The purpose of this memorandum is to notify providers, stakeholders and families of children under the age of 21 receiving Developmental Disability Waiver services in the Community Living (CL) and Family and Individual Supports (FIS) Waivers that DMAS has reached agreement with the Centers for Medicare and Medicaid (CMS) to reverse a policy implemented in November 2017 regarding the authorization of personal assistance services. 

CMS previously instructed Virginia to evaluate personal assistance hours based on criteria established in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. As a result of this policy change, decisions about the number of personal assistance hours approved for individual members relied heavily on an assessment of medical necessity. 

Starting September 4, 2019, the evaluation of the number of personal assistance hours required for our members will be based on criteria outlined in the Community Living (CL) and Family and Individual Supports (FIS) Developmental Disability Waivers. Decisions about personal assistance hours will be determined based on an assessment of the services needed for members to remain in their homes and their communities if they choose that option over institutional care.

This change will apply only to personal assistance services through the CL and FIS Waivers for members under the age of 21 for service authorization effective date on or after September 4, 2019. The Medical Necessity Assessment and Personal Care Service Authorization form, also known as the DMAS-7, will no longer be required for these members after that date. The change was already implemented, effective May 1, 2019, for individuals who are on the Commonwealth Coordinated Care Plus Waiver.

For members who experienced personal care hour reductions under EPSDT and indicate their needs are not met, the provider may submit a new authorization request to have hours reviewed under the DD Waiver criteria.  Reminder: providers are required to ensure that services are adequate to meet the member's needs.

The chart below summarizes the required documentation for service authorization requests for dates of service effective after September 4, 2019 for children under 18 years of age. The Request for Supervision form will not be needed for individuals 18 years of age and older (please see attachment). This form will be used to determine supervision hours needed for children taking into consideration health, safety and well-being and the current support system available for supervision. 

There are no changes to any other services.

Medicaid Expansion

New adult coverage began January 1, 2019.  Providers can use the same web portal and enrollment verification processes in place today to verify Medicaid expansion coverage.  In ARS, individuals eligible in the Medicaid expansion covered group will be shown as “MEDICAID EXP.”  If the individual is enrolled in managed care, the “MEDICAID EXP” segment will be shown as well as the managed care segment, “MED4” (Medallion 4.0), or “CCCP” (CCC Plus).  Additional Medicaid expansion resources for providers can be found on the DMAS Medicaid Expansion webpage at:  http://www.dmas.virginia.gov/#/medex.