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 12VAC30-120-905 - Waiver description and legal authority

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  Commonwealth Coordinated Care Plus (CCC Plus) Waiver operates under the
				  authority of § 1915 (c) of the Social Security Act and 42 CFR 430.25(b),
				  which permit the waiver of certain State Plan requirements. These federal
				  statutory and regulatory provisions permit the establishment of Medicaid
				  waivers to afford the states with greater flexibility to devise different
				  approaches to the provision of long-term services and supports. Under this
				  § 1915(c) waiver, DMAS waives § 1902(a)(10)(B) and (C) of the Social
				  Security Act related to comparability of services.
B. CCC Plus Waiver services shall be covered
				  only for Medicaid-eligible individuals who have been determined eligible to
				  require the level of care provided in either a nursing facility, specialized
				  care nursing facility, or long-stay hospital. These services shall be the
				  critical service necessary to delay or avoid the individual's placement in an
				  appropriate facility.
C. Federal
				  waiver requirements provide that the current aggregate average cost of care
				  fiscal year expenditures under this waiver shall not exceed the average per
				  capita expenditures in the aggregate for the level of care (LOC) provided in a
				  nursing facility (NF), specialized care nursing facility, or long-stay hospital
				  under the State Plan that would have been provided had the waiver not been
				  granted.
D. DMAS shall be the
				  single state agency authority, pursuant to 42 CFR 431.10, responsible for the
				  processing and payment of claims for the services covered in this waiver and
				  for obtaining federal financial participation from CMS.
E. Payments for CCC Plus Waiver services
				  shall not be provided to any financial institution or entity located outside of
				  the United States pursuant to § 1902(a)(80) of the Social Security Act.
				  Payments for CCC Plus Waiver services furnished in another state shall be (i)
				  provided for an individual who meets the requirements of 42 CFR 431.52 and (ii)
				  limited to the same service limitations that exist when services are rendered
				  within the Commonwealth's political boundaries. Waiver services shall not be
				  covered for Medicaid-eligible individuals who are inpatients of a hospital,
				  nursing facility (NF), intermediate care facility for individuals with
				  intellectual disabilities (ICF/IID), rehabilitation hospitals, assisted living
				  facility licensed by VDSS that serves five or more persons, long-stay
				  hospitals, specialized care nursing facilities, adult foster homes, or group
				  homes licensed by DBHDS.
F. An
				  individual shall not be simultaneously enrolled in more than one waiver program
				  but may be listed on the waiting list for another waiver program as long as
				  criteria are met for both waiver programs.
G. DMAS shall be responsible for the
				  following:
1. Placing individuals in
				  appropriate services that are home and community based;
2. Providing reimbursement for waiver
				  services only after the provider is enrolled and the individual's eligibility
				  process is complete;
3. Not
				  duplicating services that are required as a reasonable accommodation as a part
				  of the Americans with Disabilities Act (42 USC §§ 12131 through
				  12165) or the Rehabilitation Act of 1973 (29 USC § 794). CCC Plus Waiver
				  services shall not be authorized if another entity is required to provide the
				  services (e.g., schools, insurance) because these waiver services shall not
				  duplicate payment for services available through other programs or funding
				  streams; and
4. Ensuring providers
				  meet the following requirements:
a. Providers
				  shall consider DMAS payment for services under this waiver as payment in full
				  and no balance billing from the provider to the individual, any family member,
				  caregiver, or the employer of record (EOR) of the waiver individual shall be
				  permitted; and
b. Additional
				  voluntary payments or gifts from family members shall not be accepted by
				  providers of services.