DMAS Important Updates

A legally responsible individual is any person who has a duty under state law to care for another person and includes parents of children under age 18 (including biological, foster, stepparents, and legal guardians) and spouses.

No. However, ALL live-in attendants including LRI’s should show documentation of being in “the best interest of the client and the attendant of last resort.”

LRIs will complete an extraordinary care form that shows why an EOR is unable to hire an attendant in the community and no one else is available to provide services to the member. This means all avenues have been explored. To qualify for extraordinary care, at least one of the criteria must be met.

• Proof of inability to hire or maintain staff must be submitted by the agency or to the SF; this can include ads placed by the agency or EOR and responses, as well as any other resources used to attempt to hire staff, records to indicate high turnover of staff, or interview notes of candidates who chose not to accept the position. The agency or SF must retain this information for review by DMAS.
• “Behavioral support needs” are needs documented in the member’s record which were identified through an assessment or evaluation completed by a professional who is licensed in the commonwealth to diagnose and treat behavioral needs.  For exceptional care criteria to be met in this category, there must be evidence that the member’s behavioral needs are so great that only an LRI can safely support them at this time. There must also be evidence that the team is seeking a professional to assist the member in overcoming the barrier behaviors.
• “Medical support needs” are needs diagnosed by a medical practitioner who is licensed in the commonwealth.  Medical needs that include the need for skilled tasks must be delegated by a Registered Nurse and documented in a protocol when being reimbursed through Medicaid funds. There must be justification to support that the member’s health and safety would be at risk if an Attendant other than the LRI were to provide care. Examples of skilled needs are wound care requiring the intervention or observation of a licensed nurse or MD, tube feedings, intravenous infusions, etc.  
• Language being a factor in service delivery includes members for whom English is a second language or member uses sign language and this is documented in the record that an attendant who speaks the same language as the member is not available to provide care outside of the home.  

Copies need to be provided to your Service Facilitator prior to every request for authorization.

Your Consumer Directed Service Facilitator (CD SF) or Agency Directed (AD) provider will review and submit the form to your Care Coordinator (CC) at the Managed Care Organization (MCO), Support Coordinator (SC) at your Community Service Board (CSB), or DMAS. This Approving Authority will need to approve you to be the LRI attendant and communicate that back to the provider and to your Fiscal Agent (FA). At this time you will be able to complete enrollment packets with the Fiscal Agent. 

“Objective, written documentation” (OWD) means documentation that demonstrates there are no persons available to provide support to the individual other than the unpaid family/caregiver who lives in the home with the individual. At least one criteria must be met.

• Unable to hire staff 
  • Copies of dated advertisements
  • Copies of interview notes
  • Documentation indicating high turnover of staff
• Special behavioral needs documented in the record
  • Behavioral supports are in place/current plan is effective
  • A referral for behavioral support has been made.
• Special medical needs documented in the record that do not require skilled care
• Language is a factor in service delivery (documented in the record)

Copies need to be provided to your Service Facilitator prior to every request for authorization.

For LRI Attendants 

• An extraordinary care form must be completed and documents approved by CD or AD provider and approving authority.
• Another LRI cannot be the EOR if the individual is a minor.
• If the individual is a minor and there is an LRI attendant, the EOR must live in the local community within a 50-mile radius.
• LRIs are permitted to work up to 40 hours per week. This includes when caring for multiple children.
• LRIs may be reimbursed only for “extraordinary care.” This means LRIs will continue to be responsible for meeting the typical care needs of a member younger than 18.
• Instrumental activities for daily living, such as cooking, cleaning, laundry, etc. are not included in extraordinary care and an LRI attendant cannot bill for these task.
• RespiteShort-term care for a child or adult that allows the primary caregiver relief. More services are not available as a service line if a LRI is an attendant in the individual care team. All respite hours will be ended.
• LRI must be in the member’s best interest and the EOR will be required to continue to look for another attendant and show proof at every authorization.
• Meet all the requirements of any other paid attendant regardless of which model is used (agency or consumer-directedServices where the person using them is allowed to select, hire, fire, and train their particular caregiver(s). More)
• Documents task daily on the DMAS 487LRI form.

For LRI Employer of Record (EOR’s)

• If the LRI is the EOR the other LRI cannot be an attendant or vice versa.
• EOR requirements do not apply to an adult member who hires a spouse to be the paid attendant. (ie. 50-mile radius and separate LRI EOR)
• Must complete the DMAS 95B and the SF must agree that this EOR is in the best interest of the individual.
• Must complete an enhanced EOR agreement as part of the FA enrollment.
• The member must receive service facilitation.
• Must keep a record of the task completed on the DMAS 487LRI form and have copies available for SF review and in case of audit by DMAS.

No

No, only one LRI attendant is permitted to be employed at a time for that child.

The guardrails will go into effect Nov 11, 2023 and will affect CCC+, CL, and FIS waiverOne of the three types of developmental disability (DD) Medicaid waivers in Virginia, the Family and Individual Supports (FIS) Waiver is the waiver for the majority of people – those who need supports for between a few hours and most hours of the day, including overnight monitoring in some cases. More participants. It does not affect the EPSDT program but note that minor parents and spouses are not able to be paid attendants in the EPSDT program and do not receive respite. Live-in attendants would still need to provide OWD for all waiver types.

Yes, Consumer Directed and Agency Directed are both under the new guardrails and have the same standards.

• Extraordinary Care Form – The purpose of this form is to determine extraordinary care needs for Medicaid members under 18 or spouses receiving Consumer-Directed or Agency-Directed attendant care under CCC+, FIS, or CL waivers. This form is to be completed collaboratively by the EOR or agency, the LRI, and the waiver individual. This form should be submitted back to the service facilitator for CD services and will be sent to the approving authority.

• DMAS 95B – This form includes questions to consider if you want to become the employer of record on behalf of a member. The prospective EOR should complete the form and it should be returned to the service facilitator and reviewed for the best interest of the waiver individual.

• DMAS 487LRI – This is a weekly task checklist of the daily care needs completed by the attendant for the waiver individual. It should be signed by the Member/Employer of Record and the Attendant. The EOR should keep all copies available for review by the service facilitator and DMAS.

Yes. A LRI attendant or live-in attendant is the attendant of last resort, meaning that the EOR should continue to advertise the position and submit documentation of attempts to their service facilitator to be used for every authorization request.

The ad must be placed within the last 6 weeks and show documentation of that date. The CD EOR Manual is a wonderful tool for job descriptions and hiring attendants.

Yes, if approved the hours can be split up in that case. Two (2) Plans of Care forms will need to be created by the SF or AD provider. One shows when the LRI will work and what ADLsPersonal care tasks such as bathing, dressing, toileting, transferring, and eating/feeding. A person’s degree of independence in performing these activities is a part of determining appropriate level of care and service needs. More will be covered daily and one for the other attendant. Please note, that if any of the Plans of Care include IADL time, the LRI attendant will not be able to fill those hours.

No, in the example above the LRI attendant will only be able to work the 30 weekly hours providing support for the ADLs.

Yes, they can still be approved for more hours if that is the need of the individual. The LRI attendant is limited to working 40 hours total per week.

No. If there is an unpaid primary caregiver who regularly supports the individual and is in need of respite, respite will still be available. Only if there is an LRI attendant on the payroll will the respite be ended. If another attendant is found and the LRI attendant is disassociated from the individual as being a paid attendant and the unpaid primary caregiver meets the qualification for respite, your provider can request a respite service line.

No, the approved hours are based on the waiver individuals need, not how many hours are available for the attendant to use.

Yes, if the individual is a minor, an EOR change will need to be completed. An LRI EOR and LRI attendant cannot be in both roles for the same waiver individual.