1. Department of Medical
Assistance Services
Pre-Admission Screening
Melissa A. Fritzman
Program Supervisor
Division of Long-Term Care
Fall 2008
1

2. Why Do We Cover
Who We Cover?
Basic Services, Eligibility,
Coverage Groups, and
Patient Pay
2

3. Overview of Today’s Session
 Why Do We Cover Who We Cover?
 Why Do We Do What We Do?
 Assisted Living Pre-Admission Screenings
 What Do I Need To Get Paid?
 Criteria for Eligibility Determination Based On
Individual’s Abilities/Needs
 What Do We Look Like?
 What’s Wrong With My UAI?
 What Do Services Look Like?
3

4. Why Do We Cover Who We Cover?
Medicaid Services -
Mandatory Services -
Medicaid State Plan
(must be available statewide in the same
amount, duration, and scope to all who
meet criteria; individuals must be able to
choose providers)
4

5.  Inpatient Hospital Services
 Emergency Hospital Services
 Outpatient Hospital Services
 Nursing Facility Care
 Rural Health Clinic Services
 Federally Qualified Health Center Clinic
Services
5

6.  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
6

7.  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
 ICF/MR
7

8.  Dental Services for Persons under 21
 Physical Therapy & Related Services
 Prescribed Drugs
 Case Management Services
 Prosthetics
 Mental Health Services
 Mental Health Clinic Services
 Hospice Services
 Medicare Part B Premiums for the Medically
Needy
 PACE
8

9. Medicaid Services
Mandatory vs. Optional
Waivers
Can determine
Mandatory Optional services to be
Services Services provided
(State Plan) Can be targeted to
(State Plan
specific groups:
Option)
• Aged,
Cannot be targeted to specific groups, unless
that is part of the service definition • Disabled,
• Persons with
Developmental
Provided to both mandatory and optional disabilities,
coverage groups
• Persons who are
Mentally Ill/Mentally
Retarded
9

10. Long-Term Care Eligibility and Services
Coverage Group Financial
•Aged, blind, and Eligibility
disabled After you are
•Families with in a coverage
children group, you
•Recipients of must meet
cash assistance
•Pregnant women income and
and children asset
•Low-income guidelines, as
Medicare well as non-
beneficiaries financial
criteria.
10

11. Long-Term Care Eligibility and Services
 To be eligible for Medicaid-funded long-term care
services individuals must :
 Qualify for Medicaid; and
11

12. Long-Term Care Eligibility and Services
 Meet specified long-term care criteria
using the standardized long-term care
assessment instrument.
They are:
•Uniform Assessment Instrument (UAI) for
nursing facility level of care
•Level of Functioning (LOF)
for Intermediate Care Facility/Mentally
Retarded (ICF/MR) level of care
12

13. Long-Term Care Eligibility and Services
LTC accounts for 70 % of the total Medicaid
Budget and 30% of the individuals
Long Term Care is provided
 In institutions:
 Intermediate Care Facilities for the Mentally
Retarded (ICF/MR) (State Plan Option);
 Nursing Facility (Mandatory State Plan
service)
 Assisted Living Facilities (State Plan Option)
13

14. Long-Term Care Eligibility and Services
Long Term Care is provided
 In the community:
 Home and Community Based (1915(c))
Waivers
 Program of All-Inclusive Care For the
Elderly (PACE) (State Plan Option)
14

15. Qualify for Medicaid
 Individuals who are financially Medicaid
eligible at the time of application for LTC
services are not automatically eligible for LTC
services if they meet the functional and/or
medical nursing needs assessment.
 The local DSS must assess the individual’s
financial eligibility for Medicaid (LTC) and
calculate a patient pay. Everyone must have
a calculation, not everyone has a patient pay.
15

16. Qualify for Medicaid*
DMAS -122
 The Patient Pay (DMAS-122) is the amount that
the individual must contribute each month towards
their cost of care.
 The DMAS-122 is the service provider’s
authorization to bill Medicaid for LTC services.
 DMAS-122 is to be sent by the EW no later than
45 days from date of application, and 30 days
from the date of a reported change.
 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

17. Why Do We Do
What We Do?
Why Is Pre-Admission
Screening Important?
17

18. Why we do Pre-Admission Screenings
 In order to be eligible for long-term care services,
individuals must be screened to determine if they
meet the admission criteria.
 Virginia has one of the most stringent criteria in the
country.
 For Nursing Facilities and Home and Community
Based Waivers: The authorized assessors are the
local health departments in conjunction with the
local departments of social services and acute care
hospitals.
18

19. Preadmission Screening
Waiver Assessment Tool Screening Agency
AIDS/HIV UAI Local DSS and HD/Hospitals
ALZHEIMER’S UAI Local DSS and HD/Hospitals
EDCD UAI Local DSS and HD/Hospitals
TECH UAI Local DSS and HD/Hospitals
IFDDS LOF Local CDC
Day Support LOF Local CSB
MR LOF Local CSB
Some waivers have a wait list. LOF = Level of Functioning Tool
19

20. Preadmission Screening
Recipient’s Choice of Placement
Criteria for Criteria for
Admission to Admission to
the Waiver Institution
The individual applying for a waiver must meet
the same criteria that is used for admission to
the alternative institutional placement. 42 C.F.R.
441.302 (c)(1); 42 C.F.R. 441.303 (c)(2)

21. Alternate Institutional Placement
 There must be an alternate institutional
placement for which Medicaid pays.
 Must determine the most appropriate
institutional placement for an individual, and
must name that placement in the waiver
application.
 This does not mean that the individual must 21

22. Preadmission Screening
 The Uniform Assessment Instrument (UAI)
is an interagency assessment used by most
publicly funded human services agencies in
the Commonwealth for long-term care
services.
 The UAI is an assessment tool to gather
information to determine care needs,
service eligibility, and planning and
monitoring a person’s care needs across
agencies.
22

23. Preadmission Screening
 Read the UAI Manual !!!
 Use the UAI Manual!!!
 Knowing the definitions for items
on the UAI is critical to
determining appropriate level of
care and services.
 Assess the individual for current
functional status and/or medical
nursing needs.

24. Assisted Living Pre-
Admission Screenings
What’s Different with this Program?
24

25. Who are the Preadmission Screening Teams?
• For Assisted Living Services: The
authorized assessors are the local departments
of social services, local departments of health,
area agencies on aging, centers for
independent living, or community service
boards.
• ALFs may not complete any UAI assessments
for public pay individuals. This includes prior to
admission, the annual reassessment, and
whenever there is a significant change in
condition. ALFs may complete these
assessments for private pay individuals.
25

26. Who are the Preadmission Screening Teams?
• Emergency placements: Placement
must be approved by Adult Protective
Services (APS) through the local
department of social services and the
assessment must be completed within
seven working days from the date of
placement.
26

27. Preadmission Screening
ALF Change in Level of Care
Completed by all entities authorized to perform
initial assessments.
Performed when permanent change (expected
to last longer than 30 days) in level of care
indicated.
Follow same assessment process as initial
assessment.
Payment to assessor tied to completion of short
versus full assessment.
27

28. Preadmission Screening
New Assessment Not Needed When. . .
For Assisted Living Services Only
• Lapse in financial eligibility; or
• Transfer from one ALF to another ALF; or
• Respite care resident; or
• Discharge back to the same ALF from the
hospital (if less than 30 days) with no change
in level of care.
28

29. Preadmission Screening
ALF Prohibited Conditions
 Ventilator Dependency
 Dermal Ulcers Stage III and IV
 IV Therapy or Injections Directly into the Vein
 Airborne Infectious Diseases in a
Communicable State
 Psychotropic Medications w/o appropriate
DX and TX
 NG Tubes
 Gastric Tubes
29

30. Preadmission Screening
ALF Prohibited Conditions
 Individuals Presenting an Imminent Physical
Threat or Danger to Self or Others
 Individuals requiring continuous Nursing
Care (24/7)
 Individuals whose physician certifies
placement is no longer appropriate
 Individuals who require Maximum Physical
Assistance
 Individuals whose health care needs cannot
be met in the ALF setting.
30

31. What Do I Need
To Get Paid?
Documentation Requirements
31

32. Preadmission Screening
 For NF, Regular Assisted Living, Alzheimer’s
Assisted Living, Program for the All-Inclusive
Care of the Elderly (PACE), and Waiver
placement all 12 pages of the UAI, the
DMAS-96 form, the DMAS-95 MI/MR/RC
form, and the DMAS-97 forms are required.
 For Residential Assisted Living a short form is
required. This is the first 4 pages of the UAI,
plus the questions related to medication
administration and behavior pattern.
32

33. Criteria for Eligibility
Determination based on
Individual’s Abilities/Needs
For Nursing Facility, PACE and Home
and Community Based Care Waivers
33

34. Activities of Daily Living – There are three different ways
to meet the criteria for ADL dependencies ….
1 Dependent in 2-4 ADLs, plus semi-
dependent or dependent in behavior and
orientation, plus semi-dependent in joint AND
motion or semi-dependent in medication Have
administration, OR Medical
Nursing
2 Dependent in 5-7 ADLs plus dependent in
Mobility, OR Needs
3 Semi-Dependent in 2-7 ADLs, plus
dependent in mobility, plus dependent in
behavior and orientation.
34

35. Required Activities of Daily Living (for
purposes of Medicaid eligibility)
 Although Mobility is not
 Bathing
considered an activity of
 Dressing daily living, it is an area
 Transferring where screeners have
 Toileting questions. The definition of
 Bowel Function mobility is – the extent of
the individual’s movement
 Bladder Function
outside his/her usual
 Eating/Feeding living quarters.
35

36. Behavior and Orientation
 Behavior and Orientation are considered
one item for the purposes of criteria
determination.
 Semi-dependency and dependency are
based on the combination of both behavior
and orientation.
 Remember: In order to meet this criteria, the
individual must be dependent in both areas.
36

37. Medical Nursing Needs
 In addition to meeting functional criteria, in
order to receive Medicaid reimbursement,
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.)
37

38. Medical Nursing Needs – There are three
different ways to have one…
 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.
38

39. Examples of Medical Nursing Needs
(May or may not necessarily indicate on ongoing medical
nursing needs. Except as specified, the risk of the
identified conditions are not a medical nursing need if not
a current problem.)
 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
39

40. Examples of Medical Nursing Needs
(May or may not necessarily indicate on ongoing medical
nursing needs. Except as specified, the risk of the identified
conditions are not a medical nursing need if not a current
problem.)
 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
 Oxygen
40

41. Examples of Medical Nursing Needs
(May or may not necessarily indicate on ongoing medical
nursing needs. Except as specified, the risk of the identified
conditions are not a medical nursing need if not a current
problem.)
 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.
41

42. Examples of Medical Nursing Needs
(May or may not necessarily indicate on ongoing medical
nursing needs. Except as specified, the risk of the identified
conditions are not a medical nursing need if not a current
problem.)
 Application of aseptic dressings
 Routine catheter care;
 Respiratory therapy
 Therapeutic exercise and positioning
 Chemotherapy
 Radiation
 Dialysis
 Suctioning

43. Medical Nursing Needs Documentation Requirements
Examples of Medical Nursing Needs
(May or may not necessarily indicate on
ongoing medical nursing needs. Except as
specified, the risk of the identified conditions
are not a medical nursing need if not a current
problem.)
Seizures
 Are there medication changes?
 Are there labs being drawn for medication
levels?
43

44. Medical Nursing Needs Documentation Requirements
Seizures
 Any recent seizure activity? (Either grand
mal or petite mal)
 Family noted any blank stares?
44

45. Medical Nursing Needs Documentation Requirements
Examples of Medical Nursing Needs
(May or may not necessarily indicate on
ongoing medical nursing needs. Except as
specified, the risk of the identified conditions
are not a medical nursing need if not a
current problem.)
Supervision for Adequate Nutrition
 Documentation of weight loss/gain?
 Documentation of dehydration?
45

46. Medical Nursing Needs Documentation Requirements
Supervision for Adequate Nutrition
 Is person seeing a dietician or other health
professional on regular bases?
 Taking any supplements (ensure, boost,
Gatorade, Pedialyte, scheduled snacks,
etc.)?
46

47. Medical Nursing Needs Documentation Requirements
Examples of Medical Nursing Needs
(May or may not necessarily indicate on
ongoing medical nursing needs. Except as
specified, the risk of the identified conditions
are not a medical nursing need if not a
current problem.)
Routine Skin Care to Prevent Pressure
Ulcers
 Documentation of red areas?
 Any open areas currently?
47

48. Medical Nursing Needs Documentation Requirements
Routine Skin Care to Prevent Pressure
Ulcers
 Use of restraints or other equipment that
has in past caused breakdown?
 Any special techniques caregiver may be
doing (repositioning every 2 hours,
applying ointments, using pressure
relieving devices)?
48

49. Medical Nursing Needs Documentation Requirements
Examples of Medical Nursing Needs
(May or may not necessarily indicate on ongoing
medical nursing needs. Except as specified, the
risk of the identified conditions are not a medical
nursing need if not a current problem.)
Therapies
 Documentation of all PT, OT or Speech
therapies and the location where the
therapies are received.
49

50. Medical Nursing Needs Documentation Requirements
 If a child receives therapy services during
the school year at school, this is
acceptable.
 NOTE: Remind families that therapies
received outside of the school year can be
ordered by doctor through Home Health or
Outpatient Rehab.
50

51. What Do We Look Like?
Case Examples
51

52. 52

53. Case Examples
Mrs. Jones is a 96-year-old female with a
diagnosis of congestive heart failure and
non-insulin dependent diabetic. She is
dependent in bathing, dressing, toileting,
and needs assistance eating. Mrs. Jones
is oriented to some spheres, some of the
time and her behavior is
wandering/passive more than weekly.
53

54. Case Examples
Mrs. Jones cont’d:
Mrs. Jones’ medications must be
administered/monitored by professional
nursing staff.
Individual #1: 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.
54

55. 55

56. Case Examples
Mrs. Smith is a 60-year-old female with a
diagnosis of hypertension and non-insulin
dependent diabetes who recently suffered a
cerebral vascular accident. She has hemi-
paresis with right-sided weakness. She is
dependent in bathing, dressing, eating,
toileting, and transferring.
56

57. Case Examples
Mrs. Smith cont’d:
Mrs. Smith requires human help when
going outside the home, therefore she is
dependent in mobility. She is oriented to
all spheres all times and her behavior is
appropriate.
Individual #2: Dependent in 5 to 7 ADLs
and dependent in mobility.
57

58. 58

59. Case Examples
Mrs. Ford is a 75-year-old female with a
diagnosis of leukemia and Alzheimer’s
disease. She requires supervision in
bathing and requires mechanical help with
toileting and transferring. She is continent
of both bowel and bladder. Mrs. Ford is
disoriented to all spheres all of the time
and is abusive/aggressive/disruptive less
than weekly, which makes her dependent
in this area.
59

60. Case Examples
 Mrs. Ford, cont’d:
Her medications must be
administered/monitored by professional
nursing staff and she is currently receiving
chemotherapy treatments for her leukemia.
Individual #3: Semi-Dependent in 2 to 7
ADLs, Plus dependent in behavior and
orientation.
60

61. What’s Wrong with My UAI?
Process & Problems
61

62. Process & Problems
 First Health Services, our contractor, data
enters all pre-admission screening packages.
 The contractor will enter all pre-admission
screening packets into the VaMMIS system
allowing for payment of the screening.
 Any screenings that the VaMMIS system can
not process because they did not meet
criteria are sent to DMAS for further review.
62

63. Process & Problems
 DMAS will review the preadmission
screening packet and make the final
determination on the pre-admission
screening package.
 DMAS may call the screening team,
providers, or even visit an individual to
determine if the individual meets the
established criteria for services.
 The method of doing this is done on a case
by case basis.
63

64. Process & Problems
 Reasons that packages are returned:
No documentation of medical/nursing need
Screening documents that the individual is
in good health
No documented risk of nursing facility
placement
Not fully completed
Missing required attachments
Screeners unfamiliarity with criteria
64

65. What Do Services Look Like?
Overview of What Makes
PACE and Waivers Special
65

66. Medicaid Services
Long –Term Care
 Program for the All-Inclusive Care of
the Elderly (PACE)
 Community based waivers:
 Aids Waiver An
 Alzheimer’s Waiver increasing
 Developmentally Disabled emphasis
 Day Support Waiver
 Elderly or Disabled Consumer Direction
Waiver
 Mental Retardation Waiver
 Tech Waiver

67. Medicaid Services
Long –Term Care
 Facility based programs:
 Assisted Living
 Home Health A decreasing
 Hospice emphasis
 Nursing Facilities
Specialized Care
 ICF/MR
 Rehabilitation Programs
In / Out patient
School

68. Medicaid Services – PACE
 PACE is a Program of All Inclusive Care
for the Elderly
 Serves persons 55 and older that meet
nursing facility criteria in the community.
 Provides all health and long-term care
services centered around an adult day
health care model.
 Combines Medicaid and Medicare funding.
68

69. Medicaid Services – PACE
Map Key
Frederick
Sentara PACE Winchester
Mountain PACE Manassas Park
Loudoun
Centra PACE Clarke Falls Church
Warren
Riverside PACE Hampton Fauquier
Arlington
Shenandoah Alexandria
Riverside PACE Richmond
Rappahannock Fairfax Fairfax City
Appalachian PACE Prince
William
Manassas
Rockingham Page
Harrisonburg
 Culpeper
Stafford
Highland  Madison
Augusta King
Greene Fredericksburg
George
Staunton  Orange
Spotsylvania Westmoreland
Albemarle
Bath
Waynesboro Essex
Louisa Caroline Northumberland
Charlottesville
Lexington
Clifton Forge Fluvanna King & Richmond
Buena Vista Queen Accomack
Covington Nelson Goochland Hanover Lancaster
Alleghany Rockbridge King Middlesex
Henrico
Amherst William
Buckingham
Botetourt Powhatan Richmond New
Cumberland Kent Matthews
Craig Lynchburg Chesterfield James Gloucester Northampton
Appomattox Charles City
Roanoke Bedford Amelia
Giles Col.Heights City
Salem Prince
 Buchanan Roanoke City Prince York Poquoson
Montgomery Bedford Campbell Edward Petersburg George Surry Williamsburg
Nottoway Hampton
 Dickenson
 Tazewell Bland Dinwiddie Hopewell Isle of Newport News
 Wise Radford Charlotte
Wight
Pulaski Franklin Lunenburg Norfolk
Sussex
 Russell Floyd Portsmouth
 Norton Wythe
Smyth Pittsylvania Brunswick Virginia
Franklin Beach
 Lee Henry Suffolk
Washington Carroll Emporia
Scott Danville Southampton Chesapeake
Galax Patrick Halifax Mecklenburg
Grayson Martinsville Greensville
Bristol

70. Medicaid Services – PACE
 Community Model: Program of All
Inclusive Care for the Elderly or PACE.
Combines Medicaid and Medicare
funding to provide all medical, social, and
long-term care services through an adult
day health care center.
70

71. Medicaid Services – PACE
 Seven communities actively pursuing PACE-6
were awarded start up grants*
($250,000 each):
- PACE of Riverside at Hampton Roads*
- PACE of Riverside at Richmond*
- PACE of Centra at Lynchburg *
- PACE of Appalachian AAA at Tazewell *
- PACE of Mountain Empire AAA at Big Stone Gap *
- RFA under development for Northern Virginia *
71

72. Waivers
 Social Security Act allows states to
“waive” the freedom of choice of provider,
statewideness, and amount, duration, and
scope of services requirements in order to:
 have managed care programs (Section
1915(b);
 try new approaches through research and
demonstration (Section 1115); and
72

73. Waivers
 allow services to be provided in the
community rather than in institutions
(Section 1915(c) Home and Community
Based Care Waivers) . About 30% of long
term care spending is provided through
HCBS waivers.
73

74. Waivers
Recipient Choice
The applicant must be offered
the choice in all of the following:
 Waiver
 Alternate institution
 Providers
 Services
74

75. Waivers…………..Cost Effective
 It can be individually cost effective or cost
effective in the aggregate.
 Aggregate Cost Effectiveness : The average cost to
Medicaid for individuals enrolled in a waiver cannot
cost more than the average cost to Medicaid for
individuals in the comparable institution.
 Individual Cost Effectiveness: Cost to Medicaid for
the individual in the community can’t exceed the cost
in the comparable institution.
 DMAS has chosen to use aggregate cost
effectiveness.

76. Waivers
Community Based
Medicaid waiver funds cannot
pay for room and board.
Services must be
based in the
community
Waiver Payments are
for Services Rendered
76

77. 7 Medicaid Waivers
Alternate Institutional Placement Special Conditions VAC
Waiver Regulatory Cite
Nursing Facility/ Hospital A diagnosis of AIDS 12 VAC-30-120-140
Be experiencing medical and functional
AIDS/HIV symptoms
Nursing Facility Have a functional and medical need & a 12 VAC-30-120-10
EDCD Disability
Intermediate Care Facility for the 6 years of age or older 12 VAC-30-120-700
Mentally Retarded ICF/MR) If child under 6 years, be developmentally at risk
Developmentally and meet ICF-Criteria Waiting List
Disabled Cannot have diagnosis of MR
Intermediate Care Facility for the Must have diagnosis of MR 12 VAC-30-120-210
Mentally Retarded (ICF/MR) If child under 6 years, be developmentally at risk
Mental Retardation and meet ICF-Criteria Waiting List
Technology Specialized Care in Nursing Facility for Must be dependent on ventilator or specialized 12 VAC-30-120-70
Assisted adult / Hospital for children equipment
Day Support Intermediate Care Facility for the Must be on the MR wait list 12 VAC-30-120-1500
Mentally Retarded (ICF/MR)
Waiting List
Alzheimer’s Nursing Facility Must have diagnosis of Alzheimer’s 12 VAC-30-120
Emergency regulation

78. Waivers…..Eligibility - All Waivers
 Cannot be served in more than one waiver at
a time (federal requirement).
DD
 Can be on one waiver Waiver
EDCD
while on a waiting list Waiver
John Doe
for another waiver if John Doe
meet the criteria for
admission to both
waivers.
78

79. Waivers
Consumer-Directed Services
79

80. Waivers …….Consumer-Directed Services
 Services provided by a  The individual
enrolled Medicaid consumer or their
Agency who hires and representative
monitors staff that employs and monitors
provide services to a staff providing services
variety of individuals. exclusive to them.
80

81. Waivers …..Consumer-Directed
Personal Care Services
 Available in four of Virginia’s waivers:
 HIV/AIDS (personal care and respite)
 EDCD (personal care and respite)
 DD Waiver (personal care and respite)
 MR Waiver (personal care, respite, and
companion)
81

82. Waivers …..Consumer-Directed
Personal Care Services
 Afford recipients or family caregivers direct
control over who, how, and when services
are provided.
 Waiver recipient is the employer of record
with the IRS.
 In Virginia personal assistants are
classified as domestic workers and are not
subject to worker’s compensation claims.
82

83. Waivers …...Consumer-Directed
Personal Care Services
 The individual must be over the age of 18,
without cognitive impairment, and interested in
managing his/her own personal attendant.
 If a minor child or individual with cognitive
impairment, there must be a a responsible
family member willing and able to direct and
manage the personal attendant.
83

84. Waivers …..Consumer-Directed
Personal Care Services
Specific steps are required BEFORE
consumer directed services can
begin. The recipient or Employer of
Record (ERO) must:
 Select and meet with a Medicaid approved
Service Facilitator;
 Establish a service plan with the SF;
84

85. Waivers ……..Consumer-Directed
Personal Care Services
 Complete Employer Tax Forms Packet and
mail the tax forms to the fiscal agent (FA)
giving the authority to withhold & submit
taxes as the recipient’s agent;
 Receive preauthorization from DMAS’
contractor (KePRO) – this is accomplished by
the service facilitator’s prompt submission of
the service plan to KePRO.
 Hiring, training, documenting time worked,
and submitting time sheets for the attendant.
85

86. Waivers …..Consumer-Directed
Personal Care Services
Remember – it takes time to accomplish all
of the steps before consumer directed
services start.
Consider – Agency directed services may
be used prior to or at the same time as
consumer directed services.
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87. Waivers …..Consumer-Directed
Personal Care Services
Example: A recipient may want
consumer directed services. However,
the recipient needs services
immediately. Agency directed services
may be used until all of the
requirements for consumer direction
are accomplished by the recipient,
service facilitator and fiscal agent.
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88. Waivers …..Consumer-Directed
Personal Care Services
 At a minimum, personal assistants cannot be a
legally responsible relative (a spouse or a
parent of a minor child).* Waivers can define
differently.
 Payment is not made to other family members
unless there is objective, written documentation
as to why there are no other providers available
to provide the service.*
*These are federal requirements. 88

89. Questions and Answers
Long-Term Care Issues
Pre-Admission Screeners list serve at
http://www.dmas.virginia.gov/ltc-Pre_admin_scr
For questions, please contact the Division of
Long-Term Care at 804-225-4222, or by fax
at 804-371-4986.
Please visit the DMAS website at:
www.dmas.virginia.gov
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