Current through Register Vol. 41, No. 3, September 23, 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.
B. The
evaluation shall be the screening as designated in §
32.1-330
of the Code of Virginia, which shall preauthorize a continuum of LTSS covered
by Medicaid. These screenings shall be conducted face to face.
1. Such screenings, using the UAI, shall be
conducted by teams of representatives of (i) hospitals for individuals (adults
and children) who are inpatients; (ii) local departments of social services and
local health departments, known herein as CBTs, for adults residing in the
community and who are not inpatients; (iii) a DMAS designee for children
residing in the community who are not inpatients; and (iv) a DMAS designee for
adults residing in the community who are not inpatients and who cannot be
screened by the CBT within 30 days of the request date. All of these entities
shall be contracted with DMAS to perform this activity and be reimbursed by
DMAS.
2. All screenings shall be
comprehensive, accurate, standardized, and reproducible evaluations of
individual functional capacities, medical or nursing needs, and whether the
individual is at risk for institutional placement within 30 days of the
screening.
C.
Individuals shall not be required to be financially eligible for receipt of
Medicaid or have submitted an application for Medicaid in order to be screened
for LTSS for admission to either a NF or home and community-based
services.
D. Pursuant to §
32.1-330
of the Code of Virginia, individuals shall be screened if they are financially
eligible for Medicaid or are anticipated to become financially eligible for
Medicaid reimbursement of their NF care within six months of NF admission or
Medicaid reimbursement of home and community-based services and
supports.
E. Special circumstances.
1. Private pay individuals who will not
become financially eligible for Medicaid within six months from admission to a
Virginia nursing facility shall not be required to have a screening in order to
be admitted to the NF.
2.
Individuals who reside out of state and seek direct admission to a Virginia
nursing facility shall not be required to have a screening. Individuals who
need a screening for HCBS waiver or PACE programs and request the screening
shall be screened by the CBT or DMAS designee, as appropriate, serving the
locality in which the individual resides once the individual has relocated to
the Commonwealth.
3. Individuals
who are inpatients in an out-of-state hospital, in-state or out-of-state
veteran's hospital, or in-state or out-of-state military hospital and seek
direct admission to a Virginia NF shall not be required to have a screening.
Individuals who need a screening for HCBS waiver or PACE programs and request
the screening shall be referred, upon discharge from one of the identified
facilities, to the CBT or DMAS designee, as appropriate, serving the locality
in which the individual resides once the individual has relocated to the
Commonwealth.
4. Individuals who
are patients or residents of a state owned or operated facility that is
licensed by DBHDS and seek direct admission to a Virginia NF shall not be
required to have a screening. Individuals who need a screening for HCBS waiver
or PACE and request the screening shall be referred, upon discharge from the
facility, to the CBT or DMAS designee, as appropriate, serving the locality in
which the individual resides.
5. A
screening shall not be required for enrollment in Medicaid hospice services as
set out in 12VAC30-50-270 or home health services as set out in
12VAC30-50-160.
6. Wilson Workforce
Rehabilitation Center (WWRC) staff shall perform screenings of the WWRC
clients.
F. Failure to
comply with DMAS requirements, including competency and training requirements
applicable to staff, may result in retraction of Medicaid payments.
Statutory Authority: §
32.1-325
of the Code of Virginia;
42 USC §
1396 et
seq.
