Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-490 - Support coordination/case management for individuals with developmental disabilities

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Target group. Medicaid-eligible individuals with developmental disability
				  (other than intellectual disability) or related conditions as defined in §
										37.2-100 of the Code
				  of Virginia who are on the waiting list or are receiving services under one of
				  the Developmental Disabilities (DD) Waivers.
1. When an individual applies for the DD
				  Waivers and is found to meet the criteria as defined in 12VAC30-122-50, but
				  there is no available slot, the individual will be placed on a waitlist until a
				  slot is available. Individuals on the waitlist shall not receive developmental
				  disability support coordination/case management services unless a special
				  service need (as defined in subdivision 4 of this subsection) is identified, in
				  which case an ISP shall be developed to address the special service need.
				  Support coordinators/case managers shall make face-to-face contact with the
				  individual at least every 90 calendar days to monitor the special service need,
				  and documentation is required to support such contact. The support
				  coordinator/case manager shall assure the ISP addresses the current special
				  service needs of the individual and shall coordinate with the Department of
				  Medical Assistance Services designee to assure actual enrollment into the
				  waiver upon slot availability.
2.
				  An active individual for developmental disability support coordination/case
				  management shall mean a person for whom there is an individual support plan
				  (ISP), as defined in 12VAC30-122-20, that requires direct or individual-related
				  contacts or communication or activity with the individual, the individual's
				  family/caregiver, service providers, and significant others. Billing can be
				  submitted for an active individual only for months in which direct or
				  individual-related contacts, activity, or communications occur, consistent with
				  the goals or outcomes in the individual's ISP. Face-to-face contact between the
				  support coordinator/case manager and the individual shall occur at least every
				  90 calendar days in which there is an activity submitted for billing.
3. The unit of service is one
				  month. There shall be no maximum service limits for support coordination/case
				  management services except as related to individuals residing in medical
				  institutions or medical facilities. For these individuals, reimbursement for
				  support coordination/case management services shall be limited to 90 days
				  immediately preceding discharge from those settings. Support coordination/case
				  management for individuals in a medical institution or facility may be billed
				  for no more than two 90-day periods in a 12-month period.
4. A special service need is one that
				  requires linkage to and temporary monitoring of those supports and services
				  identified in the ISP to address an individual's mental health, behavioral, and
				  medical needs or provide assistance related to an acute need that coincides
				  with the allowable activities noted in subsection D of this section. If an
				  activity related to the special service need is provided in a given month, then
				  the support coordinator/case manager would be eligible for reimbursement. Once
				  the special service need is addressed related to the specific activity
				  identified, billing for the service shall not continue until a special service
				  need presents again.