Home care billing in Virginia

Both. CMS's 2024 state tables list Commonwealth Coordinated Care Plus as Virginia's statewide MCO plus MLTSS program under 1915(b)/1915(c) authority, started August 1, 2017, and Medallion 4.0 as the statewide MCO program for families and children; DMAS folded both into Cardinal Care Managed Care in 2023 and has run it with five plans since July 1, 2025: Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons of Virginia, Sentara Health Plans and United Healthcare of the Mid-Atlantic.¹⁴ CCC Plus waiver providers submit charges to DMAS, the MCO or the DMAS-designated service authorization contractor, in amounts not above their usual and customary charges (12VAC30-120-930, cited below). DD waiver services are authorized by DMAS or its designee and paid under the DMAS payment methodology, with support coordination through the local Community Services Board or Behavioral Health Authority (12VAC30-122-80, 12VAC30-122-120 and the DBHDS waiver page, cited below).

Provider choice: each agency selects and obtains an EVV system that meets the functional requirements of DMAS, and consumer-directed attendants use the fiscal employer agent's mobile app or IVR line. EVV data is submitted to DMAS with the provider's billing claim in a manner that conforms with agency specifications, and the regulation, effective August 18, 2021, requires six data points: the type of service, the individual who receives it, the date (month, day and year), the time the service begins and ends, the location at the beginning and end of the service, and the attendant or aide who provides it.² Personal care has needed EVV since January 1, 2020 and home health since the extended deadline of July 2023. From October 1, 2026 every agency-directed aide and consumer-directed personal care attendant, whatever their live-in status, must use an approved EVV method for every shift; the F/EA web portal is not an approved method, and shifts entered there are non-compliant. Providers keep EVV data for at least six years from the last date of service. The DD waiver regulation (12VAC30-122-125, cited below) applies the same rules to personal care, respite and companion services, except respite given by a DBHDS-licensed provider at a DBHDS-licensed program site.

Services under EVV¹

• Personal care services, agency-directed and consumer-directed, under EVV since January 1, 2020
• Respite care services, agency-directed and consumer-directed
• Companion services, including the consumer-directed version
• Home health care services, under DMAS's good faith extension to July 2023, with claims in EDI 837I format

Before Medicaid takes on payment for CCC Plus waiver services, service authorization must be obtained from DMAS or the DMAS-designated service authorization contractor for every service that requires it, after the LTSS screening team finds the individual needs the level of care of a nursing facility, long-stay hospital or specialized care nursing facility and offers the choice of waiver services, other services, institutional placement or PACE.⁷ Screenings are done by community-based teams (local departments of social services and health, hospital discharge staff and nursing facility staff) through DMAS's electronic Medicaid LTSS Screening system, eMLS, which returns the result on submission (LTSS Screening page, cited below). Any increase that exceeds the hours allowed for the individual's level of care, or any change in level of care, must be authorized by DMAS or the service authorization contractor before the increase (12VAC30-120-930, cited below); services an attendant renders before the dates Medicaid authorized are not eligible for reimbursement (12VAC30-120-920, cited below); and personal care is limited to 56 hours a week for 52 weeks a year with respite capped at 480 hours a calendar year (12VAC30-120-924, cited below). DD waiver services are authorized by DMAS or its designee within 10 working days of complete documentation, and DMAS does not pay for waiver services delivered before the authorization date (12VAC30-122-80, cited below).

Fee-for-service claims go to DMAS no later than 12 months from the date of service, and the burden of proof is on the provider to show the claim was actually, physically received by DMAS; proof of mailing or transmission alone is not enough. Members in a Cardinal Care plan are billed through that plan or the service authorization contractor, as 12VAC30-120-930 provides.¹⁵ A claim filed on time with Medicare may be paid up to six months after the Medicare disposition notice; a third-party retraction or a notice of delayed eligibility starts a fresh 12-month period; and a denied claim is reconsidered only if it was first filed within 12 months and comes back within 13 months of the original denial. Personal care and respite staff are reimbursed only when physically present and awake, up to 16 hours a day, and agency records must hold the aide's actual arrival and departure times each day, with signatures, times and dates never placed earlier than the last day of the week (12VAC30-120-935, cited below).

CGS Administrators, the A/B MAC for Jurisdiction 15, processes Medicare home health and hospice claims for Virginia, together with Colorado, Delaware, the District of Columbia, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, West Virginia and Wyoming, while Palmetto GBA holds Virginia's Part A and Part B work as the Jurisdiction M contractor (cited below).²⁰ Virginia Medicaid covers up to five licensed nurse visits, 32 home health aide visits and five visits for each rehabilitative therapy a year (July 1 to June 30) without authorization, ordered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, and more visits need DMAS prior authorization (12VAC30-50-160, cited below). A home care organization that provides home health, personal care or pharmaceutical services in a patient's residence needs a license from the Commissioner of Health, which expires on the third anniversary of issue, unless it is certified under Title XVIII or XIX, accredited by a body CMS recognizes for Medicare certification, or licensed for hospice (Code of Virginia 32.1-162.7 through 32.1-162.9, cited below).