Section 1610. Individual eligibility requirements

A. Waiver service population. The AAL Waiver shall be available through a § 1915(c) of the Social Security Act waiver to eligible aged and disabled Auxiliary Grant individuals who live in licensed assisted living facilities.

B. Eligibility criteria. To qualify for AAL Waiver services, individuals shall meet all of the following criteria:

1. The waiver individual shall be either:

a. Elderly as defined by § 1614 of the Social Security Act; or

b. Disabled as defined by § 1614 of the Social Security Act.

2. The waiver individual shall meet the criteria for admission to a nursing facility as determined by a preadmission screening team using the full UAI.

3. The waiver individual shall (i) have a diagnosis of either Alzheimer's or a related dementia as diagnosed by a licensed clinical psychologist or a licensed physician, or (ii) be a resident with a serious cognitive impairment, who resides in a safe, secure environment as defined in 22VAC40-72-10.

4. The waiver individual shall be receiving an Auxiliary Grant, and living in or seeking admission to a safe, secure unit of a DMAS-enrolled assisted living facility.

C. The waiver individual may not have a diagnosis of intellectual disability, as defined by the American Association on Intellectual and Developmental Disabilities, or a serious mental illness as defined in 42 CFR 483.102(b).

D. Assessment. Medicaid will not pay for any AAL Waiver services delivered prior to the date of the preadmission screening by the preadmission screening team and the physician signature on the Medicaid-Funded Long-Term Care Services Authorization Form (DMAS-96). Medicaid will not pay for any AAL Waiver services delivered prior to the individual's effective date of Medicaid eligibility and qualification for an Auxiliary Grant.

E. Enrollment. For the enrollment of all CMS-approved waiver slots, individuals will be reviewed on a first-come, first-served basis in accordance with available waiver funding. If there is no waiver slot available for an individual, the individual shall be placed on the waiting list. Individuals shall meet all waiver eligibility criteria in order to be placed on the waiting list.

F. Preauthorization. Before a provider can bill DMAS for AAL Waiver services, preauthorization shall be obtained from DMAS. Providers shall submit all required information to the designated preauthorization contractor within 10 business days of initiating care. If the provider submits all required information to the designated preauthorization contractor within 10 business days of initiating care, services may be authorized beginning from the date the provider initiated services but not preceding the date of the physician's signature on the Medicaid-Funded Long-Term Care Services Authorization Form (DMAS-96). If the provider does not submit all required information to either the designated preauthorization contractor or DMAS within 10 business days of initiating care, the services may be authorized beginning with the date all required information was received by the designated preauthorization contractor, but in no event preceding the date of the preadmission screening team physician's signature on the DMAS-96.

G. Review of the waiver individual's level of care. DMAS conducts this review based on the documentation submitted by the provider. The level of care assessments are performed to ensure that individuals receiving services in the waiver continue to meet the criteria for the waiver.

H. Termination of services. In the case of termination of AAL Waiver services by DMAS, waiver individuals shall be notified of their appeal rights pursuant to 12VAC30-110, Eligibility and Appeals. DMAS may terminate AAL Waiver services for any of the following reasons:

1. The AAL Waiver is no longer required to prevent or delay institutional placement;

2. The waiver individual is no longer eligible for Medicaid;

3. The waiver individual is no longer eligible to receive an Auxiliary Grant;

4. The waiver individual no longer meets AAL Waiver criteria;

5. The waiver individual has been absent from, or has not received services from, the assisted living facility for more than 30 consecutive days;

6. The waiver individual's environment does not provide for his health, safety, and welfare; or

7. The assisted living facility no longer meets safe and secure licensing standards set by DSS or standards set by DMAS for service providers.

Historical Notes

Derived from Volume 23, Issue 20, eff. July 11, 2007; amended, Virginia Register Volume 28, Issue 20, eff. July 5, 2012; Volume 31, Issue 25, eff. September 9, 2015.

Statutory Authority

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