Section 160. Participation standards for home and community-based waiver services participating providers

A. Requests for participation. Requests for participation from providers will be evaluated to determine whether the provider applicant meets the basic requirements for participation.

B. Providers approved for participation shall, at a minimum, perform the following activities:

1. For services that require licensure and/or certification, the provider must meet all licensure and/or certification requirements pursuant to 42 CFR 440.50 and 42 CFR 440.60 and any other applicable state or federal requirements;

2. The ability to document and maintain client case records in accordance with state and federal requirements;

3. Immediately notify DMAS in writing of any change in the information that the provider previously submitted to DMAS;

4. Assure freedom of choice to the client or family/caregiver, as appropriate, in seeking services from any institution, pharmacy, practitioner, or other provider qualified to perform the service or services required and participating in the Medicaid program at the time the service or services are performed;

5. Assure the freedom of the client or family/caregiver, as appropriate, to refuse medical care, treatment and services;

6. Accept referrals for services only when staff is available to initiate services and perform such services on an ongoing basis;

7. Provide services and supplies to clients in full compliance with Title VI of the Civil Rights Act of 1964, as amended (42 USC § 2000d et seq.), which prohibits discrimination on the grounds of race, color, or national origin; the Virginians with Disabilities Act (§ 51.5-1 et seq. of the Code of Virginia); § 504 of the Rehabilitation Act of 1973, as amended (29 USC § 794), which prohibits discrimination on the basis of a disability; and the Americans with Disabilities Act, as amended (42 USC § 12101 et seq.), which provides comprehensive civil rights protections to clients with disabilities in the areas of employment, public accommodations, state and local government services, and telecommunications;

8. Provide services and supplies to clients of the same quality and in the same mode of delivery as are provided to the general public;

9. Submit charges to DMAS for the provision of services and supplies to clients in amounts not to exceed the provider's usual and customary charges to the general public and accept as payment in full the amount established by DMAS' payment methodology beginning with the onset of the client's authorization date for the waiver services;

10. Use program-designated billing forms for submission of charges;

11. Maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the services provided;

a. In general, such records shall be retained for at least six years from the last date of service or as provided by applicable state or federal laws, whichever period is longer. However, if an audit is initiated within the required retention period, the records shall be retained until the audit is completed and every exception resolved. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years.

b. Policies regarding retention of records shall apply even if the provider discontinues operation. DMAS shall be notified in writing of storage location and procedures for obtaining records for review should the need arise. The location and agent, or trustee shall be within the Commonwealth of Virginia.

c. Documentation must be maintained that indicates the date, type of services rendered, and the number of hours/units provided, including the specific time frames.

12. Agree to furnish information on request and in the form requested by DMAS, the Attorney General of Virginia or his authorized representatives, federal personnel, and the state Medicaid Fraud Control Unit. The Commonwealth's right of access to provider agencies and records shall survive any termination of the provider agreement;

13. Disclose, as requested by DMAS, all financial, beneficial, ownership, equity, surety, or other interests in any and all firms, corporations, partnerships, associations, business enterprises, joint ventures, agencies, institutions, or other legal entities providing any form of health care services to recipients of Medicaid;

14. Pursuant to 42 CFR Part 431, Subpart F, 12VAC30-20-90, and any other applicable state or federal law, hold confidential and use for authorized DMAS' purposes only all medical assistance information regarding clients served. A provider shall disclose information in his possession only when the information is used in conjunction with a claim for health benefits or the data is necessary for the functioning of DMAS in conjunction with the cited laws. DMAS shall not disclose medical information to the public;

15. Notify DMAS of change of ownership, as defined in 42 CFR 489.18. When ownership of the provider changes, DMAS shall be notified at least 15 calendar days before the date of change;

16. For all facilities covered by § 1616(e) of the Social Security Act in which home and community-based waiver services will be provided, be in compliance with applicable standards that meet the requirements for board and care facilities;

17. Suspected abuse or neglect. Pursuant to §§ 63.2-1509 and 63.2-1606 of the Code of Virginia, if a participating provider knows or suspects that a home and community-based waiver service client is being abused, neglected, or exploited, the party having knowledge or suspicion of the abuse, neglect, or exploitation shall report this immediately from first knowledge to the local DSS protective services worker, to DMAS, and to DMHMRSAS Offices of Licensing and Human Rights as applicable;

18. Adhere to the provider participation agreement and the DMAS provider service manual. In addition to compliance with the general conditions and requirements, all providers enrolled by DMAS shall adhere to the conditions of participation outlined in their individual provider participation agreements and in the DMAS provider manual.

D. Recipient choice of providers. The case manager must inform the client and family/caregiver of all available waiver providers in the community in which he desires services. The client and family/caregiver shall have the option of selecting the provider of his choice from among those providers who are able to meet his needs. A client's case manager shall not be the direct staff person or immediate supervisor of a staff person who provides CMH waiver services for the client.

E. Review of provider participation standards and renewal of contracts. DMAS is responsible for assuring continued adherence to provider participation standards. DMAS shall conduct ongoing monitoring of compliance with provider participation standards and DMAS policies and periodically recertify each provider for participation agreement renewal with DMAS to provide home and community-based waiver services. A provider's noncompliance with DMAS policies and procedures, as required in the provider's participation agreement, may result in a written request from DMAS for a corrective action plan that details the steps the provider must take and the length of time permitted to achieve full compliance with the plan to correct the deficiencies that have been cited.

F. Termination of provider participation. A participating provider may voluntarily terminate his participation in Medicaid by providing 30 days' written notification. DMAS may terminate at-will a provider's participation agreement on 30 days' written notice as specified in the DMAS participation agreement. DMAS may also immediately terminate a provider's participation agreement in the event of a breach of the contract by the provider as specified in the DMAS participation agreement and also if the provider is no longer eligible to participate in the program. Such action precludes further payment by DMAS for services provided to clients subsequent to the date of termination.

G. Reconsideration of adverse actions. A provider shall have the right to appeal adverse action taken by DMAS to the extent such action is appealable under the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia). Unless otherwise provided by law, adverse action includes, but shall not be limited to, termination of the provider participation agreement by DMAS and retraction of payments from the provider by DMAS for noncompliance with applicable law, regulation, policy, or procedure. All disputes regarding provider reimbursement or termination of the agreement by DMAS for any reason shall be resolved through administrative proceedings conducted at the office of DMAS in Richmond, Virginia, unless otherwise provided by law. These administrative proceedings and judicial review of such administrative proceedings shall be conducted pursuant to the Virginia Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia), the State Plan for Medical Assistance provided for in § 32.1-325 of the Code of Virginia, and duly promulgated regulations. Court review of final agency determinations concerning provider reimbursement shall be made in accordance with the Administrative Process Act.

H. Provider appeals shall be considered pursuant to 12VAC30-10-1000 and 12VAC30-20-500 through 12VAC30-20-560.

I. It is the responsibility of the case management provider to notify DMAS, in writing, when any of the following circumstances or events occurs:

1. Home and community-based waiver services are implemented;

2. A client dies;

3. A client is discharged from all waiver services;

4. Any other circumstances (including hospitalization) that cause home and community-based waiver services to cease or be interrupted for more than 30 days; or

5. A selection by the client of a different provider of case management services.

J. Changes or termination of services. The case manager shall authorize changes to a client's CSP based on the recommendations of the service provider and approval by the client or family/caregiver, as appropriate. Providers of direct service are responsible for modifying their ISP with the involvement of the client and family/caregiver and submitting ISPs to the case manager any time there is a change in the client's condition or circumstances that may warrant a change in the amount or type of service rendered. The case manager will review the need for a change and may recommend a change to the CSP and submit this change to the DMAS-contracted preauthorization entity. The preauthorization entity will review and approve, deny, or pend for additional information the requested change to the client's CSP, and communicate this to the case manager.

K. In the case of reduction, termination, suspension or denial of home and community-based waiver services by the preauthorization contractor or DMAS staff, clients shall be notified in writing of their appeal rights by the case manager pursuant to 12VAC30-110. The case manager shall have the responsibility to identify those clients who no longer meet the level-of-care criteria or for whom home and community-based waiver services are no longer an appropriate alternative to residential placement. All CSPs are subject to approval by the Medicaid agency.

L. Termination of a provider participation agreement upon conviction of a felony. Section 32.1-325 of the Code of Virginia mandates that "any such Medicaid agreement or contract shall terminate upon conviction of the provider of a felony." A provider convicted of a felony in Virginia or in any other of the 50 states or Washington, D.C., must, within 30 days, notify the Medicaid Program of this conviction and relinquish its provider participation agreement. Reinstatement will be contingent upon provisions of state law. In addition, termination of a provider participation agreement will occur as may be required for federal financial participation.

M. Changes or termination of care. It is the DMAS staff's responsibility to authorize any changes to a client's CSP based on the recommendations of the case manager. Participating providers providing direct service are responsible for modifying the ISP if the client/family/caregiver agrees. The provider must submit the ISP to the case manager any time there is a change in the client's condition or circumstances that may warrant a change in the amount or type of service rendered. The case manager must review the need for a change and will sign the ISP if he agrees to the changes. The case manager must submit the revised CSP to the DMAS staff to receive approval for that change. DMAS staff has the final authority to approve or deny the requested change.

1. Nonemergency termination of home and community-based care services by the participating provider. The participating provider must give the client and case manager 10 business days' written notification of the intent to terminate services. The letter must provide the reasons for and the effective date of the termination. The effective date of services termination must be at least 10 days from the date of the termination notification letter. The client is not eligible for appeal rights in this situation and may pursue services from another provider.

2. Emergency termination of home and community-based care services by the participating provider. In an emergency situation when the health and safety of the client or provider agency personnel is endangered, the case manager, DMAS and the DMHMRSAS Offices of Licensing and Human Rights must be notified prior to termination of services. The 10-business day written notification period shall not be required. If appropriate, the local DSS protective services unit must be notified immediately.

3. DMAS termination of eligibility to receive home and community-based care services. DMAS has the ultimate responsibility for assuring appropriate placement of the client in home and community-based care services and the authority to terminate such services to the client for the following reasons:

a. The client no longer meets the institutional level-of-care criteria;

b. The client's environment does not provide for his health, safety, and welfare; or

c. An appropriate and cost-effective CSP cannot be developed.

N. Documentation requirements.

1. Records of minors shall be kept for at least six years after such minor has reached the age of 18 years. The case manager must retain the following documentation for quality management review by DMAS for a period of not less than six years from each client's last date of service or as provided by applicable state or federal laws, whichever period is longer.

a. The comprehensive assessment and all CSPs completed for the client;

b. All ISPs from every provider rendering waiver services to the client;

c. All supporting documentation related to any change in the ISP;

d. All related communication with the client, family/caregiver, consultants, providers, the screening entity, DMAS, DMHMRSAS, CSA, DSS and others involved in the care of the client; and

e. An ongoing log that documents all contacts made by the case manager related to the client.

2. Quality management review of client-specific documentation must be conducted by DMAS staff. This documentation must contain, up to and including the last date of service, all of the following:

a. All assessments and reassessments;

b. All ISP's developed for that client and the written reviews;

c. Documentation of the date services were rendered and the amount and type of services rendered;

d. Appropriate data, contact notes or progress notes reflecting a client's status and, as appropriate, progress or lack of progress toward the goals on the ISP; and

e. Any documentation to support that services provided are appropriate and necessary to maintain the client in the home and in the community.

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.