Section 100. Definitions

Part II. Children's Mental Health Waiver

The following words and terms when used in this regulation shall have the following meanings unless the context clearly indicates otherwise:

"Activities of daily living" or "ADLs" means personal care tasks, e.g., bathing, dressing, toileting, transferring, and eating/feeding. A client's degree of independence in performing these activities is a part of determining appropriate level-of-care and services.

"Agency-directed model" means services provided by a participating provider and where the provider is responsible for hiring, training, supervising, and firing of the staff.

"Appeal" means the process used to challenge adverse actions regarding services, benefits and reimbursement provided by Medicaid pursuant to 12VAC30-110 and 12VAC30-20-500 through 12VAC30-20-560.

"Approve" means the Department of Medical Assistance Services (DMAS) or a DMAS-contracted entity authorizes a participating provider's request for services, on behalf of a client, as medically necessary and meeting DMAS criteria for reimbursement.

"Assessment" means a face-to-face meeting conducted to identify a client's physical, emotional, behavioral, and social strengths, preferences, and needs. Assessments are performed by a DMAS-authorized provider prior to the development of the individualized service plan (ISP) and comprehensive service plan (CSP).

"Barrier crime" means those crimes as defined at § 32.1-162.9:1 or 37.2-416 of the Code of Virginia.

"Behavioral health authority" or "BHA" means the local agency, established by a city or county or combination of counties or cities or cities and counties under Chapter 1 (§ 37.2-100 et seq.) of Title 37.2 of the Code of Virginia, that plans, provides, and evaluates mental health, mental retardation, and substance abuse services in the locality or localities that it serves.

"Case management" means the assessing and planning of services; linking the client to services and supports identified in the comprehensive service plan (CSP); assisting the client directly for the purpose of locating, developing or obtaining needed services and resources; coordinating services and service planning with other agencies and providers involved with the client; enhancing community integration; making collateral contacts to promote the implementation of the CSP and community integration; monitoring to assess ongoing progress and ensuring services are delivered; and education and counseling that guides the client and develops a supportive relationship that promotes the CSP.

"Case manager" means the individual on behalf of a DMAS participating provider possessing a combination of work experience and relevant education that indicates that the individual possesses the knowledge, skills and abilities, at the entry level to provide the services described, at 12VAC30-50-420 through 12VAC30-50-430 or 12VAC30-50-480 or 12VAC30-50-130 B 5 a for case management services. The case manager may be the provider of Intensive In-Home Services or the Treatment Foster Care Case Manager or other provider as designated by DMAS.

"Centers for Medicare and Medicaid Services" or "CMS" means the unit of the federal Department of Health and Human Services that administers the Medicare and Medicaid programs.

"Child" means, for the purpose of this regulation, an individual under the age of 21 years.

"Client" means the person receiving the services.

"CMH waiver" means the Children's Mental Health § 1915(c) home and community-based services demonstration waiver.

"Community services board" or "CSB" means the local agency established by a city or county or combination of cities and/or counties under Chapter 5 (§ 37.2-500 et seq.) of Title 37.2 of the Code of Virginia, that plans, provides, and evaluates mental health, mental retardation, and substance abuse services in the jurisdiction or jurisdictions it serves.

"Community transition services" means services that are provided to individuals who are leaving the PRTF and have chosen to receive services in the community. Community transition services include assessment of the child and family; assistance with meeting the requirements of waiver enrollment; referral for Medicaid eligibility; developing a community plan of care in coordination with the family, CSA (if involved), and other involved parties; identifying community service providers; and monitoring the initial transition to the community.

"Companion" means, for the purpose of these regulations, an individual who provides companion services.

"Companion services" means assistance with skill development and with understanding family interaction, behavioral interventions for support and safety, nonmedical care, nonmedical transportation, community integration, and rewarding appropriate behaviors. This service is available through both a consumer-directed (CD) and agency-directed delivery approach and shall not exceed eight hours in one day.

"Comprehensive Services Act" or "CSA" means a collaborative system of services and funding that is child-centered, family-focused, and community-based when addressing the strengths and needs of troubled and at-risk youth and their families.

"Comprehensive service plan" or "CSP" means the overall service plan that addresses the total needs of the client in all life areas. The CSP incorporates the ISPs developed for each individual service. The CSP defines and describes the goals, objectives and expected outcomes of service(s). The client or family/caregiver, as appropriate, will be involved to the maximum extent possible in the development and revision of the CSP. The CSP includes, at a minimum: (i) a summary or reference to the assessment; (ii) goals and measurable objectives for addressing each identified need; (iii) the services, supports, and frequency of service to accomplish the goals and objectives; (iv) target dates for accomplishment of goals and objectives; (v) estimated duration of service; (vi) the role of other agencies if the plan is a shared responsibility; and (vii) the staff responsible for coordination and integration of services, including the staff of other agencies if the plan is a shared responsibility.

"Consumer-directed model" or "CD" means services for which the client or family/caregiver is responsible for hiring, training, supervising, and firing of the staff.

"Consumer-directed services facilitator" means the DMAS-enrolled provider who is responsible for supporting the client by ensuring the development and monitoring of the CD services individualized service plan (ISP), and completing ongoing review activities as required by DMAS for CD companion services and CD respite services.

"Deny" means DMAS or a DMAS-contracted entity denies a participating provider's request for services, on behalf of a client, as not medically necessary or not meeting DMAS criteria for reimbursement.

"DMAS" means the Department of Medical Assistance Services or its contractors.

"DMAS staff" means individuals employed by DMAS.

"DMHMRSAS" means the Department of Mental Health, Mental Retardation and Substance Abuse Services.

"DSM-IV" means the Diagnostic and Statistical Manual of Mental Disorders that is the standard classification of mental disorders used by mental health professionals.

"DSM-IV-TR" means the text revision of the DSM-IV, published in July 2000, which corrected errors identified in the DSM-IV and included numerous changes to the classification (i.e., disorders were added, deleted, and reorganized), to the diagnostic criteria sets, and to the descriptive text.

"DSS" means the Department of Social Services.

"Enroll" means that a client has been added to the CMH waiver after it has been determined that the client meets all of the eligibility requirements for the waiver.

"Environmental modifications" means physical adaptations to a client's home or primary place of residence or primary vehicle, which provide direct medical or remedial benefit to the client. These adaptations are necessary to ensure the health, welfare, and safety of the client, or enable the client to function with greater independence in the home. Without these adaptations, the client would require institutionalization in a psychiatric residential treatment facility (PRTF).

"EPSDT" means the "Early Periodic Screening, Diagnosis and Treatment" program administered by DMAS for children under the age of 21 according to federal guidelines that prescribe specific preventive and treatment services for Medicaid-eligible children as defined in 12VAC30-50-130.

"Family/caregiver" means the family, legal guardian, neighbor, friend, companion or co-worker, or any person who provides uncompensated care, training, guidance, companionship or support to a person served under this waiver.

"Family/caregiver training" means training and counseling services provided to families or caregivers of clients receiving services in the CMH waiver. Training includes instruction about treatment regimens and behavioral plans specified in the ISP, and shall include updates as necessary to safely maintain the client at home. Counseling may be provided to the family/caregiver to improve and develop the family's/caregiver's skills in dealing with life circumstances of parenting a child with special needs and help the client remain at home. All training/counseling will be provided on a face-to-face basis.

"Fiscal management service" or "FMS" means an agency or organization within DMAS or contracted by DMAS to handle employment, payroll, and tax responsibilities on behalf of clients who are receiving CD respite and companion services.

"Health, welfare, and safety standard" means 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 be provided safely in the community.

"Home and community-based waiver services" or "waiver services" means a variety of home and community-based services reimbursed by DMAS as authorized pursuant to § 1915(c) of the Social Security Act designed to offer clients an alternative to institutionalization. Clients may be pre-authorized to receive one or more of these services either solely or in combination, based on the documented need for the service in order to discharge the client from a PRTF.

"Individualized service plan" or "ISP" means the specific service plan developed by the service provider related solely to the specific tasks required of that service provider. The client will be involved to the maximum extent possible in the development and revision of the ISP. The ISP helps to comprise the overall CSP. The ISP includes, at a minimum: (i) a summary or reference to the assessment; (ii) goals and measurable objectives for addressing each identified need; (iii) the services, supports, and frequency of service to accomplish the goals and objectives; (iv) target dates for accomplishment of goals and objectives; (v) estimated duration of service; (vi) the role of other agencies if the plan is a shared responsibility; and (vii) the staff responsible for coordination and integration of services, including the staff of other agencies if the plan is a shared responsibility.

"In-home residential supports" means agency-directed services that increase or maintain personal self sufficiency, and facilitate the client's achievement of community inclusion and remaining in the home. The supports may be provided in the client's residence or in community settings. Community living supports provides assistance to the family in the care of their child, while facilitating the client's independence and integration into the community. The service also includes communication and relationship-building skills, and participation in leisure and community activities. These supports must be provided directly to, or on behalf of, the client enabling the client to attain or maintain his maximum potential. These supports may serve to reinforce skills or lessons taught in school, therapy, or other settings.

"Instrumental activities of daily living" or "IADLs" means tasks such as meal preparation, shopping, housekeeping, laundry, and money management.

"Legal guardian" means a person who has been legally authorized to take care of and make decisions for the client in order to protect the interests of a minor client or an adult who has been declared by the circuit court to be incapable of administering his own affairs. The powers and duties of the guardian are defined by the court and are limited to matters within the areas where the client has been determined to be incapacitated.

"Level-of-care" means the psychiatric residential treatment facility (PRTF) criteria. Review of a client's level-of-care requires the case manager to assure that the client continues to meet the PRTF criteria.

"Licensed mental health professional" or "LMHP" means a clinician in the human services field as defined at 12VAC30-50-226.

"Participating provider" means a person, institution, facility, agency, partnership, corporation, or association that meets the standards and requirements set forth by DMAS, and has a current, signed provider participation agreement with DMAS.

"Pend" means delaying the consideration of a provider's request, on behalf of a client, for services until all required information is received by the preauthorization entity.

"Person-centered planning" means a process, directed by the client or family/caregiver, as appropriate, with assistance as needed from others involved in the care of the child. Person-centered planning shall be intended to identify the strengths, capacities, preferences, needs and desired outcomes of the client.

"Personal care agency" means a participating provider that renders services designed to prevent or reduce institutional care by providing eligible clients with companions and assistants who provide companion or respite services.

"Preauthorization" means the process to approve specific services for a client by a Medicaid-enrolled provider prior to service delivery and reimbursement.

"Preauthorized" means that an individual's comprehensive service plan has been approved by DMAS or a DMAS-approved entity prior to commencement of the service by the service provider for provision and reimbursement of services.

"Primary caregiver" means the primary person who consistently assumes the role of providing direct care and support of the client to live successfully in the community without compensation for providing such care.

"Psychiatric residential treatment facility" or "PRTF" means a facility that provides 24-hour-per-day specialized, highly organized, intensive, and planned therapeutic interventions to children that are utilized to treat severe mental, emotional, and behavioral disorders.

"Qualified mental health professional" or "QMHP" means a clinician in the human services field as defined at 12VAC30-50-226.

"Respite care agency" means a participating provider that renders services designed to prevent or reduce inappropriate institutional care by providing respite services to eligible clients for their caregivers.

"Respite services" means services provided to clients and their families to offer relief to unpaid caregivers. Respite services will be provided in the client's home or place of residence, in the community, or a licensed respite facility, such as a group home. This service is available through both a CD and agency-directed delivery approach.

"Screening" means the process to evaluate the medical, emotional, psychiatric, and social needs of clients referred for screening to determine client's eligibility to be discharged from a PRTF, and to authorize Medicaid-funded community-based care for those clients who meet the CMH waiver eligibility criteria.

"Screener" means the entity or entities identified by DMAS that is responsible for performing screening for the CMH waiver.

"Serious emotional disturbance" or "SED" means a serious mental health problem in children ages birth through 21 that can be diagnosed under the DSM-IV-TR, or exhibited by all of the following: (i) problems in personality development and social functioning that have been exhibited over at least one year's time; and (ii) problems that are significantly disabling based upon the social functioning of most children that age; and (iii) problems that have become more disabling over time; and (iv) service needs that require significant intervention by more than one agency.

"Service provider" means the entity providing direct services to the client.

"Services facilitator" means the participating provider who is responsible for supporting the client by ensuring the development and monitoring of the CD Services ISP, providing employee management training, and completing ongoing review activities as required by DMAS for services with an option of a CD model. These services include companion and respite services.

"State Plan for Medical Assistance" or "the Plan" means the Commonwealth's legal document approved by CMS identifying the covered groups, covered services and their limitations, and provider reimbursement methodologies as provided for under Title XIX of the Social Security Act.

"Therapeutic consultation" means services that provide expertise, training, and technical assistance by licensed professionals to assist family members, caregivers, and other service providers in supporting the client. This service includes the assessment of the client and family strengths, observation, and developing, with the family, a culturally sensitive ISP.

"Uniform Assessment Instrument" means the uniform assessment instrument, as designated by DMAS, used to measure functional outcomes for children. This tool is used by the screener as one component of its assessment and is used to inform but not dictate a level-of-care. The completion of this tool is required for children who participate in the CMH waiver. This tool is separate from the UAI used for long-term care services in other home and community-based services waivers.

Historical Notes

Derived from Volume 24, Issue 02, eff. December 1, 2007.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.