12 Va. Admin. Code § 30-60-302

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

Section 12VAC30-60-302 - Access to Mdicaid-funded long-term services and supports

A. Medicaid-funded long-term services and supports (LTSS) may be provided in either home and community-based or institutional-based settings. To receive LTSS, the individual's condition shall first be evaluated using the designated assessment instrument, the Uniform Assessment Instrument (UAI), and other DMAS-designated forms. Screening entities shall also use the DMAS-designated forms (DMAS-95, DMAS-96, DMAS-97) and if selecting nursing facility placement, the DMAS-95 Level I (MI/IDD/RC), as appropriate, the DMAS-108, and the DMAS-109. If indicated by the DMAS-95 Level I results, the individual shall be referred to DBHDS for completion of the DMAS-95 Level II (for nursing facility placements only).

1. An individual's need for LTSS shall meet the established criteria (12VAC30-60-303) before any authorization for reimbursement by Medicaid or its designee is made for LTSS.

2. Appropriate home and community-based services shall be evaluated as an option for long-term services and supports prior to consideration of nursing facility placement.

B. The evaluation shall be the screening as designated in § 32.1-330 of the Code of Virginia, which shall preauthorize a continuum of LTSS covered by Medicaid. These screenings shall be conducted face to face.

1. Such screenings, using the UAI, shall be conducted by teams of representatives of (i) hospitals for individuals (adults and children) who are inpatients; (ii) local departments of social services and local health departments, known herein as CBTs, for adults residing in the community and who are not inpatients; (iii) a DMAS designee for children residing in the community who are not inpatients; and (iv) a DMAS designee for adults residing in the community who are not inpatients and who cannot be screened by the CBT within 30 days of the request date. All of these entities shall be contracted with DMAS to perform this activity and be reimbursed by DMAS.

2. All screenings shall be comprehensive, accurate, standardized, and reproducible evaluations of individual functional capacities, medical or nursing needs, and whether the individual is at risk for institutional placement within 30 days of the screening.

C. Individuals shall not be required to be financially eligible for receipt of Medicaid or have submitted an application for Medicaid in order to be screened for LTSS for admission to either a NF or home and community-based services.

D. Pursuant to § 32.1-330 of the Code of Virginia, individuals shall be screened if they are financially eligible for Medicaid or are anticipated to become financially eligible for Medicaid reimbursement of their NF care within six months of NF admission or Medicaid reimbursement of home and community-based services and supports.

E. Special circumstances.

1. Private pay individuals who will not become financially eligible for Medicaid within six months from admission to a Virginia nursing facility shall not be required to have a screening in order to be admitted to the NF.

2. Individuals who reside out of state and seek direct admission to a Virginia nursing facility shall not be required to have a screening. Individuals who need a screening for HCBS waiver or PACE programs and request the screening shall be screened by the CBT or DMAS designee, as appropriate, serving the locality in which the individual resides once the individual has relocated to the Commonwealth.

3. Individuals who are inpatients in an out-of-state hospital, in-state or out-of-state veteran's hospital, or in-state or out-of-state military hospital and seek direct admission to a Virginia NF shall not be required to have a screening. Individuals who need a screening for HCBS waiver or PACE programs and request the screening shall be referred, upon discharge from one of the identified facilities, to the CBT or DMAS designee, as appropriate, serving the locality in which the individual resides once the individual has relocated to the Commonwealth.

4. Individuals who are patients or residents of a state owned or operated facility that is licensed by DBHDS and seek direct admission to a Virginia NF shall not be required to have a screening. Individuals who need a screening for HCBS waiver or PACE and request the screening shall be referred, upon discharge from the facility, to the CBT or DMAS designee, as appropriate, serving the locality in which the individual resides.

5. A screening shall not be required for enrollment in Medicaid hospice services as set out in 12VAC30-50-270 or home health services as set out in 12VAC30-50-160.

6. Wilson Workforce Rehabilitation Center (WWRC) staff shall perform screenings of the WWRC clients.

F. Failure to comply with DMAS requirements, including competency and training requirements applicable to staff, may result in retraction of Medicaid payments.

12 Va. Admin. Code § 30-60-302

Derived From Virginia Register Volume 34, Issue 24, eff. 8/22/2018; Amended, Virginia Register Volume 38, Issue 12, eff. 2/16/2022; Amended, Virginia Register Volume 41, Issue 01, eff. 10/10/2024; Errata, 41:2 VA.R. 427 September 9, 2024.

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