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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 12. Health |
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Agency 30. Department of Medical Assistance Services |
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Chapter 135. Demonstration Waiver Services |
Section 120. General coverage and requirements for Children’s Mental Health Waiver services
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A. Waiver service populations. Home and community-based waiver services shall be available through a § 1915(c) of the Social Security Act waiver for clients under the age of 21 who have resided in a PRTF for at least 90 days and have been determined to continue to meet PRTF level-of-care, but with additional supports could reside in the community.
B. Required documentation, as identified by DMAS, for admission to the CMH waiver must be submitted to DMAS in order for the client to be enrolled. Upon determination by DMAS or a DMAS-contracted entity that the client is appropriate for admission to the waiver, the case manager or screener will work with the client family/caregiver, the facility currently housing the client, and client/family/caregiver-selected providers of community-based services to determine an appropriate transfer date.
C. Covered services.
1. Covered services shall include respite services (both CD and agency-directed), in-home residential supports, companion services (both CD and agency-directed), family/caregiver training, environmental modifications, community transition services and therapeutic consultation.
2. These services shall be medically appropriate and necessary to maintain the client in the community. Federal waiver requirements provide that the overall costs of community care shall be no more than the overall costs that would have been incurred at the same level of service in the PRTF.
3. Waiver services shall not be furnished to clients who are inpatients of a hospital, nursing facility, intermediate care facility for persons with mental retardation, inpatient rehabilitation facility, or a PRTF consistent with federal waiver limitations.
4. Under this § 1915(c) waiver, DMAS waives § 1902(a)(10)(B) of the Social Security Act related to comparability.
D. Requests for services. All requests for waiver services by CMH waiver clients will be reviewed under the health, welfare, and safety standard. This standard assures that a client's right to receive a waiver service is dependent on a finding that the client needs the service, based on appropriate assessment criteria and a written CSP and that services can safely be provided in the community. If the determination is made that these services cannot be safely provided to a client, then such clients shall not be approved for this waiver.
E. Medicaid reimbursement is available only for services provided when the client is present and when a qualified provider is providing the services. If the client is absent, such as in a hospitalization, no reimbursement will be provided for these waiver services.
F. Appeals. Individual appeals shall be considered pursuant to 12VAC30-110-10 through 12VAC30-110-380. Provider appeals shall be considered pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.
G. Reevaluation of service need and utilization review. Reviews and updates of the CSP and level-of-care must meet the requirements as specified by DMAS. Providers shall meet the documentation requirements as specified by DMAS and DMAS will conduct quality management reviews for services rendered. Services failing to meet DMAS' quality management standards shall not be reimbursed or shall be subject to payment recoveries.
Historical Notes
Derived from Volume 24, Issue 02, eff. December 1, 2007.