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Nursing Home and Assisted Living Pre-Admission Screening

Department of Medical Assistance Services

www.cns.state.va.us/dmas


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Goal

  • To provide information to Nursing Home and Assisted Living Pre-Admission Screening providers regarding Medicaid policies and procedures for pre-admission screenings.


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Objectives

Participants will have a better under- standing of the pre-admission screening process which will:

  • Reduce the time between the submission of pre-admission screening packages and actual reimbursement to providers for services.

  • Allow screening teams to have a better understanding of the services that can be authorized


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Objectives

Participants should be able to properly submit pre-admission screening packages and resolve error messages including:

  • Eliminating common errors up front

  • Reducing the number of error letters generated to the pre-admission screening teams


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Medicaid Program History

  • Authorized as part of the SSA Amendments of 1965, signed into law July 30, 1965.

  • Medicaid grew out of and replaced two federal grants to states programs.


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Medicaid Program History

  • Maximum federal expenditures were expected to be $238 million above the programs already in place ($1.3 billion)

  • The $238 million was exceeded in the first 6 months of the program with only 6 states implementing programs


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Medicaid Program History

  • By 1998, the Medicaid program nationally provided services to approximately 40.6 million low income individuals at a cost of $169 billion


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Medicaid Program History

  • The Virginia Medicaid program was established in 1969

  • Originally administered by the Virginia Department of Health; DMAS was created and designated as the single state agency charged with administering the program in March 1985


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Medicaid Program History

  • The Center for Medicare and Medicaid Services (CMS) is the federal oversight agency for the Medicaid program.

  • The CMS central office is located in Baltimore and Virginia’s regional office is located in Philadelphia.


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Medicaid Budget

  • DMAS expenditures for fiscal year 2000 were $2,808,983,547

  • 51.85% of Medicaid expenditures comes from federal funds (“federal financial participation or FFP”)

  • Medicaid is the primary funding source for long-term care services in Virginia


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Inpatient Hospital Services

Emergency Hospital Services

Outpatient Hospital Services

Nursing Facility Care

Rural Health Clinic Services

Federally Qualified Health Center Clinic Services

Lab and X-Ray Services

Physician Services

Home Health Services

EPSDT

Family Planning

Nurse-Midwife Services

Transportation

Medicare Premiums (Part A) - Hospital; (Part B) - Supplemental Ins. For Categorically Needy

Mandatory Services Provided Through Medicaid


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Other Clinic Services

Skilled Nursing Facility Services for Individuals under 21 years of age

Podiatrist Services

Optometrist Services

Clinical Psychologist Services

Certified Pediatric Nurse and Family Nurse Practitioner Services

Home Health: PT, OT, and Speech Therapy

Dental Services for Persons under 21

Physical, Speech & Occupational Therapies

Prescribed Drugs

Case Management Services

Prosthetics

Mental Health Services

Mental Health Clinic Services

Hospice Services

Medicare Part B Premiums for the Medically Needy

Optional Services Provided Through Medicaid


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Who is Eligible for Medicaid?

  • Categorical Eligibility

  • Aged, blind, and

  • disabled

  • Families with

  • children

  • Recipients of

  • cash assistance

  • Pregnant women

  • and children

  • Low income

  • Medicare

  • beneficiaries

Financial Eligibility

After meet a category must meet income and asset guidelines, as well as non-financial criteria.


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Medicaid Funded Long Term Care

  • In fiscal year 2000, the Virginia Medicaid Agency paid over a billion dollarsfor individuals receiving long-term care services

  • 44,100 individuals received long-term care services from Medicaid funded programs in fiscal year 2000


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Long-Term Care Services Defined

  • Institutional Services

    • Nursing Facility

    • Intermediate Care Facilities for the Mentally Retarded (ICF/MR)

  • Community Based Services

    • Waivers

    • Program of All-Inclusive Care For the Elderly (PACE)


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Eligibility for Long-Term Care Services

  • To be eligible for Medicaid-funded long-term care services individuals must :

    • Qualify for Medicaid*

    • Meet specified long-term care criteria according to a standardized long-term care assessment instrument

      • Uniform Assessment Instrument (UAI) for nursing facility level of care

      • Level of Functioning (LOF) Survey for ICF/MR level of care


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Qualifying for Medicaid

  • Individuals who are Medicaid eligible at the time of application for LTC services are not automatically eligible for LTC services if they meet the functional assessment.

  • The local DSS must assess the individual’s eligibility for Medicaid (LTC) and calculate a patient pay.Everyone must have a calculation, not everyone has a patient pay.



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The Pre-Admission Screening Process

Who, What, Where, When, How?


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Medicaid Eligibility for LTC Services

  • To be eligible for Medicaid funded long-term care services (whether they are institutional or community based,) the following requirements must be met for each individual:

  • Quality for Medicaid;

  • Meet specified long term care criteria according to standardized long term care assessment instrument (currently we use the UAI).


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What is Pre-Admission Screening?

  • According to the Code of Virginia defines preadmission screening as the following:

  • “§32.1-330. Preadmission screening required. All individuals who will be eligible for community or institutional long-term care services as defined in the state plan for medical assistance shall be evaluated to determine their need for nursing facility services as defined in that plan.


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What is Pre-Admission Screening?

  • The Department shall require a preadmission screening of all individuals who, at the time of application for admission to a certified nursing facility as defined in §32.1-123, are eligible for medical assistance or will become eligible within six months following admission. For community-based screening, the screening team shall consist of a nurse, social worker and physician who are employees of the Department of Health or the local department of social services. For institutional screening, the Department shall contract with acute care hospitals.”


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What is Pre-Admission Screening?

  • The Code of Federal Regulations defines preadmission screening as the following:

  • “§441.302 State Assurances.

  • (b) Financial accountability – The agency will assure financial accountability for funds expended for home and community-based services…

  • (c) Evaluation of need. Assurance that the Agency will provide for the following:


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What is Pre-Admission Screening?

  • (1) Initial evaluation. An evaluation of the need for the level of care provided in a hospital, a nursing facility, or an ICR/MR when there is a reasonable indication that a recipient might need the services in the near future (that is, a month or less) unless he or she receives home or community-based services. For purposes of this section, “evaluation” means a review of an individual recipient’s condition to determine—


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What is Pre-Admission Screening?

  • (i) If the recipient requires the level of care provided in a hospital as defined in §440-40 of this subchapter, a NF as defined in section 1919(a) of the Act, or an ICF/MR as defined by §440.150 of this subchapter; and

  • (ii)That the recipient, but for the provision of waiver services, would otherwise be institutionalized in such a facility.


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What is Pre-Admission Screening?

  • (d) Alternatives. Assurance that when a recipient is determined to be likely to require the level of care provided in an SNF, ICF, or ICF/MR, the recipient or his or her legal representative will be—

    • (1) Informed of any feasible alternatives available under the waiver; and

    • (2) Given the choice of either institutional or home and community-based services.”


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Why do we do pre-admission screenings?

  • To assure appropriate levels of care (i.e. home care or nursing facility care)

  • To assure appropriate service provision (i.e. specific services to meet individual needs)


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Who does the pre-admission screening?

  • Medicaid agency has responsibility to safeguard against unnecessary or inappropriate use of Medicaid services – federal requirement (42 CFR 456.3)

  • Local pre-admission screening committees (composed of local health departments, local departments of social services and acute care facilities).


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Who needs to be screened?

  • Individuals in the community or acute care/rehab hospitals who are,

  • a) Already Medicaid eligible, or

  • b) Expected to become eligible for Medicaid within 180-days of admission to the nursing facility

  • Nursing Facilities are responsible for making sure that they 180-day requirements will be fulfilled.


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Who needs to be screened?

  • Nursing Facilities are under no obligation to admit recipients who have not been pre-screened prior to admission.

  • Individuals entering a nursing facility for a short-term rehabilitation stay are subject to pre-admission screening and should be screened prior to admission.

  • Pre-admission screening is required regardless of the anticipated length of stay of an individual if Medicaid payment is expected.


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When does a screening need to be done?

  • Prior to admission to a nursing facility if you expect Medicaid to provide payment.

    NOTE: Individuals must be screened by the pre-admission screening team and deemed eligible for services. A complete assessment must be made before screeners can determine service options.


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Pre-Admission Screening

  • Nursing Home Pre-Admission Screening. The Commonwealth of Virginia requires that all individuals who currently Medicaid eligible or will become Medicaid eligible within the first 180 days of admission to nursing facility or community based care waiver service, be screened. The purpose of pre-admission screening is to ensure that the individual meet the established criteria for placement either into a nursing facility or waiver service. One of the goals is always to place individuals with the needed services in the least restrictive environment.


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Pre-Admission Screening

  • For hospitalized recipients, the acute care hospital staff completes the pre-admission screening process. For community-based recipients, it is a joint effort between the local departments of social services and the local health departments.


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Pre-Admission Screening

  • For recipients with mental health, mental retardation, or related conditions, there is an additional screening that must take place prior to service authorization. This is referred to a Level II screening for nursing facility placement and the 101 process for access to waiver services. It is the responsibility of the pre-admission screening teams to make the appropriate referrals for completion of the additional mental health, mental retardation or related condition portion.


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Questions and Answers

Some Frequently Asked Questions submitted by Pre-Admission Screening Teams


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Question?

  • Can an individual receive services under more than one Waiver at one time?

    RESPONSE: Individuals can be authorized to receive services under only one Home and Community-Based Care Waiver at any given time.


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Question?

  • On page 4, Section 2 of the UAI under ambulation there is a question about walking. If a worker marks ‘no’ and then across the page marks ‘is not performed’, the UAI is sent back, as apparently this is not correct. We need clarification on this question.

    RESPONSE: If you mark ‘no’ there is no need to complete any of the other questions on the form.


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Question?

  • Can skilled units of acute care hospitals complete a nursing home pre-admission screening?

    RESPONSE: Skilled units of acute care hospitals are not authorized to complete nursing home pre-admission screenings for any type of service. The acute care hospital must complete the pre-admission screening PRIOR to discharge to the skilled unit of the hospital. The skilled unit of the hospital is the same as any other nursing facility and recipients in that unit are subject to the same rules and regulations.


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Question?

  • Can skilled units of acute care hospitals complete a nursing home pre-admission screening?

    RESPONSE: Acute care social work staff or discharge planners may not complete the pre-admission screening forms for individuals located in the skilled units of the hospitals once admission has taken place.


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Question?

  • What about recipients who are currently in a VA Hospital? Are they subject to pre-admission screening?

    RESPONSE: Recipient admitted directly from a VA Hospital to a directly to a nursing facility is not subject to the normal pre-admission screening process. The nursing facility can accept the discharge information from the VA Hospital in place of the pre-admission screening.


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Question?

  • What about recipients who are currently in a VA Hospital? Are they subject to pre-admission screening in order to receive waiver services?

    RESPONSE: For Home and Community Based Care recipients the local community screening team (consisting of the local department of social services and the local health department) is responsible for authorization of any waiver service.


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Question?

  • Do pre-admission screening teams need to complete a decision letter for authorized services?

    RESPONSE: Yes, recipient must be given a decision letter that includes appeal information for any decision made by the pre-admission screening teams.


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Question?

  • Who can sign for the doctor on the pre-admission screening forms?

    RESPONSE: Only the reviewing physician may sign and date his signature during the completion of a pre-admission screening. Nurse or social worker signatures for the physician are not permitted. The use of rubber stamps for signatures or dating is not permitted.


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Question?

  • Can the pre-admission screening teams determine the number of hours a recipient receives under the waivered services?

    RESPONSE: NO, the pre-admission screening teams are not permitted to determine the number of hours a recipient may receive under a waivered service.


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Question?

  • What about Hospice Services?

    RESPONSE: A recipient may receive Medicaid Hospice benefits and personal care services under the Elderly and Disabled Waiver or Nursing Facility Services at the same time. For Home and Community-Based Care Waivered Services, pre-admission screening is required. The Community-Based Care provider will coordinate services with the Hospice provider.


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Question?

  • What about children? Do they have to be screened?

    RESPONSE: Children are subject to the same rules and regulations regarding pre-admission screening as adults. A pre-admission screening team must consider the risks and place the child in the most appropriate waivered service or an appropriate nursing facility that can address the needs of a child.


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Question?

  • When is a DMAS-101A and DMAS-101B completed for waiver recipients?

    RESPONSE: Upon completion of the UAI Assessment for a Home and Community-Based Care Waiver Service, if there is a diagnosis of Mental Illness, Mental Retardation or a Related Condition, then a referral for a DMAS-101A must be made to the local Community Services Board (CSB). The local CSB will then complete the DMAS-101B form and will return the completed package back to the originating screening team.


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Question?

  • When is a DMAS-101A and DMAS-101B completed for waiver recipients?

    RESPONSE: No service authorization can be made prior to the completion of both the DMAS 101-A and DMAS 101-B. Depending on the outcome of the completed DMAS 101-B, the screening team needs to review and authorize the most appropriate waiver. If you have questions, please call the Waiver Services Unit at (804) 786-1465.


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Question?

  • When is a MI/MR Level I and Level II completed for nursing facility residents?

    RESPONSE: The process is very different from referrals for a MI/MR Level I and Level II screening for nursing facility placement. All referrals for nursing facility placement must be made to the DMHMRSAS Contractor. The current contractor is Dual Diagnosis Management, LLC. They may be reached by contacting the project manager at 1-877-431-1388.


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Question?

  • What about appeal rights?

    RESPONSE: Individuals wishing to appeal determinations made by the hospital or local screening committees should notify the Appeals Division, Department of Medical Assistance Services, in writing, of his or her desire to appeal within 30 days of the receipt of the Committee’s decision letter.


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Question?

  • What about appeal rights?

    RESPONSE: All decision letters must include the following statement: “You may appeal this decision by notifying, in writing, the Appeals Division, Department of Medical Assistance Assistance Services, 600 East Broad Street, Suite 1300, Richmond, Virginia 23219. This written request for an appeal must be filed within thirty (30) days of the date of this notification.”


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The UAI

General Information to assist with completion of Pre-Admission Screening Packages


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Records Retention:

  • All pre-admission screenings forms must be retained for a period of not less than five years from the date of the screening.


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General Information - UAI

  • In an effort to reduce the time and labor involved in the screening and data entry of submitted pre-admission screening packages from providers, the Department of Medical Assistance Services has instituted a few changes to the process.


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General Information - UAI

  • First, all completed pre-admission screening packages must be submitted directly to First Health Services for processing. The address is:

  • First Health Services

  • Post Office Box 85083

  • Richmond, Virginia 23285-5083


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General Information - UAI

  • Secondly, the following information must be included with all pre-admission screenings submitted to First Health Services:

  • In Chapter I of the Virginia Medicaid Nursing Home Pre-Admission Screening Manual, page 7, page revision date 3-15-94, it states: “A $100.00 fee per pre-admission screening will be paid to acute care hospitals, private psychiatric hospitals, ASOs, and the local Nursing Home Pre-Admission Screening Committees.


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General Information - UAI

  • For the local committees, the local health department will receive $69.00 per screening and the local social services departments will receive $31.00 per screening in which they participate. The same fee per screening is used statewide and represents compensation for all services rendered and completion of the forms required to authorize Medicaid payment for nursing facility placement or community based long term care waiver services.”


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General Information - UAI

  • “Each pre-admission screening package sent to DMAS for reimbursement is reviewed for accuracy, completeness and adherence to DMAS policies and procedures. An incomplete, illegible, or inaccurate package will not be processed for payment. Reimbursement will be made only a screening which includes all the required forms that have been correctly completed and submitted to the Department of Medical Assistance Services.”


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General Information - UAI

  • Further it states,

  • “Nursing home pre-admission screening forms must be submitted to the Department of Medical Assistance Services within 30 days of the assessment date to assure prompt reimbursement. To expedite the reimbursement process for pre-admission screening, submit the pre-admission screening package with the contents in the following order:


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General Information - UAI

DMAS-96 Authorization of Services Form

UAI form (all 12 pages)

DMAS-113A and DMAS-113Bforms (if applicable)

DMAS-95 MI/MR Supplemental form (if applicable)

DMAS-101A and DMAS-101B forms (if applicable)

DMAS-97 form (Waiver Services Plan of Care)

DMAS-300 form (if applicable)

DMAS-20 form (consent to exchange information)

The Decision Letter

All other forms


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General Information - UAI

  • No additional reimbursement will be paid for updating the assessment during the same pre-admission screening process. For example, if an individual is in an acute care hospital and a nursing facility pre-admission screening is required, the hospital will be reimbursed for only one pre-admission screening per hospital admission.


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General Information - UAI

  • There will be no reimbursement for screenings received by the Department of Medical Assistance Services 12 months or more after the date of the completion of the screening.”

  • No reimbursement for completed pre-admission screenings will be made for screenings completed by non-approved DMAS pre-admission screening teams.


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The UAI

Specific Information to assist with completion of Pre-Admission Screening Packages


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Specific Information - UAI

  • Page One - Date portion of form is required.

  • Section – Identification/Background (page 1)

  • Required items for completion are:

    • Client Name

    • Client Social Security Number

    • Address (which includes street, city, state and zip)

    • City/County Code


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Specific Information - UAI

  • Section – Demographics (page 1)

  • Required items for completion are:

    • Birthdate (includes month, date and year)

    • Sex

    • Marital Status

    • Race

    • Communication of Needs


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Specific Information - UAI

  • Section - Financial Resources (page 2)

  • Required items for completion are:

    • Medicare Number

    • Medicaid Number (must include number or ‘pending’)


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Specific Information - UAI

  • Section – Physical Environment (page 3)

  • Required items for completion are:

    • Must complete the appropriate section under the following questions:

    • Where do you usually live?

    • Does anyone live with you?


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Specific Information - UAI

  • Section – Function Status (page 4)

  • Required items for completion are:

    • This entire page must be completed. Both sections must be completed.


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Specific Information - UAI

  • Section – Diagnosis and Medication Profile (page 5)

  • Required items for completion are:

    • Diagnosis Codes/Diagnosis must be present on the UAI form.

      • NOTE: DMAS will not accept diagnosis information on any other type of record such as hospital discharge forms.


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Specific Information - UAI

  • Total Number of Medications must be answered

  • How do you take your medicine(s) must be answered

    NOTE: DMAS will not accept medication information on any other type of record such as hospital discharge forms.


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Specific Information - UAI

  • Section – Physical Status (page 6)

  • Required items for completion are:

    • Joint Motion section must be completed

    • Fractures/Dislocations must be completed

    • Missing limbs must be completed

    • Paralysis/Paresis must be completed


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Specific Information - UAI

  • Section – Nutrition (page 6)

  • Required items for completion are:

    • Height

    • Weight

    • Recent Weight Gain/Loss (indicate which and amount)


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Specific Information - UAI

  • Section – Current Medical Services (page 7)

  • Required items for completion are:

    • Questions related to Therapies must be completed

    • Questions related to Medical Procedures must be completed

    • Question related pressure ulcers must be completed


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Specific Information - UAI

  • Section – Medical/Nursing Needs (page 7)

  • Required items for completion are:

    • Questions must be completed

    • Narrative portion must be completed


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Specific Information - UAI

  • Section – Psycho-Social Assessment (page 8)

  • Required items for completion are:

    • Orientation portion must be completed

    • Behavior Pattern must be completed


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Specific Information - UAI

  • Section – Assessment Summary (page 11)

  • Required items for completion are:

    • Questions must be completed related to Caregiver Assessment


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Specific Information - UAI

  • Section – Client Case Summary (page 12)

  • Required items for completion are:

    • Narrative portion must be completed


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Specific Information - UAI

  • Section – Unmet Needs (page 12)

  • Required items for completion are:

    • Questions must be completed


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Specific Information - UAI

  • Section – Assessment completed by (page 12)

  • Required items for completion are:

    • Section must be completed


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Specific Information - UAI

  • Outlined above are specific items that must be completed on each UAI that is submitted to DMAS for reimbursement. However, DMAS must stress that this form must be completed in its entirety or an error letter back to the provider seeking correction will be sent.


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Assisted Living

General Information Regarding Authorizations for Assisted Living Services


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Assisted Living Screenings

  • Such as local health departments, local departments of social services, acute care hospitals, local area agencies on aging, local community services boards, AIDS service organizations and some private mental hospitals as well as private physicians. Each individual or provide agency must have contract with DMAS to perform these screenings. The assisted living screenings can be performed individually, meaning they are not a joint effort across provider agencies.


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Who Must be Assessed?

  • All residents and applicants to Assisted Living Facilities regardless of the payment source or length of stay.

  • New admissions to Assisted Living Facilities must be assessed prior to admission.


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Who completes the assessments for public pay individuals?

  • Public Case Managers employed by the local departments of health, social services, area agencies on aging, centers for independent living, or community services boards; or

  • Other qualified assessors including acute care hospitals, state mental health and mental retardation facilities.


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Who completes the assessments for private pay individuals?

  • Qualified staff of the ALF with documented training on completion of the UAI; or

  • Independent private physicians; or upon request

  • By a public case manager or qualified assessor.


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What is to be completed for public pay individuals?

  • The short assessment (Part A) of the UAI is completed on individuals meeting Residential Living criteria. Completion of the short assessment includes completion of the Medication Administration and Behavior patterns of the UAI.

  • The full assessment (Part B) of the UAI is completed on individuals meeting Regular Assisted Living Criteria. The full assessment includes all 12 pages of the UAI.


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What is completed for private pay individuals?

  • An alternate one-page assessment form has been developed for private pay residents.

  • Collects only information needed to document the level of care.

  • Common definitions developed for the UAI is used.


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Who pays for Assessments?

  • For private pay, costs are anticipated to be minimal. Upon request, public case managers or other qualified assessors may complete for a fee. Payment is the responsibility of the resident.

  • For public pay, DMAS will reimburse $25 for a short assessment and $100 for a full assessment.


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What is the responsibility of the Assessment Agency?

  • To determine if the individual to be assessed is already AG or has made application for an AG.

  • To complete the assessment process within two weeks of referral. The following forms must be completed: DMAS-20 Consent to Exchange Information Form; UAI, DMAS-96.

  • To determine that ALF placement is appropriate.


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What is the responsibility of the Assessment Agency?

  • To determine there are no prohibited conditions present.

  • To determine appropriate level of care and authorize service on the DMAS-96; prepare authorization letter to the individual.

  • Contact the ALF of choice (determine if the ALF license matches the individual authorization and can meet the individual’s needs.)


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What is the responsibility of the Assessment Agency?

  • Submit paperwork to all entities as directed.

  • Refer individual for psychiatric/psychological, if appropriate.

  • Plan for required 12 month reassessment (make referrals if appropriate).


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What are prohibited conditions?

  • Ventilator Dependency

  • Dermal Ulcers Stages III and IV

  • IV Therapy or IV Injections

  • Communicable Airborne Infectious Disease

  • Psychotropic Medications without appropriate diagnosis and treatment plans

  • NG/G Tubes


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What are prohibited conditions?

  • Individuals who are imminent physical threat or danger to self or others

  • Individuals requiring continuous nursing care (7 days per week/24 hours per day)

  • Individuals whose physician certifies placement is no longer appropriate

  • Individuals who require maximum physical assistance (total dependence in 4 ADLs)


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What about Changes in Level of Care Assessments?

  • Completed by all entities qualified to perform initial assessments.

  • Performed only when permanent changes in level of care indicated. Temporary changes are less than 30 days.

  • Follow same assessment process as initial assessment.

  • Payment tied to completion of the short versus full assessment.


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When is a new assessment not needed?

  • If there is a current assessment completed within the last 12 months and there has been no change in level of care, then a new assessment is not needed for:

    • Lapse in financial eligibility

    • Transfer from one ALF to another ALF

    • Discharged back to the ALF from the hospital


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Who is subject to reassessment?

  • All public pay ALF residents must receive a 12 month reassessment visit

  • Hospital, State MH/MR facilities and Physicians must send a copy of the UAI, DMAS-96 and Reassessment date to the Adult Services Supervisor of the local DSS where the ALF resident will reside


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Who is subject to reassessment?

  • LDSS where the AG application is made is responsible for initial assessment; LDSS where individual resides following ALF placement is responsible for 12 month reassessment (if there is no other public agency willing to complete the reassessment)

  • Original assessor responsible for 12 month reassessment unless referral is accepted by another assessor

  • Residents receiving targeted MH/MR case management services must be reassessed by that case management agency (no additional reimbursement allowed)


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If the level of care changes, what happens to the 12-month reassessment process?

  • Treat as a change in level of care, not a 12 month reassessment

  • Complete the DMAS-96 and follow previous procedures for authorization and payment. This only applies to changes from Residential Living to Regular Assisted Living.

  • Do not complete the ALF Eligibility Communication Document or submit a HCFA-1500 claim form.


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What is the reimbursement? reassessment process?

  • $25 for completion of short 12-month reassessment only. (Record the CPT/HCPCS Code (Z8577) on the HCFA-1500 Invoice.)

  • $75 for completion of the full 12 month reassessment only. (Record the CPT/HCPCS Code (Z8578) on the HCFA-1500 Invoice.)


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What about appeal rights? reassessment process?

  • Individual does not meet minimum criteria for public payment for ALF care (Residential Living Criteria): Direct appeals to DSS.

  • Individual does not meet criteria for regular assisted living services: Direct appeals to DMAS.


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Why is it required? reassessment process?

  • To assure appropriate placement

  • To assure appropriate payment

  • To provide basic monitoring of continued appropriate placement and payment


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Case Management Services reassessment process?

General Information Regarding Case Management Services for Assisted Living Residents


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Who can provide ALF Case Management Services? reassessment process?

  • LDSSs, AAAs, CILs, CSBs, and local health departments with staff that meet the knowledge, skills and abilities (KSAs) of a case manager

  • Hospitals, State MH/MR facilities, and physicians cannot perform ALF case management services (limited to initial assessments and changes in level of care assessments only.)


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What is Medicaid funded ALF Case Management Services? reassessment process?

  • There are currently two types of activities reimbursed as Medicaid ALF case management services:

    • 12 Month Reassessment Only

    • Ongoing Targeted Case Management Services


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What are the criteria the resident must meet to receive ALF Case Management Services?

  • Require coordination of multiple services, and/or

  • Has some problem which must be addressed to ensure resident’s health and welfare, AND

  • Is not able to have other support available to assist in coordination or access of services or problem resolution


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What are the responsibilities of Targeted Case Management providers?

  • Completion of 12 month reassessment (considered on of the quarterly visits)

  • Any change in level of care assessment, as appropriate

  • Development of a plan of care that addresses the needs on the UAI and maintain a log of contacts (provide copy care plan to resident, family & ALF)


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What are the responsibilities of Targeted Case Management providers?

  • Monitor the ALF Individualized Service Plan (ISP) and other written communication concerning the care needs of the resident

  • Quarterly visits with the resident and/or his/her representative to evaluate the resident’s condition, service needs, appropriate service placement and satisfaction with care


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What are the responsibilities of Targeted Case Management providers?

  • Contact for ALF, family and other service providers to coordinate and problem solve

  • Assist with discharge, as necessary

  • Implement and monitor the plan of care


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What are the differences between the Case Manager’s plan of care and ALF Individualized Service Plan?

  • Plan of Care: Case Manager addresses needs that cannot be met by the ALF

  • Individualized Service Plan: ALF addresses needs that are set by licensing regulations

  • Do not send a copy of the plan of care to DMAS. The plan of care will be reviewed during DMAS onsite visits


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What is the DMAS reimbursement rate for ongoing Targeted Case Management?

  • $75 per quarter (12 month reassessment is included in this reimbursement)

  • Record CPT/HCPCS code Z8574 on HCFA-1500 Invoice

  • Case Management services may not be billed for same individual by any more than one type of case management provider


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Are there other Medicaid-funded Case Management Services? Case Management?

  • Case Management for Elderly Virginians

  • Case Management for Mental Health/MentalRetardation


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Services offered by the Long Term Care Division Case Management?

Specific information regarding the services offered through the Long Term Care Division


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Assisted Living Services Case Management?

  • A recipient may qualify for the residential living program by meeting one of the following criteria:

    • Rated dependent in only 1 of 7 activities of daily living (ADLs); OR

    • Rated dependent in 1 or more of 4 selected instrumental activities of daily living (IADLs); OR

    • Rated dependent in medication administration


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Assisted Living Services Case Management?

  • A recipient may qualify for the regular assisted living program by meeting one of the following criteria:

    • Rated dependent in 2 or more of 7 ADLs; OR

    • Rated dependent in behavior pattern


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Assisted Living Services Case Management?

  • The criteria for AG and an individual must meet all of the following criteria to qualify are:

    • Be over 65, or be disabled;

    • Reside in a licensed assisted living facility;

    • Be a citizen of the United States;

    • Have income that is within the allowable limits;

    • Have limited resources;

    • And have been assessed and determined to need care in an assisted living facility.


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Assisted Living Services Case Management?

  • A recipient may qualify for case management services by meeting one of the following criteria:

    • Require coordination of multiple services; AND/OR

    • Has some problem which must be addressed to ensure resident’s health and welfare; AND

    • Is not able to have other support available to assist in coordination or access of services or problem resolution


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Nursing Facility Services Case Management?

  • A recipient may qualify for nursing facility level of care by meeting one of the following criteria:

    • Dependent in 2 to 4 ADLs, Plus semi-dependent or dependent in behavior and orientation, Plus semi-dependent in joint motion or semi-dependent in medication administration; OR

    • Dependent in 5 to 7 ADLs and dependent in mobility; OR

    • Dependent in 2 to 7 ADLs, Plus dependent in behavior and orientation; AND

    • Have medical nursing needs


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PACE Services Case Management?

  • The criteria for the PACE program are as follows:

    • Be at least 55 years of age AND reside in a PACE provider’s service area; AND

    • Determined eligible for nursing facility care; AND

    • Be screened and assessed by the PACE team;

    • Agree to the terms and conditions of participation; AND

    • Have a safe plan of care


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PACE Services Case Management?

  • Services offered under this waiver are:

    • Adult Day Health Care

    • Personal Care

    • Private Duty Nursing

    • Nursing Facility Care

    • Prescribed Medications

    • Outpatient Medical Services

    • Primary or Specialty Care

    • Hospital Patient Care


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DME Services Case Management?

  • DMAS has a large number of DME providers through out the commonwealth. DMAS covers a vast array of products and supplies through our DME program. We cover everything from apnea monitors to bandages and incontinence supplies. And the list goes on to include nutritional supplements, traction equipment, walkers, wheelchair accessories and even wheelchairs.


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DME Services Case Management?

  • DME and supplies are covered services available to the entire Medicaid population. DMAS may also cover DME services when any of the following criteria are met:

  • The recipient is under age 21 and the item or supply could be covered under the Virginia State Plan for Medical Assistance (the State Plan) through the Early and Periodic Screening, Diagnosis and Treatment Program (or EPSDT); OR

  • The recipient is enrolled in the Technology Assisted Waiver; OR

  • The recipient is enrolled in the AIDS Waiver


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Hospice Services Case Management?

  • Hospice uses the interdisciplinary team approach to treat individual recipients. Most of the time hospice recipients are provided care by volunteers and family members who have been trained to assist in the care in addition to the use of professional staff. Hospice teams address all aspects of care. Such as physical, emotional, spiritual, social and even the economic stresses that may arise during the final stages of illness and even during the bereavement portion.


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Hospice Services Case Management?

  • Routine Home Care – which is at home care that is not continuous

  • Continuous Home Care – which is at home care that is predominantly nursing care and is provided as short-term crisis care. There is a minimum of 8 hours per day of care that must be provided in order to qualify for this category of care. A RN or LPN must provide for at least half the care required.


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Hospice Services Case Management?

  • Inpatient Respite Care – which is short term inpatient care provided in an approved facility (a freestanding hospice, hospital or nursing facility) to relieve the primary caregivers. There can be no more than 5 consecutive days of respite care allowed.

  • General Inpatient Care – which may be provided again in an approved facility. This category of service is usually for pain control or acute or chronic symptom management that can not be treated successfully in another setting.


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Hospice Services Case Management?

  • The services offered under hospice consist of:

    • Nursing Care

    • Home Health Aide and Homemaker Services

    • Medical Social Services

    • Physician Services

    • Counseling Services

    • Short term Inpatient Care

    • Durable Medical Equipment and Supplies

    • Drugs and Biologicals

    • Rehabilitation Services


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Home Health Services Case Management?

  • Home health services are available to all categorically and medically needy individuals determined to be eligible for Medical Assistance. As with all our services, home health services must be provided accordance with all applicable state and federal regulations and laws. They may not be of any less or greater duration, scope, or quality than that provided to recipients not receiving medical assistance from either the state or federal government. Hospice services do require prior authorization.


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Home Health Services Case Management?

  • Covered services are as follows:

    • Nursing services;

    • Home health aide services;

    • Physical therapy services;

    • Occupational therapy services; and

    • Speech therapy services


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Home Health Services Case Management?

  • The recipient is unable to leave home without assistance of others or the use of special equipment;

  • The recipient has a mental or emotional problem which is manifested in part by refusal to leave his or her home environment or is such a nature that it would be not considered safe for him or her to leave home unattended;

  • The recipient is ordered by the physician to restrict his or her activity due to a weakened condition (for example, following surgery or heart disease of such severity that stress and physical activity must be avoided);

  • The recipient has an active communicable disease, and the physician restricts the recipient to prevent exposing others to the disease


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Rehab Services Case Management?

  • DMAS currently offers both inpatient and outpatient rehabilitation services. First, let’s discuss outpatient rehabilitation services. The outpatient program was begin in 1978 and offers physical therapy, occupational therapy and speech-language pathology services. Outpatient rehab may be provided in hospitals, nursing facilities, rehabilitation hospitals, rehabilitation agencies, home health agencies and public schools.


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Rehab Services Case Management?

  • The intensive rehabilitation program was implemented in 1986 to provide comprehensive rehab services. The services include:

    • Rehabilitation nursing

    • Physical therapy

    • Occupational therapy

    • Cognitive therapy

    • Speech-language pathology

    • Social work services

    • Psychology

    • Therapeutic recreation

    • Durable medical equipment


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Waiver Services Case Management?

  • Waivers are optional programs that afford states the flexibility to develop and implement alternatives to institutionalization. The cost to Medicaid for provision of services in the community can be no higher than the cost to Medicaid for the same service in an institution.


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AIDS/HIV Waiver Case Management?

  • Under the AIDS/HIV Waiver the individual must:

    • Diagnosis of AIDS or ARC AND;

    • Documentation that the individual is experiencing medical and functional symptoms associated with AIDS or ARC, which would require nursing facility or hospital care, AND;

    • Meet nursing facility screening requirements.


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AIDS/HIV Waiver Case Management?

  • Under the AIDS/HIV Waiver an individual may receive the following services:

    • Case Management

    • Respite Care

    • Private Duty Nursing

    • Personal Care

    • Nutritional Supplements


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CDPAS Waiver Case Management?

  • Under the Consumer-Directed Personal Attendant Services Waiver a recipient must meet the following criteria for authorization:

  • Dependent in 2 to 4 ADLs, PLUS semi-dependent in joint motion or semi-dependent in medication administration; OR

  • Dependent in 4 ADLs, PLUS dependent in mobility; OR

  • Dependent in 2-7 ADLs, PLUS dependent in mobility; AND

  • Have medical nursing needs; AND

  • Must be at imminent risk of nursing facility placement


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CDPAS Waiver Case Management?

  • Services offered under this waiver are:

    • Personal Attendant Services

  • Individuals seeking placement into the CDPAS program must be free of cognitive deficits.


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    Elderly & Disabled Waiver Case Management?

    • Under the Elderly and Disabled Waiver a recipient must meet the following criteria for authorization:

    • Dependent in 2 to 4 ADLs, PLUS semi-dependent or dependent in behavior and orientation, PLUS semi-dependent in joint motion or semi-dependent in medication administration; OR

    • Dependent in 4 ADLs, PLUS dependent in mobility; OR

    • Dependent in 2-7 ADLs, PLUS dependent in mobility, PLUS dependent in behavior and orientation; AND

    • Have medical nursing needs; AND

    • Must be at imminent risk of nursing facility placement


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    Elderly & Disabled Waiver Case Management?

    • Services offered under this waiver are:

      • Personal Care

      • Respite Care

      • Adult Day Health Care


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    IFDDS Waiver Case Management?

    • Under the Individuals and Families Developmental Disabilities Waiver a recipient must meet the following criteria for authorization:

      • The individual must be 6 years of age and older and meet the “related conditions” requirements of C.F.R. § 435.1009, including autism; and

      • Not have a diagnosis of mental retardation as defined by the American Association of Mental Retardation (AAMR) 12 VAC 30-120-720


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    IFDDS Waiver Case Management?

    • Children under six years of age shall not be screened until three months prior to the month of their sixth birthday.

    • Children under six years of age shall not be approved for waiver services until the month in which their sixth birthday occurs.


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    IFDDS Waiver Case Management?

    • Meet the level of care for admission to an Intermediate Care Facility for the Mentally Retarded (ICF/MR);

    • The individual’s income cannot exceed 300% of the SSI income level and cannot be on spend-down;

    • The income of parents is not deemed (42 C.F.R. § 435.217);


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    IFDDS Waiver Case Management?

    • The individual cannot be served in another waiver

    • Earned income disregards for individuals who are employed

    • Individuals can call DMAS at (804) 786-1465 to receive a Request for Screening Form or download the form from the DMAS web site at www.cns.state.va.us/dmas/.


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    IFDDS Waiver Case Management?

    • Screenings are conducted by VDH Child Development Clinics – 11 clinics throughout state - can find list at: http:///www.vahealth.org/specialchildren/cdsclinics.htm

    • The LOF is the screening instrument used to determine if the individual meets criteria


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    IFDDS Waiver Case Management?

    • Services offered under this waiver are:

      • In Home Residential Support

      • Supported Employment

      • Environmental Modifications

      • Respite Care

      • Assistive Technology

      • Day Support

      • Therapeutic Consultation


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    IFDDS Waiver Case Management?

    • Services offered under this waiver are:

      • Personal Care

      • Skilled Nursing

      • Crisis Stabilization

      • Companion Care

      • Support Coordination

      • Consumer Directed Attendant Care

      • Consumer Directed Respite Care

      • Personal Emergency Responses Systems (PERS)

      • Family and Caregiver Training


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    MR Waiver Case Management?

    • Under the Mental Retardation Waiver a recipient must meet the following criteria for authorization:

      • Must meet criteria for ICF/MR; AND

      • Must have mental retardation or related condition; OR under age 6 at developmental risk who requires a level of care in an ICF/MR. At age 6, the child must have mental retardation


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    MR Waiver Case Management?

    • Services offered under this waiver are:

      • Residential Support

      • Supported Employment

      • Environmental Modifications

      • Respite Care

      • Assistive Technology

      • Day Support

      • Therapeutic Consultation

      • Personal Care

      • Private Duty Nursing

      • Crisis Stabilization


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    Tech Waiver Case Management?

    • Under the Technology Assisted Waiver a recipient must meet the following criteria for authorization:

      • Doctor must certify need for care; AND

      • Need substantial and ongoing skilled nursing care; AND

      • Care must be cost-effective; AND

      • Have a primary caregiver who provides 8 hours of care for each 24 hour day


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    Tech Waiver Case Management?

    • For Younger than 21: depend at least part of day on mechanical ventilator, OR prolonged IV nutritional supplements, drugs, or peritoneal dialysis, OR daily dependence on other device-based respiratory or nutritional support.

    • For 21 and Older: depend at least part of each day on mechanical ventilator, OR requires prolonged IV nutritional supplements, drugs, or ongoing peritoneal dialysis.


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    Tech Waiver Case Management?

    • Services offered under this waiver are:

      • Private Duty Nursing

      • Environmental Modifications

      • Respite Care

      • Personal Care


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    Important Information Case Management?

    • The Facility and Home Based Services Unit phone number is 804-225-4222.

    • The Waiver Services Unit phone number is 804-786-1465.

    • Our Fax number is 804-371-4986.

    • Please feel free to visit our web site at: www.cns.state.va.us/dmas


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    Thank You!! Case Management?

    We look forward to working with you to make this a successful partnership!


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