Customized Rates

Individual Eligibility Criteria

A Customized Rate will be determined based on select criteria:

The individual has exceptional medical support needs that outweigh the resources available within the current waiver rate structure, and/or

The individual has exceptional behavioral support needs that outweigh the resources available within the current waiver rate structure, and

The individual requires 1:1 or 2:1 staffing support to ensure the health and safety of the individual and those around them.

As a result, the individual may qualify for:

Higher level staffing ratios of 1:1 or 2:1 to ensure the safety of the individual and others around them.

Higher credentialed direct support staff (Specialized Staffing) to ensure proper support is given. This means that direct support professionals are required to have a higher level of expertise to provide needed specialized support to the individual.

Increased Programmatic Oversight costs associated with the need for higher qualified supervision of direct support professionals to ensure key programmatic elements related to the individual’s exceptional support needs are carried out in a safe and effective manner.

Provider Eligibility Criteria

Providers should be able to demonstrate their ability to meet the individual’s exceptional support needs through documentation of each of the following that apply:

• staff training
• employment of or contract with a Registered Nurse, and/or
• involvement of a behavioral or psychological consultant or crisis team.

Providers must demonstrate that they can meet the support needs of the individual through the employment of qualified staff trained to provide the extensive support required by the individual based on their exceptional support needs. Providers may qualify for Customized Rate reimbursement only when the provider’s staff directly performs the support activities required by the individual for whom a Customized Rate is requested.

Providers must have training policies and procedures in place and demonstrate that staff has received appropriate training including, but not limited to, positive behavioral support strategies in order to support an individual with mental illness, behavioral challenges, or both.

All staff who will be supporting an individual, particularly those for whom the Customized Rate is being requested due to complex medical needs, shall receive individual-specific training from a Registered Nurse regarding the individual’s medical condition(s), medication, risk factors, safety practices, procedures that staff are permitted to perform under nurse delegation, and any other training deemed necessary to enable the individual to be safely supported in the community. The provider must arrange for the training to be provided by qualified professionals and document the training in the provider’s record.

Providers supporting an individual via the Customized Rate due to the individual’s behavioral support needs must consult with a qualified behavioral specialist. A qualifying behavioral specialist must have one of the following credentials: LBA/BCBA, LABA/BCaBA, PBSF, Psychologist, LPC, LCSW, Psychiatrist, or Psychiatric Clinic Nurse Specialist. For more information regarding this requirement, reference 12VAC30-122-550. This qualified behavioral specialist must develop a behavior plan based on the individual’s needs and train the provider’s staff in its implementation. Both the behavior plan and staff receipt of training must be documented in the provider record.

Providers must have on file a crisis stabilization plan for all qualifying individuals with complex behavioral needs. This plan must include the direct interventions necessary to mitigate the risk of emergency psychiatric hospitalizations or institutional placement and should include, when appropriate, admission to crisis response services that are provided in the Commonwealth.