Money Follows the Person

Frequently Asked Questions and Answers

These frequently asked questions came from MFP training sessions and were prepared by the Department of Medical Assistance Services (DMAS) in collaboration with staff from the Department of Behavioral Health and Developmental Services (DBHDS). Additional questions may be submitted to Check this page frequently for updates.

Commonly-Used Terms

Money Follows the Person Program

This eight year project, funded by federal and state sources, provides individuals of all ages and all disabilities who live in institutions (nursing facilities, Intermediate Care Facilities for Individuals with Developmental Disabilities (ICF/ID) and long-stay hospitals) in the Commonwealth of Virginia options to transition to a home-and-community setting. Have resided for at least 90 consecutive days in a hospital, nursing facility (any days spent in short-term skilled rehabilitation services do not count towards the 90 days), intermediate care facility for individuals with intellectual disability (ICF/ID), long-stay hospital, institute for mental disorders (IMD), psychiatric residential treatment facility (PRTF), or a combination thereof;

Transition Coordination Provider Agency

This is a DMAS provider who is responsible for supporting the individual (and family/caregiver, as appropriate) with the activities associated with transitioning from an institution to the community using the Elderly or Disabled with Consumer Direction (EDCD) Waiver. Service descriptions, criteria, service units and limitations, and provider requirements for the service are found in 12 VAC30-120-2000.

Transition Coordination

Transition Coordination is the management and coordination of an individual’s transition from an institution to the community. Transition Coordination is a covered service only for individuals using the EDCD waiver. Transition Coordination is limited to 14 months from the date of service authorization: two months prior to transition as an MFP Demonstration service, and 12 months following transition as an EDCD Waiver service.

Transition Services

Transition Services are set-up expenses for individuals who are transitioning from an institution or licensed or certified provider-operated living arrangement to a living arrangement in a private residence where the individual is directly responsible for his or her own living expenses. Transition services are authorized for nine months up to two months of which can occur prior to the individual’s discharge from an institution. (Pre-transition is an MFP Demonstration service, and post-transition is a waiver service.) The services must be requested no later than 30 days following discharge from a provider-operated living arrangement. The service description, criteria, service units and limitation and provider requirements for this service are found in 12 VAC 30-120-2010 .

Frequently Asked Questions and Answers

General | Transition Coordination | Transition Services | Community Living | HCBS Waivers


If an eligibility worker from the local department of social services knows of someone who has expressed an interest in leaving a facility, to whom should they be referred?

Answer: The adult services worker should provide the individual with a list of Transition Coordination Provider Agencies and refer them (or their responsible party) to the DMAS web site. With permission from the individual, the eligibility worker should discuss this with the facility and the discharge planner.

Who will make the final decision related to enrolling in MFP?

Answer: This program is person-centered, meaning that the individual or surrogate decision-maker must be the decision maker related to enrollment and supports. All home-and–community-based waivers require that the health and safety of the individual be supported. Ultimately, it is the Transition Coordinator or the Support Coordinator/Case Manager, in close consultation with the individual transitioning, who determines that the program is a good match, and by enrolling the individual into the appropriate waiver, assures that all requirements of the home-and-community-based waiver will be met for the individual.

What about consumer-directed supported employment?

Answer: Due to unresolved concerns over Worker’s Compensation issues, this is not a part of the initial MFP Program.

In the MFP project, where is the money coming from? Is the money the money that which would be spent in a facility, and does that money “follow” the person into the community?

Answer: This is the concept of the program. Virginia has been working for many years to shift supports from institutional settings to home-and-community settings to better serve individuals and meet their preferences. MFP will strengthen the system of home-and-community-based supports that are already in place through Medicaid waivers. We hope that MFP will make it a little easier for people to move to home and community settings.

The funding for MFP is still a state and federal match and does not constitute a “grant” to Virginia. Instead of receiving a 50/50 match for waiver supports provided to individual after their first year of transition under the MFP Program, the federal match is 75% of all expenditures (with the state paying the rest). This match, in addition to the anticipated cost savings for serving individuals in the community instead of institutional settings, has enabled Virginia to develop and pay for enhanced waiver supports to strengthen the current long-term support system.

Will private providers receive referrals through MFP?

Answer: Individuals may choose private providers that are Medicaid enrolled support providers, as allowed by the waiver regulations. There is no change in the way waiver supports are chosen, authorized, provided or administered.

Do we have access to a risk assessment tool and, if so, who is expected to complete this?

Answer: This is a part of the development of a person-centered support plan by the Transition Coordinator or the Support Coordinator/Case Manager, depending upon the waiver.

Can you give examples of “long-stay hospitals?”

Answer: Long-stay hospitals serve people who would receive skilled care and may be ventilator dependent. The Technology-Assisted Waiver enables these individuals to be at home, close to family while services continue. There is one Medicaid-enrolled long-stay hospitals in the Commonwealth, Lake Taylor Transitional Hospital, located in the Tidewater region. Additionally, there are five that serve children with many critical medical needs.

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Transition Coordination

What agencies can become Transition Coordination Provider Agencies?

Answer: Transition Coordination Provider Agencies (agencies that employ a transition coordinator) must be either a local government agency, or a private, nonprofit organization qualified under §26 USC 501 (c)(3).

Can Area Agencies on Aging or local departments of social services be Transition Coordination Provider Agencies?

Answer: Yes, if they are enrolled as a Medicaid provider of Transition Coordination.

Who can enroll as a Transition Coordination agency--Agency, or staff who works for an authorized agency, or both?

Answer: Only an agency can enroll.

If an agency can enroll, then how do they communicate who the transition coordinator is?

Answer: Any employee of the agency who meets regulatory requirements can be a transition coordinator. When contact is made with the agency, the agency informs the individual of the name/s of staff who provide transition coordination.

How does DMAS validate the skills necessary for staff of the agency to perform this service?

Answer: DMAS reviews this during quality management reviews of the provider agency to assure that staff providing transition coordination meet the skills outlined in regulations and policy.

Who signs the Medicaid application to become a transition coordinator?

Answer: The agency’s authorized representative must sign the application.

Are there any limits to the number of enrolled Transition Coordination Provider Agencies under MFP?

Answer: No.

If an individual is enrolled in the Elderly or Disabled with Consumer-Direction (EDCD) waiver, may a Community Services Board support coordinator/case manager serve as the Transition Coordinator?

Answer: Yes, as long as the CSB has enrolled with Medicaid as a Transition Coordination Provider Agency and meets all applicable requirements.

CSBs do not have to enroll as a Transition Coordination Provider Agency to provide support to individuals who are enrolled in the EDCD Waiver. They can bill for case management through Targeted State Plan Case Management services. CSBs may not bill for Transition Coordination and Targeted State Plan Case Management services for the same time frame and for the same individual, as this is a duplication of services.

If an agency is already a Case Management Medicaid provider, do they have to apply to be a Transition Coordination Provider Agency?

Answer: Yes. If the Case Management agency would like to provide supports to individuals in the EDCD Waiver, then they need to enroll as a Medicaid provider of Transition Coordination.

If a Community Services Board enrolls as a provider for Transition Coordination in order to be able to serve a new population, does each staff person need to enroll or only the agency?

Answer: Only the agency needs to enroll as a Medicaid provider of transition coordination. The staff is covered under that provider agreement for as long as they are employed.

How will Transition Coordination agencies come into contact with individuals living in qualifying institutions?

Answer: A multifaceted approach to generate public awareness has been developed for MFP and is currently being refined. Transition Coordination Provider Agencies are encouraged to advise facilities, families, and others of the agency’s enrollment as a Medicaid provider agency for Transition Coordination. Transition Coordinators/Case Managers may visit the local nursing facilities, intermediate care facilities and long-stay hospitals to work with the administration in identifying individuals eligible for enrollment in the MFP program. Each identified individual has the right to choose if they want to transition to the community.

What is the difference between supports provided through MFP and the current waivers as it relates to case management?

Answer: Regarding case management or Transition Coordination, there is no difference. For the EDCD Waiver, Transition Coordinators perform the same basic functions as a case manager for up to 12 months after reentry to community. DMAS is currently recruiting agencies to enroll to provide Transition Coordination for individuals using the EDCD Waivers. For the Intellectual Disability (ID), HIV/AIDS, Developmental Disabilities (DD) and the Technology Assisted (Tech) Waivers, each will use the current system for case management.

Is Transition Coordination billed as a monthly rate?

Answer: Yes.

What is the reimbursement rate for Transition Coordination?

Answer: $323.50 a month.

How does Transition Coordination interface with services facilitation?

Answer: There is no change. Interfacing with the Services Facilitator is no different than with any other provider. If the individual elects to use consumer-directed supports under a waiver, the Transition Coordinator or support coordinator/case manager will include that in the support plan, and provide the individual or his/her representative a list of Service Facilitators.

If an agency wants to be a Transition Coordination Provider Agency, what does the agency need to do?

Answer: Visit the DMAS website at for a provider enrollment form. Complete the form and submit it via fax 888-335-8476 or 804-270-7027 or mail to Virginia Medicaid Provider Enrollment Services, PO Box 26803, Richmond, VA 23261-6803. The application process takes approximately 15 days, provided all of the required documentation is submitted by the applicant.

How will DD waiver be handled? Will a Transition Coordinator provide this service?

Answer: No. The DD waiver will be handled as it is now, with a case manager and DMAS oversight.

Who will be available for individuals using the EDCD Waiver when Transition Coordination ends?

Answer: The individual, supported by community agencies and waiver providers along with family as appropriate, will be responsible for coordinating supports.

When a person is hospitalized is the Transition Coordinator responsible for helping with ongoing bill paying/maintaining a household?

Answer: No. This responsibility would belong to the individual or the individual’s surrogate decision-maker, possibly with the help of their support group of family, friends, neighbors or community.

There is a post-discharge 12-month limit to Transition Coordination. What will happen to those individuals in the community once the 12-month limit has been reached?

Answer: The 12 month limit is for EDCD Waiver only. All other waivers continue with routine support coordination/case management. In the EDCD waiver there will be an array of community supports that the individual will be able to access by the time that Transition Coordination concludes, including several levels of back-up systems for emergencies to assist when there is a breakdown in supports delivery. Each individual enrolled in MFP is also enrolled in and using waiver supports; therefore, they have a designated primary back-up system within the support plan as a requirement of community re-entry. All of the waivers’ assurances for health and safety will apply to any individual enrolled in a HCBS waiver upon discharge. Additionally, through the 2-1-1 (toll free) statewide call center, there will be personnel available 24 hours per day, seven days per week to assist with information and referral and answer questions when needed. Waiver supports require that the individual be able to reside safely in the community as a prerequisite of authorization by the Support Coordinator/ Case Manager/Transition Coordinator and the service authorization entity.

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Transition Services

If an individual participating in the MFP Project chooses to leave a nursing facility and relocate to live with family, may the Transition Services be used in the family member’s home?

Answer: Please refer to the definition of Transition Services in the Commonly-Used Terms section above. Transition Services may be used in relocating an individual to a qualified home-and-community-based setting, including the home of a family member.

Can Transition Services be used to maintain housing during a hospitalization or a readmittance back to a facility setting?

Answer: No. Transition Services is to be used only for the set up of housing and active transition to a home-and-community-based setting.

If an individual leaves a facility, enters the community, then enters a hospital and then returns to the community, is the nine-month Transition Services limit extended for the length of time the individual is in a hospital??

Answer: No. Transition Services is authorized for only nine months. Once the nine months have expired, the individual no longer has access to this funding.

At what point during an individual’s transition planning process can Transition Services be used to pay for set-up costs, for example, utility deposits and/or security deposits on a rental property?

Answer: Transition Services is a waiver support created as a result of the MFP demonstration, and it is authorized for a total of nine months. Individuals may access Transition Services up to two months prior to discharge from a facility. Therefore, appropriate essential goods and services may be purchased prior to discharge with prior authorization. The Support Coordinator/Case Manager/Transition Coordinator who is working with the individual must concur and authorize these transition purchases. Utility and rental security deposits are an appropriate expense for these funds.

As a current DBHDS provider, what would we need to do to provide Transition Services?

Answer: As a current provider of ID supports, there is nothing more that you would need to do in order to serve individuals using the ID Waiver through MFP. However, your agency would be required to provide “up-front” funds for Transition Services and request reimbursement through the DMAS fiscal agent, for those funds. You will be required to complete a provider enrollment package with the DMAS fiscal agent.

How does the individual access the $5,000 Transition Services funding?

Answer: The Transition Coordinator/Support Coordinator/Case Manager works through the Transition Coordination Provider Agencies to upfront the costs of the Transition Services as items are needed/expenses are to be paid, and then submits for reimbursement to the DMAS fiscal agent.

Please clarify the billing/reimbursement process for Transition Services. How long will it take?

Answer: Reimbursement for goods and services procured through Transition Services funding will be issued within 14 business days of submission to the DMAS fiscal agent if appropriate expenditures and are provided.

I represent a private non-profit. How is an agency like mine able to provide the up-front money for Transition Services?

Answer: During the planning process, a focus group was used to provide feedback from agencies who would be involved in administering MFP throughout the Commonwealth. At this point, we are working with a reimbursement model.

Does the $5,000 Transition Services apply to residential services settings?

Answer: Generally, no. However, under MFP an adult foster home or a sponsored residential home may be a qualifying residence in which individuals may receive Transition Services through MFP. For an individual in this setting to be eligible for Transition Services, the adult foster home or sponsored residential home cannot be a waiver provider for the individual, and the individual must have control of his/her finances. This will be decided on a case by case basis.

Can Transition Services funding be used to make repairs to a group home of four or less persons?

Answer: No, Transition Services funding may not be used for this purpose.

Can Transition Services funding be used for individuals transitioning to sponsored residential homes in which there are two or fewer persons?

Answer: If the individual is contributing towards his or her own housing costs then it may be used if it is not paying for furnishings or supplies already provided by the sponsored home.

When are Environmental Modifications (EM) and Assistive Technology (AT) available under the EDCD Waiver?

Answer: For 12 months post-transition, and only if the individual is participating in the MFP Program. The providers of EM and AT may make the request directly to the service authorization entity on behalf of the individual, or the consumer-directed Services Facilitator may assist.

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Community Living

Who is going to supervise the individual when they are in the community?

Answer: MFP is similar to the current Medicaid HCBS waivers. The individual must be able to reside safely in the community setting with appropriate supports, including informal systems such as family and friends. We envision that services will be provided collaboratively, across many agencies, to fully support the individual’s needs in the community. Health and safety are prerequisites to using a waiver, and all individuals who participate in MFP receive information on health and safety.

Will individuals participating in MFP s be able to live in group homes?

Answer: A group home is an allowable community residence if the home has four (4) or fewer residents.

Our jurisdiction has long waiting lists for housing and other services. How will MFP address the issue of affordable housing?

Answer: We are aware of the affordable housing issues throughout the Commonwealth. Several agencies continue to work on this issue. MFP allows individuals to use Transition Services funding ($5,000 lifetime maximum per individual) for security deposits, set-up costs, etc. Ongoing costs such as monthly rental or mortgage expenses are not allowable costs under Transition Services. More housing support information is available in the MFP Operational Protocol Guide and on the Housing and Transportation Resource Bank page at

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HCBS Waivers

Are there limited slots for individuals participating in MFP who transition to the EDCD Waiver?

Answer: No. The MFP slots have been approved by the Centers for Medicare and Medicaid Services for MFP individuals in the EDCD waiver. This Waiver does not have a waiting list.

Are slots in the waiver limited by geographic considerations?

Answer: No, the slots have been approved statewide to ensure that everyone desiring to transition has similar opportunities.

What about food stamps and other services--may these be obtained prior to discharge or otherwise expedited?

Answer: DMAS is working with the Department of Social Services in every way possible to accommodate making this a smooth and expedited process.

People entering MFP through the EDCD, Tech or HIV/AIDS Waivers must meet nursing facility level of care. People entering MFP through the ID Waiver must meet ICF/ID level of care. These people may be incapacitated. Who makes the decisions?

Answer: There is no difference with MFP than for any other waiver. If the individual has a surrogate decision-maker, that decision maker would continue to act on behalf of the individual.Have resided for at least 90 consecutive days in a hospital, nursing facility (any days spent in short-term skilled rehabilitation services do not count towards the 90 days), intermediate care facility for individuals with intellectual disability (ICF/ID), long-stay hospital, institute for mental disorders (IMD), psychiatric residential treatment facility (PRTF), or a combination thereof;

May an individual leave a facility, be enrolled in the EDCD Waiver and receive Environmental Modifications and Assistive Technology?

Answer: Yes. Both supports are available the first year after transition for individuals participating in MFP.

Once a person transitions from a facility to the ID Waiver, is the slot handled like any other ID Waiver slot?

Answer: Yes, the slot has the same status as other “facility slots.” The individual needs to retain the slot for at least twelve months in order for that slot to become an official slot of the CSB providing support coordination/case management to the individual. Should the individual return to the facility prior to the 12th month, the slot is to be assigned to another individual residing in a facility.

If a CSB knows of individuals who have expressed a desire to leave an institution, what is the next step in the process?

Answer: The MFP Operational Protocol/Program Guidebook provides the steps to take for the entire transition process.

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This File Was Last Modified: Tuesday August 07 2012