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    Commonwealth Coordinated Care (CCC Plus) Waiver

    Useful Links

    The Application Process

    Every person who applies for Medicaid-funded long-term services and supports (LTSS) must have their Medicaid eligibility evaluated, or re-evaluated, if already Medicaid eligible, by the local department of social services (LDSS) in the city or county in which they reside.

    The CCC Plus Waiver requires people meet both financial and functional criteria. For financial eligibility, only the income/assets of the person seeking Medicaid are considered. Children are considered a household of one for the purposes of the CCC Plus Waiver financial determinations. Functional eligibility is determined through a screening process completed by the person’s local Department of Health (DOH). In order to be approved, you must meet the eligibility criteria for both financial need and functional dependencies.

    Before Applying for Medicaid & long-term services and supports (LTSS) Screening

    • Call the Moms In Motion / At Home Your Way Family Resource Specialist team at (800) 417-0908, option 2 for waiver assistance.

    Waiver assistance includes:

      • Explaining how to complete a Medicaid application for long-term services and supports (LTSS) .
        • Only include information regarding the person requesting Medicaid.Long-term services and supports
          LTSS does not have its own separate application. It utilizes the general Medicaid application for income-based coverage.
        • It’s recommended to use the paper application instead of the Virginia CommonHelp self-service portal as the portal is geared more toward income-based Medicaid benefits.
      • What to expect during your screening for long-term services and supports (LTSS).
      • How to respond to questions from long-term services and supports (LTSS) screeners.
        • Focus on your worst day and how, without the services offered with long term care Medicaid, the person and/or caregiver will struggle.
        • Discuss the ways the person differs from their typically developing peer group (i.e. not toilet trained by the average age).
        • Explain if the person has any difficulties in communicating concerns about their health, safety, and welfare.
        • Elaborate on the lack of functional capacity as it relates to activities of daily living (ADLs: bathing, dressing, toileting, transferring, eating, feeding).
          • Refer to the Screening Process section below for more information concerning functional capacity.
        • When asked if the person is at risk for facility placement, this question should be addressed as though, without the CCC Plus waiver, the person may need to be placed in a specialized facility.
          • By answering yes, this does not mean the screener will take the person to a facility.
          • Refer to the Screening Process > Risk of Facility Placement section below for more information concerning facility placement.
        • Screening considerations for children:
          • These include the person’s ability to monitor their own health, safety, and welfare, as well as any disruptive or dangerous behaviors exhibited.

    Did You Know?

    Applying for Medicaid

    • Print and complete a Medicaid Application. Only include information regarding the person requesting Medicaid. Do not complete with the household information, even though it asks for it. If completing for someone else, please answer the questions on behalf of that person, not yourself. Write “CCC Plus/Long Term Care Screening Request” at the top of the form.
    • Print and complete the financial component of the Medicaid Application, known as Appendix D. If completing for someone else, please answer the questions on behalf of that person, not yourself. Do not complete with the household information. Only the income/assets of the person seeking eligibility are considered.
    • Bring completed Application and Appendix D to your local Department of Social Services (DSS) and request a screening for Long Term Care.

    Renewing Medicaid

    People on the CCC Plus Waiver are required to renew their Medicaid annually. DSS will mail out a renewal application typically the month before the person’s renewal month. You will not be required to have another screening.

    Only include information regarding the person requesting Medicaid. Do not complete with the household information, even though it asks for it. If completing for someone else, please answer the questions on behalf of that person, not yourself. Write “CCC+ Waiver: Medicaid Renewal” at the top of the form.

    Section 5: Renewal of coverage in future years (optional) – to make it easier to determine your eligibility for help paying for health coverage in future years, you can agree to allow the Medicaid or FAMIS programs or the Marketplace to use income data, including information from tax returns. You will not receive a renewal application. Instead, you will receive notification of the outcome of your renewal. 5 years is the maximum number of years allowed.

    Waiver Screening Process

    The Long Term Services and Supports LTSS Screening Team must explore the person’s functional, medical, and nursing needs. Federal regulations governing Medicaid coverage of home- and community-based services (HCBS) in an approved waiver specify that services must only be provided to people who have a need for the level of care provided in the alternative institutional placement when there is a reasonable indication that a person might need the services unless they receive HCBS.

    Under the CCC Plus Waiver, services may be furnished only to people who meet the following criteria:

    • Who meet the nursing facility criteria as outlined in the Medicaid Long Term Services and Supports (LTSS) Screening Manual.
    • Who are eligible for Medicaid.
    • For whom an appropriate, cost-effective Plan of Care can be established, including a viable back-up plan.
    • Who are not residents of nursing facilities (licensed by the Virginia Department of Health), or assisted living facilities (licensed by DSS) that serve 5 or more people.
    • When there are no other or insufficient community resources to meet the person’s needs.
    • Whose health, safety, and welfare in the home environment can be ensured.

    CCC Plus Waiver services must be the critical services that enable the person to remain at home rather than being placed in a nursing facility. Once you have turned in your Medicaid Application, a nurse from your local DOH and a representative from DSS will schedule a screening with you. The screening will take place in the person’s home – the person being screened must be present. The nurse and representative will be looking for a documented disability, functional capacity, medical/nursing needs, and risk of facility placement.

    • Find your local DOH
    • A Uniform Assessment Instrument (UAI) will be used to assess the person
    • Helpful hints:
      • Documented Disability
        • It is often helpful to have a diagnostic list.
      • Functional Capacity
        • Evaluates a person’s ability to perform activities of daily living (ADLs), ambulation mobility, and instrumental ADLs (IADLS) in a community environment.
          • ADLs: Bathing, Dressing, Toileting, Transferring, Eating/Feeding,
          • Ambulation: Walking, Wheeling, Stair Climbing, Mobility
          • Continence: Bowel/Bladder
          • IADLs: Meal Prep, Housekeeping, Laundry, Money Management, Transport, Shopping, Cellphone Use, Home Maintenance
          • Physical Health Assessment: Joint Motion, Medication Administration, Behavior, Orientation
      • Medical/Nursing Needs
        • Determines if the person meets the medical criteria for facility level of care and/or admission.
      • Risk of Facility Placement
        • In order to qualify and be authorized for Medicaid Waiver services, a person must also be at risk for facility placement within 30 days in the absence of the CCC Plus Waiver.
      • Screening Considerations for Children
        • Assistance in refraining from unsafe interactions: impaired safety skills
        • Exhibits disruptive or dangerous behavior:
          • Abusive/Aggressive/Disruptive
          • Self-harm
          • Wandering/Eloping/Passive
          • Destroying property
          • Hyper/Hypo sensitivity
          • Constant vocalizations/perseveration
          • Sleep deprivation
          • Reported cognitive impairment
          • Lack of awareness
          • Unable to respond to cues
          • Unable to communicate basic needs and wants
          • Disorientation/Disassociation
          • Unable to follow directions
          • Unable to process information or social cues
          • Unable to recall personal information

    Screening Criteria

    A child may meet the functional capacity requirements for care when one of the following applies:

      • Rated dependent in two to four ADLs AND also rated semi-dependent OR dependent in behavior pattern AND orientation, AND also semi-dependent in joint motion OR dependent in medication administration.
      • Rated dependent in five to seven ADLs AND also rated dependent in mobility.
      • Rated semi-dependent in two to seven of the ADLs AND also rated dependent in mobility AND behavior pattern AND orientation.

    Medical/Nursing Needs

    A child with medical or nursing needs is a child whose health needs require medical or nursing supervision or care above the level, which could be provided through assistance with ADLs, medication administration, and general supervision and is not primarily for the care and treatment of mental diseases. Medical or nursing supervision or care beyond this level is required when any one of the following describes the child’s need for medical or nursing supervision:

      • The child’s medical condition requires observation and assessment to ensure evaluation of the child’s need for modification of treatment or additional medical procedures to prevent destabilization and the child, as developmentally appropriate, has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals.
      • Due to the complexity created by the child’s multiple, interrelated medical conditions, the potential for the child’s medical instability is high or medical instability exists; OR
      • The child requires at least one ongoing medical or nursing service. Ongoing means that the medical/nursing needs are continuing, not temporary, or where the person is expected to undergo or develop changes with increasing severity in status. “Ongoing” refers to the need for daily direct care and/or supervision by a licensed nurse that can’t be managed on an outpatient basis.
      • The child may also be at “risk” for facility placement if the person’s current condition and available supports are insufficient to enable the person to remain in the home. Some examples include:
        • Deterioration in the person’s condition
        • Change in support that prevents needs from being met, such as behaviors increasing, medical condition worsening
        • Change in family situation, such as new child, deployment, divorce
        • No change in condition or support, but evidence that functional, medical/nursing needs are not being met, such as inability to potty-train or inability to manage all therapies

    After Approval

    Select a model of service delivery and choose either an Agency-Directed or Consumer-Directed provider:


    • Model of service delivery where an agency is responsible for providing direct support staff, for maintaining a person’s records, and for scheduling the dates and times of the direct support staff’s presence in the person’s home for personal and respite care.


    Consumer-Directed Model

    People choosing to receive services through the Consumer-Directed (CD) model may do so by choosing a SF to provide the training and guidance needed to be an Employer of Record (EOR). As the EOR, the person is responsible for hiring, training, supervising, and firing attendants. The person may choose to designate a person to serve as the EOR on their behalf. If the person is under 18 years of age the parent or responsible adult must serve as the EOR. A person serving as the EOR cannot be the paid caregiver, attendant, or Service Facilitator (SF). An EOR can only serve on behalf of one person. The only exception to this is that EORs can serve on behalf of multiple people only if they reside at the same address. All CD services must be authorized by the service authorization contractor and require the services of an SF. Specific duties of the person or EOR, as the employer of the CD personal care attendant, include the following:

    • Checking references
    • Determining that the employee meets basic qualifications
    • Submitting required hiring documentation to the fiscal employer agent (F/EA)
    • Training, supervising performance, and submitting time sheets to the F/EA on a consistent and timely basis

    CD attendants are not eligible for Worker’s Compensation, overtime, or holiday pay.

    Initial visit with Service Facilitator (Intake)

    • Visit conducted in the home with the person present.
    • Consumer-Directed services and process are explained.
    • Employer of Record (EOR) is identified and established.
    • Support needs of the person are identified and developed in the Plan of Care (POC).
    • Signatures are collected on all DMAS-required documentation, including the EOR’s contract with the SF.
    • Electronic Visit Verification (EVV) requirement is discussed with the EOR.
    • SF and EOR schedule next visit date.
    • After the intake, the following will occur:
      • Level of Care (LOC) determined and prior-authorization for hours are requested from the Managed Care Organization (MCO).
      • Fiscal Agent Request Form (FARF) sent to FA to establish the person and EOR with the FA.

    Routine on-site visits 

    • Visit conducted in the home with the person present.
    • EOR may receive Management Training (MT) on hiring responsibilities and any changes implemented by DMAS.
    • SF and EOR discuss any updates needed for the person’s POC or any changes that have occurred since the last visit. Examples of this may include:
      • Health of the person
      • Medication changes
      • Recent hospitalizations
    • SF and EOR discuss any changes to the MCO health plan of the person, FA issues, and attendant issues (hiring/onboarding/etc.).
    • Signatures are collected on all DMAS-required documentation.
    • SF and EOR schedule next visit date.
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