[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-306752-105":53,"doc-detail-306752-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","medicaid-ltss-communication-form-dmas-225","Medicaid LTSS Communication Form DMAS-225","","DMAS-225 is used to exchange information for individuals approved for or receiving long-term services and supports (LTSS), including nursing facility care, home and community based services (HCBS waiver or PACE), and hospice. The form supports communication of Medicaid eligibility status, changes in level of care, admission or discharge, death reporting, and other provider-known factors affecting eligibility or patient pay amounts. It specifies who initiates the exchange, required form preparation steps, attachment of DMAS-96 on initial admission, and distribution of copies among LDSS, MCOs, providers, and case-management contacts.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medicaid-ltss-communication-form-dmas-225/306752/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medicaid-ltss-communication-form-dmas-225/306752.png","ImageObject",442,249,{"name":88,"@type":89},"Graffin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":25},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What individuals is the DMAS-225 form for?","Question",{"text":108,"@type":109},"DMAS-225 is for individuals approved for or receiving LTSS, including nursing facility (NF) care, HCBS (waiver services or PACE), or hospice services.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information must be communicated using the form?",{"text":113,"@type":109},"It exchanges Medicaid eligibility status, level of care changes, admissions and discharges (or death), and other provider-known information that may affect eligibility status or patient pay amounts.",{"name":115,"@type":106,"acceptedAnswer":116},"Who initiates the form and when must a new form be prepared?",{"text":117,"@type":109},"The local Department of Social Services (LDSS), MCO (for managed care individuals), or the provider initiates it. The LDSS must prepare a new form whenever a change in the individual’s circumstances results in a change in eligibility status or information needs for the MCO or provider.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306752,1790446775,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":25,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},3573418547284,"https://eur-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","| Medicaid LTSS Communication Form | Patient’s Name:\u003Cbr>Medicaid Member ID\\#: Date of Birth: / / Check one:  Fee for Service  Managed Care If Managed Care: Health Plan Name:\u003Cbr>Health Plan Representative:\u003Cbr>Phone: Email: |\n| --- | --- |\n\n\n| Provider Name: Mailing Address:\u003Cbr>Individuals in HCBS (Waiver or PACE) only: Patient’s Residential Address: Enrollee FIPS Code:\u003Cbr>Provider NPI\\#: Provider Representative.: Title:\u003Cbr>Telephone: Fax: Date: / /\u003Cbr>Patient Information: DMAS-96  attached  unavailable |\n| --- |\n|  Individual admitted to (check one):  Nursing Facility  HCBS services  Hospice services on (date) / /\u003Cbr>from (check one): Home  Hospital  Other Facility:\u003Cbr> Level of Care (NF patients only) :  ICF  SNF  Patient Pay determination requested\u003Cbr> Medicaid Per Diem Rate: $  RUGS Score (NF patients only):  HCBS Provider Hourly Rate: $\u003Cbr> Individual discharged on (date) / / to:  Home  Hospital  ALF  Other Facility  Deceased\u003Cbr> Level of care change: from:  ICF  SNF  HCBS  Hospice to:  ICF  SNF  HCBS  Hospice  Change in income, deductions, health insurance or other (specify) :\u003Cbr> Patient Funds Account balance (NF patients only) $ as of (date) / / Include any additional information here: |\n\n\n| LDSS: FIPS Code: Eligibility Worker:\u003Cbr>Telephone: Fax : Date: / /\u003Cbr>Eligibility Information: |  |  |  |\n| --- | --- | --- | --- |\n|  |  Eligible for full Medicaid services beginning / / | (date)  Eligible for QMB Medicaid only |  |\n|  |  Eligible for Medicare premium payment only |  |  |\n|  |  Ineligible for Medicaid  Ineligible for Medicaid payment of | LTC services from / / to / / |  |\n|  |  Medicare Part A insurance: Other health insurance: | LTC insurance: |  |\n|  |  Change in deductions, health insurance or other: | |  |\n\nDepartment of Medical Assistance DMAS-225 Revised 01.2020  \nMedicaid LTSS Communication Form DMAS-225  \nTo be used only for individuals approved for or receiving long-term services and supports (LTSS): nursing facility (NF) care, home and community based services (HCBS--waiver services or PACE) or Hospice.  \nPURPOSE OF FORM--To allow the local Department of Social Services (LDSS), Managed Care Organizations (MCOs), nursing facilities, waiver services providers and PACE programs to exchange information regarding:  \no The Medicaid eligibility status of an individual;  \no A change in the individual’s level of care;  \no Admission or discharge of an individual to an institution, HCBS, or Hospice, or to report the death of an individual;  \no Other information known to the provider that might cause a change in the eligibility status or patient pay amounts. (e.g. planned or incurred medical expense)  \nUSE OF FORM--Initiated by either the LDSS, MCO for individuals in a managed care plan, or the provider of care. A new form must be prepared by the LDSS whenever there is any change in the individual’s circumstances that results in a change in eligibility status or information needs to be given to the MCO or provider. The MCO or provider must use the form to document admission date, request Medicaid eligibility status, and notify the LDSS of changes in the individual’s circumstances, discharge or death.  \nNUMBER OF COPIES--Original and one copy for individuals in a NF; original and two copies for individuals in HCBS.  \nDISTRIBUTION OF COPIES—  \n• For individuals in a NF, send the original to the MCO (CCC Plus) or the NF (FFS only) .  \n• For individuals in HCBS waiver services, send the original to the following individuals:  \no MCO Care Coordinator (for individuals in a CCC Plus MCO or other managed Medicaid plans)  \no DMAS Case Manager (for FFS individuals with CCC Plus Waiver Tech Assisted services), DMAS, Division of Aging and Disability Services,  \n600 E. Broad St., Richmond, VA 23219  \no Service Facilitator (for FFS individuals in the CCC Plus Waiver with consumer-directed services),  \no Personal Care Provider (for FFS patients with CCC Plus Waiver personal care services and other services  \no Case Manager at the Co","cbCaicsXvLA4Sr5m","https://ap.wps.com/l/cbCaicsXvLA4Sr5m","pdf",742562,"English","# Purpose of Form\n# Use of Form\n# Number of Copies\n# Distribution of Copies\n# Instructions for Preparation of the Form","[{\"question\":\"What individuals is the DMAS-225 form for?\",\"answer\":\"DMAS-225 is for individuals approved for or receiving LTSS, including nursing facility (NF) care, HCBS (waiver services or PACE), or hospice services.\"},{\"question\":\"What information must be communicated using the form?\",\"answer\":\"It exchanges Medicaid eligibility status, level of care changes, admissions and discharges (or death), and other provider-known information that may affect eligibility status or patient pay amounts.\"},{\"question\":\"Who initiates the form and when must a new form be prepared?\",\"answer\":\"The local Department of Social Services (LDSS), MCO (for managed care individuals), or the provider initiates it. The LDSS must prepare a new form whenever a change in the individual’s circumstances results in a change in eligibility status or information needs for the MCO or provider.\"}]","Medicaid LTSS Communication Form DMAS-225 | PDF",1789840727]