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.
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
12VAC30-120-217 and 12VAC30-120-219 12VAC30-120-730
and 12VAC30-120-740, transition coordinators shall meet the following
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
psychosocial, health, and functional factors) 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.
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.
12VAC30-120-2000 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
HIV/AIDS, IFDDS, MR 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/MR 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/MR 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
2. Allowable costs include
, but are not limited to:
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
do 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 does 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.