Long Term Services and Supports (LTSS) Virginia

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What are Long Term Services & Supports (LTSS)?

A variety of services and supports that help elderly individuals

and/or individuals with disabilities meet their daily needs for

assistance and improve quality of life, including assistance with:

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LTSS are provided over an extended period, predominantly in

homes and communities, but also in facility-based settings (e.g.,

nursing facilities).

LTSS were traditionally covered under Virginia’s Elderly or

Disabled with Consumer Direction (EDCD) waiver program. LTSS

are also covered by HealthKeepers, Inc. under its Anthem

HealthKeepers Medicare-Medicaid plan (MMP), a Commonwealth

Coordinated Care (CCC) plan.

• Bathing

• Dressing

• Laundry

• Shopping

• Transportation

• Other basic activities of daily life

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Virginia Program

Virginia’s Elderly or Disabled with Consumer Direction (EDCD)

waiver program

Members residing in nursing facilities

Authorization/Precertification Requirements:

▪ All EDCD waiver and nursing facility services require

authorization/precertification

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LTSS Provider Responsibilities

Assisted living facilities and nursing homes must retain a copy of

the member’s plan of care on file.

Assisted living facilities are required to promote and maintain a

home-like environment and facilitate community integration.

All facility-based providers and home health care agencies must

notify an Anthem HealthKeepers MMP case manager or care

coordinator within 24 hours when a member dies, leaves the facility

or moves to a new residence.

LTSS providers will participate in the member’s Interdisciplinary

Care Team (ICT) as determined by the member’s need and

preference.

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Interdisciplinary Care Team (ICT)

A team of professionals who collaborate, either in person or

through other means, with members to develop and implement

a plan of care that meets their medical, behavioral, LTSS and

social needs.

ICTs may include physicians, physician’s assistants, LTSS

providers, nurses, specialists, pharmacists, behavioral health

(BH) providers and/or social workers appropriate for the

member’s medical diagnosis and health condition,

comorbidities and community support needs.

ICTs employ both medical and social models of care.

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Nursing Facilities

The initial level of care (LOC) is determined by the state

(custodial nursing home versus skilled nursing facility).

▪ HealthKeepers, Inc. is responsible for the coordination of annual

redeterminations.

The LOC Department of Medical Assistance Services (DMAS)

Form should be completed and submitted to the state.

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Nursing Facility Level of Care Criteria

Custodial nursing facility (NF)

Functional and medical components.

Members must qualify on both functional and medical components.

Functional (must meet one of the following):

• Dependent in 2-4 activities of daily life (ADLs), plus one of the

following:

Semidependent or dependent in behavior pattern/orientation,

Semidependent in joint motion

Dependent in medication administration

• Dependent in 5-7 ADLs, plus dependent in mobility

• Semidependent in 2-7 ADLs, plus dependent in mobility and

behavior pattern/orientation

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NF Level of Care Criteria – Custodial NF (continued)

Medical/nursing supervision (must meet one of the following):

• Requires observation and assessments to prevent

destabilization, and patient has demonstrated an inability to

self-observe or evaluate the need to contact skilled medical

professionals

• Due to multiple, interrelated medical conditions, potential for

medical instability is high or already exists

• Needs at least one ongoing medical condition; potential for

medical instability is high or already exists

• Needs at least one ongoing medical/nursing service (e.g.,

applying aseptic dressings, routine catheter care, respiratory

therapy, nutrition/hydration supervision, therapeutic

exercise/conditioning, routine colostomy care, use of physical

or chemical restraints, routine skin care to prevent pressure

ulcers in immobile individuals, chemotherapy, radiation,

suctioning, etc.)

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NF Level of Care Criteria - Specialized Care

•Skilled Nursing Facility/Adult Specialized Care

In addition to the general/custodial NF LOC criteria, to meet

specialized care LOC, the individual must at a minimum:

Visit a physician at least once every 7 days (may alternate visits

between a physician and a physician’s assistant/nurse practitioner)

Receive licensed nursing services 24/7

Receive respiratory services provided by a licensed/certified

respiratory therapist

Take part in a coordinated multidisciplinary team approach

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NF Level of Care Criteria - Specialized Care (continued)

Additionally, to meet specialized care LOC, the individual must

require at least one of the following:

Mechanical ventilation

Complex tracheostomy, meeting all of the following: • Have potential for weaning or past failed attempts at weaning

• Require nebulizer treatments four times per day with or without

chest physiotherapy

• Require pulse oximetry monitoring at least every shift

• Require respiratory assessment/documentation every shift by nurse

of respiratory therapist

• Have physician’s order for oxygen therapy with documented usage

• Require tracheostomy care daily

• Have physician’s order for suctioning, when necessary

Individual must be at risk to require subsequent mechanical

ventilation

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Reservation of Days

•Therapeutic Leave:

A NF bed may be held for therapeutic leave when the member’s/resident’s

Plan of Care (POC) provides for such leave and is noted in their chart.

Leave includes visits with relatives and friends, or admission to a

rehabilitation center for up to seven days for an evaluation.

It does not include admission to an inpatient hospital.

Limited to 18 days in any 12-month period and HealthKeepers, Inc. should

be notified.

•Bed Reservation (“Bed Hold”) - Hospitalized Residents

Bed hold payments to NF are not applicable per DMAS.

All members/residents and their families should be informed that they have

the right to be re-admitted at the time of the next available vacancy.

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Consumer Direction

Consumer direction (CD) affords members the opportunity to have choice

and control over how eligible home and community-based services (HCBS)

are provided and how much workers are paid for providing care, up to a

specified maximum amount established by DMAS.

Member participation in CD of HCBS is voluntary, and members may elect

to participate in or withdraw from CD of HCBS at any time without affecting

their enrollment.

CD is offered for members who, through the needs

assessment/reassessment process, are determined by care coordinators to

need any service specified in DMAS rules and regulations as available for

CD. These services include:

Attendant care

Personal care

In-home respite care

Companion care service

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Consumer Direction (continued)

A service that is not specified in DMAS rules and regulations as

available for consumer direction shall not be consumer-directed.

If members choose not to direct their care, they will receive authorized

HCBS through contract providers. Members who participate in CD of

HCBS choose either to serve as the employer of record for their

workers or to designate a representative to serve as the employer of

record on their behalf. The member must arrange for the provision of

needed personal care and does not have the option of going without

needed services.

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Consumer Direction (continued)

HealthKeepers, Inc. will contract with the DMAS designated

fiscal/employer agent (F/EA), PPL, Inc., to provide the following services

to EDCD waiver enrollees who choose CD of eligible waiver services:

Criminal background checks for CD employees, with appropriate

follow-up and communication to appropriate individuals

Payroll expenses for authorized hours actually worked by CD

employees, inclusive of employer share of state and federal taxes

net patient pay

• The F/EA will withhold patient pay amounts from employees’

checks. Payments or payroll to the F/EA shall reflect (be net

of) the patient pay amount

•Claims payment shall be provided to the F/EA for authorized eligible

EDCD waiver services provided by CD employees.

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Consumer Direction Service Facilitator

A consumer direction (CD) service facilitator (SF) is a facility, agent,

person, partnership, corporation or association providing supportive

services, including assistance with hiring, training, supervising and

terminating responsibilities of personal care aides/attendants who

perform basic health-related services.

Standards and requirements for CD SFs are established by DMAS.

The role of SFs is to:

Make sure individuals receive services needed

Review the manual with individuals and family/caregivers, as

appropriate.

Train individuals on the required tasks of an employer

Develop service plans and paperwork with individuals

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Service Facilitator Consumer Direction (continued)

Individuals may discuss employer concerns and questions with SFs at

any time. The SF must be an enrolled Medicaid provider for service

facilitation and cannot be:

The individual receiving services

The individual’s spouse

The individual’s parent, if the participant is a minor

A family member/caregiver who is also the CD employer

The SF files claims for the services provided and follows the applicable

codes established by DMAS for consumer-directed service facilitation.

SF can not bill for assessments and reassessments as these

functions are conducted by Anthem.

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Patient Pay

The patient pay amount is the member’s contribution toward his or her

care in a calendar month.

The DMAS-225 form can be submitted by the provider to the

Department of Social Services (DSS) to determine the member’s

patient pay amount.

DSS returns the form to providers to confirm if the member has a

financial responsibility toward the cost of his or her care, the amount

and sources of the member’s finances and the date for which the

patient pay amount would begin.

DMAS will provide the information to HealthKeepers, Inc. on a

monthly basis with enrollment.

The provider with the most authorized hours of services per month is

considered the primary service provider and takes responsibility for

collecting payment from the member.

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Patient Pay (continued)

When billing claims, providers indicate the patient pay amount on the

1500 claim form in box 29, when applicable. For a UB-04 form, the

amount is indicated as a Value Code 23 with $0.00 or greater.

This amount is deducted from reimbursement to the provider.

HealthKeepers, Inc. will deduct the patient pay based on the

information for the member received from DMAS on the enrollment

files.

The explanation of payment (EOP) to the provider indicates when the

patient pay amount has been deducted from the payment to the

provider with the most authorized hours of services.

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Personal Care Services

The number of hours billed is the amount authorized and approved in

the plan of care.

Only whole hours can be billed:

If an extra 30 or more units are provided over the course of the

calendar month, the next highest hour can be billed.

If less than 30 units are provided, the lower is billed.

Rounding hours can be done for the total monthly hours, not each

time it is billed.

Codes for Personal Care Services:

T1019

T1005

S9125

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Adult Day Health

Codes for Adult Day Health:

ADHS – S5102

Transportation – A0120

If members attend less than six hours on any given day, then it is

considered a half day of services.

At the end of the month, half days of service may be added and

rounded to the nearest whole day of service.

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Personal Emergency Response System (PERS)

Codes for PERS:

Installation – S5160

Monitoring – S5161

Only a one-time installation is billed for the member.

Monthly monitoring includes administrative cost, time, labor and

supplies associated with installation.

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