12 Va. Admin. Code § 30-60-304

Current through Register Vol. 41, No. 9, December 16, 2024

Section 12VAC30-60-304 - Requests and referrals for LTSS screening for adults and children living in the community; adults and children in hospitals; and adults and children in nursing facilities

A. LTSS screenings for adults living in the community. LTSS screenings for adults who are residing in the community and who are not hospital inpatients shall be completed and submitted by the CBT to eMLS. If the individual, or any of the other persons permitted to make such requests, requests an LTSS screening, the CBT shall be required to perform the requested LTSS screening. Every individual who applies for or requests LTSS shall have the opportunity to choose the setting and provider of services, and have this choice documented.

1. Requests for LTSS screenings shall be accepted from either an individual, the individual's representative, an adult protective service worker, the individual's physician, or an MCO care coordinator having an interest in the individual. The CBT in the jurisdiction where the individual resides shall conduct such LTSS screening. For the LTSS screening to be scheduled by the CBT, the individual shall either agree to participate or, if refusing, shall be under order of a court of appropriate jurisdiction to have an LTSS screening. Medicaid payment for services cannot be considered without agreement of the individual or the individual's representative to participate in the LTSS screening.

a. The LDSS or LHD in receipt of the request for an LTSS screening shall contact the individual or the individual's representative within seven days of the request date for screening to schedule an LTSS screening with the individual and any other persons whom the individual selects to attend the screening.

b. When the CBT has not scheduled an LTSS screening to occur within 21 days of the request date for screening, and the LTSS screening is not anticipated to be complete within 30 days of the request date for screening due to the screening entity's inability to conduct the LTSS screening, the LDSS and LHD shall, no later than seven days after the request date for screening, notify DARS and VDH staff designated for technical assistance.

2. Referrals for LTSS screenings may also be accepted by LDSS or LHD from an interested person having knowledge of an individual who may need LTSS. When the LDSS or LHD receives such a referral, the LDSS or LHD shall obtain sufficient information from the referral source to initiate contact with the individual or the individual's representative to discuss the LTSS screening process. Within seven days of the referral date, the LDSS or LHD shall contact the individual or the individual's representative to determine if the individual is interested in receiving LTSS and would participate in the LTSS screening. If the LDSS or LHD is unable to contact the individual or the individual's representative, the LDSS or LHD shall document the attempt to contact the individual or the individual's representative using the method adopted by the CBT.

a. After contact with the individual or the individual's representative, or if the LDSS or LHD is unable to contact the individual or the individual's representative, the LDSS or LHD shall advise the referring interested person that contact or attempt to contact has been made in response to the referral for an LTSS screening.

b. Information about the results of the contact shall only be shared by the LDSS or LHD with the interested person who made the referral when the LDSS or LHD has the individual's written consent or the written consent of the individual's legal representative who has such authority on behalf of the individual.

B. LTSS screenings for children living in the community. LTSS screenings for children who are residing in the community and who are not hospital inpatients shall be completed and submitted via eMLS. If the individual or parent or guardian, or any of the other persons permitted to make such requests, requests an LTSS screening, the DMAS community screening designee shall perform the requested LTSS screening. Every individual who applies for or requests LTSS shall have the opportunity to choose the setting and provider of services and have this choice documented.

1. A child who is residing in the community and is not an inpatient shall receive an LTSS screening from a DMAS community screening designee. The DMAS community screening designee may receive requests for LTSS screenings directly. Any requests for LTSS screenings for a child received by the CBT shall be forwarded directly to the DMAS designee. For the LTSS screening to be scheduled by the DMAS community screening designee, the child shall either agree to participate or, if refusing, shall be under order of a court of appropriate jurisdiction to have an LTSS screening. Medicaid payment for services cannot be considered without agreement of the individual or the individual's representative to participate in the LTSS screening.

2. The request for LTSS screening of a child residing in the community shall be accepted from the parent, legal guardian, the entity having legal custody of that child, an emancipated child, a physician, an MCO care coordinator, or a child protective service worker having an interest in the child.

3. Referrals for LTSS screenings may also be accepted from an interested person having knowledge of a child who may need LTSS. The process, timing, and limitations on the sharing of the results for referrals for LTSS screenings for children shall be the same as that set out for adults in subdivision A 2 of this section.

C. LTSS screenings in hospitals for adults and children who are inpatients. LTSS screenings in hospitals shall be completed when an adult or child who is an inpatient is discharged directly to an NF or may need LTSS in the community upon discharge or when the individual, MCO, or representative requests an LTSS screening. Medicaid payment for services cannot be considered without agreement of the individual or the individual's representative to participate in the LTSS screening. Every individual who applies for or requests LTSS shall have the opportunity to choose the setting and provider of services and have this choice documented.

1. As a part of the discharge planning process, the hospital LTSS screening team shall complete a face-to-face LTSS screening when:

a. The individual's physician, in collaboration with the individual or the individual's representative if there is one, makes a request of the hospital team. If the individual is a child, the LTSS screening shall be completed when the individual's physician, in collaboration with the child's parent, legal guardian, the entity having legal custody of the child, the emancipated child, adult protective services worker, child protective services worker, or MCO care coordinator makes a request of the hospital LTSS screening team; or

b. The individual, the individual's representative if there is one, parent, legal guardian, entity having legal custody, emancipated child, adult protective services worker, child protective services worker, or MCO care coordinator requests a consultation with hospital case management.

2. When there is a request, such individual shall receive an LTSS screening conducted by the hospital LTSS screening team regardless of if the individual is eligible for Medicaid or is anticipated to become eligible for Medicaid within six months after admission to an NF.

3. The hospital LTSS screening team shall exclude all institutionally induced dependencies from the face-to-face LTSS screening documentation.

D. LTSS screenings for individuals needing LTSS after a skilled or rehabilitation nursing facility services admission. LTSS screenings for individuals who need LTSS after receiving skilled or rehabilitation nursing facility services that are not covered by the Commonwealth's program of medical assistance services after discharge from an acute care hospital shall be completed and submitted via eMLS by NF LTSS screening teams. Medicaid payment for services cannot be considered without agreement of the individual or the individual's representative to participate in the LTSS screening. Every individual who applies for or requests LTSS shall have the opportunity to choose the setting and provider of services and have this choice documented.

1. Requests for LTSS screening shall be accepted from either an individual, the individual's representative, the individual's physician, the NF LTSS screening team, or an MCO care coordinator having an interest in the individual. The nursing facility LTSS screening team shall contact the individual or the individual's representative prior to enrollment in LTSS to schedule an LTSS screening with the individual and any other persons whom the individual selects to attend the LTSS screening.

2. Nursing facility LTSS screening teams must include at least one registered nurse and physician but may include a social worker or other members of the interdisciplinary team. The authorization or denial for Medicaid LTSS (DMAS-96 form) must be signed and attested to by the nursing facility LTSS screener and a physician.

E. LTSS screenings shall be submitted via eMLS within 30 days of the screening request.

12 Va. Admin. Code § 30-60-304

Derived From Virginia Register Volume 34, Issue 24, eff. 8/22/2018; Amended, Virginia Register Volume 38, Issue 12, eff. 2/16/2022; Amended, Virginia Register Volume 41, Issue 01, eff. 10/10/2024.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.