elderly or disabled with consumer direction services waiver

Elderly or Disabled with Elderly or Disabled with Consumer-Direction Consumer-Direction

Services WaiverServices Waiver

Department of Medical Assistance Services

www.dmas.virginia.gov

Outline of PresentationOutline of Presentation

Long Term Care Services and Eligibility What is Preadmission Screening Why is it done Case Examples How Does The New EDCD Waiver Affect

Referrals Common problems that interfere with processing of UAI

Long-Term Care Services DefinedLong-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)

Eligibility for Eligibility for Long-Term Care ServicesLong-Term Care Services

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

– Qualify for Medicaid; and

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

– Uniform Assessment Instrument (UAI) for nursing facility, PACE and Waiver level of care

Qualify for MedicaidQualify for MedicaidDMAS -122DMAS -122

The DMAS-122 is the service provider’s authorization to bill Medicaid for LTC services.

DMAS-122 is to be sent by the Eligibility Worker no later than 45 days from date of application, and 30 days from the date of a reported change.

Qualify for MedicaidQualify for MedicaidDMAS -122DMAS -122

If the individual does not receive LTC services for 30 days, he must be referred to the Eligibility Worker for a determination of continued Medicaid eligibility.

Qualify for MedicaidQualify 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.

What is Preadmission What is Preadmission ScreeningScreening

Evaluate whether a service or a combination of existing community services is available to meet the individual's needs; and to make sure those services are available.

Evaluate the medical, nursing, developmental, psychological, and social needs when there is a reasonable indication that a recipient might need institutional services in a month or less unless he or she receives home and community based services (42 CFR 441.302(c)(1))

Analyze what specific services the individual needs;

Determine the level of care required by the individual by applying existing criteria for nursing facility.

The pre-admission screening process is designed to be a team process that includes the input of both medical and social work professionals.

The screening team's assessment of the availability of community services depends upon:– Whether the needed service exists in the

community;• Whether eligibility for Medicaid coverage can

be established; and• Whether the service can be delivered at the time

and in the amount necessary to meet the individual's needs.

The screening team explores alternative settings or services, or both, which might meet the identified needs of the individual. If nursing facility placement or a combination of other services is determined to be appropriate, the screening team initiates referrals for service.

What is Preadmission What is Preadmission Screening?Screening?

Community Based Care Services

If Medicaid-funded home and community-based care services are determined to be necessary to delay or avoid nursing facility placement, the screening team is responsible for initiating referrals for service.

Preadmission ScreeningPreadmission Screening

In order to be eligible for a waiver individuals must be screened to determine if they meet the admission criteria.

If in the community, the screening is done by a nurse from the local health department and a social worker from the local department of social services

Preadmission ScreeningPreadmission Screening

If in the hospital, the hospital does the screening.

The individual who is applying for a waiver must meet

the same criteria that is used for admission to the institution. 42 C.F.R. 441.302 (c)(1); 42 C.F.R. 441.303 (c)(2)

Alternate Institutional PlacementAlternate Institutional Placement

To Receive Approval to Implement a Waiver

Criteria for Admission to the Waiver

Criteria for Admission to Institution

Nursing Facility, Waiver, and Nursing Facility, Waiver, and PACE Admission CriteriaPACE Admission Criteria

1 Dependent in 2-4 ADLs, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in medication administration, OR

2 Dependent in 5-7 ADLs plus dependent in Mobility, OR

3 Semi-Dependent in 2-7 ADLs, plus dependent in mobility, plus dependent in behavior and orientation.

AND Have Medical Nursing Needs

Activities of Daily Living Activities of Daily Living (for purposes of Medicaid eligibility)(for purposes of Medicaid eligibility)

Bathing Dressing Transferring Toileting Bowel Function Bladder Function Eating/Feeding

Medical Nursing NeedsMedical Nursing Needs

In addition to meeting functional criteria, in order for Medicaid to pay for nursing facility care, the individual must have medical or nursing supervision or care needs that are not primarily for the care and treatment of mental disease (Alzheimer’s and dementia are not considered mental diseases.)

Medical Nursing NeedsMedical Nursing Needs

The individual’s medical condition requires observation and assessment to assure evaluation of the person’s needs due to the inability for self observation or evaluation; OR

The individual has complex medical conditions which may be unstable or have the potential for instability; OR

The individual requires at least one ongoing medical or nursing service.

Examples of Medical Nursing Examples of Medical Nursing NeedsNeeds

Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder;

Use of physical or chemical restraints;

Routine skin care to prevent pressure ulcers for individuals who are immobile;

Care of small uncomplicated pressure ulcers and local skin rashes;

Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability;

Infusion therapy; and Oxygen

Examples of Medical Nursing Examples of Medical Nursing NeedsNeeds

Application of aseptic dressings;

Routine catheter care; Respiratory therapy; Therapeutic exercise

and positioning; Chemotheraphy; Radiation; Dialysis; Suctioning;

Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration;

Dependent in 2-4 ADLs, plus semi-dependent or Dependent in 2-4 ADLs, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in behavior and orientation, plus semi-dependent in joint motion or semi-dependent in dependent in joint motion or semi-dependent in

medication administration, and have medical nursing medication administration, and have medical nursing needs.needs.

Mrs. Jones is a 76-year-old who had a stroke two years ago. She has non-insulin dependent diabetes. She needs someone to turn on the water taps so she can take a bath, needs for someone button and zip clothing, is incontinent of bladder and has a catheter. Mrs. Jones usually has to be told the day and month, and sometimes does not recognize family members. Unless someone speaks directly to her, she sits passively and just stares out of the window. Mrs. Jones’ medications must be monitored since she cannot take them by herself. Mrs. Jones needs someone to take care of the catheter.

Dependent in 5 to 7 ADLs and dependent in Dependent in 5 to 7 ADLs and dependent in mobility, and have a medical nursing need.mobility, and have a medical nursing need.

Mrs. Smith is a 60-year-old female with a diagnosis of hypertension who recently suffered a stroke. She is partially paralyzed on the right side. Mrs. Smith needs someone to turn on the bath water taps, needs someone to help her dress and to button and zip clothing, needs to have her food cut up, needs help toileting, and needs help transferring from bed to chair and back. Mrs. Smith cannot walk without human support. She is oriented to all spheres all times and her behavior is appropriate. Mrs. Smith’s medications must be monitored and she needs to be closely monitored to make sure that she does not develop pressure ulcers.

Semi-Dependent in 2 to 7 ADLs, Plus dependent Semi-Dependent in 2 to 7 ADLs, Plus dependent in behavior and orientation, and mobility, and in behavior and orientation, and mobility, and

have a medical nursing need.have a medical nursing need. Mr. Ford is a 37-year-old male with a diagnosis of a

stroke with right sided weakness and dementia. He needs for someone to turn on the water taps so he can take a bath. He needs to be reminded to dress, eat, toilet, and transfer from the bed to a chair. Mr. Ford uses a walker, but must have supervision when he uses it. He is continent of both bowel and bladder. Mr. Ford does not know the day, or month, and frequently thinks he is a sixteen years old. He does not recognize family members. His behavior is aggressive or disruptive weekly or more. His medications must be monitored, and he will not take them without them being handed to him Mr. Ford forgets to eat and has a history of dehydration requiring his fluid intake to be closely monitored.

How Does The New EDCD How Does The New EDCD Waiver Affect Referrals?Waiver Affect Referrals?

Referral Process EDCDReferral Process EDCD

The process for referral to services remains the same.

If a recipient elects consumer -directed care service then you send them to a service facilitator that they have chosen.

For other services refer to the provider of that service.

What Happens to the UAI? What Happens to the UAI?

Helpful tips for processing the UAI.

What Happens to the UAI?What Happens to the UAI?

Medical Nursing Needs Not documented Fill out and answer the questions.

– Evidence of Medical instability.– Need for observation/assessment to prevent

destabilization.– Complexity created by multiple medical

conditions. – Why client’s condition requires either an

agency or consumer directed care on a daily basis.

Dependencies in – Functional – Behavior and Orientation – Mobility – Medication Administration – Joint Motion

Dependencies Not documented– Fill out the questions fully, if no check no.– Make your checks clear in each box. – Make comments legible.– Use appendix B of Preadmission Manual for

examples.

UAI missing information– Not all questions answered– Missing Information (name, dates, signatures)– Not filling out No or Yes for questions– Unable to read

UAI information– Copies of Copies hard to read. Make sure you

get a good copy to send in for processing.– Missing diagnosis – Missing pages of UAI – assure all pages sent– Sending in missing pages piece meal – can not

match up.

For Nursing Facility Placement not receiving all forms– All 12 pages UAI– Completed DMAS – 96 – Completed DMAS – 95 MI/MR Level 1– If applicable Completed DMAS – 95 MI/MR

Level 2 and – Approval letter

For Waiver Placement not receiving all forms– All 12 pages UAI– Completed DMAS – 96 – Completed DMAS – 101 A – If applicable Completed DMAS – 101 B and – Approval letter

For ALF Residential Placement not receiving all forms– The first four pages of the UAI plus questions

on Behavior, Orientation and Medication administration

– Completed DMAS – 96 – Approval letter

For ALF Residential Placement Annual Reassessment not receiving all forms– The first four pages of the UAI plus questions

on Behavior, Orientation and Medication administration

– Completed Eligibility Communication Document

For Regular ALF Placement not receiving all forms– All 12 pages UAI– Completed DMAS – 96 – Approval letter

For Regular ALF Annual Reassessments – All 12 pages UAI– Completed Eligibility Communication

Document

Remember to evaluate each person individually and against the “norm”.– For example a it is not the norm at the age of 10

to wear diapers.– At any age it is not the norm to be short of

breath– Don’t lump all Diabetic, CHF, COPD, etc.

patients into a category due to disease process. I.E. All COPD need Oxygen.

What is the EDCD Waiver?What is the EDCD Waiver?

CombinesCombines the Elderly & Disabled (E&D) and the Consumer-Directed Personal Attendant Services (CDPAS) Waivers

What will the EDCD Waiver look like?What will the EDCD Waiver look like?

CD-PAS: Consumer-directed personal care

(42-hour per week limit) Decreased patient pay if working

Elderly and Disabled: Agency Directed Personal Care Respite (including skilled respite) Adult Day Health Care Personal Emergency Response

System

EDCD•Decreased patient pay if working

•Personal Care: Agency and Consumer-directed

(no 42-hour per week limit)

•Personal Care Respite: agency and consumer-directed

• Skilled Respite – agency directed

•Adult Day Health Care

•Personal Emergency Response System (PERS)

Benefits of Combining the WaiversBenefits of Combining the Waivers

Individuals can receive either agency or consumer directed services, or both

720 hours of respite care per year for relief of unpaid caregivers, including skilled respite

Access to PERS if it replaces supervision – Agency or Consumer Directed services

Eliminated 42-hour per week limit for consumer-directed personal care

ConsiderationsConsiderations

Waiver must remain cost-effective

All Waiver recipients must have a back-up plan in order to receive services

When Did This Waiver Become When Did This Waiver Become Effective?Effective?

February 1, 2005 Recipients who were in the E&D and

CDPAS Waivers were automatically transferred into the EDCD Waiver effective February 1, 2005

Does a Provider Need a New Does a Provider Need a New Provider Number?Provider Number?

Providers will notnot be required to obtain a new provider agreement or provider number(s) to render the same type of service in the EDCD Waiver as they have in the E&D and CDPAS Waivers – If Providers want to render a service for which

they do not have a current agreement, a new provider agreement & number must be obtained for that service

E&D and CDPAS Waiver Recipients E&D and CDPAS Waiver Recipients Transferred to the EDCD WaiverTransferred to the EDCD Waiver

A recipient’s current amount of pre-authorized services remained the same

A recipient’s pre-authorization numbers for billing remained the same for Personal Care, Adult Day Care, Respite, and PERS

If a recipient was formerly in CDPAS, a new pre-authorization number will be mailed to the service facilitator

Assessment and Assessment and Authorization Authorization

Procedures for Procedures for ServicesServices

Pre-Authorization ProcessPre-Authorization Process

Pre-authorization process remains the same for all services

ExceptionException: – Currently if an individual is screened for the

CDPAS and does not have a Medicaid ID, DMAS must review the screening and mail an eligibility letter to the SF to obtain a Medicaid ID from DSS…..but

– In the EDCD Waiver, if the individual does not have a Medicaid ID, the SF will: Conduct the initial comprehensive visit. If the

individual meets the Waiver level of care criteria;

Complete a DMAS-122 with the SOC date to the eligibility worker at DSS, who will complete a DMAS-122 with the patient pay amount (if applicable);

Then submit the admission packet to WVMI for pre-authorization with the new DMAS-122

To ensure timely authorization for reimbursement, enrollments must be submitted to WVMI within ten (10) business days of the initiation of services that require authorizations, or within ten (10) business days of notification of Medicaid eligibility,… OR

Authorization begins when WVMI receives the admission packet

Pre-Authorization Process for Pre-Authorization Process for Agency & Consumer Directed Agency & Consumer Directed

ServicesServices If WVMI denies authorization for services:

– The provider will receive payment for the initial comprehensive visit;

– The CD personal care aide will be paid for services rendered; and

– WVMI will authorize services from the date of the initial assessment visit, or the date received at WVMI if received after the ten (10) day period, up to the date of the denial of services.

Nursing Facility to EDCD Waiver & Nursing Facility to EDCD Waiver & Waiver to Waiver transfersWaiver to Waiver transfers

If the individual has received services in a nursing facility or under the E&D, CDPAS, or HIV/AIDS Waivers, a new screening is not needed if EDCD Waiver services begin within 365 days of the discharge date

If the individual is transferring from EDCD Waiver to one of these services, the same rule applies

Nursing Facility/Inpatient Rehab to Nursing Facility/Inpatient Rehab to EDCD WaiverEDCD Waiver

If the individual is transferring from the EDCD Waiver into a rehab facility and is returning to the EDCD Waiver, the following rules apply:– If the date of admission into the rehab facility

into the Waiver is less than 90 days, a new screening is not needed. The provider agency must update the appropriate forms as listed in the EDCD manual

Waiver EligibilityWaiver Eligibility

Who is Eligible for EDCD?Who is Eligible for EDCD?

Under the EDCD Waiver, services may be furnished only to persons: – Who meet the nursing facility criteria as

determined by Pre-admission Screening Team;

– Who are eligible for Medicaid. – If the individual is already Medicaid eligible,

he/she must still have Medicaid eligibility re-determined when applying for Waiver services

– For whom an appropriate cost-effective plan of care can be established; Determining the cost-effectiveness is a part of

the preauthorization process– Who have no other or have insufficient

community resources to meet the individual’s needs;

– Who are residents of the Commonwealth of Virginia

Individuals cannot receive services from more than one Waiver at the same time

However, individuals can be on a waiting list for one Waiver and receive services in another Waiver if they meet the criteria for both Waivers

Earned Income AllowanceEarned Income Allowance

Individuals can keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/week.

They can keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/week

* total of earned and unearned income

Who is Not Eligible for EDCD?Who is Not Eligible for EDCD?

Services may not be furnished to persons: – Who resides in a nursing facility, an ICF/MR, a

hospital, an assisted living facility licensed by DSS or an Adult Foster Care provider certified by DSS, or a group home licensed by the Department of Mental Health & Mental Retardation & Substance Abuse Services (DMHMRSAS)

Patient PayPatient Pay

The patient pay amount, as indicated by DSS on the Patient Information Form (DMAS-122), is to be collected by the service provider who is authorized for the most hours of care per month– If the patient pay comes out of the CD

services, the SF must send the DMAS-122 with the patient pay information to the CD Fiscal Agent (This will be covered in more detail in the session on CD Payroll)

Collecting the Patient Pay: Who & Collecting the Patient Pay: Who & HowHow

1. All service providers (agency or consumer directed) must determine if the recipient is receiving multiple Waiver services – This is obtained from the recipient, caregiver

&/or family member– Call WVMI, if unsure (other Waiver service(s),

provider name, & phone #)2. Each provider must obtain # of service hours

authorized per month for each Waiver service being rendered from the other provider(s)

3. The service provider who is authorized to coordinate the most service hours per month needs to have the most recent DMAS-122 with the patient pay amount– This provider must notify the eligibility

worker at the local DSS office for future DMAS-122s

4. The provider who is receiving the DMAS-122 from DSS must send a copy to the other service providers

5. The multiple Waiver services and their providers must be noted on the revised DMAS-99 and/or DMAS-301 for ADHC each time the form is required to be completed

6. The DMAS-99 and/or DMAS-301 must also note which Waiver service the patient pay is being deducted from

EDCD Waiver ServicesEDCD Waiver Services

Available ServicesAvailable Services

Adult Day Health Care Personal Care

– Agency Directed Personal Care– Consumer-Directed Personal Care

PERS and Medication Monitoring– Available with Agency Directed & Consumer-

Directed services

Respite – two types:– Agency-Directed

Personal Care Aide Skilled (nurse) Facility Respite - A Medicaid-certified

nursing facility– Consumer-Directed

Personal Care Aide Skilled respite is not available as CD

Respite Care (Cont’)– May be authorized to receive agency-directed

AND consumer-directed respite – Cannot receive agency-directed & consumer-

directed respite simultaneously– 720 hours is the maximum number of combined

respite hours per calendar year, per individual

Respite Care (Cont’)– DMAS will pay for the first 720 billable respite

hours submitted for payment– DMAS/WVMI is unable to give an accurate up-

to-date amount of respite hours that an individual has received

Respite Care (Cont’)– When an individual transfers to a new

provider, the new provider is responsible for finding out how many respite care hours the individual has remaining for the current calendar year This includes transferring between agency-

directed & consumer-directed respite This must be done through coordination

with providers

Service Facilitation– This will covered more thoroughly in another

training session later today

Personal Care - SupervisionPersonal Care - Supervision

Supervision is covered within the personal care plan of care when the purpose is to supervise or monitor those recipients who require the physical presence of the aide to ensure their safety during times when no other support system is available;

The inclusion of supervision in the plan of care is appropriate only when the recipient cannot be left alone at any time due to mental or severe physical incapacitation

This includes recipients who cannot use a telephone to call for help due to a disability

A individual must be getting personal care in order to receive supervision

Is available in agency-directed and consumer-directed services– The provider agency must complete the

Request for Supervision Hours in Personal Care (DMAS-100) and submit to WVMI for authorization

Increase in Hours on the Plan of Increase in Hours on the Plan of CareCare

Increases in the POC above the LOC category, which is currently authorized for a recipient, cannot be retroactive– The agency or SF must obtain

preauthorization from WVMI prior to initializing an increase in hours above the LOC category

Plan of Care with a Combination of Plan of Care with a Combination of Waiver ServicesWaiver Services

A recipient may receive a combination of any of the services once authorization is obtained by WVMI. Each plan of care will be reviewed along with the other services currently authorized for a combined total

A request for additional services may or may not change the amount of services and/or # of hours authorized per week– EX: John is authorized for 25 hrs. per week

of agency-directed personal care services & wants CD services. Unless there is a need for an increase in hrs., the amount of total combined weekly hrs. will remain the same between the two services.

– If the recipient requests an increase in a service that will cause a decrease in another Waiver service currently being rendered, the provider who is initiating the change must notify the other service provider(s). WVMI will not decrease an authorized service unless that service provider submits a request for a decrease

EX: John currently receives 25 hrs of agency-directed care and 10 hrs per week of CD. John contacts the SF and request an increase in CD services but does not want to change/decrease the 25 hrs of agency care that he is receiving.

The SF will:The SF will: (a)(a) assess the needs of the recipient to determine if an increase is needed. If an increase is needed; (b)(b) contact the agency-directed provider and request a copy of the current plan of care with the schedule of care being provided by the agency; (c)(c) submit the request for authorization of CD services to WVMI, noting on the DMAS-98 that this is in addition to the agency-directed services; and (d)(d) if WVMI approves the increase, the SF must notify the the agency-directed provider of the change in John’s CD services schedule.

– EX: John’s request for an increase in CD services is denied by WVMI. His current amount of services remains authorized unchanged. With only 25 hrs allowed, the SF will discuss With only 25 hrs allowed, the SF will discuss with John the options of:with John the options of: (a) splitting the 25 hrs per week between agency-directed and consumer-directed services; or (b) use all 25 hrs in CD services; or (c) making no change in the current Waiver services

If John requests to split the 25 hrs between the agency & consumer directed services, the SF will contact the other provider of the change in services and schedule of hrs per John’s request. (a) the agency-directed provider will need to submit the DMAS-98 and the DMAS-97A/B to WVMI with the decrease in hours to agency-directed services

(b) the SF will need to submit the DMAS-98, and the DMAS-97A/B to WVMI for an increase

EX: John is currently receiving agency-directed services and wants to also receive CD services in addition to the agency-directed service. John has never received CD services. John contacts a SF and requests CD servicesJohn contacts a SF and requests CD services. .

The SF will:The SF will: (a)(a) contact the agency-directed provider and request a copy of the screening paperwork, current plan of care with a schedule of care being provided by the agency, & the DMAS-122; (b)(b) conduct an initial comprehensive visit;

(c)(c) submit the request for authorization of CD services to WVMI, noting on the DMAS-98 that this is in addition to the agency-directed services; and (d) contact the agency-directed provider of John’s request; and (e) coordinate with the agency provider the schedule of hours between the two types of services.

Updated FormsUpdated Forms

All forms are on the DMAS web siteAll forms are on the DMAS web site Agency-Directed & Consumer-Directed

Plan of Care (DMAS-97A/B) – Combines the DMAS-97A & DMAS-97B

Community-Based Care Individual Assessment Report (DMAS-99) – Combines the DMAS-99 & DMAS-99B

DMAS-99 (cont’)– More information is required on the form

Ex: Under SUPPORT SYSTEM, the provider must list all Waiver services that the individual is receiving at the time of the assessment. The name of the service provider must also be listed

Ex: The specific service provider responsible for collecting the patient pay must be noted

There are other changes on the form

Skilled Respite Record (DMAS-90A) Respite Care Needs Assessment Plan of

Care (DMAS-300)– For requesting respite care services

Request for Supervision Hours in Personal Care (DMAS-100)– Used for agency & consumer directed

services

Adult Day Health Care Interdisciplinary Plan of Care (DMAS-301)– The provider must list all Waiver services that

the individual is receiving at the time of the assessment. The name of the service provider must also be listed

– The specific service provider responsible for collecting the patient pay must be noted

Request for Services Form (DMAS-98)– Addition to the changes, this form must be

filled out correctly and completely

Request for PERS (Personal Emergency Response System) Form (DMAS-100A)– To be used for agency & consumer directed

services

New FormNew Form

Consumer-Direction Services Management Questionnaire DMAS-95B– Questions to consider if a family member is

considering managing consumer directed (CD) services on behalf of a family member

As a Participating Provider As a Participating Provider You Must-You Must-

Determine the patient’s identity. Verify the patient’s age. Verify the patient’s eligibility. Accept, as payment in full, the amount paid

by Virginia Medicaid. Bill any and all other third-party carriers.

Important ContactsImportant Contacts

MediCall ARS- Web-Based Medicaid Eligibility Provider Call Center Customer Service Provider Enrollment Commonwealth Mailing Electronic Billing

MediCall/ARS- Information MediCall/ARS- Information AvailableAvailable

Medicaid client eligibility/benefit verification

Service limit informationClaim statusPrior authorizationProvider check log

MediCallMediCall

800-884-9730800-772-9996804-965-9732804-965-9733

Automated Response System- Automated Response System- ARSARS

Web-based verification optionRegistration

virginia.fhsc.comQuestions concerning registration process800-241-8726 Web Support Helpline

DOB: 05/09/1964 F CARD# 00001

DEPARTMENT OF MEDICAL ASSISTANCE SERVICESCOMMONWEALTH OF VIRGINIA

V I RG I N I A J. R E C I P I E N T

9 9 9 9 9 9 9 9 9 9 9 9

002286

Provider Call CenterProvider Call CenterClaims, covered services, billing inquiries:

Department of Medical Assistance Services600 East Broad Street, Suite 1300

Richmond, VA 23219

800-552-8627

804-786-6273

Customer ServicesCustomer ServicesCustomer Services

Richmond, VA 23219

Provider EnrollmentProvider EnrollmentNew provider numbers or change of address:

First Health – PEUP. O. Box 26803Richmond, VA 23261888-829-5373804-270-5105804-270-7027 - Fax

Requests for DMASRequests for DMAS Forms and Manuals: Forms and Manuals:

DMAS Order DeskCOMMONWEALTH

MARTIN1700 Venable Street

Richmond, Virginia 23222

Phone: 1-804-780-0076Email:dmas@cms-mpc.com

Electronic BillingElectronic Billing

Mailing Address

EDI Coordinator-Virginia OperationsFirst Health Services Coordinator

4300 Cox RoadRichmond, VA 23060

E-mail: edivmap@fhsc.com

Phone: (800) 924-6741

Fax: (804) 273-6797

Billing on the CMS-1500Billing on the CMS-1500

MAIL HCFA-1500 MAIL HCFA-1500 FORMSFORMSTO:TO:

DEPARTMENT OF MEDICALASSISTANCE SERVICESPRACTITIONERP. O. Box 27444Richmond, Virginia 23261

TIMELY FILINGTIMELY FILING

ALL CLAIMS MUST BE SUBMITTED WITHIN ONE YEAR FROM THE DATE OF SERVICE

EXCEPTIONS– Retroactive Eligibility– Delayed Eligibility– Denied Claims

NO EXCEPTIONS– Accident Cases– Other Primary Insurance

TIMELY FILINGTIMELY FILING Submit claims with documentation attached

explaining the reason for delayed submission

You must have the word “Attachment” in Locator 10d and use modifier “22” in Locator 24D

MEDICAID

(Medicaid #)

Block 1: Check Medicaid

CHAMPUS

(Sponsor's SSN)

1. MEDICARE

(Medicare #)

CHECK MEDICAID BLOCK ONLY

2. PATIENT'S NAME (Last Name, First Name, Middle Initial)

1a. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1)

Block 1a: Recipient ID Number

(Be sure to include all 12 digits)

123456789 01 4

Block 2: Patient's Name

2. PATIENT'S NAME (Last name, First Name, Middle Initial)

Smith, Sam5. PATIENT'S ADDRESS (No., Street)

Block 10: Accident-Related

10. IS PATIENT'S CONDITION RELATED TO:

a. EMPLOYMENT? (CURRENT OR PREVIOUS)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

YES NO

PLACE (State)

You MUST check YES or NO for a, b & c20

Block 10d

You MUST use the word "ATTACHMENT"

if you attach anything to the HCFA form.

10d. RESERVED FOR LOCAL USE

ATTACHMENT

Block 14: Conditional Use

14. DATE OF CURRENT

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY (LMP)

MM DD YY

Corresponds to Block 7, Date CareBegan, on DMAS-93 form

(Required for Personal Care)

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Block 21: Diagnosis Codes

May enter up to 4 codes

Omit decimals 23

22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.

Block 22: Adjustments and Voids

1032 xxxxxxxxxxxxxxxx

Adjustment or

Resubmission

From originalremittance

Code(See HCFA instructions for list of codes) 24

23. PRIOR AUTHORIZATION NUMBER

Block 23: Prior Authorization Number - Conditional

If service requires prior authorization, enter the nine digit PA number assigned by WVMI.

DATE(S) OF SERVICEFrom To

MM DD YY MM DD YY

Block 24A: Dates of Service

08 01 04 08 08 04

08 01 04 08 31 04

Both FROM and TO datesmust be completed

Dates must be within same calendar month26

B CPlace

ofService Service

ofType

Block 24B: Place of Service

Block 24C: Type of Service

12 112-Patient's home

11-Office location

1- Medical Care

Block 24D: Procedure Codes

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIER

H2000 22

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Block 24E: Diagnosis Code

DIAGNOSISCODE

1,2Enter the entry identifier of the ICD-9-CM diagnosis code listed in Locator 21. To identify more than one diagnosis code, separate the indicators with a comma.

$ CHARGES

Block 24 F: Charges

Enter the usualand customary charges 30

ORUNITS

Block 24G: Days or Units

1Enter the number of times or hours the procedure, service, or item was provided during the service period.

COBRESERVED FOR

LOCAL USE

22-Medicaid Only

33-Billed & Paid

55-Billed, not covered

24J: COB Other Insurance

24K: $ Other Insurance Paid

Attach denial from other carrier

24J: Use for Patient Pay24J: Use for Patient Pay24K: Enter the Patient Pay 24K: Enter the Patient Pay

amount amount

Locator 24 J -Enter 3Locator 24 K If this applies to the recipient, place the

patient pay amount in 24K. The system will only calculate the patient

pay when indicated on the claim.

26. PATIENT ACCOUNT NUMBER

Block 26: Patient’s Account Number

(Optional)

12345678918765432

Block 29: Amount Paid

Personal Care Providers ONLY

Enter patient pay amount

29. AMOUNT PAID

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

Block 31: Signature & Date

If there is a signature waiveron file, you may stamp, print,

or computer-generate the signature.37

PIN# GRP#

33. PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE& PHONE #

123456789

Block 33: Provider ID # and Address

Be sure to put the MEDICAID9-digit ID number!

22. MEDICAID RESUBMISSIONCODE ORIGINAL REF. NO.

Block 22: Adjustments and Voids

1032 xxxxxxxxxxxxxxxx

Adjustment or

Resubmission

From originalremittance

Code(See HCFA instructions for list of codes) 39

Special Billing Special Billing InstructionsInstructions

Northern Virginia LocalitiesNorthern Virginia Localities

Alexandria City Clarke County Fairfax City Falls Church City Fredericksburg City Loudon County Manassas Park City Spotsylvania County Warren County

Arlington City Culpeper County Fairfax County Fauquier County King George County Manassas City Prince William County Stafford County

Personal CarePersonal Care

T1019-Personal Care– Northern Virginia $13.38 per/hr– Rest of State $11.36 per/hr

Respite CareRespite Care

S9125-LPN/hr– Northern Virginia $26.00/HR– Rest of State $21.45/HR

T1005-aide/hr– Northern Virginia $13.38/HR– Rest of State $11.36/HR

Personal/Respite CarePersonal/Respite Care Maximum hrs billed is amount on plan of

care for personal care or authorized amount for respite care

ONLY whole hours can be billed 30 extra minutes or more of care provided

over a calendar month, the next highest hour can be billed

Rounding up is for total monthly hours only

Adult Day Adult Day Health CareHealth Care

S5102-ADHC Services– Northern Virginia $47.25/per diem– Rest of State $43.05/per diem

A0120-ADHC Transportation– Northern Virginia $2.00/per trip– Rest of State $2.00/per trip*a trip is to and from the recipients residence

Adult Day Health CareAdult Day Health Care A day is defined as 6 hours or more of

attendance Less than six hours is considered a half day Half days may be added and rounded to the

nearest whole day at the end of the month Transportation must be authorized by

WVMI or the Screening Team

Personal Emergency Response Personal Emergency Response System (PERS)System (PERS)

S5160-PERS Installation– Northern Virginia $59.00– Rest of State $50.00

S5161-PERS Monitoring– Northern Virginia $35.40/per month– Rest of State $30.00/per month

PERSPERS One time installation

includes– installation– account activation– recipient and

caregiver instruction– removal of equipment

Monthly monitoring rate includes– administrative costs– time– labor– supplies

Billed as one unit

Medication MonitoringMedication Monitoring

S5160/modifier U1- Installation– Northern Virginia $88.50– Rest of State $75.00

S5185-Monthly Monitoring– Northern Virginia $59.40/per month– Rest of State $50.00/per month

Medication MonitoringMedication MonitoringNursing VisitNursing Visit

H2021/modifier TD-RN visit– Northern VA $15.00– Rest of State $12.25

H2021/modifier TE-LPN visit– Northern VA $13.00– Rest of State $10.25

Nursing visits to fill medication monitors are reimbursed bimonthly

Service Facilitation ServicesService Facilitation Services

H2000-Comprehensive Visit– Northern Virginia $209.73– Rest of State $161.56

S5109-Consumer Training– Northern Virginia $208.73– Rest of State $160.56

99509-Routine Visit– Northern Virginia $65.23– Rest of State $50.18

Service Facilitator ServicesService Facilitator Services

T1028-Reassessment Visit– Northern Virginia $105.37– Rest of State $80.28

S5116-Management Training– Northern Virginia $26.09– Rest of State $20.07

99199/modifier U1-Criminal record check– Northern Virginia $15.00– Rest of State $15.00

Per check

Service Facilitation ServicesService Facilitation Services

Registry Check-99199– Northern VA $5.00– Rest of State $5.00

Consumer Directed Personal Consumer Directed Personal Care ServicesCare Services

Personal Care and Respite Care– Northern Virginia $10.10/hr– Rest of State $7.80/hr

Patient Pay Amount and Patient Pay Amount and CollectionCollection

There must be a completed DMAS-122 form in the clients file prior to billing DMAS

For CD services, the service facilitator must also provide a copy to the fiscal agent

Provider with the most authorized hours has total patient pay collection responsibility for the client in both personal care and ADHC

If the amount of services received in a calendar month is equal to or less than the patient pay amount, only the amount for the services rendered should be collected from the recipient.

DMAS should not be billed for that month

If the amount of services rendered is greater than the amount of patient pay, an invoice should be submitted showing the total allowable charges and the patient pay amount.

DMAS will reimburse to allowable charges less the patient pay amount

WVMI’S RoleWVMI’S Role

Contracted by the Department of Medical Assistance Services (DMAS) to provide preauthorization for Elderly or Disabled with Consumer Direction Waiver

Utilize DMAS criteria in the Provider Manuals, and VA Regulations

Preauthorization OverviewPreauthorization Overview

All preauthorization requests to WVMI must be made using the REQUEST FOR SERVICES FORM (DMAS 98)– Enrollments, changes, transfers and

discharges– This is a fax or mail process

The DMAS 98 must accompany the Pre-Admission Screening Packet if the request is for a new enrollment

WVMI will verify eligibility and enrollment

Preauthorization OverviewPreauthorization Overview

WVMI will determine if the request meets DMAS Waiver criteria

WVMI will render a decision– Approval– Partial Approval– Pend– Denial– Reject

Preauthorization Number Assigned– Generated from the First Health System– Will be included in correspondence generated

from First Health

Request for Services Form (DMAS 98)Request for Services Form (DMAS 98)

Sample DMAS 98 and Instructions Sheet DMAS 98 Form Review

– Type of Request New Request Pend Response Change to Approval

– Include the PA number– Recipient and Provider Information

Medicaid number (12 digits) Provider number Contact phone number

DMAS 98 Form Review (continued)– Services Being Requested

All fields must be completed Must be National Codes Units – indicate the hours requested for

service based on the plan of care– If the request is a change, indicate the

total hours being requested Effective Date – the date services are to begin

DMAS 98 Form Review (continued)– Services Being Requested (continued)

Last date of service– Complete when going from current

waiver into either DD or MR waivers only• Requires selection of DD or MR• Effective Date is the current providers

last date of service

DMAS 98 Form Review (continued)– WVMI Tracking number

9 digits Recipient and Waiver specific Provides for quick identification Assigned to all decisions and entered on the

original Request for Services Form (DMAS 98)

Use on all correspondence with WVMI– Provider Comments

Can be used to communicate any special information regarding your request

Preauthorization DecisionsPreauthorization Decisions Reject

– If unable to process the request – no Medicaid ID number, DMAS 98, Provider information incomplete

– If a request is rejected, the entire packet of information must be resubmitted

Pend– Additional information is needed to render a

decision– A provider has a specified time frame to

respond to a pend request

Preauthorization DecisionsPreauthorization Decisions Approval

– Services meet DMAS criteria and authorization is granted as requested

Partial Approval– Not all services and/or hours of services

requested meet criteria Denial

– Services requested are not approved Decisions, with the exception of approvals, will

be faxed or mailed to the requestor

ReconsiderationsReconsiderations

Denials only Requests may be mailed or faxed Include information that justifies your request Must be received within 30 days of the date of the

denial Reconsideration decision will be made within 10

business days Written response will be faxed or mailed to

provider

AppealsAppeals

If services have not been rendered, the Medicaid recipient may request an appeal within 30 days of the written notification of the denial

If services have been rendered, the provider may appeal the adverse decision in writing within 30 days of the written notification of the denial

Mail to:Director, Appeals Division

Richmond, Virginia 23219

WVMI Service Request ResponseWVMI Service Request Response

Most requests including enrollments, changes and transfers, will be reviewed within 10 business days or less

Requests for supervision and increases above the cap will be reviewed within one business day

PERS/PERS Medication Monitoring will be reviewed within 3 business days

All voice mail messages will be returned within one business day

What to Expect With Preauthorization of What to Expect With Preauthorization of EDCD Waiver Services 2/1/2005? EDCD Waiver Services 2/1/2005?

The overall preauthorization process will change very little

Beginning 2/1/2005 the same criteria will be used in reviewing preauthorization requests for all EDCD recipients– The Plan of Care must support the need for

requested services and units/hours of service

Requests must be received within 10 business days of initiation of service or notification of Medicaid eligibility– If the request is not received timely, service

dates prior to the request receipt date will be denied therefore, providers may see an increase in partial approvals

Former CD PAS recipients will receive new PA numbers

All E&D and CDPAS Waiver recipients will receive new WVMI tracking numbers when EDCD services are reviewed

WVMI will retain all history, all former PA numbers and tracking numbers which will be cross referenced and retrievable

Obtaining information as to whether the recipient is receiving multiple waiver services– Contact WVMI

804-648-3159 or 1-800-299-9864 Press 5 and then 4, if you leave a message,

your call will be returned within one business day

WVMI will provide name and contact number of other providers

Resource MaterialsResource Materials DMAS Website - www.dmas.virginia.gov

– DMAS Provider Manuals DMAS HELPLINE

– 804-786-6273 or 800-552-8627 WVMI Website - www.qiva.org Questions about a specific request

– Call WVMI CBC Inquiry Line 804-648-3159 or 1-800-299-9864, press Option

5 and then Option 4

Definition of Consumer-Definition of Consumer-Directed ServicesDirected Services

Definition ofDefinition ofConsumer-Directed ServicesConsumer-Directed Services

Services for which the Waiver recipient or spouse, parent, adult child or guardian of the individual is responsible for hiring, training, supervising, and firing of the staff

The individual must demonstrate a need for personal assistance in activities of daily living, community access, self-administration of medication, or other medical needs, or monitoring health status or physical condition

Consumer-Directed Consumer-Directed Eligibility RequirementsEligibility Requirements

Individuals must have the capability to hire and train their own personal care aides & supervise their performance; OROR

If an individual is unable to direct his own care or is under 18 years of age, a family member/caregiver may serve as the employer on behalf of the individual

Consumer-DirectedConsumer-DirectedEligibility RequirementsEligibility Requirements

If a family/caregiver is managing the care on behalf of the individual, the caregiver will be the employer of CD services & be responsible for hiring, training, supervising, and firing care aides

Ensure that the individual has a back-up plan in case the aide is not available

Other employer duties include: – Checking of references of personal care aides,

determining that personal care aides meet basic qualifications, training care aides, supervising the care aide’s performance; and

– Submitting timesheets to the CD fiscal agent on a consistent and timely basis

Individuals choosing consumer-directed services must receive support from a CD Service Facilitator

The individual or family/caregiver must have a back-up plan for the provision of services in case the personal care aide does not show up for work as expected or terminates employment without prior notice

Inability to Obtain Inability to Obtain CD Personal Care Aide ServicesCD Personal Care Aide Services

The inability to obtain & retain personal care aides can be a serious threat to the safety & health of a individual who does not have a back-up support system

If an individual is consistently unable to hire & retain the employment of an aide, the SF should discuss transferring the individual to agency-directed services

Consumer-Directed Consumer-Directed Service FacilitationService Facilitation

Definition of aDefinition of aService Facilitation (SF) ProviderService Facilitation (SF) Provider

A participating consumer-directed (CD) service facilitator is a facility, agency, person, partnership, corporation, or association that meets the standards and requirements set forth by DMAS and has a current, signed participation agreement with DMAS

Responsibilities of the Responsibilities of the Service Facilitation ProviderService Facilitation Provider

The SF is responsible for monitoring the ongoing provision of services & the quality of care received by individuals in CD services. SF monitoring includes:– The need for support in addition to the care

provided by CD services. This includes an overall assessment of the individual’s safety and welfare in the home with CD services

Availability:The CD Services Facilitator must be available by telephone to the individual receiving CD serviceswhile the individual is receiving services

If a health and safety issue is noted by the CD Services Facilitator during a visit, he/she is obligated to report this to DSS (Child Protective Services/Adult Protective Services, as appropriate) and the Waiver Services Unit at DMAS (804-786-1465) – Failure to make a report may put your DMAS

provider agreement at risk of termination

Service Facilitation (SF) ProviderService Facilitation (SF) ProviderStaff RequirementsStaff Requirements

The SF cannot be:– The individual in the Waiver; – The spouse of the recipient; – The personal care aide rendering the care;– The parent of the recipient who is a minor

child; or– A family/caregiver who is responsible for

employing the personal care aide

ProviderProviderStaff RequirementsStaff Requirements

It is preferred that the SF possess a minimum of an undergraduate degree in a human services field or be a registered nurse currently licensed to practice in Virginia

In addition, it is preferred that the SF must have two years of satisfactory experience in the human services field working with persons with severe disabilities or the elderly

Provider Provider Staff RequirementsStaff Requirements

If the SF employed by the provider is not a RN, the provider must have RN consulting services available, either by a staffing arrangement or through a contracted consulting arrangement

The SF must have the knowledge, skills, and abilities set forth in Chapter II of the EDCD Manual

Service Facilitation Service Facilitation ServicesServices

Comprehensive VisitComprehensive Visit

The CD SF is responsible for initiating services with the individual upon accepting the referral of service from the Pre-Admission Screening Team

This must be done before the personal care aide begins services

It is done only once upon the individuals entry into CD services– Unless the individual is terminated from CBC

services and is being re-enrolled If the individual requests additional CD

services, such as respite, another comprehensive visit is not necessary. The person has already been initially assessed for CD services

If the individual changes service facilitation providers, the new provider must do a Reassessment Visit in lieu of a comprehensive visit.

A new comprehensive visit will not be paid DMAS

From the initial comprehensive visit the SF will:– Assess the individual to determine Waiver

eligibility using Community-Based Care Recipient Assessment Report (DMAS-99),

– Develop the Plan of Care on the DMAS-97A/B; and

– Ensure that the individual understands his/her rights and responsibilities in the program and sign all of the participation agreements found in the Employee Management Manual, (including those related to the Selection of Service, Fiscal Agent, and the consumer-directed services facilitator); and

All forms must be completed, signed, and dated before the individual can begin employing a personal care aide in the program

Consumer TrainingConsumer Training

The SF must provide the individual with consumer training within seven days of the completion of the Comprehensive Visit– The SF can complete the comprehensive visit

and consumer training on the same day

During the consumer training, the SF must train the individual, or caregiver, on his/her duties as an employer of CD services

Consumer TrainingConsumer Training The SF must follow the Outline & Checklist

for Consumer-Directed Recipient Training to ensure that the training content meets the minimum acceptable requirements– The service facilitator must check each subject

on the form after it has been covered, and have the required signatures and dates;

Consumer TrainingConsumer Training

– The training check list must be maintained in the individual’s file and available for review by DMAS staff; and

– Regardless of the method of training, documentation must indicate that training was received prior to the individual’s employment of a personal care aide.

Routine VisitsRoutine Visits

After the comprehensive visit and consumer training, the SF must conduct two routine onsite visits within 60 days of the initiation of care (once per month) to monitor the individual’s Plan of Care and ensure both the quality and appropriateness of services

Once the first two routine visits have been completed, the SF & the individual can decide how frequent the routine onsite visits occur

All Routine Visits must be conducted at the individual’s residence, since the individual’s environment & support system is necessary to evaluate his/her needs

The service facilitator’s documentation of the routine visit may be in the form of a progress note or a standardized form

After the initial 90 days, the SF’s supervision of the plan of care will be performed in the individual’s home on an as-needed basis

However, a face-to-face meeting with the individual must be conducted at least quarterly for personal care and every six months for respite care when it is provided as a sole service

Routine visits are not to exceed a maximum of one visit every 30 days

The SF must provide any necessary supervision to the individual and record all significant contacts in the individual’s file

During routine visits, the SF:– Must observe, evaluate, and document the

adequacy and appropriateness of the personal care aide services;

– Will review the personal care aide’s time sheets, if available;

– Must discuss the individual’s satisfaction with the type and amount of service; and

– Other documentation as list in the Manual

Reassessment VisitReassessment Visit

This must be documented on the Community-Based Care Recipient Assessment Report (DMAS-99), and must include:– A complete review of the individual's needs &

available supports, & a review of the Plan of Care

Reassessment VisitReassessment Visit

Conducted every every six months or upon the use of 300 respite hours, whichever comes first.

SF conducts a reassessment visit every six months or for individuals who are transferring from another CD SF or who requests a change in their CD services

SF-A SF-BReassessmentTransfer

Management TrainingManagement Training

There may be additional management training for the individual

SF can provide up to four hours of management training to an individual within any six-month period

Each hour of training is billed as one unit

Criminal Record CheckCriminal Record Check

All personal care aides must submit to a criminal record check– SF assist individuals by submitting the

criminal record check forms to the Virginia State Police on behalf of the individual when the individual hires a new personal aide

If the recipient is a minor, the aide must also be screened through the DSS Child Protective Services Registry

Annual Level of Care (LOC) ReviewsAnnual Level of Care (LOC) Reviews

The LOC review information is compiled on the Level of Care Review Instrument (DMAS-99C)

The LOC assessment must be completed by a RN. If the SF does not have a RN on staff, the SF must contract with a RN to complete the assessment

CD Personal Care Aide CD Personal Care Aide Requirements & DutiesRequirements & Duties

Personal Care Aide RequirementsPersonal Care Aide Requirements

Must be 18 years of age or older Must possess basic math, reading and

writing skills Must have the required skills to perform

personal care duties as specified in the individual’s Plan of Care

Must understand and agree to comply with the CD program requirements

May be registered in a CD personal care aide registry, which will be maintained by CD service facilitators

Receive periodic tuberculosis (TB) screening, cardiopulmonary resuscitation (CPR) training and an annual flu shot (unless medically contraindicated);

May not be the parent of a minor, or spouse Payment may not be made for services

furnished by other family/caregivers living under the same roof unless there is objective written documentation as to why there are no other aides available to provide the care

Family members who are employed to provide CD services must meet all CD aide qualifications

Services Performed by Services Performed by CD Personal Care AideCD Personal Care Aide

Services provided by CD personal care aides in the home include:

Activities of Daily Living (ADLs):– Assisting with care of the teeth and mouth;– Assisting with grooming (including care of

the hair, shaving, and ordinary nail care);– Bathing- routine maintenance and care of

external condom catheters is considered part of the bathing process;

Activities of Daily Living (Cont’)– Routine skin care- not to include applying

topical medications or any type of product with an “active ingredient”;

– Dressing;– Toileting; and– Feeding.

– Turning and changing position, transferring, and ambulating;

– Self-administered medications and assuring the individual received medications at prescribed times not to include in any way determining the dosage of medication; and

– Checking the temperature, pulse, respiration, and blood pressure and recording and reporting as required.

Home Maintenance Activities: – Preparing and serving meals;– Washing dishes and cleaning the kitchen;– Making the bed and changing linens;– Cleaning the individual’s bedroom, bathroom

and rooms used primarily by the personal care individual;

– Shopping for necessary supplies for the individual if no one else is available to perform the service; and

– Washing the individual’s laundry if no other family member is available or able

Transportation Transportation

Transportation is not a covered service through this waiver

Transportation to providers of Medicaid services can be arranged through the DMAS transportation broker. There are times that the aide may accompany the recipient to medical appointments or to other activities

The total time required by the personal care aide for the day, including the time required to drive the individual, cannot exceed the individual’s authorized weekly hours. If the total time required exceeds daily hours, additional time may be deducted from another day as long as this does not jeopardize the individual’s health and safety

TransportationTransportation

In no case will DMAS pay, through this Waiver, for mileage or other costs associated with transportation

As the aide is the employee of the individual receiving CD services, any arrangements for transportation not paid for by the Medicaid program are between the aide and the individual – This includes transportation necessary to

implement the CD services plan of care (for example, to permit community access and activities)

Thus, it is permissible for the aide to transport the individual in the aide or individual/family’s vehicle if the following criteria are met:– The vehicle is registered in the

Commonwealth of Virginia;– The aide has a valid Virginia driver’s license;

and– Current vehicle insurance that covers the

following:

– The insurance should cover the driver and passenger(s);

– Against loss from any liability imposed by law for damages;

– Against damages for care and loss of services, because of bodily injury to or death of any person;

– Against injury to or destruction of property caused by accident and arising out of the ownership, use, or operation of such motor vehicle or motor vehicles within the Commonwealth, any other state in the United States, or Canada;

– The insurance should insure the insured or the other person;

– Subject to a limit of exclusive of interest and costs, with respect to each motor vehicle of $25,000 because of bodily injury to or death of one person in any one accident and, subject to the limit for one person, to a limit of $50,000 because of bodily injury to or death of two or more persons in any one accident; and

– Subject to a limit of $20,000 because of injury to or destruction of property of others in any one accident

Consumer-DirectedConsumer-DirectedRespite CareRespite Care

Respite Care DefinedRespite Care Defined

Services designed to provide temporary but periodic or routine relief to the primary, unpaid caregiver

Designed to relieve the physical and emotional burdens of the caregiver and, only secondarily, the needs of the individual

Must aid in the prevention of individual or family, or both, breakdown and possible institutionalization of the individual

Consumer-Directed (CD) RespiteConsumer-Directed (CD) Respite

CD respite can be rendered by the personal aide.

Individuals receiving CD services may also receive agency-directed respite services, but not simultaneously.

The maximum amount of combined respite services is 720 hours per calendar year.

Consumer-Directed (CD) RespiteConsumer-Directed (CD) Respite

– If the recipient is receiving a combination of agency-directed and consumer-directed respite, the service providers must coordinate services

– DMAS will pay for the first 720 billable respite hours submitted for payment

– DMAS is unable to give an accurate up-to-date amount of respite hours that an individual has received

Covered ServicesCovered Services

CD respite covers the same services as regular CD services

The SF must create a plan of care on the DMAS-97A/B for CD respite services

Use the Respite Care Needs Assessment Plan of Care (DMAS-300) to request authorization for respite services

Authorization of ServicesAuthorization of Services

Authorization must be obtained from WVMI prior to beginning services.– If respite services are requested, the WVMI

Cover Sheet (DMAS-98) must be completed and sent to WVMI for authorization. This request must include the name of the primary caregiver requesting respite services, and it must also note whether the primary caregiver lives in the home with the individual.

Fiscal Agent (FA) Fiscal Agent (FA) ResponsibilitiesResponsibilities

In a nutshell:– to handle employment, payroll, and tax

responsibilities on behalf of the recipient (employee of record) who is receiving consumer-directed services

FA ResponsibilitiesFA Responsibilities

Includes: – verifying the authorization of services for

recipients– ensuring proper completion of hire packets for

assistants/companions– receiving & processing time sheets

FA ResponsibilitiesFA Responsibilities

Does Not Include– obtaining waiver service authorizations– determining the type or amount of services for

recipients– determining patient pay amounts– discharges or admissions into the waiver

Hire Packet FormsHire Packet Forms

Forms that need to be sent to the FAPersonal Attendant Provider form Recipient Notification form Employee Agreement Signatory Authority formEmployment Verification form (I 9) ‑Policies for Employees

Have the employer use the Hire Packet Check List and make copies of all completed forms.

Hire Packet RemindersHire Packet Reminders

The I-9 is the form that generates the most problems

The Signatory Authority form must be completed for each employee

Two photocopies of the two IDs used on the I-9 (Employment Verification form) can be included to expedite the process

Hire Packet RemindersHire Packet Reminders

The FA must have the originals in the Hire Packet. (Signatory Authority form may be copied if noted a true copy of original and signed)

“Recipient’s Name” = the Medicaid recipient’s name vs. the family member/caregiver name

Hire Packets Hire Packets (1281 Received Last Six Months)(1281 Received Last Six Months)

entered with in 3 business days

Need corrections21%

Not returnedto DMAS 3%

Needing CorrectionsNeeding Corrections5%

Attendant Provider

Recipient Notification

Employee Agreement

Signatory Authority

Authorization RemindersAuthorization Reminders

The attendant should not start services until the SF receives service authorization

We can not process time sheets until we have received notice of authorization

If the authorization is not retroactive, the employer will be responsible to pay the personal attendant

Time Sheet RemindersTime Sheet Reminders

Complete time sheets according to published schedule

If two services are being provided (respite & attendant) then a separate time sheet needs to be completed for each service

Print clearly When signing for another person, you must

include the recipient’s name on the time sheet

Time Sheet RemindersTime Sheet Reminders

Time sheets MUST have time in / time out recorded.

Must be signed by attendant and recipient or designee.

Be for one service and one pay period. Have legible names.

COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Personal Assistant / Companion Timesheet

Mail To: Fiscal Division Check One:

P.O. Box 662 Attendant/Assistant Richmond, VA 23218-0662 Respite Companion

Assistant/Companion Name (Please Print):

Please check the appropriate program:

Consumer-Directed Personal Attendant Services Waiver (CD-PAS): Individual and Family Developmental Disabilities Support Waiver (IFDDS): Mental Retardation Waiver (MR): AIDS Waiver:

(A Separate Time Sheet Must Be Completed For Each Service, i.e. Respite, Personal Assistant, or Companion)

WEEK 1 THURS. FRI. SAT. SUN. MON. TUES. WED. Date:

Time In: Time Out:

TOTAL:

WEEK 2 THURS. FRI. SAT. SUN. MON. TUES. WED. Date:

Time In: Time Out:

TOTAL:

TOTAL WEEKLY HOURS: WEEK 1: + WEEK 2: = TOTAL HOURS:

HOURLY RATE: $ GROSS PAY TOTAL (Total Hours x Hourly Rate):

(If Applicable, Minus) PATIENT PAY:

ADJUSTED GROSS PAY TOTAL:

My signature certifies that I have provided a service on the dates listed above. I understand that payment for this service will be from federal and state funds, and that any false claims, statements, documents, or concealment of material facts may be prosecuted under applicable federal and state laws. I also understand that, if applicable, I will receive as part of payment for my services the individual’s patient pay amount.

Assistant/Companion’s Signature: Date:

My signature certifies that I received a service on the dates listed above. I understand that, if applicable, I must pay the personal assistant/companion my patient pay amount, which goes toward the cost of services provided.

Recipient/Authorized Signator: Date: Print Recipient’s Name: DMAS-91 (02/04)

Select One Service

Name signing for recipient's name

Payroll Time LinePayroll Time Line

FA receives Authorizations from DMHMRSAS and WVMI every Monday

Hire Packets are received and processed daily

FA receives DMAS-122s from SF for patient pay entries

Pay periods are 14 days in length

Payroll Time LinePayroll Time LineSun Mon Tue Wed Thr Fri Sat

12/23 Pay period begins

12/24 12/25

12/27 12/28 12/29 12/30 12/31 11/1

1/2 1/3 1/4 1/5 Pay period ends Time sheets submitted & received

1/6 Time sheets submitted & received Audit & data entry

1/7 Time sheets submitted & received Audit & data entry

1/8 Time sheets submitted

1/9 1/10 Time sheets due by 5 p.m. Audit & data entry

1/11 Audit & data entry File sent

1/12 Funds transfer requested

1/13 1/14 Direct deposit or checks mailed

DMAS receives the 122 to determine if consumer direction services is the receiver of patient pay.

Patient pay amount is paid by the recipient to the attendant when they receive their pay stub for the pay period that contains the first day of the month.

If the recipient has more than one attendant then they MUST verify by reviewing the amount listed on the pay stub received from DMAS which attendant has had the patient pay amount deducted.

If the attendant earned less than the patient pay amount, the recipient will not receive a pay stub from DMAS and will have a negative balance until they work enough hours to earn over the patient pay amount.

Tips For SuccessTips For Success

The employer and employee should both keep a copy of the time sheet

Mail time sheets when all the service for that payroll period has been provided

Tips For SuccessTips For Success

Make sure that the FA has the employee’s current mailing address

If an employee is terminated, the FA needs to be notified

Send updated DMAS-122s to the FA

THANK YOUTHANK YOU

elderly or disabled with consumer direction services waiver

Documents

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