NURSING FACILITY TRANSITION SERVICES PROVIDER IN VIRGINIA

Fatumata Kaba
4 days ago
3 min read

HELPING INDIVIDUALS SAFELY RETURN TO THE COMMUNITY FROM INSTITUTIONAL SETTINGS WITH DIGNITY, SUPPORT, AND A PERSON-CENTERED PLAN

Nursing Facility Transition (NFT) Services in Virginia are designed to assist individuals who live in nursing homes or other institutional facilities and wish to transition back into the community. These services eh7nsure that individuals have the support, resources, and housing arrangements necessary for a successful and sustainable move.

NFT services are a key component of Virginia’s Commonwealth Coordinated Care Plus (CCC Plus) Waiver and are overseen by the Department of Medical Assistance Services (DMAS). Service coordination is carried out in collaboration with Managed Care Organizations (MCOs) and, in many cases, transition coordination agencies approved by DMAS.

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1. GOVERNING AGENCIES

Agency: Virginia Department of Medical Assistance Services (DMAS)

Role: Administers the CCC Plus Waiver and sets standards for transition services.

Agency: Managed Care Organizations (MCOs)

Role: Identify eligible individuals, authorize transition services, and coordinate care.

Agency: Virginia Housing (formerly VHDA)

Role: Offers housing assistance through vouchers and community-based housing programs (when applicable).

2. NURSING FACILITY TRANSITION SERVICES OVERVIEW

NFT services help eligible individuals move from a nursing facility into a home or community-based setting. Services are short-term, person-centered, and aim to reduce re-institutionalization.

Key covered activities include:

Pre-transition assessments and person-centered planning
Identifying and securing housing
Arranging household items and accessibility modifications
Coordinating home and community-based services (e.g., personal care, transportation)
Providing financial support for moving expenses (within limits)
Ensuring follow-up and post-move stabilization

These services are authorized by the individual's MCO and must be documented in a transition plan.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

Register your business with the Virginia State Corporation Commission (SCC)
Obtain an EIN and Type 2 NPI
Ensure staff meet minimum qualifications (see below)
Create a Transition Services Policy & Procedure Manual
Enroll as a Medicaid provider via the MES portal
Contract with MCOs for CCC Plus Waiver service authorizations
Build partnerships with local housing authorities and CSBs for referrals and support

4. VIRGINIA PROVIDER ENROLLMENT PROCESS

Step 1: Register entity, obtain EIN and NPI

Step 2: Prepare policies, staffing plans, and documentation tools

Step 3: Enroll as a Medicaid provider through DMAS MES portal

Step 4: Contract with CCC Plus MCOs for service authorization

Step 5: Begin services upon transition plan approval and MCO referral

5. REQUIRED DOCUMENTATION

SCC registration, EIN, and NPI
Medicaid provider enrollment confirmation
MCO contracts and service referral forms
NFT Policy & Procedure Manual including:
- Intake and pre-transition planning process
- Transition service delivery timeline and staff roles
- Coordination procedures with housing agencies and HCBS providers
- Expense tracking and reporting templates
- Post-transition follow-up and satisfaction surveys
- Documentation of person-centered planning and community integration efforts
- Emergency contacts and contingency planning protocols

6. STAFFING REQUIREMENTS

Role: Transition Coordinator / Specialist

Requirements:

Bachelor’s degree in human services or related field (or equivalent experience)
Knowledge of Medicaid waivers, person-centered planning, and housing options
Strong coordination and communication skills
Background check and training in HIPAA, rights, and documentation

Role: Program Supervisor (optional)

Responsibilities:

Oversight of transition services, quality assurance, and staff support

All staff must complete:

HIPAA and confidentiality training
Emergency relocation protocols
Housing navigation and tenancy support
Person-centered planning documentation and MCO compliance training

7. MEDICAID WAIVER PROGRAMS

NFT services are primarily authorized under:

CCC Plus Waiver – For individuals in nursing facilities who qualify for home and community-based services
Services must be coordinated with an MCO Transition Coordinator and included in the participant’s Transition Plan and subsequent ISP

Funding may support one-time expenses such as:

First month’s rent and security deposit
Utility setup and basic furnishings
Moving services and minor home modifications

8. TIMELINE TO LAUNCH

Phase: Business Registration & Staffing

Timeline: 2–3 weeks

Phase: Medicaid Enrollment & MCO Contracts

Timeline: 4–6 weeks

Phase: Policy Manual Finalization & Readiness Review

Timeline: 2–3 weeks

Phase: Service Launch

Timeline: Begins after MCO referral and transition plan approval

9. CONTACT INFORMATION

Virginia Department of Medical Assistance Services (DMAS)

Website: https://www.dmas.virginia.gov

MES Medicaid Provider Enrollment Portal

Website: https://vamedicaid.dmas.virginia.gov/provider

Virginia Housing

Website: https://www.virginiahousing.com

CCC Plus Managed Care Information

Website: https://www.virginiamanagedcare.com

NURSING FACILITY TRANSITION SERVICES PROVIDER IN VIRGINIA

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — VIRGINIA NURSING FACILITY TRANSITION PROVIDER

WCG helps providers navigate the complex requirements of starting a Medicaid-eligible NFT service, with a focus on housing coordination, waiver transitions, and person-centered relocation support.

Scope of Work: