Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part IX - Commonwealth Coordinated Care Plus Waiver › Section 12VAC30-120-900 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
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 or
					 feeding. An individual's degree of independence in performing these activities
					 is a part of determining appropriate level of care and service needs.
"Adult" means an individual who is 21 years of age or
					 older.
"Adult day health care" or "ADHC" means a program licensed
					 by the Virginia Department of Social Services (VDSS) as an adult day care
					 center (ADCC) and authorized as a Medicaid-enrolled provider meeting home and
					 community-based services (HCBS) settings rules that provides 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). ADHC can also refer to the
					 center where this service is provided.
"Adult protective services" or "APS" means the same as
					 defined in § 63.2-100 of the Code of Virginia.
"Agency-directed model " 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.
"Agency provider" means a public or private organization or
					 entity that holds a Medicaid provider agreement and furnishes services to
					 individuals using its own employees or subcontractors.
"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 12VAC30-20-570.
"Applicant" means an individual or representative on the
					 individual's behalf who has applied for or is in the process of applying for
					 and is awaiting a determination of eligibility for admission to the CCC Plus
					 Program Waiver.
"Assess" means to evaluate an applicant's or an
					 individual's condition, including functional status (i.e., an individual's
					 degree of dependence in performing ADLs or IADLs), current medical status,
					 psycho-social history, and environment. Information is collected from the
					 applicant or individual, applicant's or individual's representative, family,
					 and medical professionals as well as the assessor's observation of the
					 applicant or individual.
"Assessment" means one or more processes that are used to
					 obtain information about an individual, including the individual's condition,
					 personal goals and preferences, functional limitations, health status,
					 financial status, and other factors that are relevant to the determination of
					 eligibility for service. An assessment is required for the authorization of and
					 provision of services and for the development of the plan of care.
"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 (i) enable individuals to increase their abilities to
					 perform ADLs or IADLs and to perceive, control, or communicate with the
					 environment in which the individuals live or (ii) are necessary to the proper
					 functioning of the specialized equipment.
"Backup caregiver" means a secondary person who assumes the
					 role of providing direct care to and support of the waiver individual in
					 instances of emergencies and in the absence of the primary caregiver who is
					 unable to care for the individual. The backup caregiver shall perform the
					 duties needed by the waiver individual without compensation and shall be
					 trained in the skilled needs and technologies required by the waiver
					 individual. The backup caregiver shall be identified in the waiver individual's
					 records.
"Backup plan" means a secondary network of supports to
					 perform the duties needed by the waiver individual to ensure the individual's
					 health, safety, and welfare should the paid caregiver be unable to provide such
					 services. All waiver individuals are required to have a backup plan prior to
					 initiation of services and ongoing, which shall be documented in the waiver
					 individual's records. Those listed in the backup plan shall be trained in the
					 skilled needs and technologies required by the waiver individual.
"Barrier crime" means those crimes as defined at §
					 19.2-392.02 of the Code of Virginia that would prohibit either the employment
					 or 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.
"Care coordinator" means a professional from one of the
					 state's contracted managed care organizations who assists assigned individuals
					 enrolled in the CCC Plus integrated care initiative using a team-based,
					 person-centered approach to effectively manage an individual's medical, social,
					 and behavioral conditions.
"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.
"Child protective services" or "CPS" means the same as
					 defined in § 63.2-100 of the Code of Virginia.
"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.
"Commonwealth Coordinated Care Plus Program" or "CCC Plus"
					 means the DMAS mandatory integrated care initiative for certain qualifying
					 Medicaid members, including members who are dually eligible for Medicare and
					 Medicaid and members receiving long-term services and supports (LTSS). The CCC
					 Plus Program includes members who receive services through nursing facility
					 (NF) care, specialized care NF, or long-stay hospitals, or from one of the four
					 DMAS home and community-based services (HCBS) § 1915(c) waivers. Not all
					 individuals in the CCC Plus Program will qualify for the CCC Plus
					 Waiver.
"Community-based team" or "CBT" means the same as defined
					 in 12VAC30-60-301.
"Congregate living arrangement" means a living arrangement
					 in which three or fewer waiver individuals live in the same household and share
					 receipt of health care services from the same provider.
"Congregate PDN" means skilled in-home nursing provided to
					 three or fewer waiver individuals in the individuals' primary residence or a
					 group setting.
"Consumer-directed attendant" means a person who provides,
					 via the consumer-directed model of services, personal care or respite care, or
					 any combination of these two services, and who is also exempt from workers'
					 compensation.
"Consumer-directed" or "CD" means the model of service
					 delivery for which the individual 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.
"Critical incident" means any incident that threatens or
					 impacts the well-being of a waiver individual. Critical incidents shall include
					 the following incidents: medication errors, severe injury or fall, theft,
					 suspected mental or physical abuse or neglect, financial exploitation, and
					 death.
"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, family, or caregivers as inducements to use a provider's
				  services;
(v) providing continuous,
				  periodic marketing activities to the same prospective individual, family, or
				  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, family's, or caregiver's use of a provider's services.
"Direct medical benefit" means services or supplies that
					 are proper and needed for the diagnosis or treatment of a medical condition;
					 are provided for the diagnosis, direct care, and treatment of the condition;
					 and meet the standards of professional medical practice.
"DMAS" means the Department of Medical Assistance
					 Services.
"DMAS staff" means persons employed by the Department of
					 Medical Assistance Services.
"Durable medical equipment and supplies" or "DME" means
					 those items prescribed by the attending physician, generally recognized by the
					 medical community as serving a diagnostic or therapeutic purpose to assist the
					 waiver individual in the completion of everyday activities, and as being a
					 medically necessary element of the service plan without regard to whether those
					 items are covered by the State Plan for Medical Assistance.
"Early periodic screening, diagnosis and treatment" or
					 "EPSDT" means the benefit program administered by DMAS for individuals younger
					 than 21 years of age in accordance with the definition set forth at 42 CFR
					 440.40 (b) and the requirements of 42 CFR 441, Subpart B.
"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, a family member, caregiver, or another
					 person.
"Enrollment" means the process where an individual has been
					 determined to meet the financial and categorical eligibility requirements for a
					 Medicaid program or service, and the approving entity has verified the
					 availability of services for the individual requesting waiver enrollment and
					 services.
"Environmental modifications" or "EM" means physical
					 adaptations to an individual's primary residence or primary vehicle that are
					 necessary to ensure the individual's health, safety, and welfare or that enable
					 the individual to function with greater independence and shall be of direct
					 medical or remedial benefit to the individual. 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" or "F/EA" 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" means, for the purposes of
					 this waiver, that an individual's right to receive a CCC Plus 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.
"Institution" means a nursing facility, specialized care
					 nursing facility, or long-stay hospital. Individuals who receive enrollment in
					 the CCC Plus Waiver are deemed to meet the level of care necessary for
					 residence in one of these institutions or are anticipated to need to be in one
					 of these institutions within the next 30 days without the services of the
					 waiver.
"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.
"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.
"Local department of social services" or "LDSS" means the
					 entity established under § 63.2-324 of the Code of Virginia by the
					 governing city or county in the Commonwealth.
"Long-term services and supports" or "LTSS" 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.
"LTSS screening" means the process to (i) evaluate the
					 functional, nursing, and social supports of individuals referred for screening
					 for certain long-term care services and supports requiring nursing facility
					 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 an individual's 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.
"LTSS screening team" means the entity contracted with DMAS
					 that is responsible for performing the screening process pursuant to §
					 32.1-330 of the Code of Virginia.
"Managed care organization" or "MCO" means the same as the
					 definition of this term in 42 CFR 438.2.
"Medicaid Long-Term Services and Supports 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.
"Medically necessary" means those services or specialized
					 medical equipment or supplies that are covered for reimbursement under either
					 the State Plan for Medical Assistance or in a waiver program that are
					 reasonable, proper, and necessary for the treatment of an illness, injury, or
					 deficit; are provided for direct care of the condition or to maintain or
					 improve the functioning of a malformed body part; and meet the standards of
					 good professional medical practice as determined by DMAS.
"Medication monitoring" means an electronic device, which
					 is only available in conjunction with personal emergency response systems, that
					 reminds an individual to take medications at the correct dosages and
					 times.
"Minor child" means an individual who is younger than 18
					 years of age.
"Monitoring" means the ongoing oversight of the provision
					 of waiver and other services to determine that they are furnished according to
					 the waiver individual's plan of care and effectively meet the individual's
					 needs, thereby ensuring the individual's health, safety, and welfare.
					 Monitoring activities may include telephone contact; observation; interviewing
					 the individual or the trained individual representative, as appropriate, in
					 person or by telephone; or interviewing service providers.
"Nurse supervisor" means a registered nurse (RN) or
					 licensed professional nurse (LPN) hired or contracted by an agency to provide
					 the supervisory responsibilities as outlined in the waiver to the agency's
					 staff who perform personal care or respite care services to waiver
					 individuals.
"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 with DMAS or a managed care
					 organization that has a signed contract with DMAS.
"Patient pay amount" means the portion of the individual's
					 income that must be paid as the individual's share of the long-term services
					 and supports and is calculated by the local department of social services based
					 on the individual's documented monthly income and permitted deductions.
"Person-centered planning" means a fundamental process that
					 focuses on what is important to and for an individual and the needs and
					 preferences of the individual to create a plan of care.
"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
					 issued by the training entity, which is provided to DMAS during provider
					 audits.
"Personal care attendant," "attendant," or "PCA" means a
					 person who provides personal care or respite services that are directed by an
					 employer of record under the CD model of service delivery.
"Personal care services" or "PC services" means a range of
					 support services that includes assistance with ADLs or IADLs, access to the
					 community, self-administration of medication or other medical needs, and the
					 monitoring of health status and physical condition provided through the
					 agency-directed or consumer-directed model of service. Personal care services
					 shall be provided by aides or attendants within the scope of their licenses or
					 certifications, as appropriate.
"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 and at risk of
					 institutionalization to secure help in an emergency.
"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 or
					 caregiver, as appropriate, and the provider related solely to the specific
					 services necessary for the individual to remain in the community while ensuring
					 the individual's health, safety, and welfare.
"Private duty nursing services" or "PDN" means skilled
					 in-home nursing services listed in the POC that are (i) not otherwise covered
					 under the State Plan for Medical Assistance home health benefit; (ii) required
					 to prevent institutionalization; or (iii) provided within the scope of the
					 Commonwealth's Nurse Practice Act (Chapter 30 (§ 54.1-3000 et seq.) of
					 Title 54.1 of the Code of Virginia) and Drug Control Act (Chapter 34 (§
					 54.1-3400 et seq.) of Title 54.1 of the Code of Virginia).
"Provider agreement" means the contract between DMAS and a
					 participating provider under which the provider agrees to furnish services to
					 Medicaid-eligible individuals in compliance with state and federal statutes and
					 regulations and Medicaid contract requirements.
"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 services" means services provided to waiver
					 individuals 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" means the process of approving a
					 service for the individual. The process of approving is done by DMAS, its
					 service authorization contractor, or an MCO.
"Service authorization contractor" means DMAS or the entity
					 that has been contracted by DMAS, including an MCO, 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, or EOR, as appropriate) in arranging
					 for, directing, training, and managing services provided through the
					 consumer-directed model of service.
"Skilled private duty nursing services" or "skilled PDN"
					 means skilled in-home nursing services listed in the POC that are (i) not
					 otherwise covered under the State Plan for Medical Assistance home health
					 benefit; (ii) required to prevent institutionalization; and (iii) provided
					 within the scope of the Commonwealth's Nurse Practice Act (Chapter 30 (§
					 54.1-3000 et seq.) of Title 54.1 of the Code of Virginia) and Drug Control Act
					 (Chapter 34 (§ 54.1-3400 et seq.) of Title 54.1 of the Code of
					 Virginia).
"Skilled respite services" means temporary skilled nursing
					 services that are provided to waiver individuals and that are performed by an
					 LPN or RN 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 services" means set-up expenses for individuals
					 as defined at 12VAC30-120-2010.
"Unpaid primary caregiver" means the primary 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.
"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 assessment that is completed by the screening
					 entity that assesses an individual's physical health, mental health, and
					 psychosocial and functional abilities to determine if the individual meets the
					 nursing facility level of care.
"Waiver individual" or "individual" means the person who
					 has applied for and been approved to receive these waiver services.
"Weekly" means a span of time covering seven consecutive
					 calendar days.
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.