Virginia Medicaid Paid Caregiver and LRI Guide

What is a Legally Responsible Individual?

A Legally Responsible Individual, or LRI, is a parent or legal guardian of a minor, or the person’s spouse. Virginia permits paid LRI personal care in qualifying circumstances. Being a family member does not by itself establish eligibility.

A relative who is not an LRI can be subject to different caregiver rules. Tell the Care Navigator your relationship so the right requirements can be checked.

The care need matters more than the diagnosis.

For a child, paid LRI care must address extraordinary personal-care needs related to disability: assistance beyond what is ordinarily needed by a child of the same age. An autism diagnosis or another disability alone does not qualify a child.

Activities of daily living, or ADLs, include bathing, dressing, toileting, eating and moving between positions. The assessment considers the actual hands-on help needed. The care plan must identify qualifying tasks and the time required.

• Hands-on help with an ADL may be considered when it exceeds age-typical care and is properly assessed and authorized.
• Ordinary parenting, general supervision, maintaining routines and medication reminders alone do not meet the paid LRI extraordinary-care standard.
• Instrumental activities of daily living, such as shopping, housekeeping and meal preparation, are different from direct ADL assistance and are not reimbursable as extraordinary LRI care.

Up to 40 hours is a limit, not a promise.

A paid LRI may receive up to 40 reimbursable hours per week for a qualifying child. The applicable program, assessment, care plan, service authorization and health-plan rules determine the actual approved services and hours. Some families may qualify for fewer hours or may not qualify.

When an LRI cares for more than one qualifying child, DMAS describes the limit per child. Each child still needs an individual assessment and authorization. If additional help is needed from a non-LRI aide, the provider must coordinate the plans and seek the required authorization.

Understand the respite restriction before planning care.

Respite is not available for the same time that a paid LRI provides personal care or assistance. DMAS guidance is broader: it says respite is not available when there is a paid LRI, because respite is intended to relieve an unpaid primary caregiver.

Do not assume that scheduling respite outside the LRI’s paid shifts makes it covered. Ask the health plan or support coordinator to review the full arrangement and explain which additional supports, if any, can be authorized.

Three waiver names you may hear.

DD waivers have a waiting list, with slots assigned by urgency of need. Your local Community Services Board is the entry point for a DD waiver assessment. CCC Plus and DD waivers use different screening and service-authorization routes; a family cannot simply choose a waiver by name.

A Cardinal Care health plan and a waiver are different parts of coverage. A plan card does not by itself show which waiver services are authorized. First Choice’s participation must be checked for your exact coverage before care starts.

• CCC Plus Waiver: home and community services for people who meet the required nursing-facility or other specialized medical level of care. It serves children and adults and does not have a waiting list; eligibility and service authorization are still required.
• Family and Individual Supports (FIS) Waiver: a Developmental Disability waiver for children and adults, often living with family, friends or in their own homes, who need functional, medical or behavioral support.
• Community Living (CL) Waiver: a Developmental Disability waiver for children and adults who generally need more extensive or ongoing support, including people with complex needs.

Not sure which program you have?

You can begin the eligibility check with “I do not know.” A plan card, waiver letter or the name of an existing coordinator can help during follow-up, but do not upload cards or protected records to a public inquiry form.

If personal-care hours are already approved, tell us at the start. That information helps the team review starting services or a possible transfer without assuming that an existing authorization automatically covers a new caregiver or agency.