12 Va. Admin. Code § 30-122-210 - Payment for covered services (tiers)
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.
B.
Reimbursement rates for individual supported employment shall be the same as
set by the Department for Aging and Rehabilitative Services for each individual
supported employment provider agency.
C. Reimbursement for assistive technology
(AT) service (12VAC30-122-270 ), electronic home-based support service
(12VAC30-122-360 ), environmental modifications (EM) service (12VAC30-122-370
), individual and family/caregiver training service (12VAC30-122-430 ), and
transition service (12VAC30-122-560 ) shall be reimbursed based on approved
costs subject to the following limits:
1. AT
and EM approved costs for items and labor shall be reimbursed up to a per
individual, per service maximum of $5,000 per calendar year across all home and
community-based waivers.
2.
Transition services approved costs shall be reimbursed up to a per individual
maximum of $5,000 per lifetime across all home and community-based
waivers.
3. Electronic home-based
support approved costs shall be reimbursed up to a per individual maximum of
$5,000 per ISP year.
4. Individual
and family/caregiver training approved costs shall be reimbursed up to a per
individual maximum of $4,000 per ISP year.
D. Duplication of services.
1. DMAS shall not duplicate the reimbursement
for services that are required as a reasonable accommodation as a part of the
Americans with Disabilities Act (
42
USC §
12131 through 42 USC §
12165), the Rehabilitation Act of 1973 (
29 USC §
701 et seq.), the Virginians with
Disabilities Act (Title 51.5 (§
51.5-1 et
seq.) of the Code of Virginia), or any other applicable statute.
2. Payment for services under individual ISPs
shall not duplicate payments made to public agencies or private entities under
other program authorities for this same purpose.
3. Payment for services under individual ISPs
shall not be made for services that are duplicative of each other.
4. Payment for services shall only be
provided for services as set out in an individual's ISP.
5. Payments that are determined to have been
made contrary to these limitations shall be recovered by either DMAS or its
designee.
Notes
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
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