Starting January 1, 2025, full benefit dual eligible enrollees who are in Medicaid managed care and have elected to enroll in a DSNP will have their health plan enrollment aligned. Full benefit dual eligible Medicaid participants who have chosen a Dual Eligible Special Needs Plan (DSNP) will be allocated to the same Medicaid managed care plan as their DSNP starting January 1, 2025.
Medicare and Medicaid recipients will be affected. Dual eligible consumers can select between Medicare Fee-For-Service (original Medicare) and a Part-D (prescription coverage) plan or an MA plan (Medicare Managed Care or Part-C Plan) with a DSNP. Full benefit duals must participate in one of Virginia’s five managed care plans for Medicaid, with a few exceptions. In Medicaid managed care, partial benefit duals are excluded.
Please keep in mind that if your MCO changes for your Medicaid this may cause changes to your fiscal agent. If assigned a new MCO that utilizes a different fiscal agent EOR’s and Attendants will be required to go through an enrollment process with the newly assigned fiscal agent. If you have a MCO change or are affected by this change please reach out to your Service Facilitation provider and notify them as soon as possible to make the appropriate authorization requests required for this change.
LRI – Frequently Asked Questions (FAQ’s)
On March 1st, all current legally responsible individuals may continue to provide services and be reimbursed for up to 40 hours per work week. If there is a paid LRI, respite careShort-term care for a child or adult that allows the primary caregiver relief. will no longer be available.
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.
“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 uploaded to our Secure Documentation Dropbox prior to every request for authorization.
For LRI Attendants
- Respite will not be available when there is a paid LRI.
- LRI payments will be limited to 40 hours per week. LRIs are permitted to find other caregivers for the additional hours approved in the plan of care.
Yes, Consumer Directed and Agency Directed are both under the new guardrails and have the same standards.
Yes. A 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 facilitatorA Medicaid-enrolled provider who supports eligible people, and sometimes their families, in properly using consumer-directed services. 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, 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.
If you have guardianship over a loved one who is 18 or over, please view this video.
No. DMAS received federal approval to extend some of the current program rules. At this time, the Extraordinary Form will not be required.
Yes, due to the CMS-approved extension, there are no limits on who can serve as the EOR.
Can I still be paid to provide care after 3/1? Yes, LRIs can continue to work and be paid for up to 40 hours.
Not at this time. LRIs may continue to provide care up to 40 hours of care a week based on the current plan of care.
Yes, agencies may continue to pay LRIs for up to 40 hours per week for personal care. Respite care is not available when there is a paid LRI.
LRIs may be reimbursed for up to 40 hours a week regardless of the number of members they serve.
Updated as of 03/01/2024
