12 Va. Admin. Code § 30-122-10 - Purpose; legal authority; covered services; aggregate cost effectiveness; required individual and provider enrollment; individual costs

A.

1. Supports individuals with developmental disabilities to live integrated and engaged lives in their communities;

2. Standardizes and simplifies access to services;

3. Sets out and defines services that promote community integration and engagement; and

4. Improves provider capacity and quality to render covered services;

B. Legal authority.

1. Selected home and community-based waiver services shall be available through § 1915(c) waivers of the Social Security Act ( 42 USC § 1396n ). The waivers shall be named (i) Family and Individual Supports (FIS), (ii) Community Living (CL), and (iii) Building Independence (BI) and are collectively referred to as the Developmental Disabilities (DD) Waivers. These waiver services shall be required, appropriate, and medically necessary to maintain an individual in the community instead of placement in an institution.

2. The Department of Medical Assistance Services (DMAS), the single state agency pursuant to 42 CFR 431.10 responsible for administrative authority over service authorizations, delegates the processing of service authorizations and daily operations to the Department of Behavioral Health and Developmental Services in accordance with the interagency Memorandum of Understanding. DMAS shall be the single state agency authority pursuant to 42 CFR 431.10 for payment of claims for the services covered in the DD Waivers and for obtaining federal financial participation from the Centers for Medicare and Medicaid Services.

C. Covered services. The services covered in the Developmental Disabilities Waivers shall be:

1. Assistive technology service (12VAC30-122-270;

2. Benefits planning service (12VAC30-122-280 );

3. Center-based crisis support service (12VAC30-122-290 );

4. Community-based crisis support service (12VAC30-122-300 );

5. Community coaching service (12VAC30-122-310 );

6. Community engagement service (12VAC30-122-320 );

7. Community guide service (12VAC30-122-330 - reserved);

8. Companion service (12VAC30-122-340 );

9. Crisis support service (12VAC30-122-350 );

10. Electronic home-based support service (12VAC30-122-360 );

11. Environmental modification service (12VAC30-122-370 );

12. Group day service (12VAC30-122-380 );

13. Group home residential service (12VAC30-122-390 );

14. Group and individual supported employment service (12VAC30-122-400 );

15. In-home support service (12VAC30-122-410 );

16. Independent living support service (12VAC30-122-420 );

17. Individual and family/caregiver training service (12VAC30-122-430 );

18. Employment and Community Transportation (12VAC30-122-440 );

19. Peer support service (12VAC30-122-450 );

20. Personal assistance service (12VAC30-122-460 );

21. Personal emergency response system service (12VAC30-122-470 );

22. Private duty nursing service (12VAC30-122-480 );

23. Respite service (12VAC30-122-490 );

24. Services facilitation service (12VAC30-122-500 );

25. Shared living support service (12VAC30-122-510 );

26. Skilled nursing service (12VAC30-122-520 );

27. Sponsored residential support service (12VAC30-122-530 );

28. Supported living residential service (12VAC30-122-540 );

29. Therapeutic consultation service (12VAC30-122-550 );

30. Transition service (12VAC30-122-560 ); and

31. Workplace assistance service (12VAC30-122-570 ).

D. Aggregate cost effectiveness. Federal waiver requirements, as established in § 1915 of the Social Security Act and 42 CFR 430.25, provide that the average per capita fiscal year expenditures in the aggregate under the DD Waivers shall not exceed the average per capita expenditures in the aggregate for the level of care provided in ICFs/IID, as defined in 42 CFR 435.1010 and 42 CFR 483.440, under the State Plan for Medical Assistance that would have been provided had the DD Waivers not been granted.

E. No waiver services shall be reimbursed until after both the provider enrollment process and the individual eligibility determination process have been completed and the individual is enrolled in a waiver. A determination of individual eligibility for waiver services shall not determine claim reimbursement. To be considered for reimbursement, a provider's claims must be for services rendered to individuals enrolled to receive waiver services.

1. No back-dated payments shall be made for services that were rendered before the completion of the provider enrollment and the individual waiver enrollment processes.

2. Individuals who are enrolled in these waivers who choose to employ their own companions or assistants prior to the completion of the provider enrollment process shall be responsible for reimbursing such costs themselves.

3. No back dating of provider enrollment requirements shall be permitted DMAS will not reimburse for prematurely incurred costs.

F. With the exception of costs specified in subsection E of this section that waiver individuals may elect to incur, no costs for evaluations or assessments that may be required by either DMAS or DBHDS shall be borne by the individual.

Notes

12 Va. Admin. Code § 30-122-10

Derived from Virginia Register Volume 37, Issue 14, eff. 3/31/2021.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.