12 Va. Admin. Code § 30-122-80

Current through Register Vol. 41, No. 4, October 8, 2024

Section 12VAC30-122-80 - Waiver approval process; authorizing and accessing services

A. The support coordinator is notified that a slot is available when the regional supports specialist (RSS) moves the individual to projected enrollment status in the Virginia Waiver Management System (WaMS). The support coordinator shall notify the individual and family/caregiver of slot availability and available services within the offered waiver within seven calendar days of the waiver slot assignment date.

B. The individual/caregiver will confirm acceptance or declination of the slot within 15 calendar days of notification of slot availability.

C. The individual and the individual's family/caregiver, as appropriate, shall meet with the support coordinator within 30 calendar days of the waiver assignment date to (i) discuss the individual's assessed needs, existing supports, and individual preferences; (ii) discuss obtaining a medical examination, which shall have been completed no earlier than 12 months prior to the initiation of waiver services; (iii) begin to develop the personal profile; and (iv) discuss the completion of the assessment as required by 12VAC30-122-200.

D. Prior to or at the meeting to discuss the individual's assessed needs, the support coordinator shall provide the individual with a choice of services identified as needed and available in the assigned waiver, providers, and settings alternatives.

E. After the individual has accepted the waiver slot offered by the CSB or BHA, the support coordinator shall submit a DMAS-225 (Medicaid Long-Term Care Communication Form) along with a computer-generated confirmation of level-of-care eligibility to the local department of social services to determine financial eligibility for Medicaid and the waiver and any patient pay responsibilities. The DMAS-225 is the form used by the support coordinator to report information about patient pay amount changes in an individual's situation.

F. After the support coordinator has received written notification of Medicaid eligibility from the local department of social services, the support coordinator shall inform the individual, submit information to DMAS or its designee to enroll the individual in the waiver, and develop the person-centered individual support plan (ISP).

G. Once the providers are chosen, a planning meeting shall be held by the support coordinator to develop the ISP based on the individual's assessed needs, the individual's preferences, and the individual's family/caregiver preferences, as appropriate.

H. Persons invited by the support coordinator to participate in the person-centered planning meeting may include the individual, providers, and others as desired by the individual. During the person-centered planning meeting, the services to be rendered to the individual, the frequency of services, the type of provider, and a description of the services to be offered are identified and included in the ISP. At a minimum, the individual enrolled in the waiver, and the family/caregiver as appropriate, and support coordinator shall sign and date the ISP.

I. The individual, family/caregiver, or support coordinator shall contact chosen providers so that services can be initiated within 30 calendar days of the support coordinator moving the individual to active enrollment status in WaMS or confirmation of Medicaid eligibility whichever comes last. If the services are not initiated by the provider within 30 days, the support coordinator shall notify the local department of social services so that reevaluation of the individual's financial eligibility can be made.

J. In the event services are not initiated within 30 calendar days and the individual wishes to retain the waiver slot, the support coordinator will electronically submit a request in WaMS to retain the designated slot pending the initiation of services.

1. A copy of the request shall be provided to the individual and the individual's family/caregiver, as appropriate.

2. After receipt and approval of the first request to retain the slot, DBHDS shall have the authority to approve the slot-retention request in 30-day extensions, up to a maximum of four consecutive extensions, or deny such request to retain the waiver slot for the individual when at the end of each extension time period there is no evidence of the individual's efforts to utilize waiver services. All written denial notifications to the individual, and family/caregiver, as appropriate, shall be accompanied by the standard appeal rights (12VAC30-110).

3. DBHDS shall provide an electronic response to the support coordinator indicating denial or approval of the slot extension request within 10 working days of the receipt of the request for extension.

4. The support coordinator shall notify the individual in writing of any denial of the slot extension request and the individual's right to appeal.

K. The providers, in conjunction with the individual and the individual's family/caregiver, as appropriate, and the support coordinator shall develop a plan for supports for each service.

1. Each provider shall submit a copy of his plan for supports to the support coordinator. The plan for supports from each provider shall be incorporated into the ISP. The ISP shall also contain the identified risks and the steps for mitigating any identified risks.

2. The support coordinator shall review and ensure the provider-specific plan for supports meets the established service criteria for the identified needs prior to electronically submitting the plan for supports along with the results of the comprehensive assessment and a recommendation for the final determination of the need for ICF/IID level of care to DMAS or its designee for service authorization. "Comprehensive assessment" means the gathering of relevant social, psychological, medical, and level of care information by the support coordinator that are used as bases for the development of the individual support plan.

3. DMAS or its designee shall, within 10 working days of receiving all supporting documentation, review and approve, suspend for more information, or deny the individual service requests. DMAS or its designee shall communicate electronically to the support coordinator whether the recommended services have been approved and the amounts and types of services authorized or if any services have been denied.

4. Only waiver services authorized on the ISP by the state-designated agency or its designee shall be reimbursed by DMAS.

L. DMAS shall not pay for any home and community-based waiver services delivered prior to the authorization date approved by DMAS or its designee if service authorization is required.

M. Waiver services shall be approved and authorized by DMAS or its designee only if:

1. The individual is Medicaid eligible as determined by the local department of social services;

2. The individual has a diagnosis of developmental disability, as defined by § 37.2-100 of the Code of Virginia, and would, in the absence of waiver services, require the level of care provided in an ICF/IID that would be reimbursed under the State Plan for Medical Assistance;

3. The individual's ISP can be safely rendered in the community; and

4. The contents of providers' plans for supports are consistent with the ISP requirements, limitation, units, and documentation requirements of each service.

12 Va. Admin. Code § 30-122-80

Derived from Virginia Register Volume 37, Issue 14, eff. 3/31/2021.

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