Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 122 - COMMUNITY WAIVER SRVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES › Section 12VAC30-122-210 - Payment for covered services (tiers)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Waiver services shall be reimbursed
				according to the agency fee schedule unless otherwise specified in this
				section. Units of service and service limits are set out in the section for
				each service. There shall be no designated formal schedule for annual cost of
				living or other adjustments and any adjustments to provider rates shall be
				subject to available funding and approval by the General Assembly. Rate
				methodologies shall also be subject to the approval of the Centers for Medicare
				and Medicaid services.
1. Those services that
				have a Northern Virginia and Rest of State rate shall be paid based on the
				individual's place of residence.
2.
				The following services shall have variable rates based on size:
a. Group homes rates shall vary based on
				licensed bed size;
b. Group
				supported employment rates shall vary by group size; and
c. In-home residential rates shall vary by
				the number of individuals being served in the same home by one direct service
				professional.
3. There
				shall be up to four tiers of reimbursement for these services: community
				engagement, group day support, group home, independent living, sponsored
				residential support, and supported living residential. Four reimbursement tiers
				for providers shall be based on seven levels of support (as detailed in
				12VAC30-122-200 ) from resultant scores of the
				SIS®, the responses to the Virginia Supplemental
				Questions, and, as needed, a document review verification process. The DMAS
				designee shall verify the scores and levels of the individuals, as appropriate.
a. Levels of supports range from Level 1 to
				Level 7 based on the needs of the individuals.
b. Tiers of reimbursement:
(1) Tier 1 shall be used for individuals
				having Level 1 support needs.
(2)
				Tier 2 shall be used for individuals having Level 2 support needs.
(3) Tier 3 shall be used for individuals
				having either Level 3 or Level 4 support needs.
(4) Tier 4 shall be used for individuals
				having either Level 5, Level 6, or Level 7 support needs.
4. Individual-specific support
				needs, such as the intense and significant medical or behavioral supports
				needs, may warrant customized rates for additional supports as described in
				this section, in the following service settings: community coaching service,
				group day service, in-home support service, group home residential service,
				sponsored residential service, and supported living residential service.
a. In these cases, providers shall submit to
				the DMAS designee a request for a customized reimbursement rate exceeding the
				reimbursement rate for the assessed level of support of the individual. The
				request shall include contact information and a detailed explanation of the
				basis for the request, such as the individual's support needs, increased
				staffing supports needed for the individual, the types of service for which the
				request is made, increased program oversight needed for the individual, the
				individual's behavior or medical support needs, or the individual's need for
				staff with certain qualifications.
b. The request shall be reviewed by a team of
				clinical and administrative personnel from the DMAS designee to determine that
				the documentation substantiates the intense needs of the individual, whether
				medical, behavioral, or both, and that the provider has employed staff with
				higher qualifications (e.g., direct support professionals with four-year
				degrees) or increased the ratio of staff-to-individual support of one staff
				person to one individual (1:1) or, in the case of services already required to
				be provided at a 1:1 ratio, a two staff persons to one individual (2:1) ratio.
c. The customized rate methodology
				shall modify the existing rate methodology assumptions for the following
				components in the existing rate methodologies: additional hours related to
				increased or specialized staffing supports and program costs.
d. Customized reimbursement rate
				determinations may be appealed pursuant to
				12VAC30-20-500 et
				seq.
e. For those individuals
				approved for customized rates, providers shall submit to the DMAS designee at
				least annually a request if seeking continuation of the customized
				reimbursement rate. The request shall include the items specified in
				12VAC30-122-210 A 4 a, as well as documentation of continued need for a
				reimbursement rate exceeding the reimbursement rate for the assessed level of
				support of the individual. The DMAS designee shall review the request in the
				manner specified in subdivision A 4 b of this section. After the review,
				adjustment determinations for the customized rate may be made. All such
				adjustment determinations may be appealed pursuant to
				12VAC30-20-500 et
				seq.