Proposed Text
Part III
Home and Community-Based Services for Individuals with Acquired
Immunodeficiency Syndrome (AIDS) and AIDS-Related Complex
12VAC30-120-140. Definitions. (Repealed.)
"Acquired Immune Deficiency Syndrome" or
"AIDS" means the most severe manifestation of infection with the
Human Immunodeficiency Virus (HIV). The Centers for Disease Control and
Prevention (CDC) lists numerous opportunistic infections and cancers that, in
the presence of HIV infection, constitute an AIDS diagnosis.
"Activities of daily living" or "ADL"
means personal care tasks, e.g., bathing, dressing, toileting, transferring,
and eating/feeding. An individual's degree of independence in performing these
activities is part of determining appropriate level of care and service needs.
"Agency-directed services" means services for
which the provider agency is responsible for hiring, training, supervising, and
firing of the staff.
"Appeal" means the process used to challenge DMAS
when it takes action or proposes to take action that will adversely affect,
reduce, or terminate the receipt of benefits.
"Assistive technology" 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 enable individuals to increase their abilities to
perform activities of daily living, or to perceive, control, or communicate
with the environment in which they live, or that are necessary to the proper
functioning of the specialized equipment. 12VAC30-120-762 provides the service
description, criteria, service units and limitations, and provider requirements
for this service. This service shall be available only to those AIDS waiver
enrollees who are also enrolled in the Money Follows the Person demonstration
program.
"Asymptomatic" means without symptoms. This term
is usually used in the HIV/AIDS literature to describe an individual who has a
positive reaction to one of several tests for HIV antibodies but who shows no
clinical symptoms of the disease.
"Case management" means continuous reevaluation
of need, monitoring of service delivery, revisions to the plan of care and
coordination of services for individuals enrolled in the HIV/AIDS waiver.
"Case manager" means the person who provides
services to individuals who are enrolled in the waiver that enable the
continuous assessment, coordination, and monitoring of the needs of the
individuals who are enrolled in the waiver. The case manager must possess a
combination of work experience and relevant education that indicates that the
case manager possesses the knowledge, skills, and abilities at entry level, as
established by the Department of Medical Assistance Services in 12VAC30-120-170
to conduct case management.
"Cognitive impairment" means a severe deficit in
mental capability that affects areas such as thought processes, problem
solving, judgment, memory, or comprehension and that interferes with such
things as reality orientation, ability to care for self, ability to recognize
danger to self or others, or impulse control.
"Consumer-directed services" means services for
which the individual or family/caregiver is responsible for hiring, training,
supervising, and firing of the staff.
"Consumer-directed (CD) services facilitator"
means the DMAS-enrolled provider who is responsible for supporting the
individual and family/caregiver by ensuring the development and monitoring of
the consumer-directed plan of care, providing employee management training, and
completing ongoing review activities as required by DMAS for consumer-directed
personal assistance and respite care services. The CD services facilitator
cannot be the individual, the individual's case manager, direct service
provider, spouse, or parent of the individual who is a minor child, or a
family/caregiver who is responsible for employing the assistant.
"Current functional status" means the degree of
dependency in performing activities of daily living.
"DMAS" means the Department of Medical Assistance
Services.
"DMAS-96 form" means the Medicaid Funded
Long-Term Care Service Authorization Form, which is a part of the preadmission
screening packet and must be completed by a Level One screener on a
Preadmission Screening Team. It designates the type of service the individual
is eligible to receive.
"DMAS-122 form" means the Patient Information
Form used by the provider and the local DSS to exchange information regarding
the responsibility of a Medicaid-eligible individual to make payment toward the
cost of services or other information that may affect the eligibility status of
an individual.
"DSS" means the Department of Social Services.
"Designated preauthorization contractor" means
the entity that has been contracted by DMAS to perform preauthorization of
services.
"Enteral nutrition products" means enteral
nutrition listed in the durable medical equipment manual that is prescribed by
a physician to be necessary as the primary source of nutrition for the
individual's health care plan (due to the prevalence of conditions of wasting,
malnutrition, and dehydration) and not available through any other food
program.
"Environmental modifications" means physical
adaptations to a house, place of residence, primary vehicle or work site, when
the work site modification exceeds reasonable accommodation requirements of the
Americans with Disabilities Act (42 USC § 1201 et seq.), necessary to
ensure the individuals' health and safety or enable functioning with greater
independence when the adaptation is not being used to bring a substandard
dwelling up to minimum habitation standards and is of direct medical or
remedial benefit to individuals. 12VAC30-120-758 provides the service
description, criteria, service units and limitations, and provider requirements
for this service. This service shall be available only to those AIDS waiver
enrollees who are also enrolled in the Money Follows the Person demonstration
program.
"Fiscal agent" means an agency or organization
that may be contracted by DMAS to handle employment, payroll, and tax
responsibilities on behalf of the individual who is receiving consumer-directed
personal assistance services and consumer-directed respite services.
"HIV-symptomatic" means having the diagnosis of
HIV and having symptoms related to the HIV infection.
"Home and community-based care" means a variety
of in-home and community-based services reimbursed by DMAS (case management,
personal care, private duty nursing, respite care consumer-directed personal
assistance, consumer-directed respite care, and enteral nutrition products)
authorized under a Social Security Act § 1915(c) AIDS Waiver designed to offer
individuals an alternative to inpatient hospital or nursing facility placement.
Individuals may be preauthorized to receive one or more of these services
either solely or in combination, based on the documented need for the service
or services to avoid inpatient hospital or nursing facility placement. DMAS, or
the designated preauthorization contractor, shall give prior authorization for
any Medicaid-reimbursed home and community-based care.
"Human Immunodeficiency Virus (HIV)" means the
virus which leads to acquired immune deficiency syndrome (AIDS). The virus
weakens the body's immune system and, in doing so, allows
"opportunistic" infections and diseases to attack the body.
"Instrumental activities of daily living" or
"IADL" means tasks such as meal preparation, shopping, housekeeping,
laundry, and money management.
"Participating provider" means an individual,
institution, facility, agency, partnership, corporation, or association that
has a valid contract with DMAS and meets the standards and requirements set
forth by DMAS and has a current, signed provider participation agreement with
DMAS to provide Medicaid waiver services.
"Personal assistance services" or "PAS"
means long-term maintenance or support services necessary to enable an
individual to remain at or return home rather than enter an inpatient hospital
or a nursing facility. Personal assistance services include care specific to
the needs of a medically stable, physically disabled individual. Personal
assistance services include, but are not limited to, assistance with ADLs,
bowel/bladder programs, range of motion exercises, routine wound care that does
not include sterile technique, and external catheter care. Supportive services
are those that substitute for the absence, loss, diminution, or impairment of a
physical function. When specified, supportive services may include assistance
with IADLs that are incidental to the care furnished or that are essential to
the health and welfare of the individual. Personal assistance services shall
not include either practical or professional nursing services as defined in
§ 32.1-162.7 of the Code of Virginia and 12VAC5-381-360, as appropriate.
"Personal assistant" means a domestic servant for
purposes of this part and exemption from Worker's Compensation.
"Personal care agency" means a participating
provider that renders services designed to offer an alternative to
institutionalization by providing eligible individuals with personal care aides
who provide personal care services.
"Personal care services" means long-term
maintenance or support services necessary to enable the individual to remain at
or return home rather than enter an inpatient hospital or a nursing facility.
Personal care services are provided to individuals in the areas of activities
of daily living, instrumental activities of daily living, access to the
community, monitoring of self-administered medications or other medical needs,
and the monitoring of health status and physical condition. It shall be
provided in home and community settings to enable an individual to maintain the
health status and functional skills necessary to live in the community or
participate in community activities.
"Personal emergency response systems" or
"PERS" means an electronic device and monitoring service that enable
certain individuals at high risk of institutionalization to secure help in an
emergency. PERS services are limited to those individuals who live alone or are
alone for significant parts of the day and who have no regular caregiver for
extended periods of time, and who would otherwise require extensive routine
supervision. 12VAC30-120-970 provides the service description, criteria,
service units and limitations, and provider requirements for this service.
"Plan of care" means the written plan developed
by the provider related solely to the specific services required by the
individual to ensure optimal health and safety for the delivery of home and
community-based care.
"Preadmission Screening Authorization Form" means
a part of the preadmission screening packet that must be filled out by a Level
One screener on a preadmission screening team. It gives preadmission
authorization to the provider and the individual for Medicaid services, and
designates the type of service the individual is authorized to receive.
"Preadmission screening" or "PAS" means
the process to (i) evaluate the functional, nursing, and social needs of
individuals referred for preadmission screening; (ii) analyze what specific
services the individuals need; (iii) evaluate whether a service or a
combination of existing community services are available to meet the
individuals' needs; and (iv) develop the service plan.
"Preadmission screening committee/team" or
"PAS committee" or "PAS team" means the entity contracted
with DMAS that is responsible for performing preadmission screening. For
individuals in the community, this entity is a committee comprised of a nurse
from the local health department and a social worker from the local department
of social services. For individuals in an acute care facility who require
preadmission screening, this entity is a team of nursing and social work staff.
A physician must be a member of both the local committee and the acute care
team.
"Private duty nursing" means individual and
continuous nursing care provided by a registered nurse or a licensed practical
nurse under the supervision of a registered nurse.
"Program" means the Virginia Medicaid program as
administered by DMAS.
"Reconsideration" means the supervisory review of
information submitted to DMAS or the designated preauthorization contractor in
the event of a disagreement of an initial decision that is related to a denial
in the reimbursement of services already rendered by a provider.
"Respite care" means services specifically
designed to provide a temporary, periodic relief to the primary caregiver of an
individual who is incapacitated or dependent due to AIDS. Respite care services
include assistance with personal hygiene, nutritional support and environmental
maintenance authorized as either episodic, temporary relief or as a routine
periodic relief of the caregiver.
Consumer-directed respite care services may only be offered
to individuals who have an unpaid primary caregiver who requires temporary
relief to avoid institutionalization of the individual. Respite services are
designed to focus on the need of the unpaid caregiver for temporary relief and
to help prevent the breakdown of the unpaid caregiver due to the physical
burden and emotional stress of providing continuous support and care to the
individual.
"Respite care agency" means a participating
provider that renders services designed to prevent or reduce inappropriate
institutional care by providing eligible individuals with respite care aides
who provide respite care services.
"Service plan" means the written plan of services
certified by the PAS team physician as needed by the individual to ensure
optimal health and safety for the delivery of home and community-based care.
"State Plan for Medical Assistance" or "the
Plan" or "the State Plan" means the document containing 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 who are transitioning from an institution or licensed or certified
provider-operated living arrangement to a living arrangement in a private
residence where the person is directly responsible for his own living expenses.
12VAC30-120-2010 provides the service description, criteria, service units and
limitations, and provider requirements for this service.
"Uniform Assessment Instrument" or
"UAI" means the standardized multidimensional questionnaire that
assesses an individual's social, physical health, mental health, and functional
abilities.
12VAC30-120-150. General coverage and requirements for home
and community-based care services for individuals with AIDS. (Repealed.)
A. Coverage statement.
1. Coverage shall be provided under the administration of DMAS
for individuals with HIV infection, who have been diagnosed and are
experiencing the symptoms associated with AIDS, who would otherwise require the
level of care provided in an inpatient hospital or nursing facility.
2. These services shall be medically appropriate and
necessary to maintain these individuals in the community.
B. Patient eligibility requirements.
1. DMAS will apply the financial eligibility criteria
contained in the State Plan for the categorically needy and the medically
needy. Virginia has elected to cover the optional categorically needy group
under 42 CFR 435.211, 435.231 and 435.217. The income level used for 435.211,
435.231 and 435.217 is 300% of the current Supplemental Security Income payment
standard for one person.
Under this waiver, the coverage groups authorized under §
1902(a)(10)(A)(ii)(VI) of the Social Security Act will be considered as if they
were institutionalized for the purpose of applying institutional deeming rules.
The medically needy individuals participating in the waiver will also be
considered as if they were institutionalized for the purpose of applying the
institutional deeming rules.
2. Virginia will 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 that amount of the individual's total income
(including amounts disregarded in determining 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 will reduce its
payment for home and community-based services provided to an individual
eligible for home and community-based waiver services by the amount that
remains after deducting the following amounts in the following order from the
individual's income:
a. For individuals to whom § 1924(d) applies:
(1) An amount for the maintenance needs of the individual
that is equal to 300% of the categorically needy income standard for a
noninstitutionalized individual.
(2) For an individual with only a spouse living at home,
the community spousal income allowance determined in accordance with § 1924(d)
of the Social Security Act, the same as that applied for the institutionalized
patient.
(3) For an individual with a family at home, an additional
amount for the maintenance needs of the family determined in accordance with §
1924(d) of the Social Security Act, the same as that applied for the
institutionalized patient.
(4) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including:
(a) Medicare and other health insurance premiums,
deductibles, or coinsurance charges; and
(b) Necessary medical or remedial care recognized under
state law, but not covered under the state's Medicaid Plan.
b. For all other individuals:
(1) An amount for the maintenance needs of the individual
which is equal to 300% of the categorically needy income standard for a
noninstitutionalized individual.
(2) For an individual with a family at home, an additional
amount for the maintenance needs of the family which shall be equal to the medically
needy income standard for a family of the same size.
(3) Amounts for incurred expenses for medical or remedial
care that are not subject to payment by a third party including:
(a) Medicare and other health insurance premiums,
deductibles, or coinsurance charges; and
(b) Necessary medical or remedial care recognized under
state law, but not covered under the state's Medicaid Plan.
C. Assessment and authorization of home and community-based
care services for individuals on the HIV/AIDS waiver.
1. To ensure that Virginia's home and community-based care
waiver programs serve only individuals who would otherwise be placed in an
inpatient hospital or nursing facility, home and community-based care services
shall be considered only for individuals who meet DMAS' inpatient hospital or
nursing facility criteria or for individuals who are at imminent risk, defined
as within one month, of nursing facility admission. Home and community-based
care services shall be the critical service that enables the individual to
remain at home rather than being placed in an inpatient hospital or nursing
facility.
2. The individual's eligibility for home and community-based
care services shall be determined by the preadmission screening team after
completion of a thorough assessment of the individual's needs and available
supports. If an individual meets nursing facility or inpatient hospital
criteria, the PAS team shall give the individual the choice of receiving
community-based care or care in a nursing facility. In order to meet inpatient
hospital criteria, the individual must have had an inpatient hospital admission
within three months of the request for waiver services for an HIV-symptomatic
or AIDS-related reason.
3. Before Medicaid will assume payment responsibility of
home and community-based care services, preauthorization must be obtained from
the designated preauthorization contractor on all services requiring
preauthorization. Providers must submit the required information to the
designated preauthorization contractor within 10 business days of initiating
care. If the provider submits all required information to the designated
preauthorization 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
Medicaid Funded Long-Term Care Service Authorization Form (DMAS-96). If the
provider does not submit the required information to the designated
preauthorization contractor within 10 business days of initiating care, the
services may be authorized beginning from the date all required information was
received by the designated preauthorization contractor, but not preceding the
date of the PAS team physician's signature on the DMAS-96.
4. The PAS team shall explore alternative settings and/or
services to provide the care needed by the individual. If nursing facility
placement or a combination of other services are determined to be appropriate,
the screening team shall initiate referrals for service. If Medicaid-funded
home and community-based care services are determined to be the critical
services to delay or avoid inpatient hospital or nursing facility placement,
the PAS team shall develop an appropriate service plan and initiate referrals
for service.
5. The individual may be determined to be eligible to
receive services through the HIV/AIDS waiver by the preadmission screening team
if:
a. The physician who is part of the designated preadmission
screening team specifically states the individual has a diagnosis of AIDS or is
HIV symptomatic.
b. The preadmission screening team can document that the
individual is experiencing medical and functional symptoms associated with AIDS
that would, in the absence of waiver services, require the level of care
provided in a hospital, or nursing facility, the cost of which would be
reimbursed under the State Medicaid Plan. Individuals who would revert to a
nursing facility level of care without continuation of waiver services will be
allowed to continue to participate in the waiver.
6. Home and community-based care services shall not be
provided to any individual who resides in a nursing facility, an intermediate
care facility for the mentally retarded, a hospital, an assisted living facility
licensed or certified by DSS, or a group home licensed by the Department of
Mental Health, Mental Retardation and Substance Abuse Services. Additionally,
home and community-based care services shall not be provided to any individual
who resides outside of the physical boundaries of the Commonwealth, with the
exception of brief periods of time as approved by DMAS or the designated
preauthorization contractor. Brief periods of time may include, but are not
necessarily restricted to, vacation or illness.
7. The average annual cost of care for home and
community-based care services shall not exceed the average annual cost of
inpatient hospital or nursing facility care. For purposes of this subdivision,
the average annual cost of care for home and community-based care services
shall include all costs of all Medicaid covered services that would actually be
received by individuals. The average annual cost of nursing facility care shall
be determined by DMAS and shall be updated annually.
8. Individuals should not be screened multiple times within
a short period of time for the same type of service. Preadmission screenings
are valid for the following periods of time: (i) months 0 up to 6 - no updates
needed; (ii) months 6 up to 12 - update needed (do not submit for
reimbursement); and (iii) over 12 months old - new screening must be completed
(submit for reimbursement).
D. Appeals. Recipient appeals shall be considered pursuant
to 12VAC30-110-10 through 12VAC30-110-380. Provider appeals shall be considered
pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.
12VAC30-120-160. General conditions and requirements for all
providers for home and community-based care services participating providers.
(Repealed.)
A. All providers must meet the general requirements and conditions
for provider participation. In addition, there are specific requirements for
each of the service providers (case management, personal care, respite care
private duty nursing, enteral nutrition, consumer-directed personal assistance
services, and consumer-directed respite care services) which are set forth in
12VAC30-120-155 through 12VAC30-120-201.
B. General requirements. Providers approved for
participation shall, at a minimum, perform the following activities:
1. Immediately notify DMAS, in writing, of any change in the
information which the provider previously submitted to DMAS to include the
provider's physical and mailing addresses, executive staff and officers, and
contact person's name, telephone number, and fax number.
2. Assure freedom of choice to individuals in seeking
medical care from any institution, pharmacy, practitioner, or other provider
qualified to perform the service or services required and participating in the
Medicaid Program at the time the service or services were performed.
3. Assure the individual's freedom to reject medical care
and treatment.
4. Accept referrals for services only when staff is
available to initiate services.
5. Provide services and supplies to individuals in full
compliance with (i) Title VI of the Civil Rights Act of 1964 (42 USC § 2000 et
seq.); (ii) § 504 of the Rehabilitation Act of 1973 (29 USC § 70 et seq.);
(iii) Title II of the Americans with Disabilities Act of 1990 (42 USC § 126 et
seq.); and (iv) all other applicable state and federal laws and regulations.
6. Provide services and supplies to individuals in the same
quality and mode of delivery as provided to the general public.
7. Charge DMAS 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.
8. Accept Medicaid payment from the first day of
eligibility.
9. Accept as payment in full the amount established by DMAS.
10. Use program-designated billing forms for submission of
charges.
11. Maintain and retain business and professional records
sufficient to document fully and accurately the nature, scope and details of
the health care provided.
a. Such records shall be retained for at least five years
from the last date of service or as provided by applicable federal or state
laws, whichever period is longer. 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 at least five
years after such minor has reached the age of 18 years.
b. Policies regarding retention of records shall apply even
if the provider discontinues operation. DMAS shall be notified in writing of
storage, location, and procedures for obtaining records for review should the
need arise. The location, agent, or trustee shall be within the Commonwealth of
Virginia.
12. Furnish to authorized state and federal personnel, in
the form and manner requested, access to records and facilities.
13. 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.
14. Comply with all Health Insurance Portability and
Accountability Act (HIPAA) guidelines.
15. When ownership of the provider agency changes, DMAS
shall be notified within 15 calendar days prior to the date of the change.
C. Requests for participation will be screened by DMAS or
the designated contractor to determine whether the provider applicant meets the
basic requirements for participation.
D. For DMAS to approve contracts with home and community-based
care providers, providers must meet staffing, financial solvency, disclosure of
ownership and assurance of comparability of services requirements.
E. In addition to compliance with the general conditions
and requirements, all providers enrolled by DMAS shall adhere to the conditions
of participation outlined in their individual provider agreements and in the
applicable DMAS provider service manual.
F. DMAS is responsible for assuring continued adherence to
provider participation standards. DMAS shall conduct ongoing monitoring of
compliance with provider participation standards and DMAS policies.
G. Individual choice of provider agencies. If there is more
than one approved provider agency offering services in the community, the
individual will have the option of selecting the provider agency of his choice
from among those agencies that can appropriately meet the individual's needs.
H. If a participating provider wishes to voluntarily
terminate his participation in Medicaid, the provider must give DMAS written
notification 30 days prior to the desired termination date.
I. Termination of provider participation. DMAS may
administratively terminate a provider from participation upon 30 days' written
notification. DMAS may also cancel a provider agreement immediately or may give
notification in the event of a breach of the provider agreement by the provider
as specified in the DMAS provider agreement. Payment by DMAS is prohibited for
services provided to individuals subsequent to the date specified in the
termination notice. DMAS may 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. Such provider agreement terminations shall
conform to 12VAC30-10-690 and Part XII (12VAC30-20-500 et seq.) of 12VAC30-20.
DMAS shall not reimburse for services that may be rendered subsequent to such
terminations.
J. Reconsideration of adverse actions. Adverse actions may
include, but shall not be limited to disallowed payment of claims for services
rendered that are not in accordance with DMAS policies and procedures, caseload
restrictions, and contract limitation or termination. The following procedures
will be available to all providers when DMAS takes adverse action.
1. The reconsideration process shall consist of three
phases:
a. A written response and reconsideration to the
preliminary findings;
b. The informal conference; and
c. The formal evidentiary hearing.
2. The provider shall have 30 days to submit information for
written reconsideration, 30 days from the date of the notice to request the
informal conference, and 30 days to request the formal evidentiary hearing.
3. An appeal of adverse actions shall be heard in accordance
with 12VAC30-10-1000 and Part XII (12VAC30-20-500 et seq.) of 12VAC30-20.
K. Section 32.1-325 of the Code of Virginia mandates that
"Any such (Medicaid) agreement or contract shall terminate upon conviction
of the provider of a felony." A provider convicted of a felony in Virginia
or in any other of the 50 states or the District of Columbia must, within 30
days, notify the Virginia Medicaid Program of this conviction and relinquish
its provider agreement. Reinstatement will be contingent upon provisions of the
laws of the Commonwealth. Additionally, termination of a provider contract will
occur as may be required for federal financial participation.
L. Participating provider agency's responsibility for the
Medicaid Long Term Care Communication Form (DMAS-225). It is the
responsibility of the provider agency to notify DMAS or the designated
preauthorization contractor, in writing, when any of the following
circumstances occur:
1. Home and community-based care services are implemented.
2. An individual receiving services dies; or
3. An individual is discharged or terminated from services.
M. Participating provider agency's responsibility for the
Medicaid Long Term Care Communication Form (DMAS-225). It is the responsibility
of the provider agency to notify the local DSS, in writing, when any
circumstances (including hospitalization) cause home and community-based care
services to cease or be interrupted for more than 30 days.
N. Changes or termination of care.
1. Decreases in the amount of authorized care.
a. The provider may decrease the amount of authorized care
if the newly developed plan of care is appropriate and based on the needs of
the individual. If the individual disagrees with the proposed decrease, the
individual has the right to appeal to DMAS.
b. The participating provider is responsible for developing
the new plan of care and calculating the new hours of service delivery.
c. The person responsible for supervising the individual's
care shall discuss the decrease in care with the individual or family, document
the conversation in the individual's record, and shall notify the designated
preauthorization contractor and the individual or family of the change by
letter. This letter shall give the individual the right to appeal.
2. Increases in the amount of authorized personal care. If a
change in the individual's condition necessitates an increase in care, the
participating provider shall assess the need for increase and, if appropriate,
develop a plan of care for services to meet the changed needs. The provider may
implement the increase in hours without approval from DMAS or the designated
preauthorization contractor, if the amount of service does not exceed the
amount established by DMAS or the designated preauthorization contractor, as
the maximum for the level of care designated for that individual. Any increase
to an individual's plan of care that exceeds the number of hours allowed for
that individual's level of care or any change in the individual's level of care
must be preauthorized by DMAS or the designated preauthorization contractor.
3. Nonemergency termination of home and community-based care
services by the participating provider. The participating provider shall give
the individual or family, or both, five days' written notification of the
intent to terminate services. The letter shall provide the reasons for and
effective date of the termination. The effective date of services termination
shall be at least five days from the date of the termination notification letter.
This includes a provider's voluntary termination of its provider agreement with
DMAS.
4. Emergency termination of home and community-based care
services by the participating provider. In an emergency situation when the
health and safety of the individual or provider agency personnel is endangered,
DMAS or the designated preauthorization contractor must be notified prior to
termination. The five-day written notification period shall not be required. If
appropriate, the local DSS Adult or Child Protective Services must be notified
immediately.
5. Nonemergency termination of home and community-based care
services by DMAS, or the designated preauthorization contractor. The effective
date of termination will be at least 10 days from the date of the termination
notification letter. DMAS, or the designated preauthorization contractor, has
the responsibility and the authority to terminate the receipt of home and
community-based care services by the individual for any of these reasons:
a. The home and community-based care services are no longer
the critical alternative to prevent or delay institutional placement;
b. The individual no longer meets the level-of-care
criteria;
c. The individual's environment does not provide for his
health, safety, and welfare; or
d. An appropriate and cost-effective plan of care cannot be
developed.
6. If the individual disagrees with the service termination
decision, DMAS Appeals Division shall conduct a review of the individual's
service need as part of the appeals process. The individual, when requesting an
appeal, should submit documentation to indicate why the decision to deny was
incorrect. As a result of this review, DMAS Appeals Division will either uphold
or overturn the termination decision. If the termination decision is upheld,
the individual has the right to file a formal appeal to the local circuit
court. The individual filing the appeal shall have a right to the continuation
of services pending the final appeal decision pursuant to 12VAC30-110-100.
O. Suspected abuse or neglect. Pursuant to §§ 63.2-1509 and
63.2-1606 through 63.2-1610 of the Code of Virginia, if a participating
provider agency knows or suspects that an individual receiving home and
community-based care services 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 DSS Adult Protective Services or
Child Protective Services, as appropriate, and to DMAS.
P. DMAS shall conduct ongoing monitoring of compliance with
provider participation standards and DMAS policies. A provider's noncompliance
with DMAS regulations, policies, and procedures, as required in the provider's
agreement with DMAS, may result in a denial of Medicaid payment or termination
of the provider agreement.
Q. Waiver desk reviews. DMAS will request, on an annual
basis, information on every individual, that is used to assess the individual's
ongoing need for Medicaid-funded long-term care. With this request, the
provider will receive a list that specifies the information that is being
requested. If an individual is identified as not meeting criteria for the
waiver, the individual will be given 10 days' notice of termination from
services and be terminated from the waiver and will also be given appeal
rights.
12VAC30-120-170. Case management services. (Repealed.)
A. General. Case management services are offered to enable
continuous assessment, coordination and monitoring of the needs of HIV/AIDS waiver
individuals. Every HIV/AIDS waiver individual authorized for home and
community-based services shall be offered case management services as an
adjunct to other offered services. A Medicaid-eligible individual may not be
authorized for home and community-based services unless that individual is both
diagnosed with AIDS or HIV and is experiencing symptoms that require delivery
of a home and community-based service other than case management. An individual
authorized for home and community-based services for conditions of AIDS may
continue to receive case management services during periods when other home and
community-based services are not being utilized as long as receipt of case
management services can be shown to continue to prevent the individual's
institutionalization. In instances where a case management provider cannot be
located, one of the other providers (personal/respite care provider, private
duty nursing provider, or consumer-directed service facilitation provider) may
act as the case management provider as long as he meets the case management
provider qualifications and is enrolled with DMAS to provide case management
services. If an AIDS waiver individual requires case management services, this
service shall be provided as a part of the AIDS waiver. There shall be no
duplication of AIDS waiver case management services with other Medicaid state
plan case management services.
B. Special provider participation conditions. To be a
participating case management provider the following conditions shall be met:
1. The case management provider shall employ case management
staff responsible for the reevaluation of need, monitoring of service delivery,
revisions to the plan of care and coordination of services. Each case manager
shall possess, at a minimum:
a. A bachelor's degree in human services (i.e., social
work, psychology, sociology, counseling, or a related field) or nursing;
b. Knowledge of the infectious disease process
(specifically HIV) and the needs of the terminally-ill population, knowledge of
the community service network and eligibility requirements and the application
procedures for applicable assistance programs;
c. Ability to access other health and social work
professionals in the community to serve as members of a multidisciplinary team
for reevaluation and coordination of services activities, ability to organize
and monitor an integrated service plan for individuals with multiple problems
and limited resources, ability to access (or have expertise in) medical and
clinical expertise related to HIV infection and ability to demonstrate liaisons
with clinical facilities providing diagnostic evaluation and/or treatment for
individuals with HIV; and
d. Skills in communication, service plan development,
client advocacy and monitoring of a continuum of managed care.
Documentation of all staffs' credentials shall be maintained
in the provider's personnel file for review by DMAS staff. Providers of case
management may utilize the services of volunteers or employees who do not meet
these criteria to perform the day-to-day interactions with recipients
individuals commonly included in the case management process. There shall be,
however, a case manager responsible for supervision of these volunteers or
employees to include at a minimum weekly case consultations, decision-making
related to the individual's plan of care and appropriateness for waiver
services and training of the volunteers or employees interacting with the
waiver individual. The use of volunteers or other employees to perform the
day-to-day interactions does not relieve the case manager from responsibility
for direct contact (as defined below) with the individual and overall
responsibility for care management.
2. Designate a qualified staff person as case manager who
shall:
a. Complete a comprehensive initial assessment.
b. Contact the waiver individual, at a minimum, once every
30 days. If the waiver individual has a volunteer or volunteers or other staff
assigned for regular face-to-face contact, this contact by the case manager may
be a telephone contact. Otherwise, the contact by the case manager shall be a
face-to-face interaction. At a minimum, the case manager must have face-to-face
contact with the individual quarterly.
c. Contact the providers of direct waiver service or
services, at a minimum, once every 30 days. Collateral contacts with other
supports shall be made periodically, as determined by the needs of the
individual and extent of the support system. Contacts must be documented in the
individual's record.
d. Maintain a file for each individual that includes:
(1) An ongoing progress report that documents all
communications between the case manager and individual, providers, and other
contacts. This must include the amount of time the case manager interacted with
the individual on the telephone or face to face. If the case manager is
supervising a volunteer or employee who is assigned to provide day-to-day case
management interactions with the individual, the volunteer or employee must
submit to the case manager a monthly summary of all interactions between the
volunteer or employee and the individual;
(2) The individual's assessment documentation and
documentation of reassessments of level of care and need for services conducted
quarterly by the case manager and the individual's case management team;
(3) The initial plan of care and all subsequent revisions;
and
(4) Communication from DMAS, physician, service providers,
and any other parties related to the individual's Medicaid services or medical
care.
e. Review of the plan of care every three months, or more
frequently if necessary, and continue any revisions indicated by the changed
needs or support of the individual. These reviews shall be documented in the
individual's file. The documentation shall note all members of the case
management team who provided input to the plan of care.
3. Maintain a ratio of case manager staff to individual
caseload that allows optimum monitoring and reevaluation ability. The caseload
ability of the case manager may vary according to other duties, availability of
resources, stage of individuals in caseload, and utilization of volunteers.
12VAC30-120-180. Agency-directed personal care services. (Repealed.)
A. General. Agency-directed personal care services may be
offered to waiver individuals. Personal care may be offered either as the sole home
and community-based care service that avoids institutionalization or in
conjunction with the other AIDS waiver services. Individuals may continue to
work or attend post-secondary school, or both, while they receive services
under this waiver. The personal care assistant who assists the individual may
accompany the individual to work or school or both and may assist the
individual with personal needs while the individual is at work or school or
both. DMAS will also pay for any personal care services that the assistant
gives to the individual to assist him in getting ready for work or school or
both or when he returns home. DMAS or the designated preauthorization
contractor will review the individual's needs and the complexity of the
disability when determining the services that will be provided to the
individual in the workplace or school or both.
1. Effective July 1, 2011, agency-directed personal care
services shall be limited to 56 hours of medically necessary services per week
for 52 weeks per year.
2. Individual exceptions may be granted based on criteria
established by DMAS.
B. DMAS will not duplicate services that are required as a
reasonable accommodation as a part of the Americans with Disabilities Act (ADA)
(42 USC §§ 12131 through 12165) or the Rehabilitation Act of 1973. For example,
if the individual's only need is for assistance during lunch, DMAS would not
pay for the assistant to be with the individual for any hours extending beyond
lunch. For an individual whose speech is such that he cannot be understood
without an interpreter (not translation of a foreign language), or the
individual is physically unable to speak or make himself understood even with a
communication device, the assistant's services may be necessary for the length
of time the individual is at work or school or both. Workplace or school
supports through the HIV/AIDS waiver are not provided if the services are an
employer's responsibility under the Americans with Disabilities Act or § 504 of
the Rehabilitation Act.
C. The provider agency must develop an individualized plan
of care that addresses the individual's needs at home, at work or school and in
the community. DMAS will not pay for the assistant to assist the enrolled
individual with any functions related to the individual completing his job or
school functions or for supervision time during work, school, or both.
D. Special provider participation conditions. The personal
care provider shall:
1. Operate from a business office.
2. Employ (or subcontract with) and directly supervise a
registered nurse who will provide ongoing supervision of all personal care
aides.
a. The registered nurse shall be currently licensed to
practice in the Commonwealth of Virginia and have at least two years of related
clinical nursing experience (which may include work in an acute care hospital,
public health clinic, home health agency, rehabilitation hospital, nursing
facility, or as a licensed practical nurse (LPN)).
b. The registered nurse shall have a satisfactory work
record, as evidenced by references from prior job experience, including no
evidence of abuse, neglect, or exploitation of incapacitated or older adults
and children. Providers are responsible for complying with § 32.1-162.9:1 of
the Code of Virginia regarding criminal record checks. The criminal record
check documentation shall be available for review by DMAS staff who are
authorized by the agency to review these files, as a part of the utilization
review process.
c. The registered nurse supervisor shall make an initial home
assessment on or before the start of care for all new individuals admitted to
personal care, when individuals are readmitted after being discharged from
services, or are transferred from another personal care provider.
d. The registered nurse supervisor shall make supervisory
visits as often as needed, but no fewer visits than provided as follows, to
ensure both quality and appropriateness of services.
(1) A minimum frequency of these visits is every 30 days
for individuals with a cognitive impairment, as defined herein, and every 90
days for individuals who do not have a cognitive impairment.
(2) The initial home assessment visit by the registered
nurse shall be conducted to create the plan of care and assess individuals'
needs. The registered nurse shall return for a follow-up visit within 30 days
after the initial visit to assess the individual's needs and make a final
determination that there is no cognitive impairment. This determination must be
documented in the individual's record by the registered nurse. Individuals who
are determined to have a cognitive impairment will continue to have supervisory
visits every 30 days.
(3) If there is no cognitive impairment, the registered
nurse may give the individual or caregiver or both the option of having the
supervisory visit every 90 days or any increment in between, not to exceed 90
days. The registered nurse must document this conversation in the individual's
record and the option that was chosen.
(4) The provider has the responsibility of determining if
30-day registered nurse supervisory visits are appropriate for the individual.
The provider may offer the extended registered nurse supervisory visits, or the
agency may choose to continue the 30-day supervisory visits based on the needs
of the individual. The decision must be documented in the individual's record.
(5) If an individual's personal care assistant is
supervised by the provider's registered nurse less often than every 30 days and
DMAS or the designated preauthorization contractor determines that the
individual's health, safety, or welfare is in jeopardy, DMAS or the designated
preauthorization contractor may require the provider's registered nurse to
supervise the personal care aide every 30 days or more frequently than what has
been determined by the registered nurse. This will be documented and entered in
the individual's record.
e. During visits to the individual's home, the registered
nurse shall observe, evaluate, and document the adequacy and appropriateness of
personal care services with regard to the individual's current functioning
status, medical, and social needs. The personal care aide's record shall be
reviewed and the recipient's (or family's) satisfaction with the type and
amount of service discussed. The registered nurse summary shall note:
(1) Whether personal care services continue to be
appropriate.
(2) Whether the plan is adequate to meet the individual's
needs or if changes need to be made in the plan of care.
(3) Any special tasks performed by the aide and the aide's qualifications
to perform these tasks.
(4) Individual's satisfaction with the service.
(5) Hospitalization or change in the medical condition or
functioning status of the individual.
(6) Other services received by the individual and the
amount; and
(7) The presence or absence of the aide in the home during
the registered nurse's visit.
f. A registered nurse shall be available to the personal
care aide for conference pertaining to individuals being served by the aide and
shall be available to aides by telephone at all times that the aide is
providing services to personal care individuals.
g. The registered nurse supervisor shall evaluate the
aides' performance and the individual's needs to identify any insufficiencies
in the aide's abilities to function competently and shall provide training as
indicated. This shall be documented in the individual's record.
h. If there is a delay in the registered nurses'
supervisory visits, because the individual was unavailable, the reason for the
delay must be documented in the individual's record.
3. Employ and directly supervise personal care aides who
provide direct care to personal care individuals. Each aide hired by the
provider agency shall be evaluated by the provider agency to ensure compliance with
qualifications required by DMAS. Each aide shall:
a. Be able to read and write.
b. Complete a minimum of 40 hours of training consistent
with DMAS standards. Prior to assigning an aide to an individual, the provider
agency shall ensure that the aide has satisfactorily completed a training
program consistent with DMAS standards.
c. Be physically able to do the work.
d. Have a satisfactory work record, as evidenced by
references from prior job experience, including no evidence of abuse, neglect
or exploitation of incapacitated or older adults and children. Providers are
responsible for complying with § 32.1-162.9:1 of the Code of Virginia regarding
criminal record checks. The criminal record check shall be available for review
by DMAS staff who are authorized by the agency to review these files; and
e. Not be (i) the parents of minor children who are
receiving waiver services or (ii) spouses of individuals who are receiving
waiver services.
Payment may be made for services furnished by other family
members when there is objective written documentation as to why there are no
other providers available to provide the care. These family members must meet
the same requirements as aides who are not family members.
E. Required documentation for individuals' records. The
provider agency shall maintain all records of each personal care recipient.
These records shall be separate from those of nonhome and community-based care
services, such as companion or home health services. These records shall be
reviewed periodically by the DMAS staff who are authorized by DMAS to review
these files during utilization review. At a minimum these records shall
contain:
1. The most recently updated Long Term Care Uniform
Assessment Instrument (UAI), documentation of any inpatient hospital
admissions, the Medicaid-Funded Long-Term Care Service Authorization form
(DMAS-96), the Screening Team Service Plan for Medicaid-Funded Long-Term Care
(DMAS-97), the Consent to Exchange Information (DMAS-20), all Provider Agency
Plans of Care (DMAS97A), all Community-Based Care Recipient Assessment Reports
(DMAS-99), all Patient Information Forms (DMAS-122), and the Service Agreement
Between the Consumer and the Service Facilitator.
2. The initial assessment by a registered nurse completed prior
to or on the date that services are initiated.
3. Registered nurses' notes recorded and dated during any
significant contacts with the personal care aide and during supervisory visits
to the individual's home.
4. All correspondence to the individual, DMAS, the
designated preauthorization contractor.
5. Reassessments made during the provision of services.
6. Significant contacts made with family, physicians, DMAS,
the designated preauthorization contractor, formal and informal service
providers and all professionals related to the individual's Medicaid services
or medical care.
7. All Provider Aide/LPN Records (DMAS-90). The Provider
Aide/LPN Record shall contain:
a. The specific services delivered to the individual by the
aide and the individual's response to this service;
b. The aide's daily arrival and departure times;
c. The aide's weekly comments or observations about the
individual, including observations of the individual's physical and emotional
condition, daily activities, and responses to services rendered; and
d. The aide's and individual's, or responsible caregiver's,
weekly signatures, including the date, to verify that personal care services
have been rendered during that week as documented in the record. An employee of
the provider cannot sign for the individual unless he is a family member or
legal guardian of the individual.
Signatures, times and dates shall not be placed on the aide
record prior to the last date of the week that the services are delivered.
8. All individual progress reports.
12VAC30-120-190. Agency-directed respite care services. (Repealed.)
A. General. Agency-directed respite care services may be
offered to individuals as an alternative to institutional care. Respite care
may be offered to individuals in their homes or places of residence, in a
Medicaid-certified nursing facility, or in a licensed respite care facility.
Respite care is distinguished from other services in the continuum of long-term
care because it is specifically designed to focus on the need of the unpaid
primary caregiver for temporary relief. Respite care may only be offered to
individuals who have an unpaid primary caregiver living in the home who
requires temporary relief to avoid institutionalization of the individual.
Effective July 1, 2011, the authorization of respite care is limited to 480
hours per year per individual. An individual who transfers to a different
provider or is discharged and readmitted into the HIV/AIDS waiver program
within the same year will not receive an additional 480 hours of respite care.
Reimbursement shall be made on an hourly basis not to exceed a total of 480
hours per year. If an individual is receiving both agency directed and consumer
directed respite care, the total number of respite care hours cannot exceed a
total of 480 hours combined per year.
B. Special provider participation conditions. To be
approved for respite care contracts with DMAS, the respite care provider shall:
1. Operate from a business office.
2. Employ (or subcontract) with and directly supervise a
registered nurse who will provide ongoing supervision of all respite care
aides.
a. The registered nurse shall be currently licensed to
practice in the Commonwealth and have at least two years of related clinical
nursing experience which may include work in an acute care hospital, public
health clinic, home health agency, rehabilitation hospital, nursing facility or
as an LPN.
b. The registered nurse shall have a satisfactory work
record, as evidenced by references from prior job experience, including no
evidence of abuse, neglect, or exploitation of incapacitated or older adults
and children. Providers are responsible for complying with § 32.1-162.9:1 of
the Code of Virginia regarding criminal record checks. The criminal record
check shall be available for review by DMAS staff who are authorized by the
agency to review these files.
c. Based on continuing evaluations of the aides'
performance and the individuals' needs, a registered nurse supervisor shall identify
any insufficiencies in the aides' abilities to function competently and shall
provide training as indicated.
d. A registered nurse supervisor shall make an initial home
assessment visit on or before the start of care for any individual admitted to
respite care.
e. A registered nurse supervisor shall make supervisory
visits as often as needed to ensure both quality and appropriateness of
services.
(1) When respite care services are received on a routine
basis, the minimum acceptable frequency of these visits shall be every 30 days.
(2) When respite care services are not received on a
routine basis, but are episodic in nature, a registered nurse shall not be
required to conduct a supervisory visit every 30 days. Instead, a registered
nurse shall conduct the initial home visit with the respite care aide on or
before the start of care and make a second home visit during the second respite
care visit.
(3) When respite care services are routine in nature and
offered in conjunction with personal care, the supervisory visit conducted for
personal care services may serve as the registered nurse supervisory visit for
respite care. However, the registered nurse supervisor shall document
supervision of respite care separately from the personal care documentation.
For this purpose, the same individual record can be used with a separate
section for respite care documentation.
f. During visits to the individual's home, the registered
nurse shall observe, evaluate, and document the adequacy and appropriateness of
respite care services with regard to the individual's current functioning
status, medical, and social needs. The respite care aide's record shall be
reviewed and the recipient's or family's satisfaction with the type and amount
of service discussed. The registered nurse shall document in a summary note:
(1) Whether respite care services continue to be
appropriate;
(2) Whether the plan of care is adequate to meet the
individual's needs or if changes need to be made in the plan of care;
(3) The individual's satisfaction with the service;
(4) Any hospitalization or change in the medical condition
or functioning status of the individual;
(5) Other services received by the individual and the
amount of services received; and
(6) The presence or absence of the aide in the home during
the registered nurse's visit.
g. A registered nurse shall be available to the respite
care aide for conference pertaining to individuals being served by the aide and
shall be available to the aides by telephone at all times that aides are
providing services to respite care individuals.
h. If there is a delay in the registered nurse's
supervisory visits because the individual is unavailable, the reason for the
delay must be documented in the individual's record.
3. Employ and directly supervise respite care aides who
provide direct care to respite care individuals. Each aide hired by the
provider agency shall be evaluated by the provider agency to ensure compliance
with qualifications as required by DMAS. Each aide must:
a. Be able to read and write in English to the degree
necessary to perform the tasks expected.
b. Have completed a minimum 40 hours of training consistent
with DMAS standards. Prior to assigning an aide to an individual, the provider
agency shall ensure that the aide has satisfactorily completed a training
program consistent with DMAS standards.
c. Be evaluated in his job performance by the registered
nurse supervisor.
d. Be physically able to do the work.
e. Have a satisfactory work record, as evidenced by references
from prior job experience, including no evidence of abuse, neglect, or
exploitation of incapacitated or older adults and children. Providers are
responsible for complying with § 32.1-162.9:1 of the Code of Virginia regarding
criminal record checks. The criminal record check documentation shall be
available for review by DMAS staff who are authorized by the agency to review
these files.
f. Not be (i) the parents of minor children who are
receiving waiver services or (ii) the spouses of individuals who are receiving
waiver services.
Payment may be made for services furnished by other family
members when there is objective written documentation as to why there are no
other providers available to provide the care. These family members must meet
the same requirements as aides who are not family members.
4. The respite care agency may employ a licensed practical
nurse (LPN) to perform skilled respite care services which shall be reimbursed
by DMAS under the following circumstances:
a. The LPN shall be currently licensed to practice in the
Commonwealth. The LPN must have a satisfactory work record, as evidenced by
references from prior job experience, including no evidence of abuse, neglect,
or exploitation of incapacitated or older adults and children. Providers shall
be responsible for complying with § 32.1-162.9:1 of the Code of Virginia
regarding criminal record checks. The criminal record check documentation shall
be available for review by DMAS staff who are authorized by the agency to
review these files.
b. The individual has a need for routine skilled care that
cannot be provided by unlicensed personnel. This individual would typically
require a skilled level of care if in a nursing facility (i.e., individuals on
a ventilator, individuals requiring nasogastric or gastrostomy feedings, etc.).
c. No other person in the individual's support system is
able to supply the skilled component of the individual's care during the
caregiver's absence.
d. The individual is unable to receive skilled nursing visits
from any other source which could provide the skilled care usually given by the
caregiver.
e. The agency must document in the individual's record the
circumstances which require the provision of services by an LPN.
f. A physician's order for the skilled respite service, on
the Home Health Certification and Plan of Care (CMS-485) is obtained prior to
the initiation of service and is updated every six months. This order must
specifically identify the skilled tasks to be performed.
The registered nurse shall review the medications and
treatments rendered by the LPN every 60 days and verify the physician's orders.
C. Required documentation for individuals' records. The
provider agency shall maintain all records of each respite care individual.
These records shall be separate from those of nonhome and community-based care
services, such as companion or home health services. These records shall be
reviewed periodically by the DMAS staff who are authorized by the agency to
review these files during utilization review. At a minimum these records shall
contain:
1. The most recently updated Long Term Care Uniform
Assessment Instrument (UAI), documentation of any inpatient hospital
admissions, the Medicaid-Funded Long-Term Care Service Authorization form (DMAS-96),
the Screening Team Service Plan for Medicaid-Funded Long-Term Care (DMAS-97),
all Community-Based Care Assessment Reports (DMAS-99), all Provider Agency
Plans of Care (DMAS-97A and CMS-485), and all Patient Information Forms
(DMAS-122) .
2. The initial assessment by a registered nurse completed
prior to or on the date services are initiated.
3. Registered nurse's notes recorded and dated during
significant contacts with the respite care aide or LPN and during supervisory
visits to the individual's home.
4. All correspondence to the individual, DMAS, and the
designated preauthorization contractor.
5. Reassessments made during the provision of services.
6. Significant contacts made with family, physicians, DMAS,
the designated preauthorization contractor, formal and informal service
providers, and all professionals related to the individual's Medicaid services
or medical care.
7. All Provider Aide/LPN Records (DMAS-90). The provider
aide/LPN record shall contain:
a. The specific services delivered to the individual by the
respite care aide, or LPN, and the individual's response to this service.
b. The daily arrival and departure times of the aide or LPN
for respite care services.
c. Comments or observations recorded weekly about the individual.
Aide or LPN comments shall include but not be limited to observation of the
individual's physical and emotional condition, daily activities, and the
individual's response to services rendered.
d. The signatures of the aide, or LPN, and the individual
once each week to verify that respite care services have been rendered.
Signatures, times, and dates shall not be placed on the
aide record prior to the last date of the week that the services are delivered.
If the individual is unable to sign the aide record, it must be documented in
the individual's record how or who will sign in his place. An employee of the
provider shall not sign for the individual unless he is a family member or
legal guardian of the individual and has direct knowledge of the care received
by the individual.
8. All recipient progress reports.
12VAC30-120-195. Enteral nutrition products. (Repealed.)
A. General requirements and conditions.
1. Enteral nutrition products shall only be provided by
enrolled durable medical equipment (DME) providers as defined in
12VAC30-50-165.
2. DME providers shall adhere to all applicable DMAS
policies, laws, and regulations for enteral nutrition products. DME providers
shall also comply with all other applicable Virginia laws and regulations
requiring licensing, registration, or permitting. Failure to comply with such
laws and regulations shall result in denial of coverage for enteral nutrition
that is regulated by such licensing agency or agencies.
B. Service units and service limitations.
1. DME and supplies must be furnished pursuant to the AIDS
Waiver Enteral Nutrition Evaluation Form (DMAS-116).
2. A DMAS-116 shall be required for all AIDS waiver
recipients receiving enteral nutrition products. Enteral nutrition products
that do not contain a legend drug may be obtained for the individual receiving
waiver services for conditions of AIDS and HIV-symptomatic when the enteral
nutrition product is certified by the practitioner as the primary source of
nutrition, is administered orally or through a nasogastric or gastrostomy tube,
and is necessary for the successful implementation of the individual's health
care plan and the individual is not able to purchase enteral nutrition products
through other means. Coverage of enteral nutrition products does not include
the provision of routine infant formula. The amount of enteral nutrition
products that shall be reimbursed by Medicaid shall be limited by medical
necessity and cost effectiveness.
3. "Primary source" means that enteral nutrition
products are medically indicated for the treatment of the individual's
condition if the individual is unable to tolerate other forms of nutrition. The
individual may either be unable to take any oral nutrition or the oral intake
that can be tolerated is inadequate to sustain life. The focus must be on the
maintenance of weight and strength commensurate with the individual's medical
condition.
4. The DMAS-116 shall contain a practitioner's order for the
enteral nutrition products that are medically necessary to treat the diagnosed
condition and the individual's functional limitation. The order for enteral
nutrition products must be justified in the written documentation either on the
DMAS-116 or attached thereto. The DMAS-116 shall be valid for a maximum period
of six months. The validity of the DMAS-116 shall terminate when the
individual's medical need for the prescribed enteral nutrition products either
ends or when the enteral nutrition products are no longer the primary source of
nutrition.
5. A face-to-face nutritional assessment completed by
trained clinicians (e.g., physician, physician assistant, nurse practitioner,
registered nurse, or a registered dietitian) must be completed as required
documentation of the need for enteral nutrition products for both the initial
order and every six months. The DMAS-116 is required every six months.
6. The DMAS-116 shall not be changed, altered, or amended
after the practitioner has signed it. As indicated by the individual's
condition, if changes are necessary in the ordered enteral nutrition products,
the DME provider must obtain a new DMAS-116. New DMAS-116s must be signed and
dated by the practitioner within 60 days from the time the ordered enteral
nutrition products are furnished by the DME provider. The order cannot be
back-dated to cover prior dispensing of enteral nutrition products. If the
order is not signed within 60 days of the service initiation, then the date the
order is signed becomes the effective date.
7. Preauthorization of enteral nutrition products is not
required. The DME provider must assure that there is a valid DMAS-116 completed
every six months in accordance with DMAS policy and on file for all Medicaid
individuals for whom enteral nutrition products are provided. The DME provider
is further responsible for assuring that enteral nutrition products are
provided in accordance with DMAS reimbursement criteria. Upon post payment
review, DMAS will deny reimbursement for any enteral nutrition products that
have not been provided and billed in accordance with these regulations.
8. DMAS shall have the authority to determine that the
DMAS-116 is valid for less than six months based on medical documentation
submitted.
C. Provider responsibilities.
1. The DME provider must provide the enteral nutrition
products as prescribed by the practitioner on the DMAS-116. Orders shall not be
changed unless the DME provider obtains a new DMAS-116 prior to ordering or
providing the enteral nutrition products to the individual.
2. The practitioner's order (DMAS-116) must state that the
enteral nutrition products are the primary source of nutrition for the
individual and specify either a brand name of the enteral nutrition product
being ordered or the category of enteral nutrition products that must be
provided. If a practitioner orders a specific brand of enteral nutrition
product, the DME provider must supply the brand prescribed. The practitioner
order must include the daily caloric order and the route of administration for
the enteral nutrition product. Supporting documentation may be attached to the
DMAS-116 but the entire order must be on the DMAS-116.
3. Enteral nutrition products must be furnished exactly as
ordered by the practitioner on the DMAS-116. The DMAS-116 and any supporting
verifiable documentation must be complete (signed and dated by the
practitioner) and in the DME provider's possession within 60 days from the time
the ordered enteral nutrition product is initially furnished by the DME
provider.
4. The DMAS-116 may be completed by the registered nurse,
registered dietitian, physician, physician assistant, or nurse practitioner,
but it must be signed and dated by the physician.
5. The DMAS-116 must be signed and dated by the assessor and
the practitioner within 60 days of the DMAS-116 begin service date. If the
DMAS-116 is not signed and dated by the assessor and the practitioner within 60
days of the DMAS-116 begin service date, the DMAS-116 will not become valid
until the date of the practitioner's signature.
6. The DMAS-116 must include all of the following elements:
a. Height (or length for pediatric patients);
b. Weight. For initial assessments, indicate the
individual's weight loss over time;
c. Tolerance of enteral nutrition product (e.g., is the
individual experiencing diarrhea, vomiting, constipation). This element is only
required if the individual is already receiving enteral nutrition products;
d. Indication of whether or not the enteral nutrition
product is the primary or sole source of nutrition;
e. Route of administration;
f. The daily caloric order and the number of calories per
package, can, etc.;
g. Extent to which the quantity of the enteral nutrition
product is available through WIC; and
h. Title, signature, and date of the assessor and the
practitioner.
7. The DME provider shall retain a copy of the DMAS-116 and
all supporting verifiable documentation on file for DMAS' post payment review
purposes. DME providers shall not create or revise DMAS-116s or supporting
documentation for this service after the initiation of the post payment review
process. Practitioners shall not complete, or sign and date, DMAS-116s once the
post payment review has begun.
8. DME providers shall retain copies of the DMAS-116 and all
applicable supporting documentation on file for post payment reviews. Enteral nutrition
products that are not ordered on the DMAS-116 for which reimbursement has been
made by Medicaid will be denied. Supporting documentation is allowed to justify
the medical need for enteral nutrition products. Supporting documentation does
not replace the requirement of a properly completed DMAS-116. The dates of the
supporting documentation must coincide with the dates of service on the
DMAS-116 and the medical practitioner providing the supporting documentation
must be identified by name and title. DME providers shall not create or revise
DMAS-116s or supporting documentation for enteral nutrition products provided
after the post payment review has been initiated.
9. To receive reimbursement, the DME provider is expected
to:
a. Deliver only the item or items ordered by the
practitioner and approved by DMAS or the designated preauthorization
contractor;
b. Deliver only the quantities ordered by the practitioner
and approved by DMAS or the designated preauthorization contractor;
c. Deliver only the item or items for the periods of
service covered by the practitioner's order and approved by DMAS or the
designated preauthorization contractor;
d. Maintain a copy of the practitioner's order and all
verifiable supporting documentation for all DME ordered; and
e. Document all supplies provided to an individual in
accordance with the practitioner's orders. The delivery ticket must document
the individual's name and Medicaid number, the date of delivery, what was
delivered, and the quantity delivered.
10. DMAS will deny payment to the DME provider if any of the
following occur:
a. No presence of a current, fully completed DMAS-116
appropriately signed and dated by the practitioner;
b. Documentation does not verify that the item was provided
to the individual;
c. Lack of medical documentation, signed by the
practitioner to justify the enteral nutrition products; or
d. Item is noncovered or does not meet DMAS criteria for
reimbursement.
11. The enteral nutrition product vendor must provide the
supplies as prescribed by the practitioner on the DMAS-116. Orders shall not be
changed unless the vendor obtains a new DMAS-116 prior to ordering or providing
the enteral nutrition product to the individual.
12. Medicaid shall not provide reimbursement to the vendor
for services provided prior to the date prescribed by the practitioner or prior
to the date of the delivery or when services are not provided in accordance
with published policies and procedures. If reimbursement is denied for one of
these reasons, the DME provider may not bill the Medicaid recipient for the
service that was provided.
13. The following criteria must be satisfied through the
submission of adequate and verifiable documentation satisfactory to DMAS.
Medically necessary DME and supplies shall be;
a. Ordered by the practitioner on the DMAS-116;
b. A reasonable and necessary part of the individual's
treatment plan;
c. Consistent with the individual's diagnosis and medical
condition, particularly the functional limitations and symptoms exhibited by
the individual;
d. Not furnished solely for the convenience, safety, or
restraint of the individual, the family, attending practitioner, or other
practitioner or supplier;
e. Consistent with generally accepted professional medical
standards (i.e., not experimental or investigational); and
f. Furnished at a safe, efficacious, and cost-effective
level suitable for use in the individual's home environment.
12VAC30-120-201. Private duty nursing services. (Repealed.)
A. General. Private duty nursing services shall be offered
to individuals enrolled in the HIV/AIDS waiver when such services are deemed necessary
by the attending physician to avoid institutionalization by assessing and
monitoring the medical condition, providing interventions, and communicating
with the physician regarding changes in the individual's status. The hours of
private duty nursing shall be limited by medical necessity. The purpose of
private duty nursing is to provide for ongoing monitoring, continued nursing
supervision, and skilled care. This service should not be authorized when
intermittent skilled nursing visits could be utilized. Private duty nursing
services should not be provided simultaneously with LPN respite care.
B. Special provider participation conditions. To be
approved for private duty nursing contracts with DMAS, the private duty nursing
provider shall:
1. Be a home health agency licensed or certified by the
Virginia Department of Health for Medicaid participation and with which DMAS
has a signed participation agreement for private duty nursing services.
2. Demonstrate prior successful health care delivery.
3. Operate from a business office.
4. Employ (or subcontract with) and directly supervise a
registered nurse or a licensed practical nurse.
a. The registered nurse shall be currently licensed to
practice in the Commonwealth and have at least two years of related clinical
nursing experience, which may include work in an acute care hospital, public
health clinic, home health agency, rehabilitation hospital, nursing facility,
or as an LPN.
b. The LPN shall be currently licensed to practice in the
Commonwealth.
C. Limits to services.
1. Private duty nursing shall be reimbursed for a maximum of
16 hours within a 24-hour period per household.
2. In no instance shall the designated preauthorization
contractor approve an ongoing plan of care or ongoing multiple plans of care
per household that result in approval of more than 16 hours of private duty
nursing in a 24-hour period per household.
3. Congregate private duty nursing. When two waiver
individuals share a residence, there shall be a maximum ratio of one private
duty nurse to two waiver individuals. When three or more waiver individuals
share a residence, ratios will be determined by the combined needs of the
individuals.
D. Provider reimbursement.
1. All private duty nursing services shall be reimbursed at
an hourly rate determined by DMAS.
2. If the AIDS Waiver individual needs skilled nursing and
has another payer (Medicare or private insurance), the skilled nursing must be
covered by the other payer or payers first. Whatever skilled nursing services are
not covered under the primary insurance, Medicaid may cover. There shall be no
duplication of nursing services with other payers or other Medicaid State Plan
services.
3. RN/LPN shall not practice without signed physician orders
specifically identifying skilled tasks to be performed for the individual.
4. The registered nurse shall review the medications and
treatments rendered by the LPN every 60 days and verify the physician's orders.
E. Assessment and plan of care requirements.
1. The case manager shall be responsible for ensuring that
the assessment, care planning, monitoring, and review activities required by
DMAS are accomplished and documented, consistent with DMAS requirements.
2. Development of the plan of care.
a. Upon completion of the required assessments and a
determination that the individual needs substantial and ongoing skilled nursing
care, the hours of nursing service required shall be developed and approved by
the designated preauthorization contractor.
b. At a minimum, the plan of care shall include:
(1) Identification of the type, frequency, and amount of
nursing care needed. This shall include the name of the provider agency,
whether the nurse is an RN or LPN, and verification that the nurse is licensed
to practice in the Commonwealth.
(2) Identification of the type, frequency, and amount of
care that the family or other informal caregivers shall provide.
F. Individual selection of waiver services.
1. The case manager shall give the legally competent
individual, or the individual's legal guardian, or the parent of a minor child,
the choice of waiver services or institutionalization. This choice must be
documented.
2. If waiver services are chosen, the individual applicant
or his legally responsible entity will also be given the opportunity to choose
the providers of services if more than one provider is available to render the
services. This choice must also be documented. If more than one waiver
individual will reside in the home, one waiver provider shall be chosen to provide
all private duty nursing services for all waiver individuals in the home. Only
one nurse will be authorized to care for every two waiver individuals in a
residence. In the instance when more than two waiver individuals share a
residence, nursing ratios will be determined by the designated preauthorization
contractor based on the needs of all the individual living together.
3. The designated preauthorization contractor or DMAS shall
review and approve the assessment and plan of care prior to the individual's
admission to community waiver services, and prior to Medicaid payment for any
services related to the waiver plan of care.
G. Reevaluation requirements and utilization review.
1. The need for reevaluations shall be determined by the
case manager, registered nurse, DMAS, or the designated preauthorization
contractor. Reevaluations shall be conducted by these professionals as required
by the individual's needs and situation and at any time when a change in the
individual's condition indicates the need for reevaluation.
2. Utilization review shall be conducted by DMAS on all
providers to ensure consumer satisfaction, the adherence to state and federal
provider qualifications, and documentation requirements. DMAS will also ensure
the appropriate billing practices for waiver services.
H. Registered nurse supervisory duties.
1. The registered nurse shall make, at a minimum, a visit
every 30 days to the individual's home to assess the individual's/caregiver's
satisfaction with the services being provided.
2. The registered nurse shall review medications and
treatments rendered by the private duty nurse every 60 days and verify orders
with the physician signature.
3. The registered nurse shall review all discharge orders
written upon the individual's discharge from the hospital and provide a copy of
such orders to the private duty nurse rendering care to the individual in his
home.
a. The RN shall make an initial assessment visit prior to
the start of care for any individual admitted to private duty nursing.
b. During visits to the individual's home, the registered
nurse shall observe, evaluate, and document the adequacy and appropriateness of
private duty nursing services with regard to the individual's current
functioning status, medical, and social needs. The individual's or family's
satisfaction with the type and amount of service must be discussed. The
registered nurse shall document in a summary note:
(1) Whether private duty nursing services continue to be
appropriate;
(2) Whether the plan of care is adequate to meet the
individual's needs or if changes need to be made to the plan of care;
(3) The individual's satisfaction with the service;
(4) Any hospitalization or change in the medical condition
or functioning status of the individual; and
(5) Other services received and their amount.
I. Required documentation for individuals' records. The
provider agency shall maintain all records of each individual receiving private
duty nursing. These records shall be separate from those of other nonhome and
community-based care services, such as companion or home health services. These
records shall be reviewed periodically by the DMAS staff who are authorized by
DMAS to review these files during utilization review. At a minimum, the record
shall contain:
1. The most recently updated Long-Term Care Uniform
Assessment Instrument (UAI), documentation of any inpatient hospital
admissions, the Medicaid-Funded Long-Term Care Service Authorization Form
(DMAS-96), the Screening Team Service Plan for Medicaid-Funded Long-Term Care
(DMAS-97), all Home Health Certification and Plans of Care (CMS-485), Skills
Checklist for Private Duty Nursing (DMAS-259), all Patient Information Forms
(DMAS-122) and all signed physician's orders.
2. The initial assessment by the registered nurse completed
prior to or on the date services were initiated.
3. Registered nurses' notes recorded and dated during visits
to the individual's home. The registered nurses' notes shall contain:
a. The specific services delivered to the individual and
the individual's response;
b. Comments or observations about the individual. Comments
shall include but not be limited to observation of the individual's physical
and emotional condition, daily activities, and the individual's response to the
services rendered;
c. The signature by the registered nurse or the licensed
practical nurse and the individual at least once a week to verify that private
duty nursing services have been rendered. This record must be maintained in the
individual's record.
4. All correspondence to the individual, DMAS, and the
designated preauthorization contractor.
5. Reassessments made during the provision of services.
6. Significant contacts made with family, physicians, DMAS,
the designated preauthorization contractor, formal and informal service
providers and all professionals related to the individual's Medicaid services
or medical care.
Copies of all nurses' records shall be subject to review by
state and federal Medicaid representatives.
If an individual who is receiving private duty nursing is
also receiving any other service (meals on wheels, companion, home health
services, etc.), the nurse record shall indicate that these services are also
being received by the individual.
There should be no duplication of nursing services with
other Medicaid State Plan services or payors.