Current through Register Vol.. 38, No. 17, April 11, 2022
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
individual/caregiver will confirm acceptance or declination of the slot within
15 calendar days of notification of slot availability.
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.
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
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.
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
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
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
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.