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" or "ADLs" means personal care
tasks such as bathing, dressing, toileting, transferring, and eating/feeding.
An individual's degree of independence in performing these activities is a part
of determining appropriate level of care and service needs.
"Adult day health care " or "ADHC" means long-term
maintenance or supportive services offered by a DMAS-enrolled community-based
day care program providing a variety of health, therapeutic, and social
services designed to meet the specialized needs of those waiver individuals who
are elderly or who have a disability and who are at risk of placement in a
nursing facility (NF). The program shall be licensed by the Virginia Department
of Social Services (VDSS) as an adult day care center (ADCC). The services
offered by the center shall be required by the waiver individual in order to
permit the individual to remain in his home rather than entering a nursing
facility. ADHC can also refer to the center where this service is
provided.
"Agency-directed model of service" means a model of service
delivery where an agency is responsible for providing direct support staff, for
maintaining individuals' records, and for scheduling the dates and times of the
direct support staff's presence in the individuals' homes for personal and
respite care.
"Americans with Disabilities Act" or "ADA" means the United
States Code pursuant to
42 USC §
12101 et seq.
"Annually" means a period of time covering 365 consecutive
calendar days or 366 consecutive days in the case of leap years.
"Appeal" means the process used to challenge actions
regarding services, benefits, and reimbursement provided by Medicaid pursuant
to 12VAC30-110 and
12VAC30-20-500
through
12VAC30-20-560.
"Assistive technology" or "AT" 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 waiver individuals who are participating in the
Money Follows the Person demonstration program pursuant to Part XX
(12VAC30-120-2000
et seq.) 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.
"Barrier crime" means those crimes as defined at §
32.1-162.9:1
of the Code of Virginia that would prohibit the continuation of employment if a
person is found through a Virginia State Police criminal record check to have
been convicted of such a crime.
"CD" means consumer-directed.
"CMS" means the Centers for Medicare and Medicaid Services,
which is the unit of the U.S. Department of Health and Human Services that
administers the Medicare and Medicaid programs.
"Cognitive impairment" means a severe deficit in mental
capability that affects a waiver individual's areas of functioning such as
thought processes, problem solving, judgment, memory, or comprehension 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 attendant" means a person who provides,
via the consumer-directed model of services, personal care, companion services,
or respite care, or any combination of these three services, and who is also
exempt from workers' compensation.
"Consumer-directed (CD) model of service" means the model
of service delivery for which the individual enrolled in the waiver or the
individual's employer of record, as appropriate, is responsible for hiring,
training, supervising, and firing of the attendant or attendants who render the
services that are reimbursed by DMAS.
"Consumer-directed services facilitator," "CD services
facilitator," or "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 services plan of care,
providing attendant management training, and completing ongoing review
activities as required by DMAS for consumer-directed personal care and respite
services.
"DARS" means the Department for Aging and Rehabilitative
Services.
"Day" means, for the purposes of reimbursement, a 24-hour
period beginning at 12 a.m. and ending at 11:59 p.m.
"DBHDS" means the Department of Behavioral Health and
Developmental Services.
"Direct marketing" means any of the following:
(i) conducting either directly or indirectly door-to-door,
telephonic, or other "cold call" marketing of services at residences and
provider sites;
(ii) using direct mailing;
(iii) paying "finders fees";
(iv) offering financial incentives, rewards, gifts, or
special opportunities to eligible individuals or family/caregivers as
inducements to use a provider's services;
(v) providing continuous, periodic marketing activities to
the same prospective individual or family/caregiver, for example, monthly,
quarterly, or annual giveaways as inducements to use a provider's services; or
(vi) engaging in marketing activities that offer potential
customers rebates or discounts in conjunction with the use of a provider's
services or other benefits as a means of influencing the individual's or
family/caregiver's use of a provider's services.
"DMAS" means the Department of Medical Assistance
Services.
"DMAS staff" means persons employed by the Department of
Medical Assistance Services.
"Elderly or Disabled with Consumer Direction Waiver" or
"EDCD Waiver" means the CMS-approved waiver that covers a range of community
support services offered to waiver individuals who are elderly or who have a
disability who would otherwise require a nursing facility level of care.
"Employer of record" or "EOR" means the person who performs
the functions of the employer in the consumer-directed model of service
delivery. The EOR may be the individual enrolled in the waiver, a family
member, caregiver, or another person.
"Environmental modifications" or "EM" means physical
adaptations to an individual's primary home or 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.), which are necessary to ensure
the individual's health and safety or enable functioning with greater
independence and shall be of direct medical or remedial benefit to individuals
who are participating in the Money Follows the Person demonstration program
pursuant to Part XX (12VAC30-120-2000
et seq.). Such physical adaptations shall not be authorized for Medicaid
payment when the adaptation is being used to bring a substandard dwelling up to
minimum habitation standards.
"Fiscal/employer agent" means a state agency or other
entity as determined by DMAS that meets the requirements of
42 CFR
441.484 and the Virginia Public Procurement
Act, §
2.2-4300
et seq. of the Code of Virginia.
"Guardian" means a person appointed by a court to manage
the personal affairs of an incapacitated individual pursuant to Chapter 20
(§
64.2-2000 et seq.) of
Title 64.2 of the Code of Virginia.
"Health, safety, and welfare standard" means, for the
purposes of this waiver, that an individual's right to receive an EDCD Waiver
service is dependent on a determination that the waiver individual needs the
service based on appropriate assessment criteria and a written plan of care,
including having a backup plan of care, that demonstrates medical necessity and
that services can be safely provided in the community or through the model of
care selected by the individual.
"Home and community-based waiver services" or "waiver
services" means the range of community support services approved by the CMS
pursuant to § 1915(c) of the Social Security Act to be offered to
individuals as an alternative to institutionalization.
"Individual" or "waiver individual" means the person who
has applied for and been approved to receive these waiver services.
"Instrumental activities of daily living" or "IADLs" means
tasks such as meal preparation, shopping, housekeeping and laundry. An
individual's degree of independence in performing these activities is a part of
determining appropriate service needs.
"Level of care" or "LOC" means the specification of the
minimum amount of assistance an individual requires in order to receive
services in an institutional setting under the State Plan or to receive waiver
services.
"License" means proof of official or legal permission
issued by the government for an entity or person to perform an activity or
service such that, in the absence of an official license, the entity or person
is debarred from performing the activity or service.
"Licensed Practical Nurse" or "LPN" means a person who is
licensed or holds multi-state licensure to practice nursing pursuant to Chapter
30 (§
54.1-3000 et seq.) of
Title 54.1 of the Code of Virginia.
"Live-in caregiver" means a personal caregiver who resides
in the same household as the individual who is receiving waiver
services.
"Long-term care" or "LTC" means a variety of services that
help individuals with health or personal care needs and activities of daily
living over a period of time. Long-term care can be provided in the home, in
the community, or in various types of facilities, including nursing facilities
and assisted living facilities.
"Medicaid Long-Term Care (LTC) Communication Form" or
"DMAS-225" means the form used by the long-term care provider to report
information about changes in an individual's eligibility and financial
circumstances.
"Medication monitoring" means an electronic device, which
is only available in conjunction with Personal Emergency Response Systems, that
enables certain waiver individuals who are at risk of institutionalization to
be reminded to take their medications at the correct dosages and times.
"Money Follows the Person" or "MFP" means the demonstration
program, as set out in
12VAC30-120-2000
and
12VAC30-120-2010.
"Participating provider" or "provider" means an entity that
meets the standards and requirements set forth by DMAS and has a current,
signed provider participation agreement, including managed care organizations,
with DMAS.
"Patient pay amount" means the portion of the individual's
income that must be paid as his share of the long-term care services and is
calculated by the local department of social services based on the individual's
documented monthly income and permitted deductions.
"Personal care agency" means a participating provider that
provides personal care services.
"Personal care aide" or "aide" means a person employed by
an agency who provides personal care or unskilled respite services. The aide
shall have successfully completed an educational curriculum of at least 40
hours of study related to the needs of individuals who are either elderly or
who have disabilities as further set out in
12VAC30-120-935.
Such successful completion may be evidenced by the existence of a certificate
of completion, which is provided to DMAS during provider audits, issued by the
training entity.
"Personal care attendant" or "attendant" means a person who
provides personal care or respite services that are directed by a consumer,
family member/caregiver, or employer of record under the CD model of service
delivery.
"Personal care services" means a range of support services
necessary to enable the waiver individual to remain at or return home rather
than enter a nursing facility and that includes assistance with activities of
daily living (ADLs), instrumental activities of daily living (IADLs), access to
the community, self-administration of medication, or other medical needs,
supervision, and the monitoring of health status and physical condition.
Personal care services shall be provided by aides, within the scope of their
licenses/certificates, as appropriate, under the agency-directed model or by
personal care attendants under the CD model of service delivery.
"Personal emergency response system" or "PERS" means an
electronic device and monitoring service that enables certain waiver
individuals, who are at least 14 years of age, at risk of institutionalization
to secure help in an emergency. PERS services shall be limited to those waiver
individuals who live alone or who are alone for significant parts of the day
and who have no regular caregiver for extended periods of time.
"PERS provider" means a certified home health or a personal
care agency, a durable medical equipment provider, a hospital, or a PERS
manufacturer that has the responsibility to furnish, install, maintain, test,
monitor, and service PERS equipment, direct services (i.e., installation,
equipment maintenance, and services calls), and PERS monitoring. PERS providers
may also provide medication monitoring.
"Plan of care" or "POC" means the written plan developed
collaboratively by the waiver individual and the waiver individual's
family/caregiver, as appropriate, and the provider related solely to the
specific services necessary for the individual to remain in the community while
ensuring his health, safety, and welfare.
"Preadmission screening" means the process to (i) evaluate
the functional, nursing, and social supports of individuals referred for
preadmission screening for certain long-term care services requiring NF
eligibility; (ii) assist individuals in determining what specific services the
individual needs; (iii) evaluate whether a service or a combination of existing
community services are available to meet individual needs; and (iv) provide a
list to individuals of appropriate providers for Medicaid-funded nursing
facility or home and community-based care for those individuals who meet
nursing facility level of care.
"Preadmission Screening Team" means the entity contracted
with DMAS that is responsible for performing preadmission screening pursuant to
§
32.1-330
of the Code of Virginia.
"Primary caregiver" means the person who consistently
assumes the primary role of providing direct care and support of the waiver
individual to live successfully in the community without receiving compensation
for providing such care. Such person's name, if applicable, shall be documented
by the RN or services facilitator in the waiver individual's record. Waiver
individuals are not required to have a primary caregiver in order to
participate in the EDCD waiver.
"Registered nurse" or "RN" means a person who is licensed
or who holds multi-state licensure privilege pursuant to Chapter 30 (§
54.1-3000 et seq.) of
Title 54.1 of the Code of Virginia to practice nursing.
"Respite care agency" means a participating provider that
renders respite services.
"Respite services" means services provided to waiver
individuals who are unable to care for themselves that are furnished on a
short-term basis because of the absence of or need for the relief of the unpaid
primary caregiver who normally provides the care.
"Service authorization" or "Srv Auth" means the process of
approving either by DMAS, its service authorization contractor, or
DMAS-designated entity, for the purposes of reimbursement for a service for the
individual before it is rendered or reimbursed.
"Service authorization contractor" means DMAS or the entity
that has been contracted by DMAS to perform service authorization for medically
necessary Medicaid covered home and community-based services.
"Services facilitation" means a service that assists the
waiver individual (or family/caregiver, as appropriate) in directing, training,
and managing services provided through the consumer-directed model of
service.
"Services facilitator" means a DMAS-enrolled provider, a
DMAS-designated entity, or a person who is employed or contracted by a
DMAS-enrolled services facilitator that is responsible for supporting the
individual and the individual's family/caregiver or EOR, as appropriate, by
ensuring the development and monitoring of the CD services plans of care,
providing employee management training, and completing ongoing review
activities as required by DMAS for consumer-directed personal care and respite
services. Services facilitator shall be deemed to mean the same thing as
consumer-directed services facilitator.
"Skilled respite services" means temporary skilled nursing
services that are provided to waiver individuals who need such services and
that are performed by a LPN for the relief of the unpaid primary caregiver who
normally provides the care.
"State Plan for Medical Assistance" or "State Plan" means
the Commonwealth's legal document approved by CMS identifying the covered
groups, covered services and their limitations, and provider reimbursement
methodologies as provided for under Title XIX of the Social Security
Act.
"Transition coordinator" means the person defined in
12VAC30-120-2000
who facilitates MFP transition.
"Transition services" means set-up expenses for individuals
as defined at
12VAC30-120-2010.
"VDH" means the Virginia Department of Health.
"VDSS" means the Virginia Department of Social
Services.
"Virginia Uniform Assessment Instrument" or "UAI" means the
standardized multidimensional comprehensive assessment that is completed by the
Preadmission Screening Team or approved hospital discharge planner that
assesses an individual's physical health, mental health, and psycho/social and
functional abilities to determine if the individual meets the nursing facility
level of care.
"Weekly" means a span of time covering seven consecutive
calendar days.
