12 Va. Admin. Code § 30-120-905

Current through Register Vol. 41, No. 6, November 4, 2024

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

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

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

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

D. DMAS shall be the single state agency authority, pursuant to 42 CFR 431.10, responsible for the processing and payment of claims for the services covered in this waiver and for obtaining federal financial participation from CMS.

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

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

G. DMAS shall be responsible for the following:

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

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

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

4. Ensuring providers meet the following requirements:

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

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

H. DMAS or the designated service authorization contractor or managed care organization shall have the responsibility and the authority to terminate the receipt of home and community-based waiver enrollment for the waiver individual for any of the following reasons. Individuals shall be notified of their appeal rights pursuant to 12VAC30-110:

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

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

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

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

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

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

12 Va. Admin. Code § 30-120-905

Derived From Virginia Register Volume 31, Issue 010, eff. 2/12/2015; Amended, Virginia Register Volume 40, Issue 20, eff. 6/19/2024.

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