12 VAC 30-120-1010     INDIVIDUAL ELIGIBILITY REQUIREMENTS

1010 (informed consent)

Recommendation

The regulation should include specifics regarding when and how informed consent is required before services are provided or revised. Terminology relating to consent throughout the regulations should be changed to “informed” consent.

1010 C.4. (waiting list – written notice)

The waiting list process is improved with the proposed regulatory language. Requiring written notice when someone is placed on the waiting list is important because it lets the individual and case manager know where the individual is in the process.

1010 C.4. (enrollment)

Recommendation

Establish a timeline for DBHDS to respond to a request by the case manager to enroll an individual in the ID Waiver.

1010 C.4. (annual waiting list contact)

Recommendation

The proposed regulation will require case managers to annually contact individuals on the waiting list to provide a choice between ICF/DD and the ID Waiver. This annual contact is important.  We recommend that in addition to providing annual choice, the case manager should be required to assess the individual’s current needs and their placement status on the urgent or nonurgent list.

Rationale

Without current information, case managers cannot adequately determine if someone has an urgent need or the extent of an urgent need.

1010 C.4. (waiting list written notification)

Recommendation

Add a requirement that written notification be provided to the individual if their waiting list status is changed from urgent to nonurgent or nonurgent to urgent.

1010 D.3.a. (medical examination)

Recommendation

If an individual does not have Medicaid or private insurance, a medical examination should not be required until the individual is enrolled in Medicaid and adequate time is provided to schedule the exam and for the provider to write the examination report.

Rationale

Individuals should not be required to pay for requirements established by DMAS in order to receive Medicaid services. If the individual is not enrolled in Medicaid prior to waiver enrollment or if the individual’s private insurance requires a deductible that has not yet been met or a co-payment, the requirement for a medical examination should be delayed until the individual is enrolled in Medicaid.

1010 D.5. (patient pay)

Recommendation

If the designated collector of patient pay is the employer of record (EOR) for consumer-directed services, the case manager should be required to periodically monitor for changes in patient pay. If there are changes in patient pay, the case manager should notify the EOR.

Rationale

The EOR does not have access to the DMAS system and cannot monitor for changes in patient pay. The EOR depends on the case manager to inform him or her of any change to the patient pay.

1010 E.1.a. (informed consent for services)

Recommendation

Include a statement that the individual’s initial plan for services requires an agreement in writing by the individual (informed consent).

1010 E.1.c. (informed consent for services)

Recommendation

Include a statement that any modifications to the amount or type of services requires an agreement in writing by the individual (informed consent).