The Virginia DMAS-99 form, formally the Community-Based Care Member Assessment, is a Medicaid document that a waiver service provider completes during a visit with a member already receiving community-based services such as those under the Commonwealth Coordinated Care Plus (CCC Plus) waiver. The provider — not the member — fills it out, and the completed form must be placed in the member’s record within five days of the visit date. A blank copy is available through the Virginia Medicaid Enterprise System portal.
Who Fills Out the DMAS-99
The DMAS-99 is completed by the personal care agency, consumer-directed services facilitator, or other waiver service provider delivering care to the member. It is a clinical observation form; the member being assessed does not complete any part of it. The provider documents what they observe during the visit about the member’s ability to perform daily activities, their current medical condition, and the care they are actually receiving.
The top of the form asks for the provider’s agency name, provider identification number, and whether services are agency-directed or consumer-directed. It also records the member’s name, date of birth, Medicaid identification number, current address, and start-of-care date. A checkbox identifies the visit type: initial, routine, or six-month reassessment.
When the Form Is Required
The DMAS-99 is used at three points in the delivery of community-based waiver services:
- The initial visit when services begin.
- Routine visits during ongoing care.
- The mandatory six-month reassessment.
The six-month reassessment is the one with the highest stakes. It confirms that the member still meets the clinical criteria for waiver services and that the care plan still matches the member’s actual needs. Changes in ADL ratings, new diagnoses, or shifts in the support system flagged at reassessment can trigger adjustments to the member’s service plan.
What the Form Documents
The DMAS-99 is organized into sections that together produce a snapshot of the member’s care needs and living situation.
Functional Status and ADL Ratings
The largest section rates the member’s ability to perform activities of daily living. It covers five core ADLs — bathing, dressing, toileting, transferring, and eating or feeding — along with continence (bowel and bladder), mobility, orientation, and behavior. For each item, the provider selects from a range running from “Needs No Help” through levels of mechanical help, human help (supervision or physical assistance), combined mechanical and human help, “Performed by Others,” and “Is Not Performed at All.”
These ratings align with the Virginia Uniform Assessment Instrument and the screening criteria in 12VAC30-60-303. “Independent” means the person can perform the activity without help. “Semi-dependent” means mechanical help only. “Dependent” covers any level from human help onward.
Orientation and Behavior
Orientation runs on a scale from fully oriented to semi-comatose or comatose, with intermediate levels capturing whether disorientation affects some or all spheres (person, place, time) and whether it occurs sometimes or at all times. The provider also notes the source of the information. Behavior ranges from appropriate through wandering or passive to abusive, aggressive, or disruptive, with frequency markers for less than weekly or weekly and above. Space is provided to describe any inappropriate behavior in detail.
Medical and Nursing Information
This section records current diagnoses, medications, health status, ongoing medical or nursing needs, therapies or special medical procedures, recent hospitalizations with dates and reasons, and any critical incidents. The provider rates joint motion on a three-point scale (normal, limited, or immobile) and medication administration (self-administered, monitored by a layperson, or requiring professional nursing staff).
Support System
The support system section documents the waiver services the member receives: agency personal care, consumer-directed personal care, respite care, adult day health care, private duty nursing, the total weekly hours and specific schedule of aide or attendant care, and whether the aide lives with the member. It also identifies other paid and unpaid caregivers, the type and frequency of their care, and any additional Medicaid-funded or non-Medicaid-funded services.
Supervision and PERS
A separate block asks whether the member needs supervision or a Personal Emergency Response System at all times to remain safely in the community, whether the member currently receives either, and whether a medication monitor is in place. For members with a PERS unit, additional questions confirm the member is at least 14 years old, the system is adequate, and telephone service has not been disconnected.
Consumer-Directed Services
When care is consumer-directed, the form identifies the person directing or managing the care and their relationship to the member, along with the person providing hands-on care and that person’s relationship to the member.
Why the ADL Ratings Matter at Reassessment
Accurate ADL ratings on the DMAS-99 carry real weight because they feed directly into whether a member continues to meet Virginia’s nursing-facility level of care. Under 12VAC30-60-303, clinical eligibility rests on three components together: functional capacity, medical or nursing needs, and risk of nursing-facility admission within 30 days. Functional capacity alone is not enough.
The regulation identifies specific ADL combinations that satisfy the functional-capacity component. For example, a person rated dependent in two or more ADLs who is also rated semi-dependent or dependent in behavior pattern and orientation, and semi-dependent or dependent in joint motion or dependent in medication administration, meets the threshold. A person rated dependent in five to seven ADLs who is also rated dependent in mobility qualifies through a different combination. No single ADL rating in isolation triggers eligibility; the ratings work together, which is why each selection on the DMAS-99 needs to reflect what the provider actually observed.
Filing the Completed Form
After the visit, the provider files the DMAS-99 in the member’s record within five days of the date of the last visit. The form is not sent to the local Department of Social Services or submitted to DMAS as part of an eligibility application. It stays in the provider’s clinical records and must be available if DMAS requests it during an audit or review.
Providers who obtained the form by mistake are directed to send it to DMAS at 600 East Broad Street, Suite 1300, Richmond, VA 23219.
How the DMAS-99 Differs From the LTSS Screening Forms
The DMAS-99 is sometimes confused with the forms used during the initial Long-Term Services and Supports screening, but the two are distinct. The LTSS screening decides whether someone qualifies for Medicaid-funded long-term care in the first place. The DMAS-99 documents ongoing care for a person who has already qualified and is receiving community-based waiver services.
The forms used for the LTSS screening are specified in 12VAC30-60-306:
- The UAI (Uniform Assessment Instrument), the primary tool for rating ADLs, medical needs, and functional capacity during the screening.
- The DMAS-96, the Medicaid-Funded Long-Term Services and Supports Authorization Form, signed by the screening team and a physician to authorize or deny LTSS.
- The DMAS-97, the Individual Choice form, documenting whether the person selects home and community-based services or nursing-facility care.
- The DMAS-95, a supplemental form used when the individual has a suspected or known diagnosis of mental illness, intellectual disability, or a related condition.
The DMAS-99 does not appear on that list because it enters the picture only after the screening is complete and community-based services have begun.