Preliminary Draft Text
Part VII
Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in
Adult Care Residences
12VAC30-120-450. Definitions. (Repealed.)
The following words and terms, when used in this part, shall
have the following meanings unless the context clearly indicates otherwise:
"Activities of daily living (ADLs)" means
bathing, dressing, toileting, transferring, bowel control, bladder control, and
eating/feeding. A person's degree of independence in performing these
activities is a part of determining appropriate level of care and services.
"Assessor" means a case manager employed by a
public human service agency or other qualified assessor which has a contract
with the Department of Medical Assistance Services to perform assessments and
authorize service in an adult care residence.
"Assisted living facility" or
"facility" means an adult care residence which has been licensed by
the Department of Social Services to provide a level of service for adults who
may have physical or mental impairments and require at least moderate
assistance with the activities of daily living. Within assisted living, there
are two payment levels for recipients of an auxiliary grant: regular assisted
living and intensive assisted living.
"Auxiliary Grants Program" means a state and
locally funded assistance program to supplement the income of a Supplemental
Security Income (SSI) recipient or adult who would be eligible for SSI except
for excess income and who resides in a licensed adult care residence.
"Case management agency" means a public human
service agency having a contract with DMAS to provide case management services
to any adult care residence recipient who meets the criteria set forth in
Attachment 3.1, Supplement 2 of the State Plan for Medical Assistance
(12VAC30-50-470) and which employs or contracts for case management.
"Case manager" means an employee of a public
human service agency who is qualified and designated to authorize service in an
adult care residence and to perform case management functions, such as the
development, implementation, coordination and monitoring of plans of care and
completion of the annual reassessment.
"DMAS" or "department" means the
Department of Medical Assistance Services.
"DSS" means the Department of Social Services.
"General relief" means money payments and other
forms of relief made to eligible persons as established by the local department
of social services board in accordance with the rules and regulations of the
State Board of Social Services. For purposes of this part, these recipients
must reside in a public home for adults in Waynesboro and Manassas.
"Instrumental activities of daily living (IADLS)"
means meal preparation, housekeeping, laundry, and money management. A person's
degree of independence in performing these activities is a part of determining
appropriate level of care and services.
"Individualized service plan" means the written
description of actions to be taken by the assisted living facility to meet the
assessed needs of the resident. "Intensive assisted living services"
means services provided under the Social Security Act, § 1915(c) waiver
program, to persons who have dependencies in at least four ADLs, or who have a
combination of dependencies in two or more ADLs and are rated as semi-dependent
or dependent in a combination of behavior and orientation.
"Licensed health care professional" means a
health care professional as defined by § 32.1-162.7 of the Code of Virginia.
"Moderate assistance" means dependency in two or
more of the activities of daily living as documented on the uniform assessment
instrument. Included in this level of service are recipients who are dependent
in behavior pattern (i.e., the recipient exhibits acts detrimental to the life,
comfort, safety or property of the recipient or others).
"Qualified assessor" means an entity contracting
with DMAS to perform nursing facility preadmission screening or to complete the
uniform assessment instrument for a home-based and community-based waiver
program, including an independent physician contracting with DMAS to complete
the uniform assessment instrument for applicants to adult care residences, or
any hospital which has contracted with DMAS to perform nursing facility
preadmission screenings. Qualified assessors may only perform the initial
assessment or assessments for changes in level of care. Qualified assessors
will not have a contract with DMAS to provide case management services for
adult care residence recipients which includes the annual reassessment.
"Regular assisted living services" means a level
of services provided by licensed adult care residences to persons who have
dependencies in two ADLs or behavior but who do not meet the criteria for
intensive assisted living.
"Uniform assessment instrument (UAI)" means the
department-designated assessment form.
12VAC30-120-460. General coverage and requirements for
assisted living services. (Repealed.)
A. Service populations. Two levels of assisted living,
regular and intensive assisted living, shall be available to individuals
eligible for an auxiliary grant who require assistance in activities of daily
living and instrumental activities of daily living, which are above the room,
board, and supervision provided by the adult care residence as reimbursed by an
auxiliary grant program. Regular assisted living only shall be available to
individuals eligible for general relief payments residing in public homes for
adults in Waynesboro and Manassas and who meet the program criteria. The
individual shall be classified into one of these two levels by the assessor
responsible for completing the UAI and authorization of admissions to the adult
care residence.
Coverage shall be provided under a state-funded program for
individuals who have been determined to require regular assisted living
services.
Coverage shall be provided under a waiver of § 1915(c) of
the Social Security Act for individuals who have been determined to require
intensive assisted living services. This coverage is not available to general
relief recipients.
B. Covered services. DMAS shall pay the facility a per diem
fee for each recipient authorized to receive assisted living services, based on
whether the recipient is authorized for regular or intensive assisted living.
Payment of the per diem fee is limited to the days in which the recipient is
physically present in the facility.
The facility shall employ or contract with staff who will
provide hands-on assistance or supervision with ADLs and IADLs to recipients
according to the individual service plan. This plan shall be developed by the
facility in accordance with the current needs of the recipient and as specified
in 22VAC40-71-170 of the Standards and Regulations for Licensed Adult Care
Residences.
The facility shall retain a licensed health care
professional as specified in 22VAC40-71-630 J of the Standards and Regulations
for Licensed Adult Care Residences except that the records maintained by the
facility shall document that the care needs for auxiliary grant recipients
authorized to receive intensive assisted living services have been reviewed
during an onsite visit at least monthly by a licensed health care professional.
The licensed health care professional shall, as appropriate, participate in the
development and monitoring of an individualized service plan to meet the resident's
service needs.
C. Eligibility requirements. Individuals authorized to
receive optional state supplement (auxiliary grant) payments and who meet the
criteria for regular or intensive assisted living shall be eligible.
Individuals authorized to receive optional general relief
payments, who meet the criteria for regular assisted living, and who reside in
public homes for adults in Waynesboro and Manassas shall be eligible.
The department's payment for either regular or intensive
assisted living services shall not be reduced by any payment from the
individual's income.
The requirements related to spousal income and resource
allowances found in § 1924 of the Social Security Act do not apply to those
individuals receiving intensive assisted living services under a waiver of §
1915(c) of the Social Security Act.
D. Assessment and authorization of regular or intensive
assisted living services.
1. The assessor shall evaluate the individual's functional
and medical needs and authorize services to meet those needs pursuant to this
part.
2. The assessment shall be completed using the UAI, and
authorization for care shall be made based on the following criteria:
a. Regular assisted living. The individual must be
dependent in two ADLs or dependent in behavior. The rating of functional
dependencies shall be as specified in 22VAC40-745-70 of the Assessment in Adult
Care Residences regulations.
b. Intensive assisted living. The individual must be
determined to be at risk of nursing facility placement in the absence of
home-based and community-based waiver services such as those provided in an
assisted living facility and the individual's functional capacity is described
by one of the following. The rating of functional dependencies shall be as
specified in 12VAC30-60-300 of the State Plan for Medical Assistance (§ 1.1 of
Supplement 1 to Attachment 3.1 C:)
(1) Dependent in four or more ADLs;
(2) Dependent in two or more ADLs and has dependencies or
semidependencies in a combination of behavior and orientation; or
(3) Semidependent in two or more ADLs and has dependencies
in a combination of behavior and orientation.
3. Payment for regular and intensive assisted living
services shall only be available for recipients residing in a licensed assisted
living facility which has a valid DMAS provider agreement.
4. The assessor shall notify DSS eligibility personnel, upon
completion of the UAI, that the recipient has been authorized for regular or
intensive assisted living services and shall forward the UAI and authorization
forms to DMAS, the facility chosen by the recipient and to the case manager, if
case management services have been authorized.
5. The assessor shall give all recipients who have been
denied assisted living services written notification that services have been
denied and give the recipient the right to appeal the decision pursuant to DMAS
Client Appeals Regulations (Part I of 12VAC30-110-10 et seq.). The assessor
shall submit to DMAS the UAI, authorization form, and a copy of the
notification showing denial of services before reimbursement for the assessment
shall be made.
6. The assisted living facility shall forward a copy of the
Long-Term Care Preadmission Screening Authorization form, completed by the
assessor, and the individualized service plan, completed by the facility, to
DMAS for authorization to bill DMAS for regular assisted or intensive assisted
living services.
7. A recipient may not receive regular or intensive assisted
living services concurrently with any other Medicaid-funded in-home or
residential support waiver services authorized under § 1915(c) of the Social
Security Act.
8. All authorizations and individualized service plans for
assisted living services shall be subject to the approval of DMAS prior to
Medicaid payment.
E. Effective date for assisted living payments.
1. DMAS shall pay the facility for services rendered while
the recipient is both (i) determined, in accordance with regulations
promulgated by DSS, to be eligible for benefits under the auxiliary grants or
general relief program and (ii) authorized for a level of assisted living.
2. The assisted living authorization shall be considered
effective as of the date the authorization form is signed and dated, except in
the following situations:
a. In the case of an emergency placement as defined in
regulations promulgated by DSS, the assisted living authorization shall be
considered effective as of the date of the emergency placement, provided that
the authorization form is signed and dated within seven working days after the
date of the emergency placement.
b. In the case of recipients residing in a facility on
February 1, 1996, and requiring an initial assessment, the assisted living
authorization shall be considered effective, as follows: (i) August 1, 1996, provided
that the authorization form is signed and dated on or before August 1, 1996; or
(ii) as of whichever date on or after August 1, 1996, can be documented as
being the date the recipient required a level of assisted living provided that
the authorization form is signed and dated on or before February 1, 1997.
3. In addition to the requirements of subdivisions 1 and 2
of this subsection, in order for assisted living payments to be made to a
facility, the assisted living authorization shall be based on a UAI which
complies with the requirements of § 63.1-173.3 of the Code of Virginia.
12VAC30-120-470. Conditions and requirements for
participating assisted living facilities. (Repealed.)
A. General requirements. Facilities approved for
participation shall, at a minimum, perform the following activities:
1. Immediately notify DMAS, in writing, of any changes in
the level of care authorized and the individualized service plan which the
facility previously submitted to DMAS.
2. Ensure freedom of choice to recipients in seeking medical
care from any institution, pharmacy, practitioner, or other facility qualified
to perform the service or services required and participating in the Medicaid
program at the time the service or services are performed.
3. Ensure the recipient's freedom to reject medical care and
treatment.
4. Accept referrals for services only when staff is
available to deliver the required services.
5. Provide services and supplies to recipients in the same
quality and mode of delivery as provided to the general public.
6. Charge DMAS for the provision of services to recipients
in amounts not to exceed the facility's usual and customary charges to the
general public.
7. Accept DMAS payment from the first day of the recipient's
eligibility.
8. Accept as payment in full the amount established by DMAS.
9. Use program-designated billing forms for submission of
charges.
10. Record maintenance and retention requirements.
a. The facility agrees to maintain and keep adequate and
verifiable information and records as is necessary to:
(1) Identify and disclose the extent of services, as
identified on the uniform assessment instrument, the facility furnishes to
recipients;
(2) Comply with the disclosure requirements of Subpart B of
42 CFR Part 455;
(3) Assure proper payment by the DMAS;
(4) Receive payments under the Medicaid program;
(5) Satisfy or secure overpayments, or both, made under the
Medicaid program; and
(6) Survive any termination of the provider participation
agreement.
b. The facility agrees to furnish the information required
to be maintained to the DMAS, the Attorney General of Virginia or his
authorized representatives, or the state Medicaid Fraud Control Unit on request
and in the form requested. This right of access to facilities and records shall
survive any termination of this agreement.
c. Records shall be retained for at least five years from
the last date of service or as provided by applicable 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
adjustment, retraction, exception and appeal is resolved.
d. In the event a facility discontinues operation, DMAS
shall be notified in writing of the location and procedures for obtaining
stored records for review. The location, agent, or trustee shall be within the Commonwealth of Virginia.
11. Disclose all financial, beneficial, ownership, equity,
surety, or other interests it has 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 Medicaid recipients.
12. Hold confidential and use only for authorized DMAS
purposes all medical and identifying information regarding recipients served.
13. When ownership of the facility changes, DMAS shall be
notified within 15 calendar days of such change. A new DMAS provider agreement
shall be required.
B. Requests for participation. Requests for participation
must be accompanied with verification of the facility's current licensure from
DSS.
C. Facility participation standards. DMAS will contract
only with adult care residences licensed to provide assisted living services.
D. Adherence to facility contract and special participation
conditions. All adult care residences contracting with DMAS must be in
compliance with the DSS licensure requirements for assisted living facilities
(22VAC40-71-10 et seq.).
E. Choice of facilities. Recipients eligible for intensive
assisted living services shall be informed at the time of the assessment of all
available assisted living facilities in the community and shall have the option
of selecting the facility.
F. Appeals of adverse actions.
1. A facility shall have the right to appeal adverse action taken
against it by DMAS. Adverse action includes, but is not limited to, termination
of the provider agreement by DMAS, and retraction of payments from the facility
by DMAS for noncompliance with applicable law, regulation, policy or procedure.
2. A facility shall not have the right to appeal to DMAS the
following:
a. The criteria for regular assisted living services or for
intensive assisted living services;
b. The assignment or nonassignment of a recipient to a
particular level of assisted living; or
c. The methodology for calculating the per diem fee paid
for regular or intensive assisted living services.
3. Appeals procedure. The administrative appeals procedure
shall consist of the following three phases:
a. A reconsideration of the preliminary findings and a
written response to the facility by the DMAS division which made the
preliminary findings;
b. An informal fact-finding conference held in accordance
with the Administrative Process Act with a written decision issued by the
Appeals Division; and
c. A formal evidentiary hearing held in accordance with the
Administrative Process Act (§ 9-6.14:1 et seq. of the Code of Virginia) with a
written decision issued by the DMAS Director.
4. Time frames to request appeals. The facility shall have
15 days from the date of service of the notification of adverse action to
request a reconsideration, 30 days from the date of service of the written
reconsideration to request an informal fact-finding conference, and 30 days
from the date of service of the written informal fact-finding conference
decision to request a formal evidentiary hearing. The date of service shall be
deemed to be the earlier to occur of the date the notification, reconsideration
or decision (i) was mailed to the facility, or (ii) was received by the
facility. In the event the notification, reconsideration or decision being
appealed was served on the facility by mail, three days shall be added to the
applicable 15-day or 30-day period.
G. Responsibility for sharing information. It shall be the
facility's responsibility to notify the case manager, DMAS, and DSS in writing
within 30 days, or within the time frame of applicable DSS regulations,
whichever is shorter, of the occurrence of any of the following circumstances:
1. There is a change in the recipient's functional or
cognitive ability which would require a change in the authorized level of care.
Temporary changes in a recipient's condition that can be reasonably expected to
last less than 30 days do not require a new assessment, authorization, or
notification;
2. A recipient dies;
3. A recipient is discharged from the facility; or
4. Other circumstances arise (including hospitalizations)
which cause services to cease or be interrupted for more than 30 days.
H. Changes or termination of care. It shall be the
assessor's responsibility to authorize changes to a recipient's level of care
or to terminate payment for services.
1. The assessor shall communicate in writing to the facility
and the recipient any change in level of care or any termination of services.
The recipient shall be notified of the right to request a reconsideration by
DMAS of any decision that changes the level of care authorized or terminates
regular assisted living or intensive assisted living services.
2. If a reconsideration is requested by the recipient, DMAS
will review the assessor's recommendation and respond to the individual in
writing within 10 days of receipt of the request. If the assessor's decision is
upheld, DMAS shall give the recipient the right to appeal the decision pursuant
to DMAS' Client Appeals Regulations (Part I of 12VAC30-110-10 et seq.).
3. The effective date of a termination or change in level of
services shall be at least 10 days from the date of the notification letter.
I. Suspected abuse or neglect. Pursuant to § 63.1-55.3 of
the Code of Virginia, if a participating facility, qualified assessor, or case
management agency knows or suspects, or has reason to suspect, that a recipient
is being abused, neglected, or exploited, the party having knowledge or
suspicion of the abuse/neglect/exploitation shall report this to the local DSS'
adult protective services of the county or city wherein the adult resides or
wherein the abuse, neglect or exploitation is believed to have occurred.
J. Monitoring of adherence to facility participation
standards. The Department of Social Services' Division of Licensing shall be
responsible for monitoring each assisted living facility's adherence to
licensure standards which provide the basis for DMAS provider participation
standards. In addition, DMAS shall periodically conduct audits of the services
billed to DMAS and interview recipients to ensure that services are being
provided and billed in accordance with DMAS policies and procedures. A
facility's noncompliance with DMAS policies and procedures shall result in a
written request from DMAS for a corrective action plan which details the steps
the facility must take and the length of time permitted to achieve full
compliance with DMAS regulations, policies and procedures.
12VAC30-120-480. Reevaluation of service need and utilization
review. (Repealed.)
A. The case manager shall be responsible for review of each
regular assisted living or intensive assisted living recipient's need for services
at least every 12 months, or more frequently as required, to ensure proper
utilization of services. The outcome of this review shall be communicated to
the DSS eligibility staff, DMAS, the recipient, and the facility where the
resident resides.
B. The assisted living facility shall be required to
maintain the following documentation for review by the case manager and DMAS
staff for each regular assisted living or intensive assisted living resident:
1. All UAIs, authorization forms, and individualized service
plans completed for the recipient maintained for a period not less than five
years from the recipient's start of care in that facility.
2. All written communication related to the provision of
care between the facility and the assessor, case manager, licensed health care
professional, DMAS, DSS, the recipient, or other related parties.
3. A log which documents each day that the recipient is
present in the facility.