Form DMAS 97 A/B at a glance
What it is: The DMAS 97 A/B is the Agency or Consumer Direction Provider Plan of Care.
Who signs: The participant's signature is required on all plans of care.
Common mistake: Any time the RN Supervisor or Services Facilitator (SF) changes the plan of care that results in a change in the total number of weekly hours, the RN or SF must complete a new form.
What to bring and attach to Form DMAS 97 A/B
If supervision is requested, attach the Request for Supervision form (DMAS-100).
A filled-in Form DMAS 97 A/B example: an agency-directed plan for a new admission
How to fill out Form DMAS 97 A/B, box by box
Agency-Directed or Consumer-Directed Services, Participant and Provider
Mark the box that applies, Agency-Directed Services or Consumer-Directed Services, and enter the Current DMAS-99 Date.
Enter the Participant, Medicaid ID#, Provider and Provider ID#.
Categories/Tasks for each day
Personal Care: Place the total time for each task, for each day. Write the amount of time for each task to the nearest 15 minutes.
Respite Care: Place a check mark for each task.
ADL's tasks, each with a time for Monday, Tuesday, Wednesday, Thursday, Friday, Saturday and Sunday: Bathing, Dressing, Toileting, Transfer Assist, Eating Assist, Ambulate, Turn/Change Position and Grooming.
Special Maintenance tasks: Vital Signs, Supervise Meds, *Range of Motion, *Wound Care and *Bowel/Bladder Program; *MD order required.
IADLS: Meal Preparation, Clean Kitchen, Make/Change Beds, Clean Areas Used by Participant, Shop/List Supplies, Laundry, Money Management (CD only), Medical Appointments and Work/School/Social.
The form has Total ADL Time, Total Maint. Time, Total IADLS Time and TOTAL DAILY TIME for each day.
Level of Care (LOC)
Under Level of Care Determination for Weekly Hours, enter a score for each activity of daily living (ADL) based on the participant's current functioning.
Sum each ADL rating and enter the composite score under the appropriate category: A, B, or C.
The boxes are A (Score 0 - 6), B (Score 7 - 12) and C (Score 9 + wounds, tube feedings, etc.).
The form prints ~25 Hours/Week, ~30 Hours/Week and ~35 Hours/Week.
This Section Must Be Completed in its Entirety for Agency & Consumer-Directed Services.
The LOC score is not required for respite plans of care.
Common mistake: Service Authorization (SA) must be obtained prior to initiating a change outside the authorized LOC category.
The LOC score is a framework for the number of hours and is not a hard cap or guarantee.
All hours requested must be supported by the participant's person-centered needs and assessment.
Participant and Provider on the second page
On the second page, enter the Participant, Medicaid ID#, Provider and Provider ID#.
Service Plan of Care
Common mistake: Under Service Plan of Care, select only one per 97A/B: Personal Care/Assistance, LRI Personal Care/Assistance or Respite.
Reason Plan of Care Submitted
Under Reason Plan of Care Submitted, check the box for New Admission, ↑ In Hours, ↓ In Hours or Transfer.
Reason for change and additional instructions for the aide/attendant
Under Reason for change and additional instructions for the aide/attendant, write the reason for change and any additional instructions.
Required Backup Plan
Under Required Backup Plan, describe the plan details and how it is carried out, the person's name, and phone # for Services.
Plan of Care Effective Date and Total Weekly Hours
Enter the Plan of Care Effective Date and the Total Weekly Hours.
For LRI Plans of Care: substituted judgment
For LRI Plans of Care: The State must assure the Centers for Medicare and Medicaid Services (CMS) that when a legally responsible individual has decision-making authority over the selection of waiver service providers that substituted judgment on behalf of the participant has been adequately applied.
As the Nurse Supervisor/Services Facilitator, explain the process in which substituted judgment was used, the extent of the involvement of the participant, and how this arrangement was reached.
Include if the individual indicated any preferences and how.
Use additional sheets as necessary.
Signatures
Participant / Primary Caregiver: sign the Signature line, enter the Date, and write the Printed Name.
RN, LPN or SF: sign the Signature line, enter the Date, and write the Printed Name.
The LRI aide/attendant may sign on behalf of the participant.
More rules for Form DMAS 97 A/B
The participant should get a copy of both the front and back of the form.
The instructions for the DMAS-97A/B Category/Tasks are on page 3 of DMAS 97A/B Revised 8/2026.
SA approval and LRI situations
Changes that require SA approval
If the changes to the Plan of Care require SA approval, the entire and the DMAS-98 must be completed and forwarded to the SA contractor for approval.
Once received by the SA contractor, the SA analyst will review the care plan and indicate whether the request is pended, approved, or denied.
The participant will receive by mail the decision letter from the SA Contractor.
The plan is an LRI Plan of Care
Legally responsible individuals (LRI) are defined as parents or legal guardians of minors (under the age of 18) or the participant's spouse.
The Centers for Medicare and Medicaid Services requires that any personal care/assistance provided by a LRI is extraordinary care.
Extraordinary care is care that exceeds the ordinary care that would be provided to a person without a disability or chronic illness of the same age and is not a natural or normal responsibility of the LRI.
Only Activities of Daily Living are reimbursable to a LRI when extraordinary care is met.
Instrumental Activities of Daily Living and general supervision are not considered extraordinary care.
For Supervision Time and IADLS, the form prints LRI NOT ELIGIBLE.
Reimbursement may be made to LRIs for up to 40 hours per week.
When the LRI is reimbursed for providing assistance to multiple children, they may be reimbursed for up to 40 hours per week for each child.
To assist in completing the Plan of Care when there is a LRI, use Chapter IV and the Extraordinary Care Guide (Appendix E) of the CCC Plus Waiver Manual.
Tasks identified as “not extraordinary” on the guide may be approved if there is sufficient documentation that details how the task is extraordinary in care.
Attach additional sheets as necessary for all tasks.
The participant needs more than an LRI may provide
If the participant is assessed to need, or has requested, more hours or additional tasks than a LRI is permitted to provide, a second DMAS-97A/B for the non-LRI aide/attendant is required to be completed documenting the separate tasks, assessed time, and expected shift start and end times along with the LRI-specific DMAS-97A/B.
Both Plans of Care must be submitted to the service authorization entity as one request.
The participant has an LRI providing personal care/assistance
If the participant has an LRI providing personal care/assistance, respite is an incompatible service.
Where to get help with Form DMAS 97 A/B
Refer to Chapter IV of the CCC Plus Waiver Manual regarding plans of care.
Sources
[1] DMAS 97A/B (Revised 8/2026), Agency or Consumer Direction Provider Plan of Care, Virginia Department of Medical Assistance Services (the Official source link on this page).