"Critical incident" means any incident that threatens or impacts the well-being of a waiver individual. Critical incidents shall include the following incidents: medication errors, severe injury or fall, theft, suspected mental or physical abuse or neglect, financial exploitation, and death.

"Day" means, for the purposes of reimbursement, a 24-hour period beginning at 12 a.m. and ending at 11:59 p.m.

"DBHDS" means the Department of Behavioral Health and Developmental Services.

"Direct marketing" means any of the following: (i) conducting either directly or indirectly door-to-door, telephonic, or other "cold call" marketing of services at residences and provider sites; (ii) using direct mailing; (iii) paying "finders fees"; (iv) offering financial incentives, rewards, gifts, or special opportunities to eligible individuals, family, or caregivers as inducements to use a provider's services; (v) providing continuous, periodic marketing activities to the same prospective individual, family, or caregiver, for example, monthly, quarterly, or annual giveaways as inducements to use a provider's services; or (vi) engaging in marketing activities that offer potential customers rebates or discounts in conjunction with the use of a provider's services or other benefits as a means of influencing the individual's, family's, or caregiver's use of a provider's services.

"Direct medical benefit" means services or supplies that are proper and needed for the diagnosis or treatment of a medical condition; are provided for the diagnosis, direct care, and treatment of the condition; and meet the standards of professional medical practice.

"DMAS" means the Department of Medical Assistance Services.

"DMAS staff" means persons employed by the Department of Medical Assistance Services.

"Durable medical equipment and supplies" or "DME" means those items prescribed by the attending physician, generally recognized by the medical community as serving a diagnostic or therapeutic purpose to assist the waiver individual in the completion of everyday activities, and as being a medically necessary element of the service plan without regard to whether those items are covered by the State Plan for Medical Assistance.

"Early periodic screening, diagnosis, and treatment" or "EPSDT" means the benefit program administered by DMAS for individuals younger than 21 years of age in accordance with the definition set forth at 42 CFR 440.40 (b) and the requirements of 42 CFR 441, Subpart B.

"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, a family member, caregiver, or another person.

"Enrollment" means the process where an individual has been determined to meet the financial and categorical eligibility requirements for a Medicaid program or service, and the approving entity has verified the availability of services for the individual requesting waiver enrollment and services.

"Environmental modifications" or "EM" means physical adaptations to an individual's primary residence or primary vehicle that are necessary to ensure the individual's health, safety, and welfare or that enable the individual to function with greater independence and shall be of direct medical or remedial benefit to the individual. Such physical adaptations shall not be authorized for Medicaid payment when the adaptation is being used to bring a substandard dwelling up to minimum habitation standards.

"Fiscal/employer agent" or "F/EA" means a state agency or other entity as determined by DMAS that meets the requirements of 42 CFR 441.484 and the Virginia Public Procurement Act, § 2.2-4300 et seq. of the Code of Virginia.

"Guardian" means a person appointed by a court to manage the personal affairs of an incapacitated individual pursuant to Chapter 20 (§ 64.2-2000 et seq.) of Title 64.2 of the Code of Virginia.

"Health, safety, and welfare" means, for the purposes of this waiver, that an individual's right to receive a CCC Plus Waiver service is dependent on a determination that the waiver individual needs the service based on appropriate assessment criteria and a written plan of care, including having a backup plan of care, that demonstrates medical necessity and that services can be safely provided in the community or through the model of care selected by the individual.

"Home and community-based waiver services" or "waiver services" means the range of community support services approved by the CMS pursuant to § 1915(c) of the Social Security Act to be offered to individuals as an alternative to institutionalization.

"Institution" means a nursing facility, specialized care nursing facility, or long-stay hospital. Individuals who receive enrollment in the CCC Plus Waiver are deemed to meet the level of care necessary for residence in one of these institutions or are anticipated to need to be in one of these institutions within the next 30 days without the services of the waiver.

"Instrumental activities of daily living" or "IADLs" means tasks such as meal preparation, shopping, housekeeping, and laundry. An individual's degree of independence in performing these activities is a part of determining appropriate service needs.

"Level of care" or "LOC" means the specification of the minimum amount of assistance an individual requires in order to receive services in an institutional setting under the State Plan or to receive waiver services.

"License" means proof of official or legal permission issued by the government for an entity or person to perform an activity or service.

"Licensed Practical Nurse" or "LPN" means a person who is licensed or holds multi-state licensure to practice nursing pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia.

"Local department of social services" or "LDSS" means the entity established under § 63.2-324 of the Code of Virginia by the governing city or county in the Commonwealth.

"Long-term services and supports" or "LTSS" means a variety of services that help individuals with health or personal care needs and activities of daily living over a period of time. Long-term care can be provided in the home, in the community, or in various types of facilities, including nursing facilities and assisted living facilities.

"LTSS screening" means the process to (i) evaluate the functional, nursing, and social supports of individuals referred for screening for certain long-term care services and supports requiring nursing facility eligibility; (ii) assist individuals in determining what specific services the individual needs; (iii) evaluate whether a service or a combination of existing community services are available to meet an individual's needs; and (iv) provide a list to individuals of appropriate providers for Medicaid-funded nursing facility or home and community-based care for those individuals who meet nursing facility level of care.

"LTSS screening team" means the entity contracted with DMAS that is responsible for performing the screening process pursuant to § 32.1-330 of the Code of Virginia.

"Managed care organization" or "MCO" means the same as the definition of this term in 42 CFR 438.2 .

"Medicaid Long-Term Services and Supports Communication Form" or "DMAS-225" means the form used by the long-term care provider to report information about changes in an individual's eligibility and financial circumstances.

"Medically necessary" means those services or specialized medical equipment or supplies that are covered for reimbursement under either the State Plan for Medical Assistance or in a waiver program that are reasonable, proper, and necessary for the treatment of an illness, injury, or deficit; are provided for direct care of the condition or to maintain or improve the functioning of a malformed body part; and meet the standards of good professional medical practice as determined by DMAS.

"Medication monitoring" means an electronic device, which is only available in conjunction with personal emergency response systems, that reminds an individual to take medications at the correct dosages and times.

"Minor child" means an individual who is younger than 18 years of age.

"Monitoring" means the ongoing oversight of the provision of waiver and other services to determine that they are furnished according to the waiver individual's plan of care and effectively meet the individual's needs, thereby ensuring the individual's health, safety, and welfare. Monitoring activities may include telephone contact; observation; interviewing the individual or the trained individual representative, as appropriate, in person or by telephone; or interviewing service providers.

"Nurse supervisor" means a registered nurse (RN) or licensed professional nurse (LPN) hired or contracted by an agency to provide the supervisory responsibilities as outlined in the waiver to the agency's staff who perform personal care or respite care services to waiver individuals.

"Participating provider" or "provider" means an entity that meets the standards and requirements set forth by DMAS and has a current, signed provider participation agreement with DMAS or a managed care organization that has a signed contract with DMAS.

"Patient pay amount" means the portion of the individual's income that must be paid as the individual's share of the long-term services and supports and is calculated by the local department of social services based on the individual's documented monthly income and permitted deductions.

"Person-centered planning" means a fundamental process that focuses on what is important to and for an individual and the needs and preferences of the individual to create a plan of care.

"Personal care aide" or "aide" means a person employed by an agency who provides personal care or unskilled respite services. The aide shall have successfully completed an educational curriculum of at least 40 hours of study related to the needs of individuals who are either elderly or who have disabilities as further set out in 12VAC 30-120-935. Such successful completion may be evidenced by the existence of a certificate of completion issued by the training entity, which is provided to DMAS during provider audits.

"Personal care attendant," "attendant," or "PCA" means a person who provides personal care or respite services that are directed by an employer of record under the CD model of service delivery.

"Personal care services" or "PC services" means a range of support services that includes assistance with ADLs or IADLs, access to the community, self-administration of medication or other medical needs, and the monitoring of health status and physical condition provided through the agency-directed or consumer-directed model of service. Personal care services shall be provided by aides or attendants within the scope of their licenses or certifications, as appropriate.

"Personal emergency response system" or "PERS" means an electronic device and monitoring service that enables certain waiver individuals who are at least 14 years of age and at risk of institutionalization to secure help in an emergency.

"PERS provider" means a certified home health or a personal care agency, a durable medical equipment provider, a hospital, or a PERS manufacturer that has the responsibility to furnish, install, maintain, test, monitor, and service PERS equipment, direct services (i.e., installation, equipment maintenance, and services calls), and PERS monitoring. PERS providers may also provide medication monitoring.

"Plan of care" or "POC" means the written plan developed collaboratively by the waiver individual and the waiver individual's family or caregiver, as appropriate, and the provider related solely to the specific services necessary for the individual to remain in the community while ensuring the individual's health, safety, and welfare.

"Private duty nursing services" or "PDN" means skilled in-home nursing services listed in the POC that are (i) not otherwise covered under the State Plan for Medical Assistance home health benefit; (ii) required to prevent institutionalization; or (iii) provided within the scope of the Commonwealth's Nurse Practice Act (Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia) and Drug Control Act ( Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia).

"Provider agreement" means the contract between DMAS and a participating provider under which the provider agrees to furnish services to Medicaid-eligible individuals in compliance with state and federal statutes and regulations and Medicaid contract requirements.

"Registered nurse" or "RN" means a person who is licensed or who 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 nursing.

"Respite services" means services provided to waiver individuals that are furnished on a short-term basis because of the absence of or need for the relief of the unpaid primary caregiver who normally provides the care.

"Service authorization" means the process of approving a service for the individual. The process of approving is done by DMAS, its service authorization contractor, or an MCO.

"Service authorization contractor" means DMAS or the entity that has been contracted by DMAS, including an MCO, to perform service authorization for medically necessary Medicaid covered home and community-based services.

"Services facilitation" means a service that assists the waiver individual (or family, caregiver, or EOR, as appropriate) in arranging for, directing, training, and managing services provided through the consumer-directed model of service.

"Skilled private duty nursing services" or "skilled PDN" means skilled in-home nursing services listed in the POC that are (i) not otherwise covered under the State Plan for Medical Assistance home health benefit; (ii) required to prevent institutionalization; and (iii) provided within the scope of the Commonwealth's Nurse Practice Act (Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia) and Drug Control Act (Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia).

"Skilled respite services" means temporary skilled nursing services that are provided to waiver individuals and that are performed by an LPN or RN for the relief of the unpaid primary caregiver who normally provides the care.

"State Plan for Medical Assistance" or "State 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.

"Transition services" means set-up expenses for individuals as defined at 12VAC 30-120-2010.

"Unpaid primary caregiver" means the primary person who consistently assumes the primary role of providing direct care and support of the waiver individual to live successfully in the community without receiving compensation for providing such care.

"VDH" means the Virginia Department of Health.

"VDSS" means the Virginia Department of Social Services.

"Virginia Uniform Assessment Instrument" or "UAI" means the standardized multidimensional assessment that is completed by the screening entity that assesses an individual's physical health, mental health, and psychosocial and functional abilities to determine if the individual meets the nursing facility level of care.

"Waiver individual" or "individual" means the person who has applied for and been approved to receive these waiver services.

"Weekly" means a span of time covering seven consecutive calendar days.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 25, Issue 20, eff. July 9, 2009; Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-905. Waiver description and legal authority.

A. The Commonwealth Coordinated Care Plus (CCC Plus) Waiver operates under the authority of § 1915(c) of the Social Security Act and 42 CFR 430.25(b), which permit the waiver of certain State Plan requirements. These federal statutory and regulatory provisions permit the establishment of Medicaid waivers to afford the states with greater flexibility to devise different approaches to the provision of long-term services and supports. Under this § 1915(c) waiver, DMAS waives § 1902(a)(10)(B) and (C) of the Social Security Act related to comparability of services.

B. CCC Plus Waiver services shall be covered only for Medicaid-eligible individuals who have been determined eligible to require the level of care provided in either a nursing facility, specialized care nursing facility, or long-stay hospital. These services shall be the critical service necessary to delay or avoid the individual's placement in an appropriate facility.

C. Federal waiver requirements provide that the current aggregate average cost of care fiscal year expenditures under this waiver shall not exceed the average per capita expenditures in the aggregate for the level of care (LOC) provided in a nursing facility (NF), specialized care nursing facility, or long-stay hospital under the State Plan that would have been provided had the waiver not been granted.

D. 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.

E. Payments for CCC Plus Waiver services shall not be provided to any financial institution or entity located outside of the United States pursuant to § 1902(a)(80) of the Social Security Act. Payments for CCC Plus Waiver services furnished in another state shall be (i) provided for an individual who meets the requirements of 42 CFR 431.52 and (ii) limited to the same service limitations that exist when services are rendered within the Commonwealth's political boundaries. Waiver services shall not be covered for Medicaid-eligible individuals who are inpatients of a hospital, nursing facility (NF), intermediate care facility for individuals with intellectual disabilities (ICF/IID), rehabilitation hospitals, assisted living facility licensed by VDSS that serves five or more persons, long-stay hospitals, specialized care nursing facilities, adult foster homes, or group homes licensed by DBHDS.

F. An individual shall not be simultaneously enrolled in more than one waiver program but may be listed on the waiting list for another waiver program as long as criteria are met for both waiver programs.

G. DMAS shall be responsible for the following:

1. Placing individuals in appropriate services that are home and community based;

2. Providing reimbursement for waiver services only after the provider is enrolled and the individual's eligibility process is complete;

3. Not duplicating services that are required as a reasonable accommodation as a part of the Americans with Disabilities Act (42 USC §§ 12131 through 12165) or the Rehabilitation Act of 1973 (29 USC § 794). CCC Plus Waiver services shall not be authorized if another entity is required to provide the services (e.g., schools, insurance) because these waiver services shall not duplicate payment for services available through other programs or funding streams; and

4. Ensuring providers meet the following requirements:

a. Providers shall consider DMAS payment for services under this waiver as payment in full and no balance billing from the provider to the individual, any family member, caregiver, or the employer of record (EOR) of the waiver individual shall be permitted; and

b. Additional voluntary payments or gifts from family members shall not be accepted by providers of services.

H. DMAS or the designated service authorization contractor or managed care organization shall have the responsibility and the authority to terminate the receipt of home and community-based waiver enrollment for the waiver individual for any of the following reasons. Individuals shall be notified of their appeal rights pursuant to 12VAC 30-110:

1. The home and community-based waiver services are no longer the critical alternative to prevent or delay institutional placement within 30 days;

2. The waiver individual is no longer eligible for Medicaid;

3. The waiver individual no longer meets the LOC criteria required for the waiver;

4. The waiver individual's environment in the community does not provide for the individual's health, safety, or welfare;

5. The waiver individual does not have a backup plan for services in the event the provider is unable to provide services; or

6. Any other circumstances that cause services to cease or be interrupted for more than 30 consecutive calendar days.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-910. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 25, Issue 19, eff. July 1, 2009; Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-920. Individual eligibility requirements.

A. Home and community-based waiver services shall be available through a § 1915(c) waiver of the Social Security Act for the following Medicaid-eligible individuals who have been determined to be eligible for waiver services and to require the level of care provided in a nursing facility (NF), long-stay hospital, or specialized care nursing facility:

1. Individuals who are elderly as defined by § 1614 of the Social Security Act; or

2. Individuals who have a disability as defined by § 1614 of the Social Security Act.

B. The Commonwealth has elected to cover low-income families with children as described in § 1931 of the Social Security Act; aged, blind, or disabled individuals who are eligible under 42 CFR 435.121; optional categorically needy individuals who are aged and disabled who have incomes at 80% of the federal poverty level; the special home and community-based waiver group under 42 CFR 435.217; and the medically needy groups specified in 42 CFR 435.320, 435.322, 435.324, and 435.330.

1. Under this waiver, the coverage groups authorized under § 1902(a)(10)(A)(ii)(VI) of the Social Security Act shall be considered as if the individual were institutionalized in an NF, specialized care NF, or long-stay hospital for the purpose of applying institutional deeming rules. All individuals in the waiver must meet the financial and nonfinancial Medicaid eligibility criteria and meet the institutional level of care (LOC) 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 services provided to an individual who is eligible for Medicaid services under 42 CFR 435.217 by the amount of the waiver individual's total income (including amounts disregarded in determining financial 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 shall reduce its payment for home and community-based waiver services by the amount that remains after the following deductions:

a. For waiver individuals to whom § 1924(d) applies (Virginia waives the requirement for comparability pursuant to § 1902(a)(10)(B)), deduct the following in the respective order:

(1) An amount for the maintenance needs of the waiver individual that is equal to 165% of the SSI income limit for one individual. Working individuals have a greater need due to expenses of employment; therefore, an additional amount of income shall be deducted. Earned income shall be deducted within the following limits: (i) for waiver individuals 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 and (ii) for waiver individuals employed at least four 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. However, in no case shall the total amount of income (both earned and unearned) that is disregarded for maintenance exceed 300% of SSI. If the waiver individual requires a guardian or conservator who charges a fee, the fee, not to exceed an amount greater than 5.0% of the waiver 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 a waiver individual with only a spouse at home, the community spousal income allowance is 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 is determined in accordance with § 1924(d) of the Social Security Act; and

(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 the state law but not covered under the State Plan.

b. For waiver individuals to whom § 1924(d) of the Social Security Act does not apply, deduct the following in the respective order:

(1) An amount for the maintenance needs of the waiver individual that is equal to 165% of the SSI income limit for one individual. Working individuals have a greater need due to expenses of employment; therefore, an additional amount of income shall be deducted. Earned income shall be deducted within the following limits: (i) for waiver individuals employed 20 hours or more, earned income shall be disregarded up to a maximum of 300% of SSI and (ii) for waiver individuals employed at least four but less than 20 hours, earned income shall be disregarded up to a maximum of 200% of SSI. However, in no case shall the total amount of income (both earned and unearned) that is disregarded for maintenance exceed 300% 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 family at home, an additional amount for the maintenance needs of the family that shall be equal to the medically needy income standard for a family of the same size; and

(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.

C. Assessment and authorization of home and community-based waiver services.

1. To ensure that Virginia's home and community-based waiver programs serve only Medicaid eligible individuals who would otherwise be supported in an NF, specialized care NF, or long-stay hospital, home and community-based waiver services shall be considered only for individuals who are eligible for admission within 30 calendar days to one of these institutions. Home and community-based waiver services shall be the critical service to enable the individual to remain at home and in the community rather than being placed in an institution.

2. The individual's eligibility for home and community-based waiver services shall be determined by the LTSS screening team after completion of a thorough assessment of the individual's needs and available support. If the individual is determined eligible based on the procedures outlined in 12VAC 30-60-303, the LTSS screening team shall provide the individual and family or caregiver with the choice of CCC Plus Waiver services, other appropriate services, institutional placement, or Program of All Inclusive Care for the Elderly (PACE) enrollment for people 55 years of age or older.

3. The LTSS screening team shall explore alternative settings or services to provide the care needed by the individual. If Medicaid-funded home and community-based waiver services are selected by the individual, the LTSS screening team shall initiate referrals for such services.

4. Medicaid shall not pay for any home and community-based waiver services delivered prior to the date the individual establishes Medicaid financial eligibility and the date of the LTSS screening with the physician's signature on the Medicaid Funded Long-Term Care Services Authorization Form (DMAS-96).

5. Before Medicaid shall assume payment responsibility of home and community-based services, service authorization must be obtained from DMAS or the DMAS-designated service authorization contractor for all services requiring service authorization. Providers shall submit all required information to DMAS or the designated service authorization contractor within 10 business days of initiating care or within 10 business days of receiving verification of Medicaid financial eligibility from the local department of social services. If the provider submits all required information to DMAS or the designated service authorization contractor within 10 business days of initiating care, services may be authorized beginning from the date the provider initiated services but not preceding the date of the physician's signature on the DMAS-96 form. If the provider does not submit all required information to DMAS or the designated service authorization contractor within 10 business days of initiating care, the services may be authorized beginning with the date all required information was received by DMAS or the designated service authorization contractor, but in no event preceding the date of the physician's signature on the DMAS-96 form.

6. Once waiver eligibility has been determined by the LTSS screening team and referrals have been initiated, the provider or MCO shall submit a Medicaid LTSS Communication Form (DMAS-225) to the local department of social services to determine financial eligibility for the waiver program and any patient pay responsibilities. If the waiver individual has a patient pay amount, a provider shall use the electronic patient pay process for the required monthly monitoring of relevant changes. Local departments of social services shall enter data regarding a waiver individual's patient pay amount obligation into the DMAS system of record at the time action is taken on behalf of the individual either as a result of an application for LTSS, redetermination of financial eligibility, or reported change or changes in a waiver individual's situation. Procedures for the verification of a waiver individual's patient pay obligation are available in the appropriate Medicaid provider manual.

7. After the provider or MCO has received notification via the DMAS-225 process by the local department of social services and enrollment confirmation from DMAS or the designated service authorization contractor, the provider shall inform the individual, family, or caregiver so that services may be initiated.

8. The provider or MCO shall be responsible for notifying the local department of social services via the DMAS-225 when there is an interruption of services for 30 consecutive calendar days or upon discharge or transfer from the provider's services.

9. Certain home and community-based services shall not be available to individuals residing in an assisted living facility licensed by VDSS that serves four or fewer individuals. These services are: respite, PERS, ADHC, environmental modifications, and transition services. Personal care services shall be covered for individuals living in these facilities but shall not exceed five hours per day. Personal care services shall be authorized based on the waiver individual's documented need for care over and above that which is provided by the assisted living facility.

10. Individuals who are receiving Auxiliary Grants shall not be eligible for CCC Plus Waiver enrollment or services.

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

12. Individuals who are receiving PDN waiver services shall have a trained primary caregiver who accepts responsibility for the individual's health, safety, and welfare. This primary caregiver shall be responsible for all hours not provided by an RN or an LPN. The name of the trained primary caregiver shall be documented in the provider's records.

D. Waiver individual responsibilities under the consumer-directed (CD) model.

1. The individual shall be authorized for CD services and the employer of record (EOR) shall successfully complete consumer employee management training performed by the services facilitator before the waiver individual or EOR shall be permitted to hire a personal care attendant for Medicaid reimbursement. Any services rendered by an attendant prior to dates authorized by Medicaid shall not be eligible for reimbursement. Individuals who are eligible for CD services shall have the capability to hire and train their own personal care attendants and supervise the attendants' performance including creating and maintaining complete and accurate work shift entries. The EOR may be the individual or a family member, caregiver, or another person designated by the individual to serve on the individual's behalf.

2. The person who serves as the EOR shall not be permitted to be (i) the paid attendant for respite services or personal care services or (ii) the services facilitator.

3. Individuals shall not knowingly continue to accept CD personal care services when the service is no longer appropriate or necessary for their care needs and shall inform the services facilitator. If CD services continue after services have been terminated by DMAS or the designated service authorization contractor, the waiver individual shall be held liable for attendant compensation.

4. The individual or EOR, as appropriate, shall notify the services facilitator of all hospitalizations and admission to any rehabilitation hospital unit, NF, specialized care NF, or long-stay hospital as soon as possible. Failure to do so may result in the waiver individual being liable for employee compensation.

E. Waiver individuals' rights and responsibilities. DMAS shall ensure that:

1. Each waiver individual shall receive, and the provider shall provide, the necessary care and services, to the extent of provider availability, to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the person-centered planning of the individual's comprehensive assessment and plan of care (POC).

2. Waiver individuals shall have the right to participate in the development of the plan of care and to receive services from the provider with reasonable accommodation of the individual's needs and preferences except when DMAS makes a determination that the health, safety, or welfare of the waiver individual or other individuals would be endangered.

3. All waiver individuals shall have the right to:

a. Voice grievances to the provider or provider staff without discrimination or reprisal. Such grievances include those with respect to treatment that has or has not been furnished;

b. Prompt efforts by the provider or staff, as appropriate, to resolve any grievances the waiver individual may have;

c. Be free from verbal, sexual, physical, and mental abuse, neglect, exploitation, and misappropriation of property;

d. Be treated with respect and with due consideration for the individual's dignity and privacy;

e. Be free from any physical or chemical restraints or seclusion of any form that may be used as a means of coercion, discipline, convenience, or retaliation and that are not required to treat the individual's medical symptoms;

f. The privacy and confidentiality of the individual's medical and clinical records; and

g. Receive information, such as a handbook or provider directory, in a manner and format that may be easily understood (i.e., in prevalent non-English languages and using translation services) and that is readily accessible in accordance with the standards specified in 42 CFR 438.10.

4. The waiver individual if legally competent, the waiver individual's legal guardian, or the parent of the minor child shall have the right to:

a. Choose whether the individual wishes to receive home and community-based care waiver services instead of institutionalization in accordance with the assessed needs of the individual. The LTSS screening team or MCO shall inform the individual of all available waiver service providers in the community in which the waiver individual resides. The waiver individual shall have the option of selecting the provider and services of the individual's choice. Individuals enrolled in the CCC Plus Program shall have the option of selecting a provider in the MCO's contracted network and services of the individual's choice. This choice must be documented in the individual's medical record;

b. Choose a primary care physician in the community in which the individual resides;

c. Be fully informed in advance about the waiver POC and treatment needs as well as any changes in that care or treatment that may affect the individual's well-being;

d. Participate in the care planning process, choice, and scheduling of providers and services; and

e. Be provided care with privacy, dignity, and respect at all times.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 22, Issue 24, eff. September 6, 2006; Volume 25, Issue 20, eff. July 9, 2009; Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-924. Covered services; limits on covered services.

A. Covered services in the CCC Plus Waiver are as follows: adult day health care; personal care (both consumer-directed and agency-directed); respite services (both consumer-directed and agency-directed); PERS services, including medication monitoring; services facilitation; private duty nursing; assistive technology; environmental modifications; and transition services.

1. The services covered in this waiver shall be appropriate and medically necessary to maintain the individual in the community in order to prevent institutionalization and shall be cost effective in the aggregate as compared to the alternative institutional placement.

2. CCC Plus Waiver services shall not be authorized if another entity is required to provide the services (e.g., schools, insurance). Waiver services shall not duplicate services available through other programs or funding streams.

3. An individual receiving CCC Plus Waiver services who is also getting hospice care may receive Medicaid-covered personal care (agency-directed and consumer-directed), respite care (agency-directed and consumer-directed), services facilitation, private duty nursing, adult day health care, transition services, and PERS services, regardless of whether the hospice provider receives reimbursement from Medicare or Medicaid for the services covered under the hospice benefit.

4. Agency-directed and consumer-directed personal care services and respite care services shall be subject to the electronic visit verification requirements set out in 12VAC 30-60-65.

B. Disenrollment from consumer-directed services. In disenrollment situations, the waiver individual shall be offered agency-directed personal care and respite services from a provider of the waiver individual's choice.

1. A waiver individual may be found to be ineligible for CD services by either the LTSS screening team, DMAS, its designated agent, or the services facilitator. An individual may not begin or continue to receive CD services if there are circumstances where the waiver individual's health, safety, or welfare cannot be assured, including:

a. It is determined that the waiver individual cannot complete the duties of the EOR and no one else is able to assume this role;

b. The waiver individual cannot ensure his own health, safety, or welfare or develop an emergency backup plan that will ensure his health, safety, or welfare; or

c. The waiver individual has medication or skilled nursing needs or medical or behavioral conditions that cannot be met through CD services or other services.

2. The waiver individual may be involuntarily disenrolled from consumer direction if the individual or the EOR, as appropriate, is consistently unable to retain or manage the attendant as may be demonstrated by, but not necessarily limited to, a pattern of serious discrepancies with the attendant's work shift entries or noncompliance with CD EOR requirements.

3. In situations where either (i) the waiver individual's health, safety, or welfare cannot be assured or (ii) attendant work shift entry discrepancies are known, the services facilitator shall assist as requested with the waiver individual's transfer to agency-directed services as follows:

a. Verify that essential training has been provided to the waiver individual or EOR;

b. Document, in the waiver individual's record, the conditions creating the necessity for the involuntary disenrollment and actions taken by the services facilitator;

c. Discuss with the waiver individual or the EOR, as appropriate, the agency-directed option that is available and the actions needed to arrange for such services and offer choice of potential providers; and

d. Provide written notice to the waiver individual of the right to appeal such involuntary termination of consumer direction. Such notice shall be given at least 10 calendar days prior to the effective date of this change. In cases when the individual's or the provider personnel's safety may be in jeopardy, the 10 calendar days' notice shall not apply.

C. Adult day health care (ADHC) services. ADHC services shall only be offered to waiver individuals who meet LTSS screening criteria as established in 12VAC 30-60-303 and 12VAC 30-60-313 and for whom ADHC services shall be an appropriate and medically necessary alternative to institutional care. ADHC services may be offered to individuals in a VDSS-licensed adult day care center (ADCC) congregate setting. ADHC may be offered either as the sole home and community-based waiver service or in conjunction with personal care (either agency-directed or consumer-directed), respite care (either agency-directed or consumer-directed), or PERS. A multi-disciplinary approach to developing, implementing, and evaluating each waiver individual's POC shall be essential to quality ADHC services.

1. ADHC services shall be designed to prevent institutionalization by providing waiver individuals with health care services, maintenance of the individual's physical and mental conditions, and coordination of rehabilitation services in a congregate daytime setting and shall be tailored to each individual's unique needs. The minimum range of services that shall be made available to every waiver individual shall be: assistance with ADLs, nursing services, coordination of rehabilitation services, nutrition, social services, recreation, and socialization services.

a. Assistance with ADLs shall include supervision of the waiver individual and assistance with management of the individual's POC.

b. Nursing services shall include the periodic evaluation, at least every 90 days, of the waiver individual's nursing needs; provision of indicated nursing care and treatment; responsibility for monitoring, recording, and administering prescribed medications; supervision of the waiver individual in self-administered medication; support of families in their home care efforts for the waiver individuals through education and counseling; and helping families identify and appropriately utilize health care resources. Periodic evaluations may occur more frequently than every 90 days if indicated by the individual's changing condition. Nursing services shall also include the general supervision of provider staff, who are certified through the Board of Nursing, in medication management and administering medications.

c. Coordination and implementation of rehabilitation services to ensure the waiver individual receives all rehabilitative services deemed necessary to improve or maintain independent functioning, to include physical therapy, occupational therapy, and speech therapy.

d. Nutrition services shall be provided to include one or more meals per day that meets the daily nutritional requirements pursuant to 22VAC40-61-360. Special diets and nutrition counseling shall be provided as required or requested by the waiver individual.

e. Recreation and social activities shall be provided that are suited to the needs of the waiver individuals and shall be designed to encourage physical exercise, prevent physical and mental deterioration, and stimulate social interaction.

f. ADHC coordination shall involve implementing the waiver individuals' POCs, updating such plans, recording 30-day progress notes, and reviewing the waiver individuals' daily logs each week.

2. Limits on covered ADHC services.

a. A day of ADHC services shall be defined as a minimum of six hours.

b. ADHCs that do not employ professional nursing staff on site shall not be permitted to admit waiver individuals who require skilled nursing care to their centers. Examples of skilled nursing care may include: (i) tube feedings; (ii) Foley catheter irrigations; (iii) sterile dressing changing; or (iv) any other procedures that require sterile technique. The ADCC shall not permit its aide employees to perform skilled nursing procedures.

c. At any time that the center is no longer able to provide reliable, continuous care to any of the center's waiver individuals for the number of hours per day or days per week as contained in the individuals' POCs, the center shall contact the waiver individuals, family, caregivers, or MCO care coordinators, as appropriate, to initiate other care arrangements for these individuals. The center may either subcontract with another ADCC or may transfer the waiver individual to another ADCC. The center may discharge waiver individuals from the center's services but not from the waiver. Written notice of discharge shall be provided, with the specific reason or reasons for discharge, at least 10 calendar days prior to the effective date of the discharge. In cases when the individual's or the center personnel's safety may be in jeopardy, the 10 calendar days' notice shall not apply.

d. ADHC services shall not be provided, for the purpose of Medicaid reimbursement, to individuals who reside in nursing facilities, intermediate care facilities for individuals with intellectual disabilities, hospitals, assisted living facilities that are licensed by VDSS, or group homes that are licensed by DBHDS.

D. Agency-directed personal care services. Agency-directed personal care services shall be offered to persons who meet the LTSS screening criteria at 12VAC 30-60-303 and 12VAC 30-60-313 and for whom it shall be an appropriate alternative to institutional care. Agency-directed personal care services shall be comprised of hands-on care of either a supportive or health-related nature and shall include assistance with ADLs, access to the community, assistance with medications in accordance with VDH licensing requirements or other medical needs, supervision, and the monitoring of health status and physical condition. Where the individual requires assistance with ADLs, and when specified in the POC, such supportive services may include assistance with IADLs. This service shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19. Agency-directed personal care services may be provided in a home or community setting 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 may be offered either as the sole home and community-based waiver service or in conjunction with adult day health care, respite care (agency-directed or consumer-directed), or PERS. The provider shall document, in the individual's medical record, the waiver individual's choice of the agency-directed model.

1. Criteria. In order to qualify for this service, the waiver individual shall have met the LOC criteria as set out in 12VAC 30-60-303 and 12VAC 30-60-313 as documented on the UAI assessment form, and for whom it shall be an appropriate alternative to institutional care.

a. A waiver individual may receive both CD and agency-directed personal care services if the individual meets the criteria. Hours received by the individual who is receiving both CD and agency-directed services shall not exceed the total number of hours that would be needed if the waiver individual were receiving personal care services through a single delivery model.

b. CD and agency-directed services shall not be simultaneously provided but may be provided sequentially or alternately from each other.

c. The individual, family, or caregiver shall have a backup plan or caregiver for the provision of services in the event the agency is unable to provide an aide.

2. Limits on covered agency-directed personal care services.

a. 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) or the Rehabilitation Act of 1973 (29 USC § 794).

b. DMAS or its contractor shall reimburse for services delivered, consistent with the approved POC, for personal care that the personal care aide provides to the waiver individual to assist while at work or postsecondary school or both.

(1) DMAS or the designated service authorization contractor shall review the waiver individual's needs and the complexity of the disability, as applicable, when determining the services that are provided to the individual in the workplace or postsecondary school or both.

(2) DMAS shall not pay for the personal care aide to assist the waiver individual with any functions or tasks related to the individual completing a job or postsecondary school functions or for supervision time during either work or postsecondary school or both.

c. Supervision services shall be authorized to ensure the health, safety, or welfare of the waiver individual who cannot be left alone at any time or is unable to call for help in case of an emergency, and when there is no competent adult in the home able to call for help in case of an emergency.

d. There shall be a maximum limit of eight hours per day for supervision services. Supervision services shall be documented in the POC as needed by the individual.

e. Agency-directed personal care services shall be limited to 56 hours of services per week for 52 weeks per year. Exceptions may be granted based on criteria set forth in 12VAC 30-120-927.

f. Electronic visit verification requirements set out in 12VAC 30-60-65 shall apply to these agency-directed respite care services.

g. Due to the complex medical needs of waiver individuals requiring PDN services and the need for 24-hour supervision, the trained primary caregiver shall be present in the home and shall render the required skilled services during the entire time that the aide is providing unskilled care.

E. Agency-directed respite care services. Agency-directed respite care services shall be offered to waiver individuals who meet the LTSS screening criteria at 12VAC 30-60-303 and 12VAC 30-60-313 and for whom it shall be an appropriate alternative to institutional care. Agency-directed respite care services may be either skilled respite or unskilled care and shall be comprised of hands-on care of either a supportive or health-related nature and may include assistance with ADLs, access to the community, assistance with medications in accordance with VDH licensing requirements or other medical needs, supervision, and monitoring health status and physical condition. Skilled respite care shall include skilled nursing care ordered on the physician-certified POC.

1. Respite care shall only be offered to individuals who have an unpaid primary caregiver who requires temporary relief to avoid institutionalization of the waiver individual. Respite care services may be provided in the individual's home or other community settings. Respite shall also be provided in children's residential facilities in accordance with 12VAC 30-120-925.

2. When the individual requires assistance with ADLs, and where such assistance is specified in the waiver individual's POC, such supportive services may also include assistance with IADLs.

3. Unskilled respite service shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19.

4. Skilled respite care services.

a. This service shall be provided by skilled nursing staff licensed to practice in the Commonwealth under the direct supervision of a licensed, certified, or accredited home health agency with which DMAS has a provider agreement to provide PDN. Direct supervision means that the supervising RN is immediately accessible by telephone to the RN, LPN, or personal care aide who is delivering waiver-covered services to individuals.

b. Skilled respite care services shall be comprised of both skilled and hands-on care of either a supportive or health-related nature and may include all skilled nursing care as ordered on the physician-certified POC, assistance with ADLs or IADLs, administration of medications or other medical needs, and monitoring of the health status and physical condition of individuals.

c. When skilled respite services are offered in conjunction with PDN, the same individual record may be used with a separate section for skilled respite services documentation. This documentation must be clearly labeled as distinct from PDN services.

d. Individuals who reside in the same house shall be permitted to share skilled respite care service providers. The same limits on this service in the congregate setting (480 hours per calendar year per household) shall apply regardless of the type of waiver.

5. Limits on service.

a. The unit of service shall be one hour. Respite care services shall be limited to 480 hours per individual per calendar year, to be service authorized. No additional respite hours beyond the maximum limit shall be approved for payment for individuals, even those who change waiver programs. Additionally, individuals who are receiving respite services in this waiver through both the agency-directed and CD models shall not exceed 480 hours per calendar year combined.

b. If agency-directed respite care service is the only service received by the waiver individual, it must be received at least as often as every 30 days. If this service is not required at this minimal level of frequency, then the provider or MCO shall notify the local department of social services for its redetermination of eligibility for the waiver individual.

c. The individual, family, or caregiver shall have a backup plan or caregiver for the provision of services in the event the agency is unable to provide an aide.

d. Electronic visit verification requirements set out in 12VAC 30-60-65 shall apply to these agency-directed respite care services.

F. Services facilitation for consumer-directed services. Consumer-directed personal care and respite care services shall only be offered to waiver individuals who meet the LTSS screening criteria at 12VAC 30-60-303 and 12VAC 30-60-313 and for whom there shall be appropriate alternatives to institutional care.

1. Individuals who choose CD services shall receive support from a DMAS-enrolled services facilitator or a provider designated by the managed care organization as required in conjunction with CD services. The services facilitator shall document the waiver individual's choice of the CD model and whether there is a need for another person to serve as the EOR on behalf of the individual. The services facilitator shall be responsible for assessing the waiver individual's particular needs for a requested CD service, assisting in the development of the POC, providing training to the EOR on the EOR's responsibilities as an employer, and for providing ongoing support of the CD services.

2. Individuals who are eligible for CD services shall have an EOR who has the capability to hire, to train, and to fire the personal care attendant and supervise the attendant's performance, including approving the attendant's work shift entries.

a. If a waiver individual is unwilling or unable to direct the individual's own care or is younger than 18 years of age, family, a caregiver, or a designated person shall serve as the EOR on behalf of the waiver individual in order to perform these supervisory and work shift entry approval functions.

b. Specific employer duties shall include checking references of personal care attendants and determining that personal care attendants meet qualifications.

3. The individual, family, or caregiver shall have a backup plan or caregiver for the provision of services in case the attendant does not show up for work as scheduled or terminates employment without prior notice.

4. The services facilitator shall not be the waiver individual, a CD attendant, a provider of other Medicaid-covered services, the spouse of the waiver individual, the natural, adoptive, step, or foster parent or other legal guardian of the waiver individual who is a minor, or the EOR who is employing the CD attendant.

5. DMAS or the MCO shall either provide for fiscal/employer agent services or contract for the services of a fiscal/employer agent for CD services. The fiscal/employer agent shall be reimbursed by DMAS or the DMAS contractor to perform certain tasks as an agent for the EOR. The fiscal/employer agent shall handle responsibilities for the waiver individual, including payroll, employment taxes, and background checks for attendants. The fiscal/employer agent shall seek and obtain all necessary authorizations and approvals of the Internal Revenue Service in order to fulfill all of these duties.

G. Consumer-directed personal care services. CD personal care services shall be comprised of hands-on care of either a supportive or health-related nature and shall include assistance with ADLs, access to the community, monitoring of self-administered medications or other medical needs, supervision, and the monitoring of health status and physical condition. Where the waiver individual requires assistance with ADLs, and when specified in the POC, such supportive services may include assistance with IADLs. This service shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19 and as permitted by Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia. CD personal care services may be provided in a home or community setting 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 may be offered either as the sole home and community-based waiver service or in conjunction with adult day health care, respite care (agency-directed or consumer-directed), or PERS.

1. In order to qualify for this service, the waiver individual shall have met the LOC criteria as set out in 12VAC 30-60-303 and 12VAC 30-60-313 as documented on the UAI assessment instrument, and for whom it shall be an appropriate alternative to institutional care.

a. A waiver individual may receive both CD and agency-directed personal care services if the individual meets the criteria. Hours received by the waiver individual who is receiving both CD and agency-directed services shall not exceed the total number of hours that would be otherwise authorized had the individual chosen to receive personal care services through a single delivery model.

b. CD and agency-directed services shall not be simultaneously provided but may be provided sequentially or alternately from each other.

2. Limits on covered CD personal care services.

b. There shall be a limit of eight hours per day for supervision services included in the POC. Supervision services shall be authorized to ensure the health, safety, or welfare of the waiver individual who cannot be left alone at any time or is unable to call for help in case of an emergency, and when there is no other competent adult able to call for help in case of an emergency.

c. Consumer-directed personal care services shall be limited to 56 hours of services per week for 52 weeks per year. Exceptions may be granted based on criteria set forth in 12VAC 30-120-927.

d. Electronic visit verification requirements as set out in 12VAC 30-60-65 shall apply to these CD personal care services.

e. Due to the complex medical needs of waiver individuals requiring PDN services and the need for 24-hour supervision, the trained primary caregiver shall be present in the home and shall render the required skilled services during the entire time that the attendant is providing unskilled care.

3. CD personal care services at work or school shall be limited as follows:

a. DMAS or its contractor shall reimburse for services delivered, consistent with the approved POC, for CD personal care that the attendant provides to the waiver individual to assist while at work or postsecondary school or both.

b. DMAS or the designated service authorization contractor shall review the waiver individual's needs and the complexity of the disability, as applicable, when determining the services that will be provided to the individual in the workplace or postsecondary school or both.

c. DMAS shall not pay for the personal care attendant to assist the waiver individual with any functions or tasks related to the individual completing a job or postsecondary school functions or for supervision time during work or postsecondary school or both.

H. Consumer-directed respite care services. CD respite care services are unskilled care and shall be comprised of hands-on care of either a supportive or health-related nature and may include assistance with ADLs, access to the community, monitoring of self-administration of medications or other medical needs, supervision, monitoring health status and physical condition, and personal care services in a work environment.

1. In order to qualify for this service, the waiver individual shall have met the LOC criteria as set out in 12VAC 30-60-303 and 12VAC 30-60-313 as documented on the UAI form, and for whom it shall be an appropriate alternative to institutional care.

2. CD respite care services shall only be offered to individuals who have an unpaid primary caregiver who requires temporary relief to avoid institutionalization of the waiver individual. This service shall be provided in the waiver individual's home or other community settings.

3. When the waiver individual requires assistance with ADLs, and where such assistance is specified in the individual's POC, such supportive services may also include assistance with IADLs.

4. Electronic visit verification requirements as set out in 12VAC 30-60-65 shall apply to these CD respite care services.

5. Limits on covered CD respite care services.

a. The unit of service shall be one hour. Respite care services shall be limited to 480 hours per waiver individual per calendar year. If a waiver individual changes waiver programs, this same maximum number of respite hours shall apply. No additional respite hours beyond the 480 maximum limit shall be approved for payment. Individuals who are receiving respite care services in this waiver through both the agency-directed and CD models shall not exceed 480 hours per calendar year combined.

b. CD respite care services shall not include skilled nursing services with the exception of skilled nursing tasks (e.g., catheterization) that may be delegated pursuant to Part V (18VAC90-19-240 through 18VAC90-19-280) of 18VAC90-19 and as permitted by Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia).

c. If consumer-directed respite care service is the only service received by the waiver individual, it shall be received at least as often as every 30 days. If this service is not required at this minimal level of frequency, then the services facilitator or MCO shall refer the waiver individual to the local department of social services for its redetermination of Medicaid eligibility for the waiver individual.

I. Personal emergency response system (PERS).

1. Service description. PERS is a service that monitors the individual's 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 or system. PERS may also include medication monitoring devices.

a. PERS shall be authorized only when there is no other competent adult in the home who is available to call for help in an emergency or when the individual's health, safety, and welfare cannot be ensured.

b. The use of PERS equipment shall not relieve the primary or backup caregiver of the caregiver's responsibilities.

c. Service units and service limitations.

(1) PERS shall be limited to waiver individuals who are ages 14 years and older who also either live alone or are alone for significant parts of the day and who have no regular caregiver for extended periods of time. PERS shall only be provided in conjunction with receipt of personal care services (either agency-directed or consumer-directed), respite services (either agency-directed or consumer-directed), or adult day health care. A waiver individual shall not receive PERS if the individual has a cognitive impairment as defined in 12VAC 30-120-900.

(2) 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 shall be the one-month rental price set by DMAS in its fee schedule. The one-time installation of the unit shall include installation, account activation, individual and family or caregiver instruction, and subsequent removal of PERS equipment when it is no longer needed.

(3) PERS services shall be capable of being activated by a remote wireless device and shall be connected to the waiver individual's telephone line or system. The PERS console unit must provide hands-free voice-to-voice communication with the response center. The activating device must be (i) waterproof, (ii) able to automatically transmit to the response center an activator low battery alert signal prior to the battery losing power, (iii) able to be worn by the waiver individual, and (iv) automatically reset by the response center after each activation, thereby ensuring that subsequent signals can be transmitted without requiring manual resetting by the waiver individual.

(4) All PERS equipment shall be approved by the Federal Communications Commission and meet the Underwriters' Laboratories, Inc. (UL) safety standard.

(5) Medication monitoring units shall be physician ordered. In order to be approved to receive the medication monitoring service, a waiver individual shall also receive PERS services. Physician orders shall be maintained in the waiver individual's record. In cases where the medical monitoring unit must be filled by the provider, the person who is filling the unit shall be either an RN or an LPN. The units may be filled as frequently as a minimum of every 14 days. There must be documentation of this action in the waiver individual's record.

J. Transition services. Transition services, as defined at 12VAC 30-120-2010, provide for individuals to move from institutional placements or licensed or certified provider-operated living arrangements to private homes or other qualified settings. The individual's transition from an institution to the community shall be coordinated by the facility's discharge planning team. The discharge planner shall ensure that CCC Plus Waiver eligibility criteria shall be met.

1. Transition services shall be authorized by DMAS or its designated agent in order for reimbursement to occur.

2. To qualify for the service, the waiver individual shall be discharged after 90 consecutive days of residence from an institution, intermediate care facility for individuals with intellectual disabilities, institution for mental disease, or psychiatric residential treatment facility.

3. Transition services shall be provided in conjunction with personal care (agency-directed or consumer-directed), respite care (agency-directed or consumer-directed), private duty nursing, or adult day health care services.

4. Transition services may be provided by DMAS enrolled area agencies on aging, centers for independent living, and local departments of social services.

K. Assistive technology (AT).

1. Assistive technology (AT) shall be portable and shall be authorized per calendar year. AT services are the specialized medical equipment and supplies, including those devices, controls, or appliances, specified in the individual's plan of care, but that are not available under the State Plan for Medical Assistance, that enable a waiver individual to increase the individual's ability to perform ADLs or IADLs or to perceive, control, or communicate with the environment in which the individual lives.

2. In order to qualify for these services, the individual shall have a demonstrated need for specialized medical equipment and supplies 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. AT shall be covered in the least expensive manner.

3. AT services shall be available for a waiver individual who has a demonstrated need for equipment for remedial or direct medical benefit. This service includes ancillary supplies and equipment necessary for the proper functioning of such items.

4. Service units and service limitations.

a. The cost for AT shall not be carried over from one calendar year to the next. Each item must be service authorized by either DMAS or the DMAS-designated service authorization contractor for each calendar year.

b. The maximum funded expenditure per individual for all AT covered procedure codes (combined total of AT items and labor related to these items) shall be $5,000 per calendar year for an individual regardless of waiver, or regardless of whether the individual changes waiver programs, for which AT is approved. The service unit shall always be one, for the total cost of all AT being requested for a specific timeframe.

c. AT may be provided in the individual's home or community setting.

d. AT shall not be approved for purposes of convenience of the caregiver or provider or restraint of the individual, recreation or leisure, educational purposes, or diversion activities.

e. AT shall be carried out in the least expensive manner possible to achieve the goal required for the individual's health, safety, and welfare. AT shall be reimbursed in a manner that is reasonable and customary not to exceed the provider's usual and customary charges to the general public.

f. An independent, professional consultation shall be obtained from a qualified professional who is knowledgeable of that item for each AT request prior to approval by the service authorization contractor or managed care organization and may include training on such AT by the qualified professional. The consultation shall not be performed by the provider of AT to the individual.

g. All AT shall be authorized by DMAS, the designated service authorization contractor, or managed care organization prior to billing or providing services to the individual.

h. Items that are reasonable accommodation requirements of the Americans with Disabilities Act, the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia), or the Rehabilitation Act (20 USC § 794) or are required to be provided through other funding sources shall be excluded from Medicaid coverage. 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), Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia), or the Rehabilitation Act of 1973 (29 USC § 794).

i. AT services or equipment shall not be rented but shall be purchased.

j. Shipping, freight, or delivery charges shall not be billable to DMAS or the waiver individual, as such charges are considered noncovered items.

(1) All products shall be delivered, demonstrated, and installed and in working order prior to submitting any claim for them to Medicaid.

(2) The date of service on the claim shall be within the service authorization approval dates, which may be prior to the delivery date as long as the initiation of services commenced during the approved dates.

(3) The service authorization shall not be modified to accommodate delays in product deliveries. In such situations, the provider must seek a new service authorization.

(4) When two or more waiver individuals live in the same home or congregate living arrangement, the AT shall be shared to the extent practicable consistent with the type of AT and the needs of the individuals as documented in their POCs. There shall be no duplication of AT in the same house when such product can be used for a communal purpose.

k. Assistive technology shall not be available to individuals younger than 21 years of age through the CCC Plus Waiver. Assistive technology for individuals younger than 21 shall be accessed through the EPSDT benefit.

l. AT exclusions.

(1) Medicaid shall not reimburse for any AT devices or services that may have been rendered prior to authorization from DMAS or the designated service authorization contractor.

(2) Providers that supply AT for the waiver individual may not perform assessments, consultations, or write specifications for that individual. Any request for a change in cost (either an increase or a decrease) requires justification and supporting documentation of medical need and service authorization by DMAS or the designated service authorization contractor. The vendor shall receive a copy of the professional evaluation in order to purchase the items recommended by the professional. If a change is necessary, the vendor shall notify the assessor to ensure the changed items meet the individual's needs.

(3) All equipment or supplies already covered by a service provided for in the State Plan shall not be purchased under the waiver as AT. Such examples include:

(a) Specialized medical equipment, durable or nondurable medical equipment, ancillary equipment, and supplies necessary for life support;

(b) Adaptive devices, appliances, and controls that enable an individual to be more independent in areas of personal care and ADLs or IADLs; and

L. Environmental modifications (EM).

1. Environmental modifications (EM) shall consist of adaptations documented in the waiver individual's POC and may include the installation of nonportable 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 health, safety, and welfare of the waiver 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, flooring, roof repairs, central air conditioning, or decks. Adaptations that add to the total square footage of the home shall be excluded from this benefit, except when necessary to complete an authorized 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 shall be prior authorized by the service authorization contractor or managed care organization. Modifications may only be made to a vehicle if it is the primary vehicle being used by the waiver individual. This service does not include the purchase or lease of vehicles. This service shall not include general repairs to a residence or vehicle.

2. In order to qualify for these services, the waiver individual shall have a demonstrated need for modifications of a remedial or direct medical benefit offered in the individual's primary home or primary vehicle to ensure the individual's health, welfare, or safety or specifically to improve the individual's personal functioning. Modifications may include a generator for a waiver individual who is dependent on mechanical ventilation for 24 hours a day and when the generator is used to support the medical equipment and supplies necessary for the individual's welfare. This service shall encompass those items not otherwise covered in the State Plan for Medical Assistance or through another program. EM shall be covered in the least expensive manner.

3. Service units and service limitations.

a. The maximum funded expenditure per individual for all EM covered procedure codes (combined total of EM items and labor related to these items) shall be $5,000 per calendar year for an individual regardless of waiver, or regardless of whether the individual changes waiver programs, for which EM is approved. Unexpended portions of this maximum amount shall not be accumulated across one or more years to be expended in a later year. The service unit shall always be one, for the total cost of all EM being requested for a specific timeframe.

b. All EM shall be authorized by DMAS or the DMAS-designated service authorization contractor prior to billing or providing services to the individual.

c. Modifications shall not be used to bring a substandard dwelling up to minimum habitation standards.

d. EM shall not be approved for purposes of convenience of the caregiver or provider or restraint of the waiver individual.

e. Only the actual cost of material and labor is reimbursed. There shall be no additional markup.

f. EM shall be carried out in the least expensive manner possible to achieve the goal required for the individual's health, safety, and welfare.

g. All services shall be provided in the individual's primary residence in accordance with applicable state or local building codes and appropriate permits or building inspections, which shall be provided to DMAS or the DMAS contractor.

h. Proposed modifications that are to be made to rental properties shall have prior written approval of the property's owner. Modifications to rental properties shall only be valid if it is an independently operated rental facility with no direct or indirect ties to any other Medicaid service provider.

i. Modifications may be made to a vehicle if it is the primary vehicle used by the individual. This service shall not include the purchase of, lease of, or the general repair of vehicles. Repairs of modifications that have been reimbursed by DMAS shall be covered.

j. The EM provider shall ensure that all work and products are delivered, installed, and in good working order prior to seeking reimbursement from DMAS. The date of service on this provider's claim shall be within the service authorization approval dates, which may be prior to the completion date as long as the work commenced during the approval dates. The service authorization shall not be modified to accommodate installation delays. All requests for cost changes (either increases or decreases) shall be submitted to DMAS or the DMAS-designated service authorization contractor for revision to the previously issued service authorization and shall include justification and supporting documentation of medical needs.

k. 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 Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia), or the Rehabilitation Act of 1973 (29 USC § 794).

4. EM exclusions.

a. There shall be no duplication of previous EM services within the same residence such as multiple nonportable wheelchair ramps or previous modifications to the same room.

b. Adaptations or improvements to the primary home that shall be excluded are of general utility and are not of direct medical or remedial benefit to the waiver individual, such as, but not limited to, carpeting; flooring; roof repairs; central air conditioning or heating; general maintenance and repairs to a home; additions or maintenance of decks or fences; maintenance, replacement, or addition of sidewalks, driveways, or carports; or adaptations that only increase the total square footage of the home.

c. EM shall not be covered by Medicaid for general leisure or diversion items, items that are recreational in nature, items for educational purposes, or items that may be used as an outlet for adaptive or maladaptive behavioral issues. Such noncovered items may include swing sets, playhouses, climbing walls, trampolines, protective matting or ground cover, sporting equipment, hot tubs, or exercise equipment, such as special bicycles or tricycles.

d. EM shall not be covered by Medicaid if payment for such modifications can be made through the Fair Housing Act (42 USC § 3601 et seq.), the Virginia Fair Housing Law (§ 36-96.1 et seq. of the Code of Virginia) or the Americans with Disabilities Act (42 USC § 12101 et seq.).

e. EM shall not include the costs of removal or disposal, or any other costs, of previously installed modifications, whether paid for by DMAS or any other source.

f. Providers who supply EM to a waiver individual shall not perform assessments, consultations, or write EM specifications for such individuals .

g. EM shall not cover payment for modifications or items that can be made through other Medicaid services, such as durable medical equipment.

M. Private duty nursing. PDN for a single individual and individuals residing in the same home, as defined in 12VAC 30-120-900, shall be provided for individuals who have serious medical conditions or complex health care needs. To receive this service, an individual must require specific skilled and continuous nursing care on a regularly scheduled or intermittent basis performed by an RN or an LPN. Once waiver eligibility has been determined by the LTSS screening team and a determination that the individual requires ongoing skilled nursing care has been made, then the PDN hours shall be authorized by DMAS or the DMAS-designated service authorization contractor.

1. PDN services shall be rendered according to a POC authorized by DMAS or the DMAS-designated service authorization contractor and shall have been certified by a physician as medically necessary to enable the individual to remain at home.

2. No reimbursement shall be provided by DMAS for either RN or LPN services without signed physician orders that specifically identify skilled nursing tasks to be performed for the individual.

3. Limits placed on the amount of PDN that will be approved for reimbursement shall be consistent with the individual's support needs and medical necessity but shall not exceed 112 hours per week. The maximum PDN hours authorized per week for individuals shall be based on their technology and documented medical necessity justification.

4. For individuals, whether living separately or in a congregate setting, PDN shall be reimbursed up to a maximum 112 hours per week (Sunday through Saturday) per waiver individual living in the household.

5. The individual shall be determined to need a medical device and ongoing skilled nursing care when such individual meets Category A or all eight criteria in Category B:

a. Category A. Individuals who depend on mechanical ventilators; or

b. Category B. Individuals who have a complex tracheostomy as defined by:

(1) Tracheostomy with the potential for weaning off of it, or documentation of attempts to wean, with subsequent inability to wean;

(2) Nebulizer treatments ordered at least four times a day or nebulizer treatments followed by chest physiotherapy provided by a nurse or respiratory therapist at least four times a day;

(3) Pulse oximetry monitoring at least every shift due to unstable oxygen saturation levels;

(4) Respiratory assessment and documentation every shift by a licensed respiratory therapist or nurse;

(5) Oxygen therapy with documented usage under a physician's order;

(6) Daily tracheostomy care;

(7) Tracheostomy suctioning under a physician's order; and

(8) At risk of requiring subsequent mechanical ventilation.

6. PDN shall not be available to individuals younger than 21 years of age as a waiver service. PDN for individuals younger than 21 shall be accessed through the EPSDT benefit.

7. PDN services may include consultation and training for the primary caregiver.

8. The provider shall be responsible for notifying the LDSS, the service authorization contractor, and the managed care organization should the primary residence of the individual be changed, should the individual be hospitalized, should the individual die, or should the individual be absent from the Commonwealth for 48 hours or more.

9. Exclusions from DMAS coverage of PDN:

a. PDN hours shall not be reimbursed while the individual is receiving emergency care or during emergency transport of the individual to emergency care facilities. The RN or LPN shall not transport the waiver individual to emergency care facilities.

b. PDN services may be ordered but shall not be provided simultaneously with skilled respite care or personal care services. These services may be provided sequentially or alternately from each other.

c. Providers shall not bill prior to receiving the physician's dated signature on the individual's POC for services provided and DMAS or DMAS-designated service authorization contractor's authorization or determination of PDN hours.

d. Time spent transporting the waiver individual shall not be reimbursed by DMAS.

e. DMAS shall not reimburse for PDN services through the CCC Plus Waiver and PDN services through the EPSDT benefit at the same time.

10. Congregate PDN.

a. If more than one waiver individual resides in the home, the same waiver provider shall be chosen to provide all PDN services for all waiver individuals in the home.

b. Only one nurse shall be authorized to care for no more than two waiver individuals in such arrangements. In instances when three waiver individuals share a home, nursing ratios shall be determined by DMAS or its designated agent based on the needs of all the individuals who are living together. These congregate PDN hours shall be at the same scheduled shifts.

c. The unpaid primary caregiver shall be shared and shall be responsible for providing all care needs when a private duty nurse is not available.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-925. Respite coverage in children's residential facilities.

A. Individuals who have a diagnosis of intellectual disability (ID) or developmental disability (DD) shall be eligible to receive respite services in children's residential facilities that are licensed for respite services for children with ID or DD.

B. These respite services shall be covered consistent with the requirements of 12VAC 30-120-924, 12VAC 30-120-930, and 12VAC 30-120-935, whichever is in effect at the time of service delivery with the following exceptions:

1. An assessment by the nurse supervisor shall be conducted at the onset of each use of respite in the children's residential facility;

2. Documentation of each utilization of respite in a children's residential facility will document the arrival and departure times of the individual instead of the arrival and departure times of each staff member; and

3. The nurse supervisor shall review the utilization of respite services in the children's residential facility. The nurse supervisor shall not be required to conduct the supervisory visit in the home of the waiver individual.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 28, Issue 6, eff. January 1, 2012; amended, Virginia Register Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-927. Exception criteria for personal care services.

DMAS shall apply the following criteria to individuals who request approval of personal care hours in excess of the maximum allowed 56 hours per week. In order to qualify for personal care hours in excess of 56 hours per week, the waiver individual shall:

1. Presently have a minimum level of care of B (the waiver individual has a composite activities of daily living (ADL) score between seven and 12 and has a medical nursing need) or C (the waiver individual has a composite ADL score of nine or higher and has a skilled medical nursing need).

2. In addition to meeting the requirements set out in subdivision 1 of this section, the individual shall have at least one of the following:

a. Documentation of dependencies in all of the following activities of daily living: bathing, dressing, transferring, toileting, and eating or feeding, as defined by the current LTSS screening criteria (12VAC 30-60-303) submitted to the service authorization contractor via DMAS-99;

b. Documentation of dependencies in both behavior and orientation as defined by the current LTSS screening criteria (12VAC 30-60-303) submitted to the service authorization contractor via DMAS-99; or

c. Documentation from the local department of social services that the individual has an open case (as described in subdivisions 2 c (1) and 2 c (2) of this section) with either adult protective services (APS) or child protective services (CPS) and is therefore in need of additional services beyond the maximum allowed 56 hours per week. Documentation can be in the form of a phone log contact or any other documentation supplied (submitted to the service authorization contractor via attestation).

(1) For APS, an open case is defined as a substantiated APS case with a disposition of needs protective services and the adult accepts the needed services.

(2) For CPS, an open case is defined as being open to CPS investigation if it is both founded by the investigation and the completed family assessment documents the case with moderate or high risk.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 32, Issue 7, eff. December 30, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-930. General requirements for home and community-based participating providers.

A. The following agency-directed services shall be provided through an agency that is either (i) licensed by VDH, (ii) certified by VDH under provisions of Title XVIII or Title XIX of the Social Security Act, or (iii) accredited either by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or by the Community Health Accreditation Program (CHAP) established by the National League of Nursing for Medicaid participation: personal care, respite care, PDN, skilled respite care, and congregate PDN. The provider shall make available verification of its license, certification, or accreditation upon request.

B. Requests for participation shall be screened by DMAS or the designated DMAS contractor to determine whether the provider applicant meets the requirements for participation, as set forth in the provider agreement, and demonstrates the abilities to perform, at a minimum, the following activities:

1. Screen all new and existing employees and contractors to determine whether any are excluded from eligibility for payment from federal health care programs, including Medicaid (i.e., via the United States Department of Health and Human Services Office of Inspector General List of Excluded Individuals or Entities (LEIE) website). Immediately report in writing to DMAS any exclusion information discovered to: DMAS, ATTN: Program Integrity/Exclusions, 600 East Broad Street, Suite 1300, Richmond, VA 23219, or email to providerexclusions@dmas.virginia.gov;

2. Immediately notify DMAS in writing of any change in the information that the provider previously submitted to DMAS;

3. Ensure freedom of choice to individuals in seeking services from any institution, pharmacy, practitioner, or other provider qualified and enrolled in Medicaid at the time of delivery to perform the service required, except for waiver individuals who are subject to the DMAS Client Medical Management program as set out in Part XIII of 12VAC 30-130 or are enrolled in a Medicaid managed care organization;

4. Ensure the individual's freedom to refuse medical care, treatment, and services;

5. Accept referrals for services only when staff is available to initiate and perform such services on an ongoing basis;

6. Provide services and supplies to individuals in full compliance with Title VI (42 USC § 2000d et seq.) of the Civil Rights Act of 1964, which prohibits discrimination on the grounds of race, color, religion, or national origin; the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia); § 504 of the Rehabilitation Act of 1973 (29 USC § 794), which prohibits discrimination on the basis of a disability; and the Americans with Disabilities Act of 1990 (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;

7. Provide services and supplies to individuals of the same quality and in the same mode of delivery as are provided to the general public;

8. Submit charges to DMAS, the MCO, or the DMAS-designated service authorization contractor for the provision of services and supplies to 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 payment methodology beginning with the individual's authorization date for the waiver services;

9. Use only DMAS-designated forms for service documentation, except when otherwise permitted. The provider shall not alter the DMAS forms in any manner without prior written approval from DMAS;

10. Use DMAS-designated billing forms for submission of charges;

11. Perform no type of direct marketing activities to Medicaid individuals;

12. Maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the services provided.

a. In all instances of forms required to be in records, all documents shall have original notes, dates, and signatures. Copied, re-dated, and photocopied forms, notes and signatures are prohibited. Signatures shall not be dated prior to the last date of rendered services for the appropriate form being used.

b. In general, such records shall be retained for a period of at least six years from the last date of service or as provided by applicable federal and state 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 a period of at least six years after such minor has reached 18 years of age.

c. Policies regarding retention of records shall apply even if the provider discontinues operation. DMAS shall be notified in writing of the storage location and procedures for obtaining records for review should the need arise. The location, agent, or trustee shall be within the Commonwealth;

13. Furnish information on the request of and in the form requested to DMAS or its contractors, the Attorney General of Virginia or their authorized representatives, federal personnel, and the state Medicaid Fraud Control Unit. The Commonwealth's right of access to provider agencies and records shall survive any termination of the provider agreement;

14. 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 recipients of Medicaid;

15. Pursuant to 42 CFR 431.300 et seq., § 32.1-325.3 of the Code of Virginia, and the Health Insurance Portability and Accountability Act (HIPAA), safeguard and hold confidential all information associated with an applicant or enrollee or individual that could disclose the identity of the applicant, enrollee, or individual. Access to information concerning the applicant, enrollee, or individual shall be restricted to persons or agency representatives who are subject to the standards of confidentiality that are consistent with that of the agency and any such access must be in accordance with the provisions found in 42 CFR 431.306 and 12VAC 30-20-90;

16. When ownership of the provider changes, notify DMAS in writing at least 15 calendar days before the date of change;

17. Pursuant to §§ 63.2-100, 63.2-1509, and 63.2-1606 of the Code of Virginia, if a participating provider or the provider's staff knows or suspects that a home and community-based waiver services individual is being abused, neglected, or exploited, the party having knowledge or suspicion of the abuse, neglect, or exploitation shall report this immediately to the local department of social services adult or child protective services department as applicable or to the toll-free, 24-hour hotline as described on the local department of social services' website. Employers shall ensure and document that their staff is aware of this requirement;

a. The party having knowledge or suspicion of abuse, neglect, or exploitation shall also report this immediately to DMAS or its authorized contractor separately as a critical incident. The provider shall ensure that in such instances of suspected or known abuse, neglect, or exploitation that DMAS or its authorized contractor are informed after notifying adult or child protective services and will document the date and time of report.

b. If a participating provider or the provider's staff knows or suspects that a waiver individual has incurred a critical incident that does not include suspected or known abuse, neglect, or exploitation, the party having knowledge or suspicion of the critical incident shall report this immediately to DMAS or the DMAS-designated contractor. Employers shall ensure and document that their staff is aware of this requirement and maintain copies of all records of reported critical incidents in the individual's file.

18. In addition to compliance with the general conditions and requirements, adhere to the conditions of participation outlined in the provider's participation agreements, in the applicable DMAS provider manual, and in other DMAS laws, regulations, and policies. DMAS shall conduct ongoing monitoring of compliance with provider participation standards and DMAS policies. A provider's noncompliance with DMAS policies and procedures may result in a retraction of Medicaid payment or termination of the provider agreement, or both;

19. Meet minimum qualifications of staff.

a. For reasons of Medicaid individuals' safety and welfare, all employees shall have a satisfactory work record, as evidenced by at least two references from prior job experience, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children. In instances of employees who have worked for only one employer, such employees shall be permitted to provide one appropriate employment reference and one appropriate personal reference including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children.

b. Pursuant to 42 CFR 441.302 and 42 CFR 441.352, within 30 calendar days of employment, the staff or volunteer shall obtain an original criminal record clearance with respect to convictions for offenses specified in § 19.2-392.02 of the Code of Virginia or an original criminal history record from the Central Criminal Records Exchange.

(1) DMAS shall not reimburse a provider for services provided by a staff member or volunteer who works in a position that involves direct contact with a waiver individual until an original criminal record clearance or original criminal history record has been received. DMAS shall reimburse services provided by such staff member or volunteer during only the first 30 calendar days of employment if the provider can produce documented evidence that such person worked only under the direct supervision of another staff member or volunteer for whom a background check was completed in accordance with the requirements of this section. If an original criminal record clearance or original criminal history record is not received within the first 30 calendar days of employment, DMAS shall not reimburse the provider for services provided by such employee on the 31st calendar day through the date on which the provider receives an original criminal record clearance or an original criminal history record.

(2) DMAS shall not reimburse a provider for services provided by a staff member or volunteer who has been convicted of any offense set forth in clause (i) of the definition of barrier crime in § 19.2-392.02 of the Code of Virginia unless all of the following conditions are met: (i) the offense was punishable as a misdemeanor; (ii) the staff member or volunteer has been convicted of only one such offense; (iii) the offense did not involve abuse or neglect; and (iv) at least five years have elapsed since the conviction.

c. The staff or volunteer shall provide the hiring facility with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside of the Commonwealth.

d. Provider staff and volunteers shall 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://oig.hhs.gov.

e. Provider staff and volunteers who serve waiver individuals who are minor children shall be screened through the VDSS Child Protective Services (CPS) Central Registry. Provider staff and volunteers shall not be reimbursed for services provided to the waiver individual effective on the date and thereafter that the VDSS CPS Central Registry check confirms the provider's staff person or volunteer has a finding.

20. Comply with the electronic visit verification requirements set out in 12VAC 30-60-65.

21. Providers shall comply with requirements for person-centered planning and home and community-based settings as described in 42 CFR 441.301. As part of the person-centered planning process, providers shall discuss the available services to the individual to meet the individual's needs and shall not perform services that are not identified or agreed upon in the person-centered plan.

C. DMAS shall 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. 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 U.S. territories shall within 30 days of such conviction notify DMAS of this conviction and relinquish its provider agreement. Such provider agreement terminations, subject to applicable appeal rights, shall conform to § 32.1-325 D and E of the Code of Virginia and Part XII (12VAC 30-20-500 et seq.) of 12VAC 30-20.

D. Home and community-based waiver services providers shall meet the following standards:

1. Staffing, financial solvency, disclosure of ownership, and ensuring comparability of services requirements as specified in the applicable provider manual;

2. The ability to document and to maintain waiver individuals' case records in accordance with state and federal requirements;

3. Compliance with all applicable laws, regulations, and policies pertaining to CCC Plus Waiver services.

E. The waiver individual shall have the option of selecting a Medicaid-enrolled provider that can appropriately meet the individual's needs.

F. A participating provider may voluntarily terminate its participation in Medicaid by providing 30 days' written notification to DMAS.

G. Except as otherwise provided by state or federal law, DMAS may terminate at will a provider's participation agreement on 30 days' written notice as specified in the DMAS participation agreement. DMAS may immediately terminate a provider's participation agreement if the provider is no longer eligible to participate in the Medicaid program. Such action precludes further payment by DMAS for services provided to individuals on or after the date specified in the termination notice.

H. The provider or the managed care organization shall be responsible for completing the DMAS-225 form to notify the designated service authorization contractor and the local department of social services when any of the following events occur:

1. Home and community-based waiver services are started;

2. A waiver individual dies;

3. A waiver individual is discharged from the provider's CCC Plus Waiver services;

4. Any other events (including hospitalization) that cause home and community-based waiver services to cease or be interrupted for more than 30 consecutive calendar days; or

5. Changes in the individual's status that may affect the individual's patient pay amount or financial Medicaid eligibility.

I. Changes or termination of services.

1. The provider may decrease the amount of authorized care if the revised POC is appropriate and based on the medical needs of the waiver individual. The participating provider shall collaborate with the waiver individual or the family, caregiver, or EOR, as appropriate, to develop the new POC and calculate the new hours of service delivery. The provider shall discuss the decrease in care with the waiver individual or family, caregiver, or EOR, document the conversation in the waiver individual's record, and notify the designated service authorization contractor. The service authorization contractor shall process the decrease request and the waiver individual shall be notified of the change by letter. This letter shall clearly state the waiver individual's right to appeal this change.

2. If a change in the waiver individual's condition necessitates an increase in care, the participating provider shall assess the need for the increase and collaborate with the waiver individual and family, caregiver, or EOR, and MCO care coordinator as appropriate, to develop a POC for services to meet the changed needs. The provider may implement the increase in personal care hours prior to approval from DMAS, or the designated service authorization contractor, if the amount of services does not exceed the total amount established by DMAS as the maximum for the level of care designated for that individual on the plan of care.

3. Any increase to a waiver individual's POC that exceeds the number of hours allowed for that individual's level of care or any change in the waiver individual's level of care shall be authorized by DMAS or the designated service authorization contractor prior to the increase and be accompanied by adequate documentation justifying the increase.

4. In an emergency situation when the health, safety, or welfare of the waiver individual or provider personnel is endangered, the provider shall notify DMAS, or the designated service authorization contractor in writing prior to discontinuing services. The provider shall give written notification to the waiver individual discontinuing services. An advance written notification period shall not be required. If appropriate, local department of social services adult or child protective services shall be notified immediately.

5. In a nonemergency situation, when neither the health, safety, nor welfare of the waiver individual or provider personnel is endangered, the participating provider shall give the waiver individual at least 10 calendar days' written notification (plus three days for mail transit for a total of 13 calendar days from the letter's date) of the intent to discontinue services. The notification letter shall provide the reasons for and the effective date the provider will be discontinuing services.

J. Staff education and training requirements.

1. RNs shall (i) be currently licensed to practice in the Commonwealth as an RN, or shall hold multi-state licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia; (ii) have at least one year of related clinical nursing experience, which may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, or nursing facility, specialized care nursing facility, or long-stay hospital or as an LPN who worked for at least one year in one of these settings; and (iii) meet the requirements of subdivision A 19 of this section regarding criminal record checks and consent to a search of the VDSS Child Protective Services Central Registry if the waiver individual is a minor child. The RN shall not be compensated for services provided to the waiver individual if this record check verifies that the RN has been convicted of a barrier crime described in § 32.1-162.9:1 of the Code of Virginia or if the RN has a founded complaint confirmed by the VDSS Child Protective Services Central Registry.

2. LPNs shall work under supervision as set out in 18VAC90-19-70. LPNs shall (i) be currently licensed to practice in the Commonwealth as an LPN, or shall hold multi-state licensure privilege pursuant to Chapter 30 (§ 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia; (ii) have at least one year of related clinical nursing experience, which may include work in an acute care hospital, public health clinic, home health agency, rehabilitation hospital, NF, specialized care NF, or long-stay hospital. The LPN shall meet the qualifications and skills, prior to being assigned to care for the waiver individual, that are required by the individual's POC; and (iii) meet the requirements of subdivision A 19 of this section regarding criminal record checks and consent to a search of the VDSS Child Protective Services Central Registry if the waiver individual is a minor child. The LPN shall not be compensated for services provided to the waiver individual if this record check verifies that the LPN has been convicted of a barrier crime described in § 32.1-162.9:1 of the Code of Virginia or if the LPN has a founded complaint confirmed by the VDSS Child Protective Services Central Registry.

3. All RNs and LPNs who provide PDN services shall have either (i) at least six months of related clinical experience as documented in their work history, which may include work in acute care hospitals, long-stay hospitals, rehabilitation hospitals, or specialized care nursing facilities, or (ii) completed a provider training program related to the care and technology needs of the assigned waiver individual.

a. Training programs established by providers shall include, at a minimum, the following:

(1) Trainers (either RNs or respiratory therapists) shall have at least six months hands-on successful experience in the areas in which the trainer provides training, such as ventilators, tracheostomies, peg tubes, and nasogastric tubes.

(2) Training shall include classroom time as well as direct hands-on demonstration of mastery by the trainee of the specialized skills required to work with individuals who have technology dependencies.

(3) The training program shall include the following subject areas as they relate to the care to be provided by the nurse: (i) human anatomy and physiology, (ii) medications frequently used by technology dependent individuals, (iii) emergency management, and (iv) the operation of the relevant equipment.

(4) Providers shall ensure a nurse's competency and mastery of the skills necessary to care successfully for a waiver individual prior to assignment. Documentation of successful completion of such training course and mastery of the specialized skills required to work with individuals who have technology dependencies shall be maintained in the provider's personnel records. This documentation shall be provided to DMAS upon request.

b. The RN supervisor for nurses providing PDN shall be currently licensed to practice nursing in the Commonwealth and have at least one year of related clinical nursing experience, which may include work in an acute care hospital, long-stay hospital, rehabilitation hospital, or specialized care nursing facility.

4. Personal care aides who are employed by personal care agencies that are licensed by VDH shall meet the requirements of 12VAC5-381. In addition, personal care aides shall also receive annually a minimum of 12 documented hours of agency-provided training in the performance of these services.

5. Personal care aides who are employed by personal care agencies that are not licensed by VDH shall have completed an educational curriculum of at least 40 hours of study related to the needs of individuals who are either elderly or who have disabilities, as ensured by the provider prior to being assigned to the care of an individual, and shall have the required skills and training to perform the services as specified in the waiver individual's POC and related supporting documentation.

a. Personal care aides' required initial (that is, at the onset of employment) training shall be met in one of the following ways: (i) registration with the Board of Nursing as a certified nurse aide; (ii) graduation from an approved educational curriculum as listed by the Board of Nursing; or (iii) completion of the provider's educational curriculum, which must be a minimum of 40 hours in duration, as taught by an RN who meets the same requirements as the RN listed in subdivision 1 of this subsection.

b. In addition, personal care aides shall also be required to receive annually a minimum of 12 documented hours of agency-provided training in the performance of these services, which shall be documented in the aide's record.

6. Personal care aides shall:

a. Be at least 18 years of age or older;

b. Be able to read and write English to the degree necessary to perform the expected tasks and create and maintain the required documentation;

c. Be physically able to perform the required tasks and have the required skills to perform services as specified in the waiver individual's supporting documentation;

d. Have a valid social security number that has been issued to the personal care aide by the Social Security Administration;

e. Meet the requirements of subdivision A 19 of this section regarding criminal record checks and, if the waiver individual is a minor, consent to a search of the VDSS Child Protective Services Central Registry.

f. Understand and agree to comply with the DMAS CCC Plus Waiver requirements; and

g. Receive tuberculosis (TB) screening as specified in the criteria used by VDH.

7. Consumer-directed personal care attendants shall:

a. Be 18 years of age or older;

b. Be able to read and write in English to the degree necessary to perform the tasks expected and create and maintain the required documentation;

c. Be physically able to perform the required tasks and have the required skills to perform consumer-directed services as specified in the waiver individual's supporting documentation;

d. Have a valid social security number that has been issued to the personal care attendant by the Social Security Administration;

e. Meet the requirements of subdivision A 19 of this section and, if the waiver individual is a minor, consent to a search of the VDSS Child Protective Services Central Registry;

f. Understand and agree to comply with the DMAS CCC Plus Waiver requirements;

g. Receive tuberculosis (TB) screening as specified in the criteria used by VDH; and

h. Be willing to attend training at the request of the individual, family, caregiver, or EOR.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 31, Issue 10, eff. February 12, 2015; Volume 40, Issue 20, eff. June 19, 2024; Errata, 40:22 VA.R. 1892 June 17, 2024.

12VAC30-120-935. Participation standards for specific covered services.

A. The personal care providers, respite care providers, ADHC providers, private duty nursing providers, and services facilitators shall develop an individualized POC that addresses the waiver individual's service needs. Such plan shall be developed in collaboration with the waiver individual or the individual's family, caregiver, or EOR, as appropriate.

B. DMAS shall not reimburse for any waiver services rendered to waiver individuals when either (i) the spouse of the waiver individual or (ii) the natural, adoptive, step, or foster parent or other legal guardian of the minor child waiver individual is the one providing the service.

1. Payment shall not be made for personal care or respite services furnished by other family members living under the same roof as the waiver individual unless there is objective written documentation as to why no other person or provider is available to render the service. The nurse supervisor or services facilitator shall initially make the determination and document it fully in the individual's record.

2. Payment shall not be made for AT, EM, transition services, or services facilitation services furnished by other family members living under the same roof as the waiver individual receiving services.

3. Payment shall not be made for PDN services furnished by other family members, legal guardians of the waiver individual, or other persons living under the same roof as the waiver individual receiving the service.

4. Family members who are approved to be reimbursed for providing personal care or respite care services shall meet the same qualifications as all other personal care aides or CD attendants.

5. Payment shall not be made for respite care services if the primary caregiver, as identified in the records, receives payment for providing personal care services to the individual. Providers shall document the primary caregiver and whether the caregiver is paid or unpaid in the individual's record prior to requesting respite care service authorization.

C. Agency providers shall employ appropriately licensed professional staff who can provide the covered waiver services required by the waiver individual. Providers shall require that the supervising RN or LPN be available by phone at all times that the LPN or aide is providing services to the waiver individual.

D. Agency staff (RNs, LPNs, or aides) or CD attendants shall only be reimbursed by DMAS for services if they are physically present with the waiver individual and are awake to perform the services outlined in the individual's plan of care.

E. A single agency-directed aide, consumer-directed attendant, RN, or LPN who provides personal care or respite services shall be reimbursed at a maximum limit of 16 hours per day for services rendered to an individual in order to ensure the health and safety of the individual receiving these services.

F. Failure to provide the required services, conduct the required reviews, and meet the documentation standards as stated in this section shall result in audited providers returning overpayments to DMAS.

G. In addition to meeting the general conditions and requirements, home and community-based services participating providers shall also meet the following requirements:

1. ADHC services provider. In order to provide home and community-based services, adult day health center (ADHC) shall:

a. Hold a license with VDSS for adult day care center (ADCC) and make available a copy of the current VDSS license for DMAS review and verification prior to the provider applicant's enrollment as a Medicaid provider;

b. Meet and maintain compliance with provisions of home and community-based rules as detailed in the provider agreement and as described in 42 CFR 441.301; and

c. Employ the following:

(1) A director who shall be responsible for overall management of the center's programs and employees pursuant to 22VAC40-61-130. The director shall be the provider's contact person for DMAS and the designated service authorization contractor and shall be responsible for responding to communication from DMAS and the designated service authorization contractor. The director shall be responsible for ensuring the development of the POCs for waiver individuals. The director shall assign a staff member to act as the ADHC coordinator for each waiver individual and shall document the identity of the ADHC coordinator in each individual's record. The ADHC coordinator can be the director, the activities director, RN, or therapist. The ADHC coordinator shall be responsible for management of the waiver individual's POC and for its review with the program aides and any other staff, as necessary.

(2) An RN who shall be responsible for administering to and monitoring the health needs of waiver individuals. The RN may also contract with the center. The RN shall be responsible for the planning and implementation of the POC involving multiple services where specialized health care knowledge may be needed. The RN shall be present a minimum of eight hours each month at the center. DMAS may require the RN's presence at the center for more than this minimum standard depending on the number of waiver individuals who are in attendance and according to the medical and nursing needs of the waiver individuals who attend the center. Although DMAS does not require that the RN be a full-time staff position, there shall be an RN available, either in person or by telephone, to the center's waiver individuals and staff during all times that the center is in operation. The RN shall be responsible for:

(a) Providing periodic evaluation of the nursing needs of each waiver individual at least every 90 days or sooner when there is a change in the individual's ADHC level of care needs;

(b) Providing the nursing care and treatment as documented in the waiver individual's POC; and

(c) Monitoring, recording, and administering of prescribed medications or supervising the waiver individual in self-administered medication.

(3) Personal care aides who shall be responsible for overall care of waiver individuals such as assistance with ADLs, social or recreational activities, and other health and therapeutic-related activities. Each program aide hired by the provider shall be screened to ensure compliance with training and skill mastery qualifications required by DMAS. The aide shall, at a minimum, have the following qualifications:

(a) Be 18 years of age or older;

(b) Be able to read and write in English to the degree necessary to perform the tasks expected and create and maintain the required waiver individual documentation of services rendered;

(c) Be physically able to perform the work and have the skills required to perform the tasks required in the waiver individual's POC;

(d) Have a valid social security number issued to the program aide by the Social Security Administration;

(e) Have satisfactorily completed an educational curriculum as set out in this subdivision. Documentation of successful completion shall be maintained in the aide's personnel file and be available for review by DMAS staff. Prior to assigning a program aide to a waiver individual, the center shall ensure that the aide has either (i) registered with the Board of Nursing as a certified nurse aide; (ii) graduated from an approved educational curriculum as listed by the Board of Nursing; or (iii) completed the provider's educational curriculum, at least 40 hours in duration, as taught by an RN who is licensed in the Commonwealth or who holds a multi-state licensing privilege.

(4) An activities director who shall be responsible for directing recreational and social activities for the ADHC recipients. The director, at a minimum, shall have the following qualifications:

(a) A minimum of 48 semester hours or 72 quarter hours of post-secondary education from an accredited college or university with a degree in recreational therapy, occupational therapy, or a related field such as art, music, or physical education, and

(b) Have one year of related experience, which may include work in an acute care hospital, rehabilitation hospital, or nursing home, or have completed a course of study including the prescribed internship in occupation, physical, or recreational therapy or music, dance, art therapy, or physical education.

(5) The ADHC coordinator who shall coordinate, pursuant to 22VAC40-61-280, the delivery of the activities and services as prescribed in the waiver individual's POC and keep such plans updated, record 30-day progress notes concerning each waiver individual, and review the waiver individual's daily records each week. If a waiver individual's condition changes more frequently, more frequent reviews and recording of progress notes shall be required to reflect the individual's changing condition. Copied or re-dated notes are not acceptable.

d. Recreation and social activities responsibilities. The center shall provide planned recreational and social activities suited to the waiver individual's needs and interests and designed to encourage physical exercise, prevent deterioration of each waiver individual's condition, and stimulate social interaction.

e. The ADHC shall allow the care coordinator, DMAS, or the managed care organization to meet with waiver individuals to complete the annual individual experience survey, as required in the provisions of 42 CFR 441.301.

f. The center shall maintain all records of each Medicaid individual. These records shall be reviewed periodically by DMAS staff or its designated agent who is authorized by DMAS to review these files. At a minimum, these records shall contain:

(1) DMAS required forms as specified in the center's provider-appropriate guidance documents;

(2) Interdisciplinary POCs developed, in collaboration with the waiver individual, family, or caregiver, or both as may be appropriate, by the center's director, RN, and therapist, as may be appropriate, and any other relevant support persons;

(3) Documentation of interdisciplinary staff meetings that shall be held at least every three months to reassess each waiver individual, evaluate the adequacy of the POC, and make any necessary revisions;

(4) At a minimum, 30-day goal-oriented progress notes recorded by the designated ADHC coordinator. If a waiver individual's condition and treatment POC changes more often, progress notes shall be written more frequently than every 30 days (copied or re-dated notes are not acceptable);

(5) The daily record of services provided shall contain the specific services delivered by center staff. The record shall also contain the arrival and departure times of the waiver individual and shall be signed weekly by either the director, activities director, RN, or therapist employed by the center. The record shall be completed on a daily basis, neither before nor after the date of services delivery. At least once a week, a staff member shall chart significant comments regarding care given to the waiver individual. If the staff member writing comments is different from the staff signing the weekly record, that staff member shall sign the weekly comments. A copy of this record shall be given weekly to the waiver individual, family, or caregiver, and it shall also be maintained in the waiver individual's medical record; and

(6) All contacts shall be documented in the waiver individual's medical record, including correspondence made to and from the individual with family, caregivers, physicians, DMAS, the designated service authorization contractor, formal and informal services providers, and all other professionals related to the waiver individual's Medicaid services or medical care.

2. Agency-directed personal care services. The personal care provider agency shall hire or contract with and directly supervise an RN who provides ongoing supervision of all personal care aides and LPNs. LPNs may supervise, pursuant to their licenses, personal care aides based upon RN assessment of the waiver individual's health, safety, and welfare needs.

a. The RN supervisor shall make an initial home assessment visit on or before the start of care for all individuals admitted to personal care, when a waiver individual is readmitted after being discharged from services, or if the individual is transferred from another provider, ADHC, or other waiver service.

b. Within 30 days after the initial home assessment visit, the RN supervisor shall visit the individual and the individual's family or caregiver, as appropriate, to monitor the plan of care, to reassess the individual's needs, and to determine if the services rendered are adequate to ensure the health, safety, and welfare of the individual.

c. During a home visit, the RN supervisor shall evaluate, at least every 90 days, the LPN supervisor's performance and the waiver individual's needs to ensure the LPN supervisor's abilities to function competently and shall provide training as necessary. This shall be documented in the waiver individual's record. A reassessment of the individual's needs and review of the POC shall be performed and documented during these visits.

d. The nurse supervisor shall also make supervisory visits based on the assessment and evaluation of the care needs of waiver individuals as often as needed and as defined in this subdivision to ensure both quality and appropriateness of services.

(1) The personal care provider agency shall have the responsibility of determining when supervisory visits are appropriate for the waiver individual's health, safety, and welfare. Supervisory visits shall be at least every 90 days. This determination must be documented in the waiver individual's record by the RN on the initial assessment and in the ongoing assessment records.

(2) If DMAS determines that the waiver individual's health, safety, or welfare is in jeopardy, DMAS may require the provider's nurse supervisor to supervise the personal care aides more frequently than once every 90 days. These visits shall be conducted at this designated increased frequency until DMAS determines that the waiver individual's health, safety, or welfare is no longer in jeopardy. This shall be documented by the provider and entered into the individual's record.

(3) During visits to the waiver individual's home, the nurse supervisor shall observe, evaluate, and document the adequacy and appropriateness of personal care services with regard to the individual's current functioning status, medical needs, and social needs. The nurse supervisor shall review the record of the aide or LPN and discuss with the individual, family, or caregiver the satisfaction with the type and amount of services.

(4) If the nurse supervisor must be delayed in conducting the regular supervisory visit, such delay shall be documented in the waiver individual's record with the reasons for the delay. Such supervisory visits shall be conducted within 15 calendar days of the waiver individual's first availability.

(5) A nurse supervisor shall be available to the personal care aide for conferences pertaining to waiver individuals being served by the aide.

(a) The nurse supervisor shall be available to the aide by telephone at all times that the aide is providing services to waiver individuals.

(b) The nurse supervisor shall evaluate the personal care aide's performance and the waiver individual's needs to identify any insufficiencies in the personal care aide's abilities to function competently and shall provide training as indicated. This shall be documented in the waiver individual's record.

(6) Licensed practical nurses (LPNs). As permitted by the license, the LPN may supervise personal care aides. To ensure both quality and appropriateness of services, the LPN supervisor shall make supervisory visits of the aides as often as needed, but no fewer visits than provided in a waiver individual's POC as developed by the RN in collaboration with the individual and the individual's family or caregivers, or both, as appropriate.

(a) During visits to the waiver individual's home, an LPN-supervisor shall observe, evaluate, and document the adequacy and appropriateness of personal care services, the individual's current functioning status, medical needs and social needs. The personal care aide's record shall be reviewed and the waiver individual's, family's, or caregiver's, satisfaction with the type and amount of services discussed.

(b) The LPN supervisor shall evaluate the personal care aide's performance and the waiver individual's needs to identify any insufficiencies in the aide's abilities to function competently and shall provide training as required to resolve the insufficiencies. This shall be documented in the waiver individual's record and reported to the RN supervisor.

(c) An LPN supervisor shall be available to personal care aides for conferences pertaining to waiver individuals being served by them.

(7) Personal care aides. The agency provider may employ and the nurse supervisor shall directly supervise personal care aides who provide direct care to waiver individuals. Each aide hired to provide personal care shall be evaluated by the provider to ensure compliance with qualifications and skills required by DMAS pursuant to 12VAC 30-120-930.

e. Required documentation for a waiver individual's records. The provider shall maintain all records for each individual receiving personal care services. These records shall be separate from those of non-home and community-based waiver services, such as companion or home health services. These records shall be reviewed periodically by DMAS or its designated agent. At a minimum, the record shall contain:

(1) All personal care aides' records (DMAS-90) to include (i) the specific services delivered to the waiver individual by the aide; (ii) the personal care aide's actual daily arrival and departure times; (iii) the aide's weekly comments or observations about the waiver individual, including observations of the individual's physical and emotional condition, daily activities, and responses to services rendered; and (iv) any other information appropriate and relevant to the waiver individual's care and need for services.

(2) The personal care aide's and individual's or responsible caregiver's signatures, including the date, shall be recorded on these records verifying that personal care services have been rendered during the week of the service delivery.

(a) An employee of the provider shall not sign for the waiver individual unless that employee is a family member or unpaid caregiver of the waiver individual.

(b) Signatures, times, and dates shall not be placed on the personal care aide record earlier than the last day of the week in which services were provided no more than seven calendar days from the date of the last service.

3. Agency-directed respite care services.

a. To be approved as a respite care provider with DMAS, the respite care agency provider shall:

(1) Employ or contract with and directly supervise either an RN or LPN, or both, who will provide ongoing supervision of all respite care aides or LPNs, as appropriate. An RN shall provide supervision to all direct care and supervisory LPNs.

(a) When respite care services are received on a routine basis, the minimum acceptable frequency of the required nurse supervisor's visits shall not exceed every 90 days, based on the initial assessment. If a waiver individual is also receiving personal care or private duty nursing services, the respite care nurse supervisory visit may coincide with the personal care nurse supervisory visits. However, the nurse supervisor shall document supervision of respite care separately from the personal care documentation. For this purpose, the same individual record may be used with a separate section for respite care documentation.

(b) When respite care services are not received on a routine basis but are episodic in nature, a nurse supervisor shall conduct the home supervisory visit with the aide or LPN on or before the start of care. The RN or LPN shall review the utilization of respite services either every six months or upon the use of half of the approved respite hours, whichever comes first. If a waiver individual is also receiving personal care services from the same provider, the respite care nurse supervisory visit may coincide with the personal care nurse supervisory visit.

(c) During visits to the waiver individual's home, the nurse supervisor shall observe, evaluate, and document the adequacy and appropriateness of respite care services to the waiver individual's current functioning status, medical needs, and social needs. The nurse supervisor shall review the record of the aide or LPN and discuss with the individual, family, or caregiver the satisfaction with the type and amount of services.

(d) Should the required nurse supervisory visit be delayed, the reason for the delay shall be documented in the waiver individual's record. This visit shall be completed within 15 days of the waiver individual's first availability.

(2) Employ or contract with aides to provide respite care services who shall meet the same education and training requirements as personal care aides.

(3) Employ an LPN or RN to perform skilled respite care services when skilled respite services are offered. Such services shall be reimbursed by DMAS under the following circumstances:

(a) The waiver individual shall have a documented need for routine skilled respite care that cannot be provided by unlicensed personnel, such as an aide. These waiver individuals would typically require a skilled level of care involving, for example but not necessarily limited to, ventilators for assistance with breathing or either nasogastric or gastrostomy feedings;

(b) No other person in the waiver individual's support system is willing and able to supply the skilled component of the individual's care during the unpaid primary caregiver's absence; and

(c) The waiver individual is unable to receive skilled nursing visits from any other source that could provide the skilled care usually given by the unpaid primary caregiver.

(4) Document in the waiver individual's record the circumstances that require the provision of skilled respite services by an LPN or RN. At the time of the LPN's or RN's service, the LPN or RN shall also provide all of the skilled respite services normally provided by an aide.

b. Required documentation for a waiver individual's records. The provider shall maintain all records for each waiver individual receiving respite services. These records shall be clearly labeled and maintained separately from those of non-home and community-based waiver services, such as companion or home health services. These records shall be reviewed periodically either by the DMAS staff or a contracted entity who is authorized by DMAS to review these records. At a minimum these records shall contain:

(1) Forms as specified in the DMAS guidance documents.

(2) All respite care LPN, RN, or aide records shall contain:

(a) The specific services delivered to the waiver individual by the LPN, RN, or aide;

(b) The respite care LPN's, RN's, or aide's daily arrival and departure times;

(c) Comments or observations recorded weekly about the waiver individual. LPN, RN, or aide comments shall include observation of the waiver individual's physical, medical, and emotional condition, daily activities, the individual's response to services rendered, and documentation of vital signs if taken as part of the POC.

(3) Skilled respite care LPN or RN records, which may be documented on the DMAS 90-A, shall be reviewed and signed by the supervising RN and shall contain:

(a) The signatures of the skilled respite care LPN or RN and waiver individual or responsible family or caregiver, including the date, verifying that skilled respite care services have been rendered during the week of service delivery as documented in the record.

(b) An employee of the provider shall not sign for the waiver individual unless the employee is a family member or unpaid caregiver of the waiver individual.

(c) Signatures, times, and dates shall not be placed on the skilled respite care LPN or aide record earlier than the last day of the week in which services were provided. Nor shall signatures be placed on the respite care LPN or aide records later than seven calendar days from the date of the last service.

4. Consumer-directed (CD) services facilitation for personal care and respite services.

a. Any services rendered by attendants prior to dates authorized by DMAS or the service authorization contractor shall not be eligible for Medicaid reimbursement and shall be the responsibility of the waiver individual.

b. If the services facilitator is not an RN, then the services facilitator shall inform the primary health care provider for the individual that services are being provided within 30 days from the start of such services and request consultation with the primary health care provider, as needed. This shall be done after the services facilitator secures written permission from the individual to contact the primary health care provider. The documentation of this written permission to contact the primary health care provider shall be retained in the individual's medical record. All contacts with the primary health care provider shall be documented in the individual's medical record.

c. The services facilitator or any staff or volunteer of the services facilitator providing direct service to Medicaid individuals shall meet the following qualifications:

(1) To be enrolled as a Medicaid services facilitator and maintain provider status, the services facilitator shall have sufficient knowledge, skills, and abilities to perform the activities required of such providers. In addition, the services facilitator shall have the ability to maintain and retain business and professional records sufficient to fully and accurately document the nature, scope, and details of the services provided.

(2) Effective January 11, 2016, all services facilitators and volunteers providing direct service to Medicaid individuals shall:

(a) Have a satisfactory work record as evidenced by at least two references from prior job experience with no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children. In instances of employees who have worked for only one employer, such employees shall be permitted to provide one appropriate employment reference and one appropriate personal reference, including no evidence of abuse, neglect, or exploitation of incapacitated or older adults or children.

(b) Within 30 calendar days of employment, the services facilitator, staff, or volunteer shall obtain an original criminal record clearance with respect to convictions for offenses specified in § 19.2-392.02 of the Code of Virginia or an original criminal history record from the Central Criminal Records Exchange. The staff or volunteer shall also submit to a screening through the VDSS Child Protective Services (CPS) Central Registry if serving a waiver individual who is a minor child. Provider staff and volunteers shall not be reimbursed for services provided to the waiver individual effective on the date and thereafter that the VDSS CPS Central Registry check confirms the provider's staff person or volunteer has a finding.

(i) DMAS shall not reimburse a provider for services provided by a staff or volunteer who works in a position that involves direct contact with a waiver individual until an original criminal record clearance or original criminal history record has been received. DMAS shall reimburse services provided by such a staff person during only the first 30 calendar days of employment if the provider can produce documented evidence that such person worked only under the direct supervision of another staff person for whom a background check was completed in accordance with the requirements of this section. If an original criminal record clearance or original criminal history record is not received within the first 30 calendar days of employment, DMAS shall not reimburse the provider for services provided by such staff or volunteer on the 31st calendar day through the date on which the provider receives an original criminal record clearance or an original criminal history record.

(ii) DMAS shall not reimburse a provider for services provided by a staff or volunteer who has been convicted of any offense set forth in clause (i) of the definition of barrier crime in § 19.2-392.02 of the Code of Virginia unless all of the following conditions are met: (i) the offense was punishable as a misdemeanor; (ii) the staff or volunteer has been convicted of only one such offense; (iii) the offense did not involve abuse or neglect; and (iv) at least five years have elapsed since the conviction.

(c) The staff or volunteer shall provide the hiring entity with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges, whether within or outside of the Commonwealth.

(d) 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://www.oig.hhs.gov.

(3) Effective January 11, 2016, all services facilitators shall possess the required degree and experience, as follows:

(a) Prior to initial enrollment by DMAS as a services facilitator or being hired by a Medicaid-enrolled services facilitator provider, all new 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 possess a minimum of two years of satisfactory direct care experience supporting individuals with disabilities or older adults; or (ii) a bachelor's degree in a non-health or human services field and possess a minimum of three years of satisfactory direct care experience supporting individuals with disabilities or older adults.

(b) Persons who are services facilitators prior to January 11, 2016, shall not be required to meet the degree and experience requirements of subdivision 4 c (3) (a) of this subsection unless required to submit a new application to be a services facilitator after January 11, 2016.

(4) Effective April 10, 2016, all services facilitators shall complete required training and competency assessments. Satisfactory competency assessment results shall be kept in the service facilitator's record. All new services facilitators shall complete training and pass the corresponding competency assessment with a score of at least 80% in order to begin and to continue being reimbursed for or working with waiver individuals for the purpose of reimbursement for services through this waiver.

(5) As a component of the renewal of the Medicaid provider agreement, all services facilitators shall pass the competency assessment every five years and achieve a score of at least 80%.

(6) The services facilitator shall have access to a computer with Internet access that meets the security standards of Subpart C 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.

(7) The 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 services facilitator's application form, found in supporting documentation, or be observed during a job interview. Observations during the interview must be documented. The knowledge, skills, and abilities include:

(a) Knowledge of:

(i) Types of functional limitations and health problems that may occur in individuals with disabilities or older adults, as well as strategies to reduce limitations and health problems;

(ii) Physical care that may be required by individuals with disabilities or older adults, such as transferring, bathing techniques, bowel and bladder care, and the approximate time those activities normally take;

(iii) Equipment and environmental modifications that may be required by individuals with disabilities or older adults that reduce the need for human help and improve safety;

(iv) Various long-term care program requirements, including institutional and assisted living facility placement criteria, Medicaid waiver services, and other federal, state, and local resources that provide personal care and respite services;

(v) CCC Plus Waiver requirements, as well as the administrative duties for which the services facilitator will be responsible;

(vi) How to conduct assessments (including environmental, psychosocial, health, and functional factors) and their uses in services planning;

(vii) Interviewing techniques;

(viii) The individual's right to make decisions about, direct the provisions of, and control one's own consumer-directed services, including hiring, training, managing, approving the work shift entries of, and firing of an attendant;

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

(x) General principles of record documentation.

(b) Skills in:

(i) Negotiating with individuals, family, caregivers, and service providers;

(ii) Assessing, supporting, observing, recording, and reporting behaviors;

(iii) Identifying, developing, or providing services to individuals with disabilities or older adults; and

(iv) Identifying services within the established services system to meet the individual's needs.

(i) Report findings of the assessment or onsite visit, either in writing or an alternative format for individuals who have visual or hearing impairments;

(ii) Demonstrate a positive regard for individuals and their families;

(iii) Be persistent and remain objective;

(iv) Work independently, performing job position duties under general supervision;

(v) Communicate effectively orally and in writing; and

(vi) Develop a rapport and communicate with individuals from diverse cultural backgrounds.

(8). Failure to satisfy the competency assessment requirements and meet all other requirements shall result in a retraction of Medicaid payment or the termination of the provider agreement, or both.

d. Initiation of services and service monitoring.

(1) Upon entry into consumer-directed services, the services facilitator shall make an initial comprehensive home visit at the primary residence of the individual to collaborate with the individual or the individual's family or caregiver, as appropriate, to identify the individual's needs, assist in the development of the plan of care with the waiver individual and individual's family or caregiver, as appropriate, and provide EOR management training within seven days of the initial visit. The initial comprehensive home visit shall be conducted only once upon the individual's entry into consumer-directed services. The individual shall receive one comprehensive visit per lifetime. If the individual changes service facilitators, the new services facilitator shall complete a reassessment visit in lieu of a comprehensive visit. The EOR management training shall be limited to one visit per EOR.

(2) Within 30 days after the initial comprehensive visit, the services facilitator shall visit the individual and the individual's family or caregiver, as appropriate, to monitor the plan of care, to reassess the individual's needs, and to determine if the services rendered are adequate to ensure the health, safety, and welfare of the individual. During this visit, the services facilitator, individual, EOR, and family or caregiver, as appropriate, shall agree to the frequency of routine visits, which shall be conducted at least every 90 days but no more frequently than every 30 days. The agreement shall be documented in the service facilitator's records.

(3) During the routine visit, the services facilitator shall continue to monitor the plan of care on an as-needed basis and shall conduct face-to-face meetings with the individual and may include the EOR, family, or caregiver. Such visits shall be documented in the individual's medical record.

(4) When respite is the sole service provided, the services facilitator shall review the utilization of consumer-directed respite services, either every six months or upon the use of half of the approved respite services hours, whichever comes first, and shall conduct a face-to-face meeting with the individual and may include the family or caregiver, as appropriate. Such visits shall be documented in the individual's record.

(5) Every six months, the services facilitator shall conduct a face-to-face reassessment visit with the individual and EOR, family, or caregiver, as appropriate. During the visit, the services facilitator shall review the individual's current functional and support status, review all services the individual receives, including the existing plan of care, discuss the individual's and EOR's satisfaction with services, update the plan of care as necessary, and submit new service authorization requests for personal care hours and other waiver services if necessary. The services facilitator shall not conduct a routine visit and reassessment visit during the same visit but shall submit reimbursement for only a reassessment visit.

(6) During all visits with the individual, the services facilitator shall observe, evaluate, and consult with the individual or EOR and may include the family or caregiver to document the adequacy and appropriateness of consumer-directed services with regard to the individual's current functioning, cognitive status, and medical and social needs. The services facilitator's written summary of the visit shall include at a minimum:

(a) Discussion with the waiver individual, family, caregiver, or EOR, as appropriate, concerning whether the service is adequate to meet the waiver individual's needs;

(b) Any suspected abuse, neglect, or exploitation and to whom it was reported;

(c) Any special tasks performed by the consumer-directed attendant and the consumer-directed attendant's qualifications to perform these tasks;

(d) The individual's, family's, caregiver's, or EOR's satisfaction with the service;

(e) Any hospitalization or change in medical condition, functioning, or cognitive status;

(f) The presence or absence of the attendant during the services facilitator's visit; and

(g) The appropriateness of the EOR to fulfill the responsibilities of the role.

(7) The services facilitator shall provide follow-up management training to the individual or EOR, as appropriate, under the following circumstances:

(a) The training shall be requested by the individual or EOR. Training shall not be provided at the request of the services facilitator, family, caregiver, or attendant;

(b) The training shall be limited to the role and responsibilities of the EOR. Training shall not include duties that are to be performed by the attendant;

(d) The services facilitator shall utilize the management training service to reimburse for tuberculosis screening, cardiopulmonary resuscitation training, and influenza immunization for the attendant at the request of the EOR. Requests for reimbursement shall be limited to the exact cost of the activity. Documentation of the cost and receipt of such activities shall be maintained in the individual's record.

e. DMAS, its designated contractor, or the fiscal/employer agent shall request a criminal record check and a check of the VDSS Child Protective Services Central Registry if the waiver individual is a minor child, in accordance with 12VAC 30-120-930, pertaining to the consumer-directed attendant on behalf of the waiver individual and report findings of these records checks to the EOR.

f. The services facilitator shall review and verify copies of work shift entries to ensure that the hours approved in the plan of care are being provided and are not exceeded. If discrepancies are identified, the services facilitator shall discuss these with the individual or EOR to resolve discrepancies and shall notify the fiscal/employer agent. The services facilitator shall also review the individual's plan of care to ensure that the individual's needs are being met. Failure to conduct such reviews and verifications of work shift entries and maintain the documentation of these reviews shall result in a recovery by DMAS of payments made in accordance with 12VAC 30-80-130.

g. The services facilitator shall maintain records of each individual served. At a minimum, these records shall contain:

(1) Results of the initial comprehensive home visit completed prior to or on the date services are initiated and subsequent reassessments and changes to the supporting documentation;

(2) The personal care plan of care. Such plans shall be reviewed by the provider every 90 days, annually, and more often as needed, and modified as appropriate. The respite services plan of care shall be included in the record and shall be reviewed by the provider every six months or when half of the approved respite service hours have been used whichever comes first. For the annual review and in cases where either the personal care or respite care plan of care is modified, the plan of care shall be reviewed with the individual, the family or caregiver, and EOR, as appropriate;

(3) The services facilitator's dated notes documenting any contacts with the individual, family, caregiver, or EOR and visits to the individual (copied or re-dated notes are not acceptable);

(4) All contacts, including correspondence, made to and from the individual, EOR, family or caregiver, physicians, DMAS, the designated service authorization contractor, MCO, formal and informal services provider, and all other professionals related to the individual's Medicaid services or medical care;

(5) All employer management training provided to the individual or EOR to include, for example, (i) receipt of training on the individual's or EOR's responsibilities for the accuracy of the consumer-directed attendant's work shift entries and (ii) the availability of the Consumer-Directed Employer of Record Manual available at http://dmas.virginia.gov;

(6) All documents signed by the individual or EOR, as appropriate, that acknowledge the responsibilities as the employer; and

(7) The DMAS required forms as specified in the DMAS Commonwealth Coordinated Care Plus Waiver Manual.

Failure to maintain all required documentation shall result in action by DMAS to recover payments made in accordance with 12VAC 30-80-130. Repeated instances of failure to maintain documentation may result in cancellation of the Medicaid provider agreement.

h. In instances when the individual is consistently unable either to hire or retain the employment of a personal care attendant to provide consumer-directed personal care or respite services such as, for example, a pattern of discrepancies with the attendant's work shift entries, the services facilitator shall make arrangements, after conferring with DMAS or the managed care organization, to have the needed services transferred to an agency-directed services provider of the individual's choice or discuss with the individual, family, caregiver, or EOR other service options.

i. Waiver individual, family or caregiver, and EOR responsibilities.

(1) The individual shall be authorized for the consumer-directed model of service, and the EOR shall successfully complete EOR management training performed by the services facilitator before the individual or EOR shall be permitted to hire a consumer-directed attendant for Medicaid reimbursement. Any service that may be rendered by a consumer-directed attendant prior to authorization by Medicaid shall not be eligible for reimbursement by Medicaid. Individuals who are eligible for consumer-directed services shall have the capability to hire and train their own consumer-directed attendants and supervise the consumer-directed attendants' performances. In lieu of handling their consumer-directed attendants themselves, individuals may have a family or caregiver, or other designated person serve as the EOR on their behalf. The EOR shall be prohibited from also being the Medicaid-reimbursed consumer-directed attendant for respite or personal care or the services facilitator for the individual.

(2) Individuals shall acknowledge that consumer-directed personal care services shall not continue when the service is no longer appropriate or necessary for the individual's care needs and that the individual shall inform the services facilitator of a change in care needs. If the consumer-directed model of services continues after services have been terminated by DMAS or the designated service authorization contractor, the individual shall be held liable for the consumer-directed attendant compensation.

(3) Individuals shall notify the services facilitator of all hospitalizations or admissions, for example, any rehabilitation hospital, rehabilitation hospital unit, nursing facility, specialized care nursing facility, or long-stay hospital as consumer-directed attendant services shall not be reimbursed during such admissions. Failure to do so may result in the individual being held liable for the consumer-directed employee compensation.

5. Personal emergency response systems. In addition to meeting the general conditions and requirements for home and community-based waiver services participating providers as specified in 12VAC 30-120-930, PERS providers must also meet the following qualifications and requirements:

a. A PERS provider shall be a personal care agency, a durable medical equipment provider, a licensed home health provider, or a PERS manufacturer. All such providers shall have the ability to provide PERS equipment, direct services (i.e., installation, equipment maintenance, and service calls), and PERS monitoring;

b. The PERS provider shall provide an emergency response center with fully trained operators who are capable of (i) receiving signals for help from an individual's PERS equipment 24 hours a day, 365 or 366 days per year, as appropriate; (ii) determining whether an emergency exists; and (iii) notifying an emergency response organization or an emergency responder that the PERS individual needs emergency help;

c. A PERS provider shall comply with all applicable Virginia statutes, all applicable regulations of DMAS, and all other governmental agencies having jurisdiction over the services to be performed;

d. The PERS provider shall have 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 waiver individual's notification of a malfunction of the console unit, activating devices, or medication monitoring unit and shall provide temporary equipment, as may be necessary for the waiver individual's health, safety, and welfare, while the original equipment is being repaired or replaced;

e. The PERS provider shall install, consistent with the manufacturer's instructions, all PERS equipment into a waiver individual's functioning telephone line or system within seven days of the request of such installation unless there is appropriate documentation of why this timeframe cannot be met. The PERS provider shall furnish all supplies necessary to ensure that the system is installed and working properly. The PERS provider shall test the PERS device monthly, or more frequently if needed, to ensure that the device is fully operational;

f. The PERS installation shall include local seize line circuitry, which guarantees that the unit shall have priority over the telephone connected to the console unit should the telephone be off the hook or in use when the unit is activated;

g. A PERS provider shall maintain a data record for each waiver individual at no additional cost to DMAS or the waiver individual. The record shall document all of the following:

(1) Delivery date and installation date of the PERS equipment;

(2) Waiver individual or caregiver signature verifying receipt of the PERS equipment;

(3) Verification by a monthly test that the PERS device is operational;

(4) The waiver individual's contact information, to be updated annually or more frequently as needed, as provided by the individual or the individual's caregiver or EOR;

(5) A case log documenting the waiver individual's utilization of the system, all contacts, and all communications with the individual, caregiver or EOR, and responders;

(6) Documentation that the waiver individual is able to use the PERS equipment through return demonstration; and

(7) Copies of all equipment checks performed on the PERS unit;

h. The PERS provider shall have backup monitoring capacity in case the primary system cannot handle incoming emergency signals;

i. The emergency response activator shall be capable of being activated either by breath, touch, or some other means and shall be usable by waiver individuals who are visually or hearing impaired or physically disabled. The emergency response communicator shall be capable of operating without external power during a power failure at the waiver individual's home for a minimum period of 24 hours. The emergency response console unit shall also be able to self-disconnect and redial the backup monitoring site without the waiver individual resetting the system in the event it cannot get its signal accepted at the response center;

j. PERS providers shall be capable of continuously monitoring and responding to emergencies under all conditions, including power failures and mechanical malfunctions. It shall be the PERS provider's responsibility to ensure that the monitoring agency and the monitoring agency's equipment meet the following requirements. The PERS provider shall be capable of simultaneously responding to multiple signals for help from the waiver individuals' PERS equipment. The PERS provider's equipment shall include the following:

(1) A primary receiver and a backup receiver, which shall be independent and interchangeable;

(2) A backup information retrieval system;

(3) A clock printer, which shall print out the time and date of the emergency signal, the waiver individual's identification code, and the emergency code that indicates whether the signal is active, passive, or a responder test;

(4) A backup power supply;

(5) A separate telephone service;

(6) A toll-free number to be used by the PERS equipment in order to contact the primary or backup response center; and

(7) A telephone line monitor, which shall give visual and audible signals when the incoming telephone line is disconnected for more than 10 seconds;

k. The PERS provider shall maintain detailed technical and operation manuals that describe PERS elements, including the installation, functioning, and testing of PERS equipment; emergency response protocols; and recordkeeping and reporting procedures;

l. The PERS provider shall document and furnish within 30 days of the action taken, a written report for each emergency signal that results in action being taken on behalf of the waiver individual. This excludes test signals or activations made in error. This written report shall be furnished to (i) the personal care provider; (ii) the respite care provider; (iii) the services facilitation provider; (iv) in cases where the individual only receives ADHC services, to the ADCC provider; or (v) to the transition coordinator for the service in which the individual is enrolled; and

m. The PERS provider shall obtain and keep on file a copy of the most recently completed DMAS-225 form. Until the PERS provider obtains a copy of the DMAS-225 form, the PERS provider shall clearly document efforts to obtain the completed DMAS-225 form from the personal care provider, respite care provider, services facilitation provider, or ADCC provider.

6. Assistive technology (AT) and environmental modification (EM) services. AT and EM shall be provided only to waiver individuals by providers who have current provider participation agreements with DMAS.

a. AT shall be rendered by providers having a current provider participation agreement with DMAS as durable medical equipment and supply providers. An independent, professional consultation shall be obtained, as may be required, from qualified professionals who are knowledgeable of that item for each AT request prior to approval by either DMAS or the service authorization contractor and may include training on such AT by the qualified professional. Independent, professional consultants shall include speech or language therapists, physical therapists, occupational therapists, physicians, behavioral therapists, certified rehabilitation specialists, or rehabilitation engineers. Providers that supply AT for a waiver individual may not perform assessment or consultation, write specifications, or inspect the AT for that individual. AT shall be delivered within 60 days from the start date of the authorization. The AT provider shall ensure that the AT functions properly.

b. In addition to meeting the general conditions and requirements for home and community-based waiver services participating providers as specified in 12VAC 30-120-930, as appropriate, environmental modifications shall be provided in accordance with all applicable state or local building codes by contractors who have provider agreements with DMAS. Modifications shall be completed within a year of the start date of the authorization.

c. Providers of AT and EM services shall not be permitted to recover equipment that has been provided to waiver individuals whenever the provider has been charged, by either DMAS or its designated service authorization agent, with overpayments and is therefore being required to return payments to DMAS.

d. Providers of AT and EM services shall maintain in each individual's record all supporting documentation of the costs and estimates of the service. Should there be a change in the cost of the service, the new cost and estimate documentation shall also be included along with justification of the change in cost.

7. Transition services. This service shall be provided consistent with Part XX (12VAC 30-120-2000 et seq.) of 12VAC 30-120.

8. Private duty nursing (PDN).

a. This service shall be provided through a home health agency licensed or certified by VDH for Medicaid participation and with which DMAS has a contract for either PDN or congregate PDN or both.

b. The provider shall operate from a business office.

c. The provider shall employ (or subcontract with) and directly supervise an RN or an LPN. The LPN and RN shall be currently licensed to practice in the Commonwealth. Prior to providing PDN services, the RN or LPN shall have either (i) at least six months of related clinical nursing experience or (ii) completed a provider training program related to the care and technology needs of the waiver individual as described in 12VAC 30-120-930 J 3. Regardless of whether a nurse has six months of experience or completes a provider training course, the provider agency shall be responsible for assuring all nurses who are assigned to an individual are competent in the care needs of that individual.

d. As part of direct supervision, the RN supervisor shall make, at a minimum, a visit every 30 days to ensure both quality and appropriateness of PDN to assess the individual's and the family's or caregiver's satisfaction with the services being provided, to review the medication and treatments, and to update and verify that the most current physician signed orders are in the home record.

(1) The waiver individual shall be present when the supervisory visits are made;

(2) At least every other visit shall be in the individual's primary residence;

(3) When a delay occurs in the RN supervisor's visits because the individual is unavailable, the reason for the delay shall be documented in the individual's record, and the visit shall occur as soon as the individual is available. Failure to meet this standard may result in a DMAS recovery of payments made; and

(4) Additional supervisory visits may be required under the following circumstances: (i) at the provider's discretion; (ii) at the request of the individual; (iii) when a change in the individual's condition has occurred; (iv) any time the health, safety, or welfare of the individual could be at risk; and (v) at the request of the DMAS staff.

e. When skilled respite services are routine in nature and offered in conjunction with personal care (PC) services for adults, the RN supervisory visit conducted for personal care may serve as the supervisory visit for respite services. However, the supervisor shall document supervision of skilled respite services separately. For this purpose, the same individual record can be used with a separate section clearly labeled for documentation of skilled respite services.

f. For DMAS-enrolled PDN providers that also provide PC services, the provider shall employ or subcontract with and directly supervise an RN who will provide ongoing supervision of all personal care aides. The supervising RN shall be currently licensed to practice nursing in the Commonwealth and have at least one year of related clinical nursing experience, which may include work in an acute care hospital, long-stay hospital, rehabilitation hospital, nursing facility, or specialized care nursing facility. In addition to meeting the general conditions and requirements for home and community-based waiver services participating providers as specified in 12VAC 30-120-930 and this section for PDN, providers shall also comply with the requirements of this section in the provision of PC services.

g. The following documentation shall be maintained for every individual for whom DMAS-enrolled providers render these services:

(1) Physicians' orders for these services shall be maintained in the individual's record as well as at the individual's primary residence. All recertifications of the POC shall be performed within the last five business days of each current 60-day period. The physician shall sign the recertification before Medicaid reimbursement shall occur;

(2) All assessments, reassessments, and evaluations (including the complete LTSS screening packet or risk evaluations) made during the provision of services, including any required initial assessments by the RN supervisor completed prior to or on the date services are initiated and changes to the supporting documentation by the RN supervisor;

(3) Progress notes reflecting the individual's status and, as appropriate, progress toward the identified goals in the POC (copied or re-dated notes are not acceptable);

(4) All related communication with the individual and the individual's representative, the DMAS-designated agent for service authorization, consultants, DMAS, VDSS, formal and informal service providers, all required referrals, as appropriate, to adult protective services or child protective services and all other professionals concerning the individual;

(5) All service authorization decisions rendered by the DMAS staff or the DMAS-designated service authorization contractor;

(6) All POCs completed with the individual, family, or caregiver, as appropriate, and specific to the service being provided and all supporting documentation related to any changes in the POC; and

(7) Notes of any verbal or nonverbal cues, motions, signals, or actions the individual makes to indicate distress or uses to call in case of an emergency. The individual, primary caregiver, or family, as appropriate, shall share this information with the RN or LPN at the onset of services. Documentation of these cues shall be kept in the individual's record and shall be reviewed periodically to ensure the individual is still able to perform these cues.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 35, Issue 2, eff. October 27, 2018; Errata 35:3 VA.R. 502 October 1, 2018; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-940. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-945. Payment for covered services.

A. DMAS shall not reimburse providers, either agency-directed or consumer-directed, for any staff training required by these waiver regulations or any other training that may be required.

B. All services provided in the CCC Plus Waiver shall be reimbursed at a rate established by DMAS in its agency fee schedule.

1. DMAS or its contractor shall reimburse a per diem fee for ADHC services that shall be considered as payment in full for all services rendered to that waiver individual as part of the individual's approved ADHC plan of care.

2. Personal care (agency-directed and consumer-directed), respite (agency-directed and consumer-directed), and PDN care services shall be reimbursed on an hourly basis consistent with the agency's fee schedule. Effective July 1, 2021, a single consumer-directed attendant who provides personal care or respite services shall be reimbursed at the regular rate for up to 40 hours per week for authorized services rendered and at one and a half times the regular rate for up to 16 hours per week beyond 40 hours. This shall not apply to consumer-directed attendants who are exempt from overtime requirements under 29 USC § 552.102 of the federal Fair Labor Standards Act, 29 USC § 201 et seq.

3. Transition services. The total costs of these transition services shall be limited to $5,000 per waiver individual per lifetime and shall be expended within nine months from the start date of authorization. Transition services shall be reimbursed at the actual cost of the item; no mark ups shall be permitted.

4. Reimbursement for assistive technology (AT) and environmental modification (EM) services shall be as follows:

a. All AT services provided in the CCC Plus Waiver shall be reimbursed as a service limit of one and up to a per member annual maximum of $5,000 per calendar year regardless of waiver. These limits shall apply regardless of whether the waiver individual remains in this waiver or changes to another waiver program. AT services shall be reimbursed in a manner that is reasonable and customary not to exceed the provider's usual and customary charges to the general public. No markups shall be permitted.

b. All EM services provided in the CCC Plus Waiver shall be reimbursed as a service limit of one and up to a per member annual maximum of $5,000 per calendar year regardless of waiver. These limits shall apply regardless of whether the individual remains in this waiver or changes to another waiver program. All EM services shall be reimbursed at the actual cost of material and labor and no mark ups shall be permitted.

5. PERS monthly fee payments shall be consistent with the agency's fee schedule.

C. Duplication of services.

1. DMAS shall not duplicate services that are required as a reasonable accommodation as a part of the American with Disabilities Act (42 USC §§ 12131 through 12165), the Rehabilitation Act of 1973 (29 USC § 794), or the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia).

2. Payment for waiver services shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose. All private insurance benefits for these waiver-covered services shall be exhausted before Medicaid reimbursement can occur as Medicaid shall be the payer of last resort.

3. DMAS payments for EM services shall not be duplicative in homes where multiple waiver individuals reside.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015; amended, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-950. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-960. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-970. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; amended, Virginia Register Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-980. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 22, Issue 10, eff. February 22, 2006; repealed, Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-990. Quality management review; utilization review; level of care (LOC) reviews.

A. DMAS shall perform quality management reviews for the purpose of assuring high quality of service delivery consistent with the attending physicians' orders, approved POCs, service authorized services for the waiver individuals, and DMAS compliance with CMS assurances. Providers identified as not meeting the standards consistent with such orders, POCs, and service authorizations shall be required to submit corrective action plans (CAPs) to DMAS for approval. Once approved, such CAPs shall be implemented to resolve the cited deficiencies.

B. If DMAS staff determines, during any review or at any other time, that the waiver individual no longer meets the criteria for participation in the waiver (such as functional dependencies, medical/nursing needs, risk of NF placement, or Medicaid financial eligibility), then DMAS staff, as appropriate, shall deny payment for waiver services for such waiver individual and the waiver individual shall be discharged from the waiver.

C. Securing service authorization shall not necessarily guarantee reimbursement pursuant to DMAS utilization review of waiver services.

D. Failure to meet documentation requirements and supervisory reviews in a timely manner may result in either a plan of corrective action or retraction of payments.

E. Once waiver enrollment occurs, Level of Care Eligibility Re-determination audits (LOCERI) shall be performed at DMAS.

1. This independent electronic calculation of eligibility determination is performed and communicated to the DMAS supervisor. Any individual whose LOCERI audit shows failure to meet eligibility criteria shall receive a second manual review and may receive a home visit by DMAS staff.

2. The agency provider and the CD services facilitator shall submit to DMAS upon request an updated DMAS-99 LOC form, information from a current DMAS-97 A/B form, and, if applicable, the DMAS-225 form for designated waiver individuals. This information is required by DMAS to assess the waiver individual's ongoing need for Medicaid-funded long-term care and appropriateness and adequacy of services rendered.

F. DMAS or its designated agent shall periodically review and audit providers' records for these services for conformance to regulations and policies and concurrence with claims that have been submitted for payment. When a waiver individual is receiving multiple services, the records for all services shall be separated from those of non-home and community-based care services, such as companion or home health services. Failure to maintain the required documentation may result in DMAS' determination of overpayments against providers and requiring such providers to repay these overpayments pursuant to § 32.1-325.1 of the Code of Virginia.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

12VAC30-120-995. Appeals.

A. Providers shall have the right to appeal actions taken by DMAS. Provider appeals shall be considered pursuant to § 32.1-325.1 of the Code of Virginia and the Virginia Administrative Process Act (§ 2.2-4000 et seq.) of the Code of Virginia and DMAS regulations at 12VAC 30-10-1000 and Part XI (12VAC 30-20-500 et seq.) of 12VAC 30-20.

B. Individuals shall have the right to appeal actions taken by DMAS. Individuals' appeals shall be considered pursuant to 12VAC 30-110-10 through 12VAC 30-110-370. DMAS shall provide the opportunity for a fair hearing, consistent with 42 CFR Part 431, Subpart E.

C. The individual shall be advised in writing of such denial and of his right to appeal consistent with DMAS client appeals regulations 12VAC 30-110-70 and 12VAC 30-110-80.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 31, Issue 10, eff. February 12, 2015.

Part X
Intellectual Disability Waiver

Article 1
Definitions and General Requirements [Repealed]

12VAC30-120-1000. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; amended, Virginia Register Volume 32, Issue 20, eff. June 29, 2016; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1005. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1010. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1012. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 32, Issue 20, eff. June 29, 2016; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1020. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; amended, Virginia Register Volume 30, Issue 7, eff. January 2, 2014; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1030. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1040. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1060. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1062. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 32, Issue 20, eff. June 29, 2016; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1070. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1072. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 32, Issue 20, eff. June 29, 2016; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1080. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1082. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 32, Issue 20, eff. June 29, 2016; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1088. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1090. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 29, Issue 20, eff. July 4, 2013; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

Part XV
Day Support Waiver for Individuals with Mental Retardation

12VAC30-120-1500. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 24, Issue 6, eff. December 26, 2007; amended, Virginia Register Volume 25, Issue 20, eff. July 9, 2009; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1510. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 24, Issue 6, eff. December 26, 2007; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1520. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 24, Issue 6, eff. December 26, 2007; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1530. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 24, Issue 6, eff. December 26, 2007; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1540. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 24, Issue 6, eff. December 26, 2007; repealed, Virginia Register Volume 37, Issue 14, eff. March 31, 2021.

12VAC30-120-1550. (Repealed.)

Historical Notes

Part XVI
Alzheimer's Waiver

12VAC30-120-1600. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 23, Issue 20, eff. July 11, 2007; amended, Virginia Register Volume 28, Issue 20, eff. July 5, 2012; Volume 31, Issue 25, eff. September 9, 2015; repealed, Virginia Register Volume 38, Issue 11, eff. March 3, 2022.

12VAC30-120-1605. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 28, Issue 20, eff. July 5, 2012; repealed, Virginia Register Volume 38, Issue 11, eff. March 3, 2022.

12VAC30-120-1610. (Repealed.)

Historical Notes

12VAC30-120-1620. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 23, Issue 20, eff. July 11, 2007; amended, Virginia Register Volume 28, Issue 20, eff. July 5, 2012; repealed, Virginia Register Volume 38, Issue 11, eff. March 3, 2022.

12VAC30-120-1630. (Repealed.)

Historical Notes

12VAC30-120-1640. (Repealed.)

Historical Notes

12VAC30-120-1650. (Repealed.)

Historical Notes

12VAC30-120-1660. (Repealed.)

Historical Notes

12VAC30-120-1670. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 28, Issue 20, eff. July 5, 2012; repealed, Virginia Register Volume 38, Issue 11, eff. March 3, 2022.

12VAC30-120-1680. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 28, Issue 20, eff. July 5, 2012; repealed, Virginia Register Volume 38, Issue 11, eff. March 3, 2022.

Part XVII
Home and Community-Based Services for Technology Assisted Individuals Waiver [Repealed]

12VAC30-120-1700. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 30, Issue 12, eff. March 13, 2014; repealed, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-1705. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 30, Issue 12, eff. March 13, 2014; repealed, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-1710. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 30, Issue 12, eff. March 13, 2014; amended, Virginia Register Volume 33, Issue 25, eff. September 6, 2017; repealed, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-1720. (Repealed.)

Historical Notes

12VAC30-120-1730. (Repealed.)

Historical Notes

12VAC30-120-1740. (Repealed.)

Historical Notes

12VAC30-120-1750. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 30, Issue 12, eff. March 13, 2014; repealed, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-1760. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 30, Issue 12, eff. March 13, 2014; repealed, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

12VAC30-120-1770. (Repealed.)

Historical Notes

Derived from Virginia Register Volume 30, Issue 12, eff. March 13, 2014; repealed, Virginia Register Volume 40, Issue 20, eff. June 19, 2024.

Part XX
Money Follows the Person

12VAC30-120-2000. Transition coordinator.

A. Service description.

1. Transition coordination means the DMAS-enrolled provider who is responsible for supporting the individual and family/caregiver, as appropriate, with the activities associated with transitioning from an institution to the community pursuant to the Elderly or Disabled with Consumer Direction waiver.

2. Transition coordination services include, but are not limited to, the development of a transition plan; the provision of information about services that may be needed, in accordance with the timeframe specified by federal law, prior to the discharge date, during and after transition; the coordination of community-based services with the case manager if case management is available; linkage to services needed prior to transition such as housing, peer counseling, budget management training, and transportation; and the provision of ongoing support for up to 12 months after discharge date.

B. Criteria.

1. In order to qualify for these services, the individual shall have a demonstrated need for transition coordination of any of these services. Documented need shall indicate that the service plan cannot be implemented effectively and efficiently without such coordination from this service. Transition coordination services must be prior authorized by DMAS or its designated agent.

2. The individual's service plan shall clearly reflect the individual's needs for transition coordination provided to the individual, family/caregivers, and providers in order to implement the service plan effectively. The service plan includes, at a minimum: (i) a summary or reference to the assessment; (ii) goals and measurable objectives for addressing each identified need; (iii) the services, supports, and frequency of service to accomplish the goals and objectives; (iv) target dates for accomplishment of goals and objectives; (v) estimated duration of service; (vi) the role of other agencies if the plan is a shared responsibility; and (vii) the staff responsible for coordination and integration of services, including the staff of other agencies if the plan is a shared responsibility.

C. Service units and limitations. The unit of service shall be specified by the DMAS fee schedule. The services shall be explicitly detailed in the supporting documentation. Travel time is an in-kind expense within this service and is not billable as a separate item. Transition coordination may not be billed solely for purposes of monitoring. Transition coordination shall be available to individuals who are transitioning from institutional care to the community. Transition coordination service providers shall be reimbursed according to the amount and type of service authorized in the service plan based on a monthly fee for service.

D. Provider requirements. In addition to meeting the general conditions and requirements for home and community-based care participating providers as specified in 12VAC 30-120-730 and 12VAC 30-120-740, transition coordinators shall meet the following qualifications:

1. Transition coordinators shall be employed by one of the following: a local government agency; a private, nonprofit organization qualified under 26 USC § 501(c)(3); or a fiscal management service with experience in providing this service.

2. A qualified transition coordinator shall possess, at a minimum, a bachelor's degree in human services or health care and relevant experience that indicates the individual possesses the following knowledge, skills, and abilities. These shall be documented on the transition coordinator's job application form or supporting documentation, or observable in the job or promotion interview. The transition coordinator shall be at least 21 years of age.

3. Transition coordinators shall have knowledge of (i) aging, independent living, the impact of disabilities, and transition planning; (ii) individual assessments, including psychosocial, health, and functional factors, and their uses in service planning, (iii) interviewing techniques, (iv) individuals' rights, (v) local human and health service delivery systems, including support services and public benefits eligibility requirements, (vi) principles of human behavior and interpersonal relationships, (vii) interpersonal communication principles and techniques, (viii) general principles of file documentation, and (ix) the service planning process and the major components of a service plan.

4. Transition coordinators shall have skills in negotiating with individuals and service providers; observing, and reporting behaviors; identifying and documenting an individual's needs for resources, services and other assistance; identifying services within the established services system to meet the individual's needs; coordinating the provision of services by diverse public and private providers; analyzing and planning for the service needs of the individual; and assessing individuals using DMAS' authorized assessment forms.

5. Transition coordinators shall have the ability to demonstrate a positive regard for individuals and their families or designated guardian; be persistent and remain objective; work as a team member, maintaining effective interagency and intraagency working relationships; work independently, performing position duties under general supervision; communicate effectively, both verbally and in writing; develop a rapport; communicate with different types of persons from diverse cultural backgrounds; and interview.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 25, Issue 20, eff. July 9, 2009; amended, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.

12VAC30-120-2010. Transition services.

A. Service description. "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, which may include an adult foster home, where the person is directly responsible for his own living expenses. 12VAC 30-120-2000 provides the service description, criteria, service units and limitations, and provider requirements for this service.

The individual's transition from an institution to the community shall have a transition coordinator in order to receive EDCD Waiver services or a case manager or health care coordinator if he shall be receiving services through either the IFDDS, ID, or Technology Assisted Waivers.

B. Criteria for receipt of services. In order to be provided, transition services shall be prior authorized by DMAS or its designated agent. These services include rent or utility deposits, basic furniture and appliances, health and safety assurances, and other reasonable expenses incurred as part of a transition. For the purposes of transition services, an institution means an ICF/IID, a nursing facility, or a specialized care facility/hospital as defined at 42 CFR 435.1009. Transition services do not apply to an acute care admission to a hospital.

C. Service units and limitations.

1. Services are available for one transition per individual and must be expended within nine months from the date of authorization. The total cost of these services shall not exceed $5,000, per person lifetime limit coverage of transition costs to residents of nursing facilities, specialized care facility/hospitals, or ICF/IID, who are Medicaid recipients and are able to return to the community. The $5,000 maximum allowance must be expended within nine months from the date of authorization for transition services. It shall not be available to the individual after that period of time. The DMAS designated fiscal agent shall manage the accounting of the transition service. The transition coordinator for the EDCD Waiver or the case manager or health care coordinator, as appropriate to the waiver, shall ensure that the funding spent is reasonable and does not exceed the $5,000 maximum limit.

2. Allowable costs include:

a. Security deposits and the first month's rent that are required to obtain a lease on an apartment or home;

b. Essential household furnishings required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed/bath linens;

c. Set-up fees or deposits for utility or services access, including telephone, electricity, heating and water;

d. Services necessary for the individual's health, safety, and welfare such as pest eradication and one-time cleaning prior to occupancy;

e. Moving expenses;

f. Fees to obtain a copy of a birth certificate or an identification card or driver's license; and

g. Activities to assess need, arrange for, and procure needed resources.

3. The services are furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, are clearly identified in the service plan and the person is unable to meet such expense, or when the services cannot be obtained from another source.

4. The expenses shall not include ongoing monthly rental or mortgage expenses, food, regular utility charges, or household items that are intended for purely diversional/recreational purposes. This service shall not include services or items that are covered under other waiver services such as chore, homemaker, environmental modifications and adaptations, or specialized supplies and equipment.

D. Provider requirements. Providers must be enrolled as a Medicaid Provider for Transition Coordination or Case Management and work with the DMAS designated agent to receive reimbursement for the purchase of appropriate transition goods or services on behalf of the individual.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 25, Issue 20, eff. July 9, 2009; amended, Virginia Register Volume 32, Issue 6, eff. January 1, 2016.

Forms (12VAC30-120)

Virginia Uniform Assessment Instrument (UAI) (1994)

Consent to Exchange Information, DMAS-20 (rev. 4/2003)

Provider Aide Record (Personal/Respite Care), DMAS-90 (rev. 6/2012)

LPN Skilled Respite Record, DMAS-90A (eff. 7/2005)

Personal Assistant/Companion Timesheet, DMAS-91 (rev. 8/2003)

Questionnaire to Assess an Applicant's Ability to Independently Manage Consumer-Directed Services, DMAS-95 Addendum (rev. 8/2005)

Medicaid Funded Long-Term Care Service Authorization Form, DMAS-96 (rev. 8/2012)

Individual Choice - Institutional Care or Waiver Services Form, DMAS-97 (rev. 8/2012)

Agency or Consumer Direction Provider Plan of Care, DMAS-97A/B (rev. 3/2010)

Community-Based Care Recipient Assessment Report, DMAS-99 (rev. 9/2009)

Community-Based Care Level of Care Review Instrument, DMAS-99LOC (undated)

Medicaid LTC Communication Form, DMAS-225 (rev.10/2011)

Technology Assisted Waiver Provider RN Initial Home Assessment, DMAS-116 (11/2010)

Technology Assisted Waiver/EPSDT Nursing Services Provider Skills Checklist for Individuals Caring for Tracheostomized and/or Ventilator Assisted Children and Adults, DMAS-259 (undated)

Home Health Certification and Plan of Care, CMS-485 (rev. 2/1994)

IFDDS Waiver Level of Care Eligibility Form (eff. 5/2007)

Request for Screening for Individual and Family Developmental Disabilities Support Waiver (DD Waiver), DMAS 305 (rev. 3/2009)

DD Medicaid Waiver - Level of Functioning Survey Summary Sheet, DMAS-458 (undated)

Technology Assisted Waiver Adult Aide Plan of Care, DMAS 97 T (rev. 6/2008)

Technology Assisted Waiver Supervisory Monthly Summary, DMAS 103 (rev. 4/2008)

Technology Assisted Waiver Adult Referral, DMAS-108 (rev. 1/2017)

Technology Assisted Waiver Pediatric Referral, DMAS-109 (rev. 1/2017)

Documents Incorporated by Reference (12VAC30-120)

Intellectual Disability: Definition, Classification, and Systems of Supports, 11th edition, 2010, American Association on Intellectual and Developmental Disabilities, 501 3rd Street, NW, Suite 200, Washington, DC 20001-2760

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), 2000, American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, Virginia 22209

Diagnostic and Statistical Manual of Mental Disorders (DSM-5®), Fifth Edition, copyright 2013, American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, Virginia 22209, http:/www.psychiatry.org/dsm5

Underwriter's Laboratories Safety Standard 1635, Standard for Digital Alarm Communicator System Units, Third Edition, January 31, 1996, with revisions through August 15, 2005

Underwriter's Laboratories Safety Standard 1637, Standard for Home Health Care Signaling Equipment, Fourth Edition, December 29, 2006

MR/ID Waiver Slot Assignment Process, August 20, 2010, Department of Behavioral Health and Developmental Services

Virginia Medicaid Provider Manual

Chapter I: General Information (rev. 12/1/2011)

Chapter II: Provider Participation Requirements (rev. 2/8/2012)

Chapter III: Recipient Eligibility (rev. 12/1/2011)

Chapter IV: Covered Services and Limitations (rev. 7/14/2010)

Chapter V: Billing Instructions (rev. 1/26/2011)

Chapter VI: Quality Management Review (rev. 7/14/2010)

Chapter VII: Day Support Waiver (rev. 7/14/2010)

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

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