A. Service description. Benefits planning is an individualized analysis and consultation service. This service assists recipients of a DD Waiver and social security (SSI, SSDI, SSI/SSDI) to understand their personal benefits and explore their options regarding working, how to begin employment, and the impact employment will have on their state and federal benefits. This service includes education and analysis about current benefits status and implementation and management of state and federal work incentives as appropriate. Benefits planning involves the development of written resource materials that aid individuals and their families/legal representatives in understanding current and future rewards that come from working, thereby reducing uncertainties associated with losing necessary supports and benefits if they choose to work or stay on the job. This service facilitates individuals in making informed choices concerning the initiation of work. Furthermore, it provides information and education to individuals currently employed in making successful transition to financial independence.

B. Criteria and allowable activities. Each of the allowable activities is available contingent on the individual meeting criteria for receipt of the service activity. Receipt of this service shall not be tied to the receipt of any other covered waiver or Medicaid service. This service may be authorized one time per allowable activity per individual per calendar year. However, a service may be reauthorized within a calendar year if the individual's situation has changed in terms of disability conditions, benefit type, or employment status. Allowable activities include the following, which may be appropriate for the individual as documented in his plan for supports:

1. Pre-employment benefits review that may include:

a. Benefits planning query (BPQY) from Social Security Administration (SSA). Description: A BPQY provides information about an individual's disability cash benefits, health insurance, scheduled continuing disability reviews, representative payee, and work history, as stored in SSA's electronic records. The BPQY is an important planning tool for the individual or other person who may be developing customized services for an individual who expresses interest in employment or remaining on the job.

b. Pre-employment benefits summary and analysis (BS&A). Description: Work with and on behalf of the individual to develop a benefits and net income analysis report with both a current scenario and at least two other potential scenarios involving Social Security work incentives.

c. Employment change benefits summary and analysis. Description: Work with and on behalf of the individual when the individual experiences a change in employment status to develop a benefits and net income analysis report with both a current scenario and at least two other potential scenarios involving Social Security work incentives.

2. Work incentives development or revisions (PASS, IRWE, BWE, IDA): Work with the individual and family/legal representative to develop:

a. Plan to achieve self-support (PASS):

(1) Part 1 description: In collaboration with the individual and support system, develop a plan to achieve self-support (PASS) and ensure submission to the SSA.

(2) Part 2 description: Ensure the approval of the PASS plan from the SSA PASS cadre through modifications or other appropriate services.

b. Impairment related work expenses (IRWE). Description: IRWEs reduce the amount of income that Social Security counts against an individual's benefits by deducting the expense from their total countable wages. In order to qualify for the IRWE, the expense shall be related to the individual's disability, work, and be an expense without which the individual cannot work. This service involves working with the individual to develop and submit appropriate forms and supporting documents to SSA to successfully obtain the IRWE work incentive.

c. Blind work expenses (BWE). Description: Work with and on behalf of an individual confirmed to be blind to develop and submit appropriate forms and supporting documents to SSA to successfully obtain the BWE work incentive. Given these circumstances, SSI will not count any earned income when the primary diagnosis is blindness and the expense is reasonably attributed to earning the income, that is, guide dog, transportation to and from work, etc.

d. Individual development accounts (IDA). Description: Work with and on behalf of the individual to develop matched savings accounts to assist the individual in saving toward the purchase of a lifelong asset such as a home.

e. Student earned income exclusion (SEIE). Description: Work with and on behalf of the individual to develop and submit appropriate documents to SSA to receive benefits under the SEIE work incentive. SEIE allows individuals younger than 22 years of age who regularly attend school or are involved in a vocational education program to exclude earned income up to a certain amount per a month.

f. Medicaid while working (Social Security Act § 1619(b)). Description: Work with and on behalf of the individual to develop and submit an appropriate letter and supporting documents to SSA, Virginia Department of Social Services (VDSS), and Medicaid to receive benefits under § 1619(b), which provides the continuation of Medicaid when a beneficiary loses his SSI due to earnings above the SSI threshold.

g. Medicaid works (Virginia's Medicaid Buy-In Program). Description: Work with and on behalf of the individual who is currently eligible for or receiving Medicaid to complete and submit the Medicaid Works agreement and supporting documents to the VDSS to enroll in the Medicaid Buy-In Program (may include Medicaid application or updating the resource section of the Medicaid application). This enables workers with disabilities the opportunity to earn higher income and retain more in savings or resources than is typically allowed by Medicaid.

h. Work incentive revisions. Description: Work with and on behalf of the individual to revise one of the work incentives plans listed in this subdivision B 2 as determined necessary by a significant change in status.

3. Resolution of SSA benefits issues (e.g., overpayments, subsidies, student earned income exclusion, Medicaid while working):

a. Overpayments. Description: Work with and on behalf of the individual to address Social Security overpayments that arise.

b. Subsidies. Description: Work with and on behalf of the individual to develop and submit appropriate documents to SSA to receive the subsidy work incentive.

c. Work activity reports. Description: Assist the individual family/legal representative in filling out and returning forms to SSA.

4. Other services:

a. ABLEnow. Description: Work with and on behalf of the individual and family, if applicable, to open an ABLEnow account.

b. Financial health assessment. Description: The financial health assessment (FHA) is a tool used to gauge an individual's understanding of his current financial situation.

5. All activities may be conducted in either a face-to-face or HIPAA compliant telehealth method of delivery.

C. Service units and limitations. Providers may not bill for waiver benefits planning services while the eligible individual has an open employment services case with DARS and is eligible for the same service through DARS.

1. The annual year limit for benefits planning services is $3,000. No unspent funds from one plan year may be accumulated and carried over to subsequent plan years.

2. Hourly limits per activity:

a. Plan for Achieving Self-Support-Part 1 7.0 hours.

b. Plan for Achieving Self Support-Part 2 12.5 hours.

c. Impairment Related Work Expense 9.0 hours.

d. Blind Work Expense 9.0 hours.

e. Section 1619(b) Medicaid 4.5 hours.

f. Student Earned Income Exclusion 9.0 hours.

g. Subsidy 9.0 hours.

h. Work Activity Reports: 6.0 hours.

i. Medicaid Works 5.5 hours.

j. Overpayment 3.5 hours.

k. Benefits Planning Query 1.0 hours.

l. Pre-Employment BSA 7.0 hours.

m. WorkWORLD Summary and Analysis 7.0 hours.

n. Individual Development Accounts 7.0 hours.

o. Section 301/Able Now 4.5 hours.

p. Financial Health Assessment 3.5 hours.

q. WI Revisions 7.0 hours.

3. Billing for telehealth is permitted for up to 100% of the billable hours for any given month.

D. Provider qualifications and requirements.

1. All providers of benefits planning services shall maintain and adhere to current, signed participation agreements with DMAS. The provider designated in this agreement shall directly submit claims to DMAS for reimbursement.

2. Eligible providers for benefits planning services shall possess written verification that they are one of the following:

a. A nationally certified SSA community work incentive coordinator (CWIC); or

b. A DARS certified work incentive specialist advocate (WISA) approved vendor.

3. Only providers that have completed required community financial empowerment and financial literacy training from the Consumer Financial Protection Bureau (CFPB) and Your Money, Your Goals will be eligible to receive payment for a completed financial health assessment.

E. Documentation requirements for service providers.

1. Providers shall include in each individual's record:

a. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

b. Documentation that shall confirm the amount of time spent with the individual, as well as the amount of time dedicated to completion of the work surrounding the benefits planning activity/document.

c. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

d. All documents shall be completed as they relate to benefits planning activities. If the individual or the family has withdrawn from the process prior to the document's completion, all portions that were completed should be documented along with a note that describes the circumstances during each session.

e. A written review supported by documentation in the individual's record shall be submitted to the support coordinator quarterly, during any quarters in which the service was provided, with the plan for supports if modified.

f. Documentation that all available and appropriate funding sources (including those offered by Virginia Medicaid State Plan, DARS, and the Department of Education), have been explored and exhausted.

g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits.

A. Service description. Community coaching is a service designed for individuals who need one-to-one support in a variety of community settings in order to build a specific skill or set of skills to address particular barriers that prevent individuals from participating in activities of community engagement. In addition to skill building, this service includes routine and safety supports. Community coaching service shall be covered in the FIS, CL, and BI waivers.

B. Criteria and allowable activities. Community coaching service shall be provided to individuals who require one-to-one support to address identified barriers in their plans for supports that prevent them from participating in the community engagement service. Community coaching activities shall be documented in the plan for supports and be sensitive to the individual's age, abilities, and personal preferences. Community coaching may be provided through a telehealth model; however, not all allowable activities may be provided through that model. The allowable activities specifically noted as such below may be incorporated into the PFS and accompanying schedule depending on the individual's specific needs and desired outcomes.

C. Allowable activities shall include, as may be appropriate for the individual as documented in his plan for supports:

1. One-on-one skill building and coaching to facilitate participation in community activities and opportunities such as:

a. Activities and public events in the community (telehealth permissible);

b. Community education, activities, and events (telehealth permissible); and

c. Use of public transportation if available and accessible.

2. Skill building and support in positive behavior, relationship building, and social skills (telehealth permissible).

3. Routine supports with the individual's self-management, eating, and personal care needs in the community (telehealth permissible).

4. Assuring the individual's safety through one-to-one supervision in a variety of community settings.

5. Monitoring the individual's health and physical condition and providing supports with medication and other medical needs (telehealth permissible).

6. Providing routine supports and safety supports with transportation to and from community locations and resources.

C. Service units and limitations.

1. The unit of service shall be one hour.

2. The community coaching service, alone or in combination with the community engagement service, group day service, workplace assistance service, or supported employment service shall not exceed 66 hours per week.

3. This service shall be provided at a ratio of one staff to one individual. This service shall not be provided within a group setting. The service may be provided in the community in conjunction with other Medicaid services delivered in a group of individuals for the purpose of addressing socialization needs when supported by the plan for supports. Group participation will be permitted on a limited basis.

4. Billing for telehealth is limited to 10% of the billable hours for any given month.

D. Provider qualifications and requirements.

1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.

2. Providers shall be licensed by DBHDS as providers of the non-center-based day support service.

3. Providers shall have a current, signed provider participation agreement with DMAS to provide this service. The provider designated in the participation agreement shall directly provide the service and bill DMAS for reimbursement.

4. Providers shall ensure that staff who provide the community coaching service meet provider training and competency requirements as specified in 12VAC30-122-180.

5. The DSP providing community coaching service shall not be an immediate family member of an individual receiving the community coaching service. For an individual receiving the sponsored residential service, the DSP providing the community coaching service shall not be a member of the sponsored family residing in the sponsored residential home.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as detailed in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, and then clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individuals' record, which is submitted to the support coordinator at least quarterly with the plan for supports, if modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

f. An attendance log or similar document maintained by the provider that indicates the date, type of service rendered, and the number of hours and units provided, including specific timeframe.

g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

h. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.

2. Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation; (ii) person contacted or observed; (iii) a summary about the direct support professional's performance and service delivery; and (iv) any action planned or taken to correct problems identified during supervision and oversight.

3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description.

1. Community engagement service means a service that supports and fosters an individual's abilities to acquire, retain or improve skills necessary to build positive social behavior, interpersonal competence, greater independence, employability, and personal choices necessary to access typical activities and functions of community life such as those chosen by the general population. The community engagement service may include community education or training and volunteer activities.

2. The community engagement service shall provide a wide variety of opportunities to facilitate and build relationships and natural supports in the community, while utilizing the community as a learning environment. These activities are conducted at naturally occurring times and in a variety of natural settings in which the individual may actively interact with persons without disabilities, other than those who are being paid to support the individual. The activities shall enhance the individual's involvement with the community and facilitate the development of relationships and natural supports.

3. The community engagement service shall be covered in the FIS, CL, and BI waivers.

B. Criteria and allowable activities.

1. The community engagement service shall be provided in the least restrictive and most integrated community settings possible according to the individual's plan for supports and individual choice. Community engagement may be provided through a telehealth model; however, not all allowable activities may be provided through that model. The allowable activities specifically noted as such below may be incorporated into the PFS and accompanying schedule depending on the individual's specific needs and desired outcomes.

2. Allowable activities shall include, as appropriate for the individual as documented in his plan for supports:

a. Skill building, education, support, and monitoring that assists the individual with the acquisition and retention of skills in the following areas: (i) participation in activities and public events in the community, (ii) participation in community educational activities and events (telehealth permissible), (iii) development of interests and activities that encourage therapeutic use of leisure time (telehealth permissible), (iv) participation in volunteer experiences, (v) maintenance of contact with family and friends (telehealth permissible), and (vi) development of independence in activities of daily living (telehealth permissible).

b. Skill building and education in self-direction designed to enable the individual to achieve one or more of the following outcomes, particularly through community collaborations and social connections developed by the provider (e.g., partnerships with community entities such as senior centers, arts councils): (i) development of self-advocacy skills (telehealth permissible); (ii) exercise of civil rights (telehealth permissible); (iii) acquisition of skills that promote the ability to exercise self-control and responsibility over services and supports received or needed (telehealth permissible); (iv) acquisition of skills that enable the individual to become more independent, integrated, or productive in the community (telehealth permissible); (v) development of communication skills and abilities (telehealth permissible); (vi) furtherance of spiritual practices as desired by the individual; (vii) participation in cultural activities as desired by the individual (telehealth permissible); (viii) development of skills that enhance career planning goals in the community (telehealth permissible); (ix) development of living skills (telehealth permissible); (x) promotion of health and wellness, including administration of medication (telehealth permissible); (xi) development of orientation to the community and mobility in the community; (xii) access to and utilization of public transportation so as to develop the ability to achieve the desired destination; or (xiii) interaction with volunteers from the community in program activities.

c. Providing routine supports and safety supports with transportation to and from community locations and resources.

C. Service units and limitations.

1. Community engagement service shall be a tiered service for reimbursement purposes.

2. The unit of service shall be one hour.

3. The community engagement service alone or in combination with the group day service, community coaching service, workplace assistance service, or supported employment service shall not exceed 66 hours per week.

4. Other than time for planning community activities, this service shall be delivered in the community and shall not take place in a licensed residential or day setting or in the individual's residence.

5. This service may be provided in groups no larger than three individuals with a minimum of one DSP.

6. This service may include planning community activities with the individuals present in a group of no more than three individuals, although this shall be limited to no more than 10% of the total number of authorized hours per month.

7. Providers shall only be reimbursed for the tier to which the individual has been assigned based on the individual's assessed and documented needs.

8. Billing for telehealth is limited to 10% of the billable hours for any given month.

D. Provider qualifications and requirements.

1. Providers shall meet all of the requirements set out in 12VAC30-122-110 through 12VAC30-122-140.

2. Providers shall be licensed by DBHDS as providers of the non-center-based day support service.

3. Providers shall have a current, signed provider participation agreement with DMAS in order to provide this service. The provider designated in the participation agreement shall directly provide the service and bill DMAS for reimbursement.

4. Providers shall ensure that staff providing community engagement service meet provider training and competency requirements as specified in 12VAC30-122-180.

5. The DSP providing community engagement service shall not be an immediate family member of an individual receiving the community engagement service. For an individual receiving sponsored residential service, the DSP providing the community engagement service shall not be a member of the sponsored family residing in the sponsored residential home.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, and then clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individual's record, which is submitted to the support coordinator at least quarterly with the plan for supports modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

f. An attendance log or similar document that is maintained and indicates the date, type of service rendered, and the number of hours and units provided, including the specific timeframe.

g. All correspondence to the individual and individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

h. Written documentation of all contacts with family/caregiver, physicians, providers, and all professionals regarding the individual.

2. Supervision of DSP shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight.

3. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. Community guide services include direct assistance to promote individuals' self-determination through brokering specific community resources that lead to connection to and independent participation in integrated, independent housing or community activities so as to avoid isolation. This means that community guides investigate and coordinate as necessary the available naturally occurring community resources to facilitate the individual's participation in those resources of interest to the individual. Community guides provide information and directed assistance that aids the individual in developing supportive community relationships and exploring specific community resources that promote implementation of the person-centered plan. This service involves face-to-face contact with the individual to determine the individual's specific interests and exploration of community resources, which may lead to typical community activities or settings in which the individual will engage or reside. In addition, there is a component of supporting the individual that may occur without the individual present. Community guide services involve assisting the individual to identify the type of community options that maximize the individual's opportunities for meaningful engagement and growth in independence. The community guide shall provide the in-depth individualized assistance needed to connect with community activities and foster engagement distinct from the generic activities provided through routine support coordination. This service is designed to be short-term and periodic in nature.

B. Criteria and allowable activities. This service may be provided by persons with one of two emphases:

1. General community guide. This involves the utilization of existing assessment information regarding the individual's general interests to determine specific preferred activities and venues that are available in the individual's community to which the individual desires to be connected (e.g., clubs, special interest groups, physical activities/sports teams, etc.) to promote inclusion and independent participation in the life of the individual's community. The desired result is an increase in daily or weekly natural supports, as opposed to increasing hours of paid supports. Allowable activities include the following for the individual as documented in the individual's plan for supports:

a. Utilize assessment and other information provided by the support coordinator along with an in depth discussion with the individual and people who know the individual. Discussion shall involve an outline of the individual's interests to develop a plan for supports that contains a step by step strategy for the individual and family or friends, as appropriate, to reduce barriers and challenges in accessing community resources or activities to support those interests. The plan for supports shall identify targeted actions that will promote community integration and independent or naturally supported involvement;

b. Assist the individual in connecting to the identified, non-Medicaid funded community resources by researching and contacting the parties responsible for the identified integrated activities, supports, services, or resources delineated in the individual's plan for supports;

c. Provide advocacy and informal counseling that helps guide the individual in problem solving and decision making that enhances the individual's ability to interact and contribute to the local community;

d. Escort the individual or demonstrate on site the means of accessing the identified integrated community activities, supports, services, or resources;

e. Follow up with the individual to determine and document the individual's participation in or utilization of the activities, supports, services, or resources to which the community guide assisted in connecting.

2. Community housing guide. This service involves supporting an individual's move to independent housing by helping with transition and tenancy sustaining activities. The community housing guide shall work in collaboration with the support coordinator, regional housing specialist, and others to support the individual in achieving and sustaining integrated, independent living. Allowable activities include the following as documented in the individual's plan for supports:

a. Conduct a tenant screening that identifies the individual's preferences and barriers related to successful tenancy using the community housing guide tenant screening form;

b. Develop a plan using the community housing guide roadmap form with outcomes and support activities that the community guide shall provide to identify and secure safe, affordable housing to include assisting with implementation and making recommendations to the support coordinator as to waiver support services and activities needed in the individual support plan;

c. Assist with the housing search and application process;

d. Help identify and request resources to cover expenses, such as security deposit, moving costs, furnishings, adaptive aids, environmental modifications, and other one-time expenses;

e. Assist in arranging for and supporting the details of the move;

f. Provide education and training on the role, rights, and responsibilities of the tenant and landlord during the transition from home or congregate setting;

g. Provide training in being a good tenant and lease compliance; support with activities related to household management as part of the transitional support activities;

h. Assist in resolving disputes with landlords or neighbors to reduce risk of eviction or other adverse action during the period of time that community guide services are authorized; and

i. Assist with the housing recertification process if or when requested by the support coordinator or the individual's support team.

C. Service units and limitations.

1. Community guide is expected to be a short, periodically intermittent, intense service associated with a specific outcome. An individual may receive one or more of the two types of community guide services in an ISP year. Each type of community guide service may be authorized for up to six consecutive months, and the cumulative total across both may be no more than 120 hours in a plan year.

2. Community guide activities conducted not in the presence of the individual, such as researching and contacting potential sites, supports, services, and resources, shall not comprise more than 25% of authorized plan for support hours.

3. The community guide shall not supplant, replace, or duplicate activities that are required to be provided by the support coordinator. Prior to accessing funding for this waiver service, all other available and appropriate funding sources, including those offered by Virginia Medicaid State Plan, DARS, and DOE, shall be explored and exhausted.

4. Other than elements of the service which are for community integration purposes, all allowable activities for both types of Community Guide services may be provided via telehealth up to 100% of the authorized and delivered units of service per month, depending on what has been identified in the ISP.

D. Provider qualifications and requirements.

1. General community guide services shall be provided by persons who have successfully completed and received a certificate of completion for both The Learning Community's:

a. Person-Centered Thinking training; and

b. Community Connections training.

2. The community housing guide services shall be provided by persons who have successfully completed:

a. Person-Centered Thinking training; and

b. DBHDS Independent Housing Curriculum Modules 1-3.

3. Providers shall maintain a signed provider participation agreement with DMAS to provide community guide services.

4. The provider designated in the participation agreement shall directly provide the services and bill DMAS for reimbursement.

E. Documentation requirements for service providers.

1. Providers shall include in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.

b. The provider's plan for supports shall follow requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, and clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered and documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individual's record, which is submitted to the support coordinator at least quarterly with the plan for supports, if modified.

f. Documentation that all other available and appropriate funding sources, including those offered by Virginia Medicaid State Plan, DARS, and DOE, have been explored and exhausted.

g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

h. Written documentation of all contacts with family/caregiver, physicians, formal and informal service providers, and all professionals regarding the individual.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits.

A. Service description. Group day service means a service provided to help the individual acquire, retain, or improve skills of self-help, socialization, community integration, career planning, and adaptation via opportunities for peer interactions, community integration, and enhancement of social networks. This service typically shall be offered in a nonresidential setting. Skill-building shall be a component of this service unless the individual has a documented progressive condition, in which case group day service may focus on maintaining skills and functioning and preventing or slowing regression rather than acquiring new skills or improving existing skills. Group day service shall be covered in the FIS, CL, and BI waivers.

B. Criteria and allowable activities. For group day service, an individual shall demonstrate the need for skill-building or supports offered primarily in settings other than the individual's own residence that allows the individual an opportunity for being a productive and contributing member of his community. In addition, group day service shall be available for individuals who can benefit from the supported employment service, but who need group day service as an appropriate alternative or in addition to the supported employment service. Group day may be provided through a telehealth model; however, not all allowable activities may be provided through that model. The allowable activities specifically noted as such below may be incorporated into the PFS and accompanying schedule depending on the individual's specific needs and desired outcomes.

1. Allowable activities shall include, as may be appropriate for the individual as documented in his plan for supports:

a. Developing problem-solving abilities; sensory, gross, and fine motor control abilities; and communication and personal care skills (telehealth permissible);

b. Developing self, social, and environmental awareness skills;

c. Developing skills as needed in (i) positive behavior, (ii) using community resources, (iii) community safety and positive peer interactions, (iv) volunteering and participating in educational programs in integrated settings, and (v) forming community connections or relationships (telehealth permissible for (i) - (v));

d. Supporting older adults in participating in meaningful retirement activities in their communities (i.e., clubs and hobbies);

e. Skill-building and providing routine supports related to ADLs and IADLs.

f. Monitoring the individual's health and physical condition and providing supports with medication and other medical needs (telehealth permissible).

g. Providing safety supports in a variety of community settings (telehealth permissible);

h. Career planning and resume developing based on career goals, personal interests, and community experiences (telehealth permissible); and

i. Providing routine supports and safety supports with transportation to and from community locations and resources.

2. Group day service shall be coordinated with the therapeutic consultation plan, as applicable.

C. Service units and limits.

1. This service unit shall be one hour. Group day service, alone or in combination with the community engagement service, community coaching service, workplace assistance service, or supported employment service, shall not exceed 66 hours per week. Group day service shall occur one or more hours per day on a regularly scheduled basis for one or more days per week in settings that are separate from the individual's home.

2. Group day service shall be a tiered service for reimbursement purposes. Providers shall only be reimbursed for the individual's assigned level and tier.

3. Group day service staffing ratios shall be based on the activity and the individual's needs as set out in the individual's plan for supports and shall be at least one staff to seven individuals.

4. Providers shall be reimbursed only for the amount of group day service that are rendered as established in the individual's approved plan for supports based on the setting, intensity, and duration of the service to be delivered.

5. In instances where group day service staff are required to ride with the individual to and from group day service, the group day service staff time may be billed as group day service, provided that the billing for this time does not exceed 25% of the total time the individual spent in the group day service activity for that day. Documentation shall be maintained to verify that billing for group day service staff coverage during transportation does not exceed 25% of the total time spent in the group day service for that day.

6. Billing for telehealth is limited to 10% of the billable hours for any given month.

D. Provider requirements.

1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.

2. Providers of the group day service shall hold either day support or community-based day support current licenses issued by DBHDS.

3. Providers of the group day service shall also be currently enrolled as providers with DMAS. Providers designated on the DMAS provider agreement shall:

a. Render this service directly;

b. Ensure that appropriate documentation of the delivery of service supports claims that are filed for reimbursement; and

c. Comply with HCBS setting requirements per 42 CFR 441.301.

4. Claims that are not supported by appropriate documentation may be subject to recovery by DMAS or its designee due to utilization reviews or audits.

5. Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight.

6. Providers shall ensure that staff providing group day service meet provider training and competency requirements as specified in 12VAC30-122-180.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the most current, completed, standard, age-appropriate assessment form.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

f. An attendance log or similar document that is maintained and that indicates the date, type of service rendered, and the number of hours and units provided, including specific timeframe.

g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator/case manager, DMAS, and DBHDS.

h. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims submitted for reimbursement that are not supported by provider documentation made available to DMAS or its designee shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. Group and individual supported employment service may be performed for a single individual (as in individual supported employment (ISE)) or in small groups (as in group supported employment) of individuals (two to eight individuals). This service shall consist of ongoing supports provided by a job coach that enable individuals to be employed in an integrated work setting and may include assisting the individual, either as a sole individual or in small groups, to locate a job or develop a job on behalf of the individual, as well as activities needed by the individual to sustain paid work. Group and individual supported employment service shall be covered in the FIS, CL, and BI waivers.

1. Group and individual supported employment service shall be provided in work settings where persons without disabilities are employed. Group and individual supported employment service shall be designed especially for individuals with developmental disabilities who face impediments to employment due to the nature and complexity of their disabilities, irrespective of age or vocational potential, that is, the individual's ability to perform work.

2. Group and individual supported employment service shall be available to individuals for whom competitive integrated employment at or above the minimum wage is unlikely without ongoing supports and who because of their disabilities need ongoing support to perform in a work setting. The individual's assessment and ISP shall clearly reflect the individual's need for employment-related skill-building.

3. Group and individual supported employment service shall be provided in one of two models: individual or group.

a. Individual supported employment service shall be one-on-one ongoing support that enables individuals to work in an integrated setting. The outcome of this service shall be sustained paid employment at or above minimum wage in an integrated setting in the general workforce in a job that meets personal and career goals. For this service, reimbursement of supported employment shall be limited to actual documented interventions or collateral contacts by the provider as required by the individual receiving waiver services. Reimbursement shall not be provided for the supervisory activities rendered as a normal part of the regular business setting and not for the amount of time the individual enrolled in the waiver is in the supported employment situation.

b. Group supported employment service shall be continuous support provided by staff in a naturally occurring place of employment to groups of two to eight individuals with disabilities and involves interactions with the public and coworkers who do not have disabilities. This service shall be provided in a community setting that promotes integration into the workplace and interaction in the workplace between participants and people without disabilities. Examples include mobile crews and other business-based workgroups employing small groups of workers with disabilities in the community. Group supported employment settings shall comply with the HCBS setting requirements per 42 CFR 441.301.

B. Criteria and allowable activities.

1. Only activities that specifically pertain to the individual shall be allowable activities under the supported employment service, and DMAS shall cover this service only after determining that this service is not available from DARS or the local school system, for individuals younger than 22 years of age and eligible for school services under IDEA.

2. To qualify for this service, the individual shall have demonstrated that competitive employment at or above the minimum wage is unlikely without ongoing supports and that because of the individual's disability, he needs ongoing support to perform in a work setting.

3. The plan for supports shall document the amount of supported employment required by the individual.

4. Allowable activities for both individual and group supported employment service include the following job development tasks, supports, and training. For DMAS reimbursement to occur, the individual shall be present, unless otherwise noted, when these activities occur:. Individual and group supported employment may be provided through a telehealth model; however, not all allowable activities may be provided through that model. The allowable activities specifically noted as such below may be incorporated into the PFS and accompanying schedule depending on the individual's specific needs and desired outcomes.

a. Vocational or job-related discovery or assessment;

b. Person-centered employment planning that results in employment related outcomes (telehealth permissible);

c. Individualized job development, with or without the individual present, that produces an appropriate job match for the individual and the employer to include job analysis or determining job tasks, or both (telehealth permissible). This element shall be limited to individual supported employment service only and shall not be permitted for group supported employment service.

d. Negotiation with prospective employers, with or without the individual present (telehealth permissible);

e. On-the-job training in work skills required to perform the job;

f. Ongoing evaluation, supervision, and monitoring of the individual's performance on the job, which does not include supervisory activities rendered as a normal part of the business setting (telehealth permissible);

g. Ongoing support necessary to ensure job retention, with or without the individual present (telehealth permissible);

h. Supports to ensure the individual's health and safety;

i. Development of work-related skills essential to obtaining and retaining employment, such as the effective use of community resources, break or lunch areas, and transportation systems; and

j. Staff provision of transportation between the individual's place of residence and the workplace when other forms of transportation are unavailable or inaccessible. The job coach shall be present with the individual during the provision of transportation.

C. Service units and limits.

1. Providers shall be reimbursed only for the amount and type of supported employment included in the individual's plan for supports. The unit of service for individual supported employment shall be one hour, and the service shall be limited to 40 hours per week per individual. The unit of service for group supported employment shall be one hour, and the service shall be limited to 40 hours per week per individual.

2. Reimbursement for group supported employment service shall be based on the size of the group. Individual supported employment service shall be billed according to the DARS fee schedule.

3. Group and individual supported employment service alone or in combination with the community engagement service, community coaching service, workplace assistance service, or group day service shall not exceed 66 hours per week. Group supported employment service shall take place in nonresidential settings separate from the individual's home.

4. For time-limited and service authorized periods (not to exceed 24 hours) individual supported employment service may be provided in combination with day service or residential service for purposes of discovery under customized employment. Customized employment means a flexible process designed to personalize the employment relationship between a job candidate or employee and an employer in a way that meets the needs of both. It is based on identifying the strengths, conditions, and interests of a job candidate or employee through a process of discovery.

5. Group and individual supported employment service shall include a skills development component along with the provision of supports, as needed.

6. Individual supported employment service can be provided simultaneously with the workplace assistance service to ensure that the workplace assistant is trained and appropriately supervised about supporting an individual through the best practices of individual supported employment.

a. Individual supported employment may be provided with workplace assistance (WPA) when the individual is nearing stability in his job and the job coach will be transitioning the individual's supports to the workplace assistance. Individual supported employment and workplace assistance may be provided concurrently for a limited time as defined in the individual's plan for supports in order to assure stability on the job site.

b. Individual supported employment and WPA may also occur together for the purpose of follow along services as defined by DARS. During follow along, the job coach would oversee the plan implementation as well as continue to interface with the employment provider and the individual's systems to ensure continuity of employment services.

7. Individual ineligibility for supported employment service through DARS or IDEA shall be documented in the individual's record, as applicable. If the individual is ineligible to receive service through IDEA, documentation is required only for lack of DARS funding. Acceptable documentation for the lack of DARS or IDEA funding would include either written documentation from DARS or the school system or a progress note that records the content of a communication that includes a name, date, and person contacted, documented either in the individual's file maintained by the support coordinator, on the ISP, or the supported employment provider's supporting documentation. Unless the individual's circumstances change, for example, the individual is seeking a new job, the original verification may be forwarded into the current record or repeated on the supporting documentation on an annual basis.

8. Billing for telehealth is limited to 10% of the billable hours for any given month.

D. Provider requirements.

1 Providers shall meet all of the requirements set forth in 12VAC30-122-110 through 12VAC30-122-140.

2. Providers shall have a current, signed provider participation agreement with DMAS. The provider designated in this agreement shall directly provide the service and bill DMAS for reimbursement.

3. Providers shall be DARS-contracted providers of supported employment service. DARS shall verify that these providers meet criteria to be providers through a DARS-recognized accrediting body. DARS shall provide the documentation of this accreditation verification to DMAS and DBHDS upon request.

4. Providers shall maintain their accreditation in order to continue to receive Medicaid reimbursement. Providers who lose their accreditation, regardless of the reason, shall not be eligible to receive Medicaid reimbursement and shall have their provider agreements terminated by DMAS effective the same date as the date of the loss of accreditation. Reimbursements made to such providers after the date of the loss of the accreditation shall be subject to recovery by DMAS. Providers whose accreditation is restored shall be permitted to re-enroll with DMAS upon presentation of accreditation documentation and a new signed provider participation agreement.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as established in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

f. Documentation that indicates the date, type of service rendered, and the number of hours provided, including specific timeframe. An attendance log or similar document shall be maintained for group supported employment.

g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

h. Written documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.

i. Documentation of the size of the group for group supported employment.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. In-home support service means a residential service that takes place in the individual's home, family home, or community settings that typically supplement the primary care provided by the individual, family, or other unpaid caregiver and is designed to ensure the health, safety, and welfare of the individual. The individual shall be living in his own home or his family home. This service shall include a skill building (formerly called training) component, along with the provision of supports that enable an individual to acquire, retain, or improve the self-help, socialization, and adaptive skills required for successfully living in his community. In-home support service shall be covered in the FIS and CL waivers.

B. Criteria and allowable activities. To be eligible for in-home support service, individuals shall require help with adaptive skills necessary to reside successfully in the home and community-based settings. In-home supports may be provided through a telehealth model in the home setting to support individuals in remaining independent and ensure continuity of care, as well as increasing monitoring of vulnerable individual's health and safety. However, not all allowable activities may be provided through that model. The allowable activities specifically noted as such below may be incorporated into the PFS and accompanying schedule depending on the individual's specific needs and desired outcomes.

Allowable activities include the following as may be appropriate for the individual as documented in his plan for supports:

1. Skill-building and routine supports related to ADLs and IADLs (telehealth permissible);

2. Skill-building, routine supports, and safety supports related to the use of community resources, such as transportation, shopping, dining at restaurants, and participating in social and recreational activities;

3. Supporting the individual in replacing challenging behaviors with positive, accepted behaviors for home and community environments (telehealth permissible);

4. Monitoring the individual's health and physical condition and providing routine and safety supports with medication or other medical needs (telehealth permissible);

5. Providing supports with transportation to and from community sites and resources; and

6. Providing general supports as needed (telehealth permissible).

C. Service units and limitations.

1. The unit shall be one hour and shall be reimbursed according to the number of individuals served.

2. In-home support service shall not typically be provided 24 hours per day but may be authorized for brief periods up to 24 hours a day when necessary.

3. In-home support service shall not be covered for the individual simultaneously with the coverage of the group home residential service, supported living residential service, or sponsored residential service.

4. Individuals may have in-home support service, personal assistance service, and respite service in their ISP but shall not receive these Medicaid-reimbursed services simultaneously (i.e., on the same dates and times).

5. All individuals shall have a backup plan prior to initiating services in cases of emergency or should the provider be unable to render services as needed. This backup plan shall be shared with the provider and support coordinator at the onset of services and updated with the provider and support coordinator as necessary.

6. Billing for telehealth is limited to 20% of the billable hours for any given month.

D. Provider qualifications and requirements.

1. All providers of the in-home support service shall have current, signed participation agreements with DMAS. The provider designated in this agreement shall directly submit claims to DMAS for reimbursement.

2. Providers of the in-home support service shall be licensed by DBHDS as providers of supportive in-home service.

3. Providers shall ensure that staff providing in-home supports meet provider training and competency requirements as specified in 12VAC30-122-180.

4. Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the ISP, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

f. An attendance log or similar document that is maintained and that indicates the date, type of service rendered, and the number of hours and units provided, including specific timeframe.

g. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

h. Written documentation of all contacts with the individual's family/caregiver, physicians, providers, and all professionals regarding the individual.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits.

A. Service description. Independent living support service means a service provided to adults 18 years of age and older that offers targeted skill building and supports necessary for individuals to secure and maintain their own home in the community. An individual receiving this service typically lives alone or with roommates in the individual's own home or apartment. The supports may be provided in the individual's residence or in other community settings. Independent living support service shall be covered in the BI waiver.

B. Criteria and allowable activities. The need for independent living support service shall be clearly indicated in the ISP. Independent living support service shall be authorized for Medicaid reimbursement only when the individual requires this service and the service is set out in the plan for supports. This service shall include a skills development component along with the provision of supports as needed. Allowable activities include the following:

1. Skill building and supports necessary to promote the individual's stability in the individual's own home and community in the absence of a primary caregiver living in the residence;

2. Skill-building and supports to promote the individual's community participation and inclusion in meaningful activities;

3. Skill-building and supports to increase the individual's socialization skills and maintain relationships;

4. Skill-building and supports to improve and maintain the individual's health, safety, and fitness, as necessary;

5. Skill-building and supports to promote the individual's decision-making and self-determination;

6. Skill-building and supports to improve and maintain, as needed, the individual's skills with ADLs and IADLs;

7. Routine supports with transportation to and from community locations and resources; and

8. General supports, as needed.

C. Service units and limits.

1. The independent living support service unit of service delivery shall be a month or, when beginning or ceasing the service, may be a partial month. Sufficient hours of service shall be provided to meet the requirements set forth in the plan for supports.

2. Independent living support service shall not be provided in a licensed residential setting.

3. Independent living support service is a tiered service for reimbursement purposes. Providers shall only be reimbursed for the individual's assigned level and tier.

4. All allowable activities may be provided via telehealth up to 25% of the authorized plan for support hours; limited to no more than 2 hours per day.

D. Provider requirements.

1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.

2. Independent living support service shall be provided by agencies licensed by DBHDS as providers of supportive in-home service. These providers shall have a signed participation agreement with DMAS.

3. The provider designated on the agreement shall directly render this service and shall directly bill DMAS for reimbursement.

4. Providers shall ensure that staff providing independent living support service meet provider training and competency requirements as specified in 12VAC30-122-180.

5. Supervision of DSPs shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed, signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the plan for supports, analyzed to determine if the strategies are effective, summarized, then clearly documented in the progress notes or supports checklist.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individual's record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

g. Written documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. Individual and family/caregiver training service provides training and counseling to individuals, families, or caregivers of individuals enrolled in the waiver including participation in educational opportunities designed to improve the family's or caregiver's ability to care for and support the individual enrolled in the waiver. This service shall also provide educational opportunities for the individual to better understand his disability and increase his self-determination and self-advocacy. Individual and family/caregiver training service shall be covered in the FIS waiver.

B. Criteria and allowable activities. All activities may be conducted in either a face-to-face or HIPAA-compliant telehealth method of delivery. Any training provided via a telehealth model must include both an audio and visual component.

1. Individuals who are enrolled in the FIS waiver and their family/caregivers, as appropriate, may participate in this service. DMAS shall cover this service as authorized by the individual's ISP.

2. For the purpose of this service, "family" means the same as set forth in 12VAC30-122-20.

C. Service units and limits.

1. Individual and family/caregiver training service is only available in the FIS waiver.

2. Individual and family/caregiver training service may be authorized for up to $4,000 per ISP year.

3. Travel expenses and room and board expenses shall not be covered.

4. Billing for telehealth is permitted for up to 100% of the billable hours for any given month.

D. Provider requirements.

1. Providers shall meet all of the requirements of 12VAC30-122-110 through 12VAC30-122-140.

2. Providers shall have a signed, current provider participation agreement with DMAS in order to be reimbursed for providing individual and family/caregiver training.

3. Providers shall have the necessary licensure or certification as required for their profession, that is, RNs shall have a current license to practice nursing in the Commonwealth or shall hold a multistate licensure privilege.

4. Individual and family/caregiver training service shall be provided by enrolled provider entities with expertise in, experience in, or demonstrated knowledge of the training topic set out in the plan for supports.

5. Individual and family/caregiver training service may be provided through seminars and conferences organized by the enrolled provider entities.

6. Individual and family/caregiver training service may also be provided by individual practitioners who have experience in or demonstrated knowledge of the training topics. Individual practitioners may include psychologists, teachers or educators, social workers, medical personnel, personal care providers, therapists, and providers of other services such as day and residential support services.

7. Qualified provider types include:

a. Staff of home health agencies, community developmental disabilities service agencies, developmental disabilities residential providers, community mental health centers, public health agencies, hospitals, clinics, or other agencies or organizations; and

b. Individual practitioners, including licensed or certified personnel such as RNs, LPNs, psychologists, speech-language therapists, occupational therapists, physical therapists, licensed clinical social workers, licensed behavior analysts, and persons with other education, training, or experience directly related to the specified needs of the individual as set out in the ISP.

E. Service documentation and requirements.

1. The support coordinator shall maintain a plan for supports that includes:

a. Identifying information such as provider name, provider number, responsible person and telephone number, effective dates for the service, and if applicable, person-centered review dates;

b. Expected outcomes of the training; and

c. Specific training or activities showing frequency, location, dates and times, and to whom the training was provided.

2. The provider shall maintain and relay to the support coordinator contact notes or a summary documenting:

a. Date, location, hours, and summary of each training event;

b. Plan for support desired outcome that was addressed;

c. Specific details of the training activities conducted, including person to whom activities were directed;

d. Training delivered as planned or modified; and

e. Effectiveness of strategies and satisfaction of the individual or family member/caregiver.

3. Person-centered reviews by the provider (i) shall be required quarterly if the training extends three months or longer, (ii) shall be forwarded to the support coordinator, and (iii) shall include:

a. A summary of the quarter's activities;

b. Training recipient's status and satisfaction with the service; and

c. Training outcomes and effectiveness.

4. Provider and support coordinator documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. Peer mentor supports provide information, resources, guidance, and support from an experienced, trained peer mentor to an individual who is a waiver recipient. This service is delivered to waiver recipients by other individuals with developmental disabilities who are or have been service recipients, have shared experiences with the individual, and provide support and guidance to him. The service is designed to foster connections and relationships that build individual resilience. Peer mentor supports encourage individuals with developmental disabilities to share their successful strategies and experiences in navigating a broad range of community resources beyond those offered through the waiver with waiver participants so that the waiver participant is better able to advocate for and make a plan to achieve integrated opportunities and experiences in living, working, socializing, and staying healthy and safe in his own life, as well as to overcome personal barriers which are inhibiting him from being more independent. Peer mentoring is intended to assist with empowering the individual receiving the service. This service is delivered based on the support needs of the individual as outlined in his person-centered plan. This service shall require the use of a peer support service administrative provider enrolled with DMAS that shall be responsible for directly coordinating the service and directly billing DMAS for reimbursement. This service is designed to be short-term and periodic in nature.

B. Criteria and allowable activities. Allowable activities may include the following for the individual as documented in the individual's plan for supports:

1. The administering agency facilitates peer to peer "matches" and follows up to ensure the matched relationship meets the individual's expectations;

2. The peer mentor has face-to-face contact with the individual to discuss the individual's specific interests or desired outcomes related to realizing greater independence and the barriers to achieving them;

3. The peer mentor explains community services and programs and suggests strategies to the individual to achieve the individual's desired outcomes, particularly related to living more independently, engaging in paid employment, and expanding social opportunities in order to reduce the need for supports from family members or paid staff;

4. The peer mentor provides information from his experiences to help the individual in problem solving, decision making, developing supportive community relationships, and exploring specific community resources that promote increased independence and community integration; or

5. The peer mentor assists the individual in developing a personal plan for accessing the identified integrated community activities, supports, services, or resources.

6. All activities may be conducted in either a face-to-face or HIPAA-compliant telehealth method of delivery that allows the peer mentor to view the individual and converse with him.

C. Service units and limitations.

1. Peer mentor supports is expected to be a short, periodically intermittent, intense service associated with a specific outcome. Peer mentor supports may be authorized for up to six consecutive months, and the cumulative total across that timeframe may be no more than 60 hours in a plan year.

2. The peer mentor shall not supplant, replace, or duplicate activities that are required to be provided by the support coordinator. Prior to accessing funding for this waiver service, all other available and appropriate funding sources shall be explored and exhausted.

3. Peer mentors cannot mentor their own family members.

4. Peer mentors shall be at least 21 years of age and may provide these supports only to individuals 16 years of age and older.

5. Individuals who receive supports through DD Waiver or other waivers may be peer mentors.

6. Billing for telehealth is permitted for up to 100% of the billable hours for any given month.

D. Provider qualifications and requirements.

1. The administering agency shall be a DBHDS licensed provider of DD Waiver services, employment service organization, or center for independent living. The administering agency shall serve as the enrolled provider and maintain the documentation of the peer mentor's qualifications, criminal background and Child Protective Registry (if service recipient is younger than 18 years of age) checks, and other required documentation.

2. Peer mentor supports shall be provided by an individual with a developmental disability who has lived independently in the community for at least one year and is or has been a recipient of services, including to publicly-funded housing, Medicaid waiver services, work incentives, and supported employment.

3. The peer mentor shall have completed DBHDS's DD Peer Mentor training curriculum and passed the accompanying test.

4. The peer mentor supports administering agency shall have a signed provider participation agreement with DMAS.

E. Documentation requirements for service providers.

1. Providers shall include in each individual's record:

a. A copy of the completed, standard, age-appropriate assessment form as described in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation which shall confirm the individual's amount of time in services, a log of contacts, and information regarding the type of supports delivered to the individual.

d. Documentation to support units of service delivered, and the documentation shall correspond with billing. Providers shall maintain separate documentation for each type of service rendered for an individual.

e. A written review supported by documentation in the individual's record shall be submitted to the support coordinator quarterly, during any quarters in which the service was provided, with the plan for supports, if modified. This written review shall list the dates and nature of contacts and a statement about the individual's satisfaction with the service.

f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

g. Written documentation of all contacts with family/caregiver, physicians, formal and informal service providers, and all professionals regarding the individual.

h. Documentation of the peer mentor's qualifications, as well as criminal background and Child Protective Registry (if service recipient is younger than 18 years of age) checks.

2. Administering agency documentation shall support all claims submitted for DMAS reimbursement. Claims that are not supported by appropriate documentation shall be subject to recovery by DMAS as a result of utilization reviews and audits.

A. Service description. Individuals enrolled in the FIS or CL waivers may select the consumer-directed model of service delivery for certain services, absent any of the specified conditions that preclude such a choice, and may also receive support from a services facilitator. Services facilitation service shall be a separate waiver service and shall be used only in conjunction with consumer-directed personal assistance service, respite service, or companion service.

B. Criteria and allowable activities.

1. Services facilitators shall train individuals enrolled in the waiver, or the individual's employer of record (EOR), as appropriate, to direct, such as select, hire, train, supervise, and authorize timesheets of their own assistants who are rendering personal assistance services, respite services, and companion services.

2. The services facilitator shall also make an initial comprehensive home visit to collaborate with the individual and the individual's family/caregiver, as appropriate, (i) to identify the individual's needs for a requested consumer-directed service; (ii) to assist in the development of the plan for supports with the individual and the individual's family/caregiver, as appropriate; (iii) provide employer management training to the individual or EOR, as appropriate, on his responsibilities as an employer; and (iv) to provide ongoing support of the consumer-directed model of service. The services facilitator shall provide employer management training to the EOR within seven days of the initial visit. Training regarding the responsibilities of an Employer of Record may be delivered through either a face-to-face or via a HIPAA-compliant telehealth method.

a. The initial comprehensive home visit shall be completed only once upon the individual's entry into the consumer-directed model of service regardless of the number or type of consumer-directed services that an individual is approved to receive.

b. If an individual changes services facilitators, the new services facilitator shall complete a reassessment visit in lieu of a comprehensive visit.

c. The employer management training shall be completed before the individual or EOR may hire an assistant who is to be reimbursed by DMAS.

d. After the initial visit, the services facilitator shall continue to monitor the individual's plan for supports quarterly (i.e., every 90 days) and more often as needed. If consumer-directed respite service is provided, the services facilitator shall review the utilization of consumer-directed respite service either every six months or upon the use of 240 respite service hours, whichever comes first.

3. An in-person meeting shall occur between the services facilitator and the individual at least every six months to reassess the individual's needs and to ensure appropriateness of any consumer-directed service received by the individual. During these visits with the individual, the services facilitator shall observe, evaluate, and consult with the individual, EOR, and the individual's family/caregiver, as appropriate, for the purpose of assessing the adequacy and appropriateness of consumer-directed service with regard to the individual's current functioning, medical needs, and social needs. The services facilitator's written summary of the visit shall include:

a. Discussion with the individual and EOR or individual's family/caregiver, as appropriate, whether the particular consumer-directed service is adequate to meet the individual's needs;

b. Any suspected abuse, neglect, or exploitation and to whom it was reported;

c. Any special tasks performed by the assistant or companion and the assistant's or companion's qualifications to perform these tasks;

d. The individual's and EOR's or individual's family/caregiver's, as appropriate, satisfaction with the assistant's or companion's service;

e. Any hospitalization or change in medical condition, functioning, or cognitive status;

f. The presence or absence of the assistant or companion in the home during the services facilitator's visit; and

g. Any other service received and the amount.

4. The services facilitator, during routine quarterly visits, shall also review and verify time worked as needed to ensure that the number of hours approved in the plan for supports is not exceeded. If discrepancies are identified, the services facilitator shall discuss these with the individual or EOR to resolve discrepancies and shall notify the fiscal/employer agent as defined in 12VAC30-122-170. If an individual is consistently identified as having discrepancies in his timesheets, the services facilitator shall contact the support coordinator. Failure to review and verify timesheets and maintain documentation of such reviews shall subject the provider to recovery of payments made by DMAS in accordance with 12VAC30-80-130.

5. The services facilitator shall be available during standard business hours to the individual or EOR by telephone.

6. The consumer-directed services facilitator shall assist the individual or EOR with employer issues as requested by either the individual or EOR.

7. The services facilitator shall also complete the assessments, reassessments, and supporting documentation necessary for consumer-directed service.

8. Service facilitation service shall be provided on an as-needed basis as mutually agreed to by the individual, EOR, and services facilitator but at a minimum quarterly routine visits shall take place. Services facilitator service shall be documented in the supporting documentation for consumer-directed service, and the service facilitation provider shall bill consistent with the supporting documentation. Claims that are not adequately supported by this supporting documentation may be subject to a DMAS recovery of expenditures.

9. If an EOR is consistently unable to hire and retain an assistant to provide consumer-directed services, the services facilitator shall contact the support coordinator and DBHDS to transfer the individual, at the choice of the individual, to a provider that provides Medicaid-funded agency-directed companion service, personal assistance service, or respite care service, as may be appropriate.

10. If an individual enrolled in consumer-directed service has a lapse in consumer-directed service for more than 60 consecutive calendar days, the services facilitator, or the individual or family/caregiver functioning as the services facilitator, shall notify the support coordinator so that consumer-directed service may be discontinued, and the option afforded to the individual to change to agency-directed service as long as the individual still qualifies for the service.

C. Service units and limits. The limits and requirements for individuals' selection of consumer-directed service shall be as follows:

1. In order to be approved to use the consumer-directed model of service, the individual enrolled in the waiver shall meet the requirements as specified in 12VAC30-122-150. Support coordinators shall document in the individual support plan the individual's choice for the consumer-directed model and whether or not the individual chooses service facilitation. The support coordinator shall document in the individual's record that the individual will serve as the EOR or that there is a need or desire for another person to serve as the EOR on behalf of the individual.

2. The consumer-directed services facilitator who is to be reimbursed by DMAS shall not be the individual enrolled in the waiver; a direct service provider; the individual's spouse; a parent or legal guardian of the individual who is a minor child; or the EOR who is employing the assistant or companion.

3. The services facilitator shall document the individual's back-up plan in case the assistant or companion does not report for work as expected or terminates employment without prior notice.

4. Should the assistant or companion not report for work or terminate his employment without notice, then the services facilitator shall, upon the individual's or EOR's request, provide management training to ensure that the individual or the EOR is able to recruit and employ a new assistant or companion.

5. Billing for service delivery via telehealth for service facilitation is limited to employer management training.

D. Provider requirements.

1. To be enrolled as a services facilitator and maintain provider status, the services facilitator provider shall have sufficient resources to perform the required activities, including the ability to maintain and retain business and professional records sufficient to document fully and accurately the nature, scope, and details of the service provided.

2. All consumer-directed services facilitators, whether employed by or contracted with a DMAS enrolled services facilitator provider, shall meet all of the qualifications set out in this subsection. To be enrolled, the services facilitator shall also meet the combination of work experience and relevant education set out in this subsection that indicate the possession of the specific knowledge, skills, and abilities to perform this function.

a. If the services facilitator is not an RN then, within 30 days from the start of such service, the services facilitator shall inform the primary health care provider for the individual enrolled in the waiver that consumer-directed service is being provided and request skilled nursing or other consultation as needed by the individual. Prior to contacting the primary health care provider, the services facilitator shall obtain the individual's written consent to make such contact. This written consent shall be retained by the services facilitator in the individual's record.

b. All services facilitators shall possess, at a minimum, either (i) an associate's degree from an accredited college in a health or human services field or be a registered nurse currently licensed to practice in the Commonwealth or hold a multistate licensure privilege, and demonstrate at least two years of satisfactory direct care experience supporting individuals with disabilities or older adults or children or (ii) have a bachelor's degree in a non-health or human services field and a minimum of three years of satisfactory direct care experience supporting individuals with disabilities or older adults. Services facilitators enrolled prior to January 11, 2016, are not required to meet the education requirements.

c. All consumer-directed services facilitators shall:

(1) Have a satisfactory work record as evidenced by two references from prior job experiences from any human services work. Such references shall not include any evidence of abuse, neglect, or exploitation of elderly individuals, persons with disabilities, or children;

(2) Submit to a criminal background check prior to employment. Proof that the criminal record check was conducted shall be maintained in the record of the services facilitator;

(3) If providing service to minors, submit to a search of the VDSS Child Protective Services Central Registry; and

(4) Not be debarred, suspended, or otherwise excluded from participating in federal health care programs, as listed on the federal List of Excluded Individuals and Entities (LEIE) database at http://www.olg.hhs.govfraud/exclusions/exclusions%20list.asp.

d. The services facilitator shall not be compensated for service provided to the waiver individual prior to the results of the background check or any subsequent background check verifies that the services facilitator (i) has been convicted of a barrier crime as defined in 12VAC30-122-20; (ii) has a founded complaint confirmed by the VDSS Child Protective Services Central Registry; or (iii) is found to be listed on the LEIE database. In accordance with 12VAC30-80-130, DMAS shall seek refunds of overpayments.

e. All services facilitators shall complete the DMAS-approved services facilitator training and pass the corresponding competency assessment with a score of at least 80% prior to being approved as a services facilitator or being reimbursed for waiver services. The competency assessment and all corresponding competency assessments shall be kept in the services facilitator's personnel record.

f. Failure to complete the competency assessment prior to providing this service shall result in a retraction of Medicaid payment or the termination of the provider agreement, or both.

g. As a component of the renewal of the provider agreement, all consumer-directed services facilitators shall take and pass the competency assessment every five years and achieve a score of at least 80%.

h. The consumer-directed services facilitator shall have access to a computer with secure Internet access that meets the requirements of 45 CFR Part 164 for the electronic exchange of information. Electronic exchange of information shall include, for example, checking individual eligibility, submission of service authorizations, submission of information to the fiscal employer agent, and billing for service.

i. All consumer-directed services facilitators shall possess a demonstrable combination of work experience and relevant education that indicates possession of the following knowledge, skills, and abilities. Such knowledge, skills, and abilities shall be documented on the application form, found in supporting documentation, or be observed during the job interview. Observations during the interview shall be documented. The knowledge, skills, and abilities include:

(1) Knowledge of:

(a) Types of functional limitations and health problems that may occur in individuals with developmental disabilities, as well as strategies to reduce limitations and health problems;

(b) Physical assistance that may be required by individuals with developmental disabilities, such as transferring, bathing techniques, bowel and bladder care, and the approximate time those activities normally take;

(c) Equipment and environmental modifications that may be required by individuals with developmental disabilities that reduce the need for human help and improve safety;

(d) Various long-term care program requirements, including nursing home and ICF/IID placement criteria; Medicaid waiver services; and other federal, state, and local resources that provide personal assistance service, respite service, and companion service;

(e) DD Waivers requirements, as well as the administrative duties for which the services facilitator will be responsible;

(f) Conducting assessments, including environmental, psychosocial, health, and functional factors, and their uses in service planning;

(g) Interviewing techniques;

(h) The individual's right to make decisions about, direct the provisions of, and control his consumer-directed personal assistance service, companion service, and respite service, including hiring, training, managing, approving timesheets, and firing an assistant or companion;

(i) The principles of human behavior and interpersonal relationships; and

(j) General principles of record documentation.

(2) Skills in:

(a) Negotiating with individuals and the individual's family/caregivers, as appropriate, and providers;

(b) Assessing, supporting, observing, recording, and reporting behaviors;

(c) Identifying, developing, or providing service to individuals with developmental disabilities; and

(d) Identifying services within the established system to meet the individual's needs.

(3) Abilities to:

(a) Report findings of the assessment or onsite visit, either in writing or an alternative format, for individuals who have visual impairments;

(b) Demonstrate a positive regard for individuals and their families;

(c) Be persistent and remain objective;

(d) Work independently, performing position duties under general supervision;

(e) Communicate effectively, orally and in writing; and

(f) Develop a rapport and communicate with individuals of diverse cultural backgrounds.

E. Service documentation and requirements.

1. In addition to the documentation required by 12VAC30-122-340, 12VAC30-122-460, and 12VAC30-122-490, the services facilitator shall maintain a record of each individual containing elements as set out in this section. The services facilitator's record about the individual shall contain:

a. Documentation of all employer management training provided to the individual enrolled in the waiver and the EOR, as appropriate, including the individual's or the EOR's, as appropriate, receipt of training on his responsibility for the accuracy and timeliness of the assistant's or companion's timesheets;

b. All documents signed by the individual enrolled in the waiver or the EOR, as appropriate, that acknowledge their legal responsibilities as the employer; and

c. All contacts and consultations documented in the individual's medical record. Failure to document such contacts and consultations shall be subject to a DMAS recovery of payments made.

2. Progress notes shall meet the standards contained in 12VAC30-122-120.

3. CD services facilitators responsible for individual assessment and reassessment shall maintain the following listed records and documentation in individuals' records:

a. All copies of the consumer-directed plan for support, all supporting documentation related to consumer-directed services, and DMAS-225 (Medicaid Tong-Term Care Communication Form), which is the form used by the support coordinator to report information about patient pay amount changes in an individual's situation.

b. A copy of the most recently completed SIS^® assessment or the approved alternative assessment form noted in 12VAC30-122-200 A, and an initial assessment completed by the services facilitator prior to or on the date the service is initiated.

c. Consumer-directed services facilitator's notes recorded and dated at the time of service delivery. The consumer-directed services facilitator's written summary of visits shall include at minimum:

(1) Discussion with the individual and EOR or individual's family/caregiver, as appropriate, whether the particular consumer-directed service is adequate to meet the individual's needs;

(2) Any suspected abuse, neglect, or exploitation and to whom it was reported;

(3) Any special tasks performed by the assistant and the assistant's qualifications to perform these tasks;

(4) The individual's and EOR's or individual's family/caregiver's, as appropriate, satisfaction with the assistant's service;

(5) Any hospitalization or change in medical condition, functioning, or cognitive status; and

(6) The presence or absence of the assistant in the home during the services facilitator's visit.

d. All correspondence to the individual and EOR, as appropriate, to others concerning the individual, and to the support coordinator, DMAS, and DBHDS.

e. All management training provided to the individual or EOR, as appropriate, including the responsibility for the accuracy of the timesheets.

f. All documents signed by the individual or EOR, as appropriate, that acknowledge the responsibilities of the employer.

g. Documentation indicating that desired outcomes and support activities of the plan for supports have been reviewed by the consumer-directed services facilitator provider quarterly, annually, and more often as needed. The results of the review shall be submitted to the support coordinator. For the annual review and in cases where the plan for supports is modified, the plan for supports shall be reviewed with and agreed to by the individual enrolled in the waiver and the individual's family/caregiver, as appropriate, and signed and dated by the individual or the individual's family/caregiver

h. Contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.

4. Service facilitation records shall be provided to DMAS or DBHDS upon request.

5. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. Therapeutic consultation service means professional consultation provided by members of psychology, social work, rehabilitation engineering, behavior analysis/consultation, speech-language pathology therapy, occupational therapy, psychiatry, psychiatric clinical nursing, therapeutic recreation, or physical therapy disciplines that are designed to assist individuals, parents, guardians, family members, and any other providers of support services with implementing the individual support plan. This service shall provide assessments, development of a therapeutic consultation support plan, and teaching in any of these designated specialty areas to assist family members, caregivers, and other providers in supporting the individual enrolled in the waiver. The individual's therapeutic consultation service support plan shall clearly reflect the individual's needs, as documented in the assessment information, for specialized consultation provided to family/caregivers and providers. Therapeutic consultation service shall be covered in the FIS and CL waivers.

A therapeutic consultation service support plan is the report of recommendations resulting from a therapeutic consultation that is developed by the professional consultant after he spends time with the individual to determine the individual's needs in his area of expertise.

B. Criteria and allowable activities.

1. To qualify for therapeutic consultation service, the individual shall have a documented need for consultation. Documented need shall indicate that the ISP cannot be implemented effectively and efficiently without such consultation as provided by this covered service and approved through service authorization. The need for this service shall be based on the individual's ISP and shall be provided to an individual for whom specialized consultation is clinically necessary. Therapeutic consultation service may be provided in individuals' homes and in appropriate community settings, such as licensed or approved homes or day support programs, as long as they are intended to facilitate implementation of individuals' desired outcomes as identified in their ISP.

2. Allowable activities for this service shall include:

a. Interviewing the individual, family members, caregivers, and relevant others to identify issues to be addressed and desired outcomes of consultation;

b. Observing the individual in daily activities and natural environments and observing and assessing the current interventions, support strategies, or assistive devices being used with the individual;

c. Assessing the individual's need for an assistive device for a modification or adjustment of an assistive device, or both, in the environment or service, including reviewing documentation and evaluating the efficacy of assistive devices and interventions identified in the therapeutic consultation plan;

d. Developing data collection mechanisms and collecting baseline data as appropriate for the type of consultation service provided;

e. Designing a written therapeutic consultation plan or a behavioral support plan detailing the interventions, environmental adaptations, and support strategies to address the identified issues and desired outcomes, including recommendations related to specific devices, technology, or adaptation of other training programs or activities. The plan may recommend training relevant persons to better support the individual simply by observing the individual's environment, daily routines, and personal interactions;

f. Demonstrating (i) specialized, therapeutic interventions; (ii) individualized supports; or (iii) assistive devices;

g. Training family/caregivers and other relevant persons to assist the individual in using an assistive device; to implement specialized, therapeutic interventions; or to adjust currently utilized support techniques;

h. Intervening directly, by behavioral consultants, with the individual and demonstrating to family/caregivers or staff such interventions. Such intervention modalities shall relate to the individual's identified behavioral needs as detailed in established specific goals and procedures set out in the ISP; and

i. Consulting related to person centered therapeutic outcomes, in person, over the phone, or via video feed consistent with in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).

j. All activities may be conducted in either a face-to-dace or HIPAA compliant telehealth method of delivery.

C. Service units and limits.

1. The unit of service shall be one hour.

2. The services shall be explicitly detailed in the plan for supports.

3. Travel time and written preparation and telephone communication shall be considered as in-kind expenses within therapeutic consultation service and shall not be reimbursed as separate items.

4. Therapeutic consultation shall not be billed solely for purposes of monitoring the individual.

5. Behavioral consultation.

a. Only behavioral consultation in the therapeutic consultation service may be offered in the absence of any other waiver service.

b. Initial requests for behavioral consultation may not be authorized for more than 180 days.

c. Behavioral support plans will be submitted with subsequent authorizations as well as baseline data for the initial request after assessment and then an annual summary of quarterly data for re-renewals.

6. Other than behavioral consultation, therapeutic consultation service shall not include direct therapy provided to individuals enrolled in the waiver and shall not duplicate the activities of other services that are available to the individual through the State Plan for Medical Assistance. Behavior consultation may include direct behavioral interventions and demonstration of such interventions to family members or staff.

7. Billing for telehealth is permitted for up to 100% of the billable hours for any given month.

D. Provider requirements. Professionals rendering therapeutic consultation service, including behavior consultation, shall meet all applicable state licensure or certification requirements.

1. Behavior consultation shall only be provided by (i) a licensed behavior analyst or a licensed assistant behavior analyst or (ii) a positive behavior supports facilitator endorsed by a recognized positive behavior supports organization or who meets the criteria for psychology consultation.

2. Psychology consultation shall only be provided by the following individuals licensed in the Commonwealth of Virginia: (i) a psychologist, (ii) a licensed professional counselor, (iii) a licensed clinical social worker, (iv) a psychiatric clinical nurse specialist, or (v) a psychiatrist.

3. Speech consultation shall only be provided by a speech-language pathologist who is licensed by the Commonwealth of Virginia.

4. Occupational therapy consultation shall only be provided by an occupational therapist who is licensed by the Commonwealth of Virginia.

5. Physical therapy consultation shall only be provided by a physical therapist who is licensed by the Commonwealth of Virginia.

6. Therapeutic recreation consultation shall only be provided by a therapeutic recreation specialist who is certified by the National Council for Therapeutic Recreation Certification.

7. Rehabilitation consultation shall only be provided by a rehabilitation engineer or certified rehabilitation specialist.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed age-appropriate assessment as detailed in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. A written therapeutic consultation support plan detailing the recommended interventions or support strategies for providers and family/caregivers to better support the individual enrolled in the waiver in the service.

(1) Behavior support plans will contain the following information, at a minimum: (i) demographic information, (ii) person-centered information, (iii) history and rationale, (iv) functional behavior assessment, (v) behaviors targeted for decrease, (vi) hypothesized functions of behavior, (vii) proactive strategies and antecedent interventions, (viii) replacement behaviors and behaviors targeted for increase; (ix) consequence interventions (when indicated), (x) safety and crisis guidelines (when indicated), (xi) any additional recommendations (linkages, etc.), and (xii) appropriate signatures and plan for training.

(2) Documentation of who was trained on the plan and when and where should be maintained and a plan for ongoing training should be determined.

d. Ongoing progress note documentation of rendered consultative service that may be in the form of contact-by-contact or monthly notes that must be contemporaneously signed and dated, that identify each contact including location and recipient of training activities, the amount of time spent on the activity, what was accomplished, and the professional who made the contact and rendered the service.

e. If the consultation service extends three months or longer, written quarterly reviews that are completed by the provider and forwarded to the support coordinator. If the consultation service extends beyond one year or when there are changes to the plan for supports, the plan for supports shall be reviewed by the provider with the individual, individual's family/caregiver, as appropriate, and the support coordinator and shall be submitted to the support coordinator for service authorization, as appropriate.

(1) For behavioral therapeutic consultation, the quarterly review shall include graphed data and a summary of this data.

(2) For behavioral therapeutic consultation, the annual review shall include graphed or tabled data that is trended across the first three quarters.

f. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

g. Written progress note documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.

h. A contemporaneously signed and dated final disposition summary that is forwarded to the support coordinator within 30 days following the end of this service and that includes:

(1) Strategies utilized;

(2) Objectives met;

(3) Unresolved issues; and

(4) Consultant recommendations.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.

A. Service description. Workplace assistance service means supports provided to an individual who has completed job development and completed or nearly completed job placement training (i.e., individual supported employment) but requires more than the typical job coach services, as in 12VAC30-122-400, to maintain stabilization in his employment. This service is supplementary to individual supported employment service. Workplace assistance service shall be covered in the FIS and CL waivers.

B. Criteria and allowable activities. Workplace assistance services may be provided through a telehealth model; however, not all allowable activities may be provided through that model. The allowable activities specifically noted as such below may be incorporated into the PFS and accompanying schedule depending on the individual's specific needs and desired outcomes.

1. The activity shall not be work skills training that would normally be provided by a job coach.

2. This service shall be delivered in their natural employment setting, where and when the service is needed.

3. The service shall facilitate the maintenance of and inclusion of the individual in an employment situation.

4. Allowable activities include:

a. Habilitative supports related to nonwork skills needed for the individual to maintain employment such as appropriate behavior, health maintenance, time management, or other skills without which the individual's continued employment would be endangered (telehealth permissible);

b. Habilitative supports needed to make and strengthen community connections (telehealth permissible);

c. Routine supports with personal care needs; however, this cannot be the sole use of workplace assistance service; and

d. Safety supports needed to ensure the individual's health and safety.

C. Service units and limits.

1. A unit shall be one hour. Workplace assistance service may be provided during the time that the individual being served is working, up to and including 40 hours a week. There shall be no annual limit on how long this service may remain authorized.

2. Workplace assistance service shall not be provided simultaneously (i.e., the same dates and times) with work-related personal assistance service. This service shall not be provided solely for the purpose of providing assistance with ADLs to the individual when the individual is working.

3. The service delivery ratio shall be one staff person to one waiver individual.

4. The combination of workplace assistance service, community engagement service, community coaching service, supported employment service, and group day service shall not exceed 66 hours per week.

5. Workplace assistance service can be provided simultaneously with individual supported employment (ISE) service to ensure that the workplace assistant is trained and supervised appropriately in supporting the individual through ISE best practices.

6. Billing for telehealth is limited to 10% of the billable hours for any given month.

D. Provider requirements. Providers shall meet the following requirements:

1. Providers shall be either:

a. Providers of supported employment services with DARS. DARS shall verify that these providers meet criteria to be providers through a DARS-recognized accrediting body. DARS shall provide the documentation of this accreditation verification to DMAS and DBHDS upon request.

(1) DARS-contracted providers shall maintain their accreditation in order to continue to receive Medicaid reimbursement.

(2) DARS-contracted providers that lose their accreditation, regardless of the reason, shall not be eligible to receive Medicaid reimbursement and shall have their provider agreement terminated by DMAS. Reimbursements made to such providers after the date of the loss of the accreditation shall be subject to recovery by DMAS; or

b. Licensed by DBHDS as a provider of non-center-based day support service.

2. These providers shall hold current provider participation agreements with DMAS. The provider designated on the signed agreement shall submit claims to DMAS for reimbursement and shall maintain the required documentation that supports the claims submitted for reimbursement.

3. Providers shall ensure that staff providing workplace assistance service meet provider training and competency requirements as specified in 12VAC30-122-180. In addition, prior to seeking reimbursement for this service from DMAS, these providers shall ensure that staff providing workplace assistance service have completed training regarding the principles of supported employment. The documentation of the completion of this training shall be maintained by the provider and shall be provided to DMAS and DBHDS upon request.

4. The direct support professional providing workplace assistance service shall coordinate his service provision with the job coach if there is one working with the individual providing individual supported employment service to the individual being supported.

5. Supervision of direct support staff shall be provided consistent with the requirements in 12VAC30-122-120 by a supervisor meeting the requirements of 12VAC35-105-590. Providers shall make available for inspection documentation of supervision, and this documentation shall be completed and signed by the staff person designated to perform the supervision and oversight. This documentation shall include, at a minimum, the following: (i) date of contact or observation, (ii) person contacted or observed, (iii) a summary about the direct support professional's performance and service delivery, and (iv) any action planned or taken to correct problems identified during supervision and oversight.

E. Service documentation and requirements.

1. Providers shall include signed and dated documentation of the following in each individual's record:

a. A copy of the completed age-appropriate assessment as detailed in 12VAC30-122-200.

b. The provider's plan for supports per requirements detailed in 12VAC30-122-120.

c. Documentation as detailed in 12VAC30-122-120. Data shall be collected as described in the plan for supports, reviewed, summarized, and included in the regular progress note supporting documentation.

d. A written review supported by documentation in the individuals' record that is submitted to the support coordinator at least quarterly with the plan for supports, if modified. For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented.

e. All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS.

f. Written progress note documentation of contacts made with the individual's family/caregiver, physicians, providers, and all professionals concerning the individual.

2. Provider documentation shall support all claims submitted for DMAS reimbursement. Claims for payment that are not supported by supporting documentation shall be subject to recovery by DMAS or its designee as a result of utilization reviews or audits.