reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-21 - Utilization control of nonparticipating out-of-state inpatient hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
Inpatient hospital services provided out of state to a
				  Medicaid recipient who is a resident of the Commonwealth of Virginia shall only
				  be reimbursed under any one of the following conditions. It shall be the
				  responsibility of the hospital, when requesting prior authorization for the
				  admission, to demonstrate that one of the following conditions exists in order
				  to obtain authorization. It shall be the responsibility of the admitting
				  physician to adhere to these restrictions. Services provided out of state for
				  circumstances other than these specified exceptions shall not be covered. When,
				  during post payment utilization review, inappropriate or inaccurate payments
				  are determined to have been made for reasons other than those specified herein,
				  DMAS shall recover the inappropriately expended funds.
1. The medical services must be needed
				because of a medical emergency;
2.
				Medical services must be needed and the recipient's health would be endangered
				if he were required to travel to his state of residence;
3. The state determines, on the basis of
				medical advice, that the needed medical services, or necessary supplementary
				resources, are more readily available in the other state;
4. It is general practice for recipients in a
				particular locality to use medical resources in another state.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-25 - Utilization control: freestanding psychiatric hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Psychiatric services in freestanding
				psychiatric hospitals shall only be covered for eligible persons younger than
				21 years of age and older than 64 years of age.
B. Prior authorization required. DMAS shall
				monitor, consistent with state law, the utilization of all inpatient
				freestanding psychiatric hospital services. All inpatient hospital stays shall
				be preauthorized prior to reimbursement for these services. Services rendered
				without such prior authorization shall not be covered.
C. All Medicaid services are subject to
				utilization review and audit. Absence of any of the required documentation may
				result in denial or retraction of any reimbursement. In each case for which
				payment for freestanding psychiatric hospital services is made under the State
				Plan:
1. A physician must certify at the time
				of admission, or at the time the hospital is notified of an individual's
				retroactive eligibility status, that the individual requires or required
				inpatient services in a freestanding psychiatric hospital consistent with
				42 CFR
				456.160.
2. The physician, physician assistant, or
				nurse practitioner acting within the scope of practice as defined by state law
				and under the supervision of a physician, must recertify at least every 60 days
				that the individual continues to require inpatient services in a psychiatric
				hospital.
3. Before admission to a
				freestanding psychiatric hospital or before authorization for payment, the
				attending physician or staff physician must perform a medical evaluation of the
				individual and appropriate professional personnel must make a psychiatric and
				social evaluation as cited in
				42 CFR
				456.170.
4. Before admission to a freestanding
				psychiatric hospital or before authorization for payment, the attending
				physician or staff physician must establish a written plan of care for each
				recipient patient as cited in
				42 CFR
				441.155 and 456.180. The plan shall also
				include a list of services provided under written contractual arrangement with
				the freestanding psychiatric hospital (see
				12VAC30-50-130) that will be
				furnished to the patient through the freestanding psychiatric hospital's
				referral to an employed or contracted provider, including the prescribed
				frequency of treatment and the circumstances under which such treatment shall
				be sought.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-70 - Utilization control: home health services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Home health services that meet the
				standards prescribed for participation under Title XVIII, will be
				supplied.
B. Home health services
				shall be provided by a home health agency that is (i) licensed by the Virginia
				Department of Health, (ii) certified by the Virginia Department of Health under
				provisions of Title XVIII (Medicare) or Title XIX (Medicaid) of the Social
				Security Act, or (iii) accredited by any organization recognized by the Centers
				for Medicare and Medicaid Services (CMS) for purposes of Medicare
				certification. Services shall be provided on a part-time or intermittent basis
				to a recipient in any setting in which normal life activities take place. Home
				health services shall not be furnished to individuals residing in a hospital,
				nursing facility, intermediate care facility for individuals with intellectual
				disabilities, or any setting in which payment is or could be made under
				Medicaid for inpatient services that include room and board. Home health
				services must be ordered or prescribed by a physician, nurse practitioner (NP),
				clinical nurse specialist (CNS), or physician assistant (PA) and must be part
				of a written plan of care that the practitioner shall review at least every 60
				days.
C. Covered services. Any one
				of the following services may be offered as the sole home health service and
				shall not be contingent upon the provision of another service.
1. Nursing services;
2. Home health aide services;
3. Physical therapy services;
4. Occupational therapy services;
				or
5. Speech-language pathology
				services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-75 - Durable medical equipment (DME) and supplies

Current through Register Vol. 40, No. 24, July 15, 2024
A. No provider shall have a claim of
				ownership on DME reimbursed by Virginia Medicaid once it has been delivered to
				the Medicaid individual. Providers shall only be permitted to recover DME, for
				example, when DMAS determines that it does not fulfill the required medically
				necessary purpose as set out in the Certificate of Medical Necessity (CMN),
				when there is an error in the ordering practitioner's CMN, or when the
				equipment was rented. DMAS shall not reimburse the DME and supply provider for
				services that are provided either:
(i) prior
				to the date prescribed by the licensed practitioner; (ii) prior to the date of
				the delivery; or (iii) when services are not provided in accordance with DMAS'
				published regulations and guidance documents. In instances when the DME or
				supply is shipped directly to the Medicaid individual, the DME provider shall
				confirm that the DME or supplies have been received by the individual before
				submitting his claim for payment to DMAS.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-80 - Utilization control: Optometrists' services

Current through Register Vol. 40, No. 24, July 15, 2024
Optometrists' services are limited to examinations
				  (refractions) after preauthorization by the state agency except for eyeglasses
				  as a result of an Early and Periodic Screening, Diagnosis, and Treatment
				  (EPSDT).
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 396 E 5
					 of the 1995 Appropriations Act.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-100 - Utilization control: Incorporation of specialized quality standards

Current through Register Vol. 40, No. 24, July 15, 2024
Standards in other specialized high quality programs such as
				  the program of Crippled Children's Services will be incorporated as
				  appropriate.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 396 E 5
					 of the 1995 Appropriations Act.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-110 - Utilization control: Effect of geographic boundaries on provision of care

Current through Register Vol. 40, No. 24, July 15, 2024
Provisions will be made for obtaining recommended medical
				  care and services regardless of geographic boundaries.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 396 E 5
					 of the 1995 Appropriations Act.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-120 - Quality management: Intensive physical rehabilitative rehabilitation or CORF services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Within
				24 hours of an individual's admission for either intensive inpatient
				rehabilitation or CORF services, a physician shall be required to complete and
				sign and date the admission certification statement, as defined in
				12VAC30-50-225 and
				42 CFR
				456.60, of the need for intensive
				rehabilitation or CORF services and the initial plan of care or orders.
1. Excluding CORF services, all other plans
				of care for inpatient rehabilitation services, including 60-day
				recertifications and the 60-day plan of care renewal orders shall be ordered by
				either a physician or a licensed practitioner of the healing arts including,
				but not limited to, nurse practitioners or physician assistants, within the
				scope of their licenses under state law.
2. If therapy services are recertified by a
				practitioner of the healing arts other than a physician, supervision shall be
				performed by a physician as required by §§ 54.1-2952 and 54.1-2957.01
				of the Code of Virginia and 42 CFR 456.60.
3. For CORF providers, federal requirements
				do not permit nurse practitioners or physician assistants to order CORF
				intensive rehabilitation services. A physician shall be responsible for all
				documentation requirements including, but not limited to, admission
				certifications, recertifications, plans of care, progress notes, discharge
				orders, and any other required documentation (
				42 CFR
				485.58(a)(i) ).
4. Admission certification requirements shall
				apply to all individuals who are currently Medicaid eligible and to those
				individuals for whom a retroactive Medicaid eligibility determination is
				anticipated for coverage of an inpatient rehabilitative stay or for CORF
				services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-130 - Hospice services

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Admission criteria.
1. Service election. To
				be eligible for hospice coverage under Medicare or Medicaid, the recipient
				shall be "terminally ill," defined as having a life expectancy of six months or
				less, and except for individuals under 21 years of age, elect to receive
				hospice services rather than active treatment for the illness. Both the
				attending physician (if the individual has an attending physician) and the
				hospice medical director, or the attending physician and the physician member
				of the interdisciplinary team, must initially certify the life expectancy. The
				election statement shall include (i) identification of the hospice that will
				provide care to the individual; (ii) the individual's or representative's
				acknowledgment that he has been given a full understanding of the palliative
				rather than curative nature of hospice care as it relates to the individual's
				terminal illness; (iii) with the exception of children, defined as persons
				younger than 21 years of age, acknowledgment that certain Medicaid services are
				waived by the election; (iv) the effective date of the election; and (v) the
				signature of the individual or representative.
2. Service revocation. The recipient shall
				have the right to revoke his election of hospice services at any time during
				the covered hospice periods. DMAS shall be contacted if the recipient revokes
				his hospice services. If the recipient reelects the hospice services, the
				hospice periods will begin as an initial timeframe. Therefore, the
				certification and time requirements in this subsection will apply. The
				recipient cannot retroactively receive hospice benefits from previously unused
				hospice periods. The recipient's written revocation statement shall be
				maintained in the recipient's medical record.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-140 - Community mental health services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Utilization
				review general requirements. Utilization reviews shall be conducted, at a
				minimum annually for each enrolled provider, by the Department of Medical
				Assistance Services (DMAS) or its contractor. During each review, an
				appropriate sample of the provider's total Medicaid population will be selected
				for review. An expanded review shall be conducted if an appropriate number of
				exceptions or problems are identified.
B. The review by DMAS or its contractor shall
				include the following items:
1. Medical or
				clinical necessity of the delivered service;
2. The admission to service and level of care
				was appropriate;
3. The services
				were provided by appropriately qualified individuals as defined in the Amount,
				Duration, and Scope of Services found in 12VAC30-50; and
4. Delivered services as documented are
				consistent with recipients' Individual Service Plans, invoices submitted, and
				specified service limitations.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-145 - Mental retardation utilization criteria

Current through Register Vol. 40, No. 24, July 15, 2024
Utilization reviews shall include determinations that
				  providers meet all the requirements of Virginia state regulations found in
				  12VAC30-50-95 through
				  12VAC30-50-310.
Appropriate use of case management services for persons with
				  mental retardation requires the following conditions to be met:
1. The individual must require case
				management as documented on the consumer service plan of care which is
				developed based on appropriate assessment and supporting data. Authorization
				for case management services shall be initially obtained from DMHMRSAS staff
				annually.
2. An active client shall
				be defined as an individual for whom there is a plan of care in effect which
				requires regular direct or client-related contacts or communication or activity
				with the client, family, service providers, significant others and other
				entities including a minimum of one face-to-face contact within a 90-day
				period.
3. The plan of care shall
				address the individual's needs in all life areas with consideration of the
				individual's age, primary disability, level of functioning and other relevant
				factors.
a. The plan of care shall be
				reviewed by the case manager every three months to ensure the identified needs
				are met and the required services are provided. The review will be due by the
				last day of the third month following the month in which the last review was
				completed. A grace period will be given up to the last day of the fourth month
				following the month of the prior review. When the review was completed in a
				grace period, the next subsequent review shall be scheduled three months from
				the month the review was due and not the date of the actual review.
b. The need for case management services
				shall be initially assessed and justified through the development of an annual
				consumer service plan.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-147

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
											32.1-325 of the Code of
					 Virginia; 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-150 - Quality management review of outpatient rehabilitation therapy services

Current through Register Vol. 40, No. 24, July 15, 2024
A. The following
				general conditions shall apply to reimbursable outpatient rehabilitation
				therapy services:
1. The covered services and
				medical necessity criteria as set out in
				12VAC30-50-200 shall apply to
				these outpatient rehabilitation therapy services.
2. Outpatient rehabilitative therapy
				services, as defined in 42
				CFR 440.130, shall be prescribed by a
				licensed physician or a licensed practitioner of the healing arts, specifically
				either a nurse practitioner or physician assistant, and be part of a written
				plan of care.
3. . Quality
				management reviews shall be performed by DMAS or its contractor to ensure that
				all rehabilitative services provided to Medicaid individuals are medically
				necessary and appropriate. Services not specifically documented in the
				individual's medical record as having been rendered shall be deemed not to have
				been rendered and no reimbursement shall be provided.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-160 - Utilization review of case management for recipients of auxiliary grants

Current through Register Vol. 40, No. 24, July 15, 2024
A. Criteria of need
				for case management services. It shall be the responsibility of the assessor
				who identifies the individual's need for residential or assisted living in an
				adult care residence to assess the need for case management services. The case
				manager shall, at a minimum, update the assessment and make any necessary
				referrals for service as part of the case management annual visit. Case
				management services may be initiated at any time during the year that a need is
				identified.
B. Coverage limits.
				DMAS shall reimburse for one case management visit per year for every
				individual who receives an auxiliary grant. For individuals meeting the
				following ongoing case management criteria, DMAS shall reimburse for one case
				management visit per calendar quarter:
1. The
				individual needs the coordination of multiple services and the individual does
				not currently have support available that is willing to assist in the
				coordination of and access to services, and a referral to a formal or informal
				support system will not meet the individual's needs; or
2. The individual has an identified need in
				his physical environment, support system, financial resources, emotional or
				physical health which must be addressed to ensure the individual's health and
				welfare and other formal or informal supports have either been unsuccessful in
				their efforts or are unavailable to assist the individual in resolving the
				need.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-180

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
											32.1-325 of the Code of
					 Virginia; 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-200 - Ticket to Work and Work Incentives Improvement Act (TWWIIA) basic coverage group: alternative benefits for Medicaid Buy-In program

Current through Register Vol. 40, No. 24, July 15, 2024
A. The state elects
				to provide alternative benefits under § 1937 of the Social Security Act.
				The alternative benefit package will be available statewide.
B. The population who will be offered opt-in
				alternative coverage and who will be informed of the available benefit options
				prior to having the option to voluntarily enroll in an alternative benefit
				package consists of working individuals with disabilities enrolled pursuant to
				the Social Security Act, § 1902(a)(10)(A)(ii)(XV) (Ticket to Work and Work
				Incentives Improvement Act) covered group or who meet the income, resource and
				eligibility requirements for the § 1902(a)(10)(A)(ii)(XV) covered
				group.
C. Medicaid Buy-In: program
				outreach.
1. Future Medicaid Works
				solicitations will be geared towards individuals who are currently covered in
				the SSI and blind and disabled 80% federal poverty level groups; the letter
				will be an invitation to consider going to work, or to increase how much they
				work, and inform them that they will still be able to keep their Medicaid
				health care coverage.
2. They will
				be advised that this is voluntary and will enable them to earn higher income
				and retain more assets from their earnings. It will also explain that this
				option includes an alternative benefits package comprised of their regular
				Medicaid benefits plus personal assistance services for those who need personal
				assistance and related services in order to live and work in the community. It
				will be clearly stated that this program is optional. Their local eligibility
				worker will be able to review the advantages and disadvantages of this option
				in order to assist individuals in making an informed choice.
3. Current Medicaid Works enrollees will each
				receive personal communication by mail advising them of the new alternative
				benefits package and the steps needed in order to access personal assistance
				services. Should an enrolled individual be dissatisfied with this option or be
				unable to continue to be employed, their eligibility worker will reevaluate
				eligibility for other covered groups pursuant to changing the individual back
				to regular Medicaid coverage and, if necessary, to accessing personal
				assistance and related services through the existing home-based and
				community-based services waivers.
4. Brochures describing this work incentive
				opportunity and alternative benefits option shall be prominently displayed and
				readily available at local departments of social services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-300

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-302 - Access to Medicaid-funded long-term services and supports

Current through Register Vol. 40, No. 24, July 15, 2024
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), 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.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-303 - Screening criteria for Medicaid-funded long-term services and supports

Current through Register Vol. 40, No. 24, July 15, 2024
A. Functional
				capacity alone shall not be deemed sufficient to demonstrate the need for
				nursing facility care admission or authorization for home and community-based
				services and supports. An individual shall be determined to meet the nursing
				facility criteria when:
1. The individual has
				both limited functional capacity, medical or nursing needs, and is at risk of
				NF admission within 30 days according to the requirements of this section;
				or
2. The individual is rated
				dependent in some functional limitations, but does not meet the functional
				capacity requirements, and the individual requires the daily direct services or
				supervision of a licensed nurse that cannot be managed on an outpatient basis
				(e.g., clinic, physician visits, home health services).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-304 - Requests and referrals for screening for adults and children living in the community and adults and children in hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Screenings for
				adults living in the community. Screenings for adults who are residing in the
				community but who are not inpatients shall be completed and submitted by the
				CBT to ePAS. If the individual, or any of the other persons permitted to make
				such requests, requests a screening, the CBT shall be required to perform the
				requested screening; otherwise, CBTs shall not be required to screen
				individuals who are not expected to become financially eligible for
				Medicaid-funded LTSS within six months of the screening.
1. Requests for screenings shall be accepted
				from either an individual, the individual's representative, an adult protective
				service worker, the individual's physician, or an MCO care coordinator having
				an interest in the individual. The CBT in the jurisdiction where the individual
				resides shall conduct such screening. For the screening to be scheduled by the
				CBT, the individual shall either agree to participate or, if refusing, shall be
				under order of a court of appropriate jurisdiction to have a screening.
a. The LDSS or LHD in receipt of the request
				for a screening shall contact the individual or his representative within seven
				days of the request date for screening to schedule a screening with the
				individual and any other persons whom the individual selects to attend the
				screening.
b. When the CBT has not
				scheduled a screening to occur within 21 days of the request date for
				screening, and the screening is not anticipated to be complete within 30 days
				of the request date for screening due to the screening entity's inability to
				conduct the screening, the LDSS and LHD shall, no later than seven days after
				the request date for screening, notify DARS and VDH staff designated for
				technical assistance.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-306 - Submission of screenings

Current through Register Vol. 40, No. 24, July 15, 2024
A. The screening
				entity shall complete and submit the following forms to DMAS electronically via
				ePAS:
1. DMAS-95 - MI/IDD/RC (Supplemental
				Assessment Process Form Level I), as appropriate;
2. DMAS-96 (Medicaid-Funded Long-Term Care
				Service Authorization Form);
3.
				DMAS-97 (Individual Choice - Institutional Care or Waiver Services), as
				applicable;
4. UAI (Uniform
				Assessment Instrument);
5. DMAS-108
				(Tech Waiver Adult Referral); and
6. DMAS-109 (Tech Waiver Pediatric
				Referral).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-307

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-308 - Nursing facility admission and level of care determination requirements

Current through Register Vol. 40, No. 24, July 15, 2024
Prior to an individual's admission, the NF shall review the
				  completed screening forms to ensure that applicable NF admission criteria have
				  been met, documented, and submitted via e-PAS unless the individual meets any
				  of the special circumstances set out in
				  12VAC30-60-302 E. NFs shall not
				  accept paper screening forms as proof that admission criteria have been met and
				  documented.
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-310 - Competency training and testing requirements

Current through Register Vol. 40, No. 24, July 15, 2024
By June 30, 2019, each person performing screenings on behalf
				  of a screening entity shall complete required training and competency tests. A
				  score of at least 80% on each module for each person who is required to give
				  final approval on screenings on behalf of the screening entity shall constitute
				  satisfactory competency test results. The most current competency test results
				  shall be kept in the screening entity's personnel records for each person
				  performing screenings for the screening entity. Such documentation results
				  shall be provided to DMAS upon its request.
1. All persons who are required by the
				screening entity to give final approval of screenings shall complete the
				DMAS-approved training and pass the corresponding competency tests with a score
				of at least 80% for each module of the training prior to performing
				screenings.
2. Upon successful
				completion of the initial training, each person who is required to give final
				approval of screenings on behalf of the screening entity shall complete the
				shortened refresher course no less than every three years. A score of at least
				80% on the refresher module shall be required for a person to continue to
				perform screenings or give final approval of screenings on behalf of the
				screening entity.
3. Failure to
				satisfy the training and competency tests requirements may result in the
				retraction of Medicaid payment.
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-312

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-313 - Individuals determined to not meet criteria for Medicaid-funded long-term services and supports

Current through Register Vol. 40, No. 24, July 15, 2024
Notwithstanding
				  12VAC30-60-302 E, an individual
				  shall be determined not to meet the medical or nursing and functional criteria
				  for Medicaid-funded LTSS when there is no screening or MDS to document the
				  individual meets the medical or nursing and functional criteria or when one of
				  the following specific care needs solely describes the individual's
				  condition:
1. The individual requires
				minimal assistance with ADLs, including those individuals whose only need in
				all areas of functional capacity is for prompting to complete the
				activity;
2. The individual
				independently uses mechanical devices such as a wheelchair, walker, crutch, or
				cane;
3. The individual requires
				limited diets such as a mechanically altered, low-salt, low-residue, diabetic,
				reducing, or other restrictive diets;
4. The individual requires medications that
				can be independently self-administered or administered by the
				caregiver;
5. The individual
				requires protection to prevent him from obtaining alcohol or drugs or to
				address a social or environmental problem;
6. The individual requires minimal staff
				observation or assistance for confusion, memory impairment, or poor judgment;
				or
7. The individual's primary need
				is for behavioral management that can be provided in a community-based
				setting.
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-315 - Periodic evaluations for individuals receiving Medicaid-funded long-term services and supports

Current through Register Vol. 40, No. 24, July 15, 2024
A. Once an
				individual is enrolled in home and community-based services, the home and
				community-based services provider shall be responsible for conducting periodic
				evaluations to ensure that the individual meets, and continues to meet, the
				waiver program or PACE criteria, if appropriate. These periodic evaluations
				shall be conducted using the Level of Care Review tab in the Medicaid portal at
				(
https://www.virginiamedicaid.dmas.virginia.gov/wps/portal
).
				The home and community-based services provider shall promptly evaluate the
				individual after he experiences a significant change in his condition, as
				defined in
				12VAC30-60-301.
B. Once an individual is admitted to a NF,
				the NF shall be responsible for conducting periodic evaluations to ensure that
				the individual meets, and continues to meet, the NF criteria. For this purpose,
				the NF shall use the federally required Minimum Data Set (MDS) form (see
				https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits
				/MDS30RAIManual.html [File Link Not Available]). The post-admission evaluation
				shall be conducted no later than 14 days after the date of NF admission and
				promptly after an individual's significant change in his condition, as defined
				in 12VAC30-60-301.
C. For individuals who are enrolled in an MCO
				that is responsible for providing LTSS, the MCO shall conduct periodic
				evaluations by qualified MCO staff to ensure the individual continues to meet
				criteria for LTSS. The MCO shall promptly evaluate the individual after he
				experiences a significant change in his condition, as defined in
				12VAC30-60-301.
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-316 - Criteria for continued nursing facility care using the Minimum Data Set (MDS)

Current through Register Vol. 40, No. 24, July 15, 2024
Individuals may be considered appropriate for nursing
				  facility care when one of the following describes their medical or nursing
				  needs and functional capacity as recorded on the Minimum Data Set (MDS) of the
				  Resident Assessment Instrument that is specified by the Commonwealth.
1. Functional capacity:
a. The individual meets criteria for two to
				four of the Activities of Daily Living, plus Behavior and Orientation; and
				Joint Motion;
b. The individual
				meets criteria for five to seven of the Activities of Daily Living and also for
				Locomotion; or
c. The individual
				meets criteria for two to seven of the Activities of Daily Living and also for
				Locomotion, and Behavior and Orientation. An individual in this category will
				not be appropriate for nursing facility care unless he also has a medical
				condition requiring treatment or observation by a nurse.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-318 - Definitions to be applied when completing the MDS

Current through Register Vol. 40, No. 24, July 15, 2024
A. Activities of Daily Living (ADLs):
1. Transfer (§E(1)(b)). In order to meet
				this ADL, the individual must score a 1, 2, 3, 4, or 8 as described below:
a. (0) Independent -- No help or oversight --
				OR -- help/oversight provided only 1 or 2 times during last seven days
b. (1) Supervision -- Oversight,
				encouragement or cueing provided 3+ times during last seven days -- OR --
				supervision plus physical assistance provided on 1 or 2 times during last seven
				days
c. (2) Limited assistance --
				Resident highly involved in activity; received physical help in guided
				maneuvering of limbs or other nonweight bearing assistance 3+ times -- OR --
				more help provided only 1 or 2 times during last seven days
d. (3) Extensive assistance -- While resident
				performed part of activity, over last seven-day period, help of following type
				or types was provided 3 or more times: weight-bearing support or full staff
				performance during part (but not all) of last seven days
e. (4) Total dependence -- Full staff
				performance of activity during entire seven days
f. (8) Activity did not occur during the
				entire seven-day period. Use of this code is limited to situations where the
				ADL activity was not performed and is primarily applicable to fully bed-bound
				residents who neither transferred from bed nor moved between locations over the
				entire seven-day period.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-320 - Adult ventilation/tracheostomy specialized care criteria

Current through Register Vol. 40, No. 24, July 15, 2024
A. General
				description. The resident must have long-term health conditions requiring close
				medical supervision, 24 hour licensed nursing care, and specialized services or
				equipment.
B. The targeted adult
				population requiring specialized care includes individuals requiring mechanical
				ventilation and individuals with a complex tracheostomy who require
				comprehensive respiratory therapy services.
C. Criteria.
1. The individual must require at a minimum:
a. Physician visits at least once weekly. The
				initial physician visit must be made by the physician personally and subsequent
				required physician visits after the initial visit may alternate between
				personal visits by the physician and visits by a physician assistant or nurse
				practitioner.
b. Skilled nursing
				services 24 hours a day. A registered nurse must be on the nursing unit on
				which the resident resides, 24 hours a day, whose sole responsibility is the
				designated unit.
c. Respiratory
				services provided by a licensed board-certified respiratory therapist (these
				services must be available 24 hours a day).
d. Coordinated multidisciplinary team
				approach to meet needs.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-340 - Pediatric and adolescent specialized care criteria

Current through Register Vol. 40, No. 24, July 15, 2024
§ 3.0 General description. The child must have ongoing
				  health conditions requiring close medical supervision, 24 hours licensed
				  nursing supervision, AND specialized services or equipment. The recipient must
				  be age 21 or under.
§ 3.1 Targeted population.
A. Children requiring mechanical
				ventilation
B. Children with
				communicable diseases requiring universal or respiratory precautions (excluding
				normal childhood diseases such as chicken pox, measles, strep throat,
				etc.)
C. Children requiring ongoing
				intravenous medication or intravenous nutrition administration
D. Children requiring daily dependence on
				device based respiratory or nutritional support (tracheostomy, gastrostomy,
				etc.)
E. Children requiring
				comprehensive rehabilitative therapy service
F. Children with terminal illness
§ 3.2 Criteria.
A. The child must require at a minimum:
1. Physician visits at least once weekly (the
				initial physician visit must be made by the physician personally. Subsequent
				required physician visits after the initial visit may alternate between
				personal visits by the physician and visits by a physician assistant or nurse
				practitioner.)
2. Skilled nursing
				services 24 hours a day (a registered nurse must be on the nursing unit on
				which the child is residing, 24 hours a day, whose sole responsibility is that
				nursing unit)
3. Coordinated
				multidisciplinary team approach to meet needs
4. The nursing facility must coordinate with
				appropriate state and local agencies for the educational and habilitative needs
				of the child. These services must be age appropriate and appropriate to the
				cognitive level of the child. Services must also be individualized to meet the
				specific needs of the child and must be provided in an organized and proactive
				manner. Services may include but are not limited to school, active treatment
				for mental retardation, habilitative therapies, social skills and leisure
				activities. The services must be provided for a total of 2 hours per day,
				minimum.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-350 - Criteria for coverage of specialized treatment beds

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS will pay $10 per day toward the cost
				of specialized treatment beds for eligible NF recipients who have at least one
				treatable Stage IV pressure ulcer. Specialized treatment bed means either an
				air-fluidized bed or a low-air-loss bed. To be approved for this service, the
				following criteria must be met:
1. The
				individual must have at least one Stage IV pressure ulcer as documented on the
				MDS.
2. The individual must require
				the use of a specialized treatment bed as ordered by a physician for the
				treatment of at least one Stage IV pressure ulcer.
3. The nursing facility must obtain
				authorization by submitting the authorization request to DMAS or the
				preauthorization agent.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-360

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-361 - Criteria for supports and services in intermediate care facilities for individuals with intellectual disabilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section establishes standard criteria
				that shall be met by individuals in order to receive Medicaid payment for care
				in intermediate care facilities for individuals with intellectual disabilities
				(ICF/IID). Once the individual has been screened and found to meet these
				criteria, Medicaid covers the costs of care only when the individual is
				receiving appropriate supports and services and when active treatment, as set
				forth in
				42 CFR
				483.440(a), is being
				provided.
B. Supports and services
				that are provided in facilities for individuals with developmental or
				intellectual disabilities for the purpose of claiming Medicaid reimbursement
				requires individualized, person-centered planned programs of supports and
				services to address habilitative needs or health needs, or both, as set forth
				in
				42 CFR
				483.21.
1.
				Such care may be a combination of habilitative, rehabilitative, and health
				services directed toward increasing or maintaining the highest mental,
				physical, and psychosocial skills and abilities of the individual. Individuals
				with degenerative conditions shall receive supports and services designed to
				retain skills and functioning and to prevent further regression to the extent
				possible. Examples of such care include (i) skill building in the activities of
				daily living, (ii) skill building in task-learning, (iii) learning socially
				acceptable behaviors, (iv) learning basic community living skills, (v) health
				care and health maintenance, and (vi) skill building in self
				direction.
2. The overall objective
				of facility based supports and services, as set out in the person-centered
				plan, shall be the attainment of the optimal physical, intellectual, social, or
				task learning level that the individual can presently or potentially
				achieve.