12VAC30-122-200.Supports Intensity Scale® requirements; Virginia Supplemental Questions; levels of support; supports packages.

A.1- Delete “to 72” and add “or older” after “years of age.” If the SIS is only validated to age 72 then language should be added to automatically assign all individuals age 72 or older to Level 5, Tier 4. Level 5 is the highest level denoting significant need in general but not specifying it to medical or behavioral. Tier 4 is mid-range denoting significant need, which is appropriate for an aging population. However, there should be a statement that these individuals shall not be excluded from consideration of an individualize rate because of medical or behavioral needs. • Recommend the addition of “Individuals who are older than 72 years of age shall be assessed using either the SIS or an alternative instrument (alternative instrument or instruments to be named in the regulations).”  

A.2.a - Change “three” to “four” to stay consistent with the CL application • A.4.- DELETE. The specific scoring protocol should be in a Medicaid Memo, not in the regulations. • D – DELETE entre section/paragraph. This is a reserved section intended to explain the establishment of supports packages as a profile of the mix and extent of services anticipated to be needed by individuals with similar levels, needs and abilities. Due to 2019 General Assembly budget language which prohibits the implementation of supports packages unless specifically authorized by the General Assembly, this section is not necessary.

 Add a new D – “Requires that the results of the SIS be provided within 10 days of scoring in an understandable format and that the service coordinated be required to explain the results and implications of the SIS score and avenues of appeal.”

 Add a new E.- “An automatic, independent review of the SIS administration process and results when an individual’s SIS Score changes despite a lack of change in their health or other circumstances, upon request.” 12VAC30-122-210. Payment for covered services (tiers). •

A.4.e. – Modify the language to “The DMAS designee shall review each individual’s needs on at least…..” An individual’s needs are being reviewed not an individual themselves.

 C.1. Recommend an increase to the $5,000 annual limit on assistive technology deemed appropriate to the cost and utility of today’s technology. The current limit is years old and has not kept up with changes in technology and/or the emphasis on expanding the use of technology to replace more cost intensive staffing services. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years, etc. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new assistive technology without raising the overall multi-year dollar limits. The limit is also included in 12VAC30-122-270 Assistive technology service.

C 1: Recommend an increase to the $5,000 annual limit for environmental modifications from the current maximum annual cap of $5,000 to a level deemed appropriate to the cost of such modifications. This limit is years old and it is increasingly difficult for families and individuals to secure modifications that will allow them to remain in their homes over their lifespan for this small amount of funding. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new environmental modifications without raising the overall multi-year dollar limits.

 C 3. Recommend an increase to the cost of electronic home-based supports from the current maximum of $5,000 per calendar year. This limit is not sufficient for up-to-date technology as well as any associated monthly monitoring fees. The purpose of these supports is to enable individuals who so desire to live more independently with less staff intrusion into their lives. The benefit should be consistent with the average cost of this type of support. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new electronic home-based supports technology without raising the overall multi-year dollar limits.

 4.b. The current application for customized Waiver rates requests data for the previous six months. If the provider has already served the individual for six months with a 1:1 ratio that is effectively supporting the individual to reduce behaviors, the provider should be allowed to submit data from the service period before 1:1 staffing began.

12VAC30-122-240. Services covered in the Building Independence Waiver. • Add Agency and CD Companion and Personal Assistance, and Individual & Caregiver Training to the BIS waiver. With the addition of these services, there may be more interest in utilizing this lower cost waiver by persons on the Priority 1 waiting list.

12VAC30-122-250. Services covered in the Community Living Waiver.

Add Family and Caregiver Training. This service is applicable to all individuals and families and should not be limited to the FIS waiver.

12VAC30-122-260 – Services covered: Family and Individual Support Waiver. Add Independent Living Services to the FIS waiver. This service can assist individuals living on their own or wishing to live on their own. 12VAC30-122-270 - Assistive technology service.

 A.(ii)- STRIKE “with the environment in which they live” and ADD a new (iii) “actively participate in other waiver services that are part of their plan.” Renumber the current item (iii) to item (iv). AT should be available to support any service in a person’s ISP. It should not be limited to the environment in which the individual lives. It should be available to support an individual in any approved service and promote inclusion in all aspects of an individual’s life.

12VAC30-122-280 - Benefits Planning Services (reserved).

 This service is now available (Medicaid Memo Sept. 4, 2018). It should be included in the final DD Waiver regulations out for public comment.

12VAC30-122-300 - Community-based crisis support service.  After means add “planned crisis prevention and emergency crisis stabilization services provided to”; strike “a service”. This brings it in line with Center-based Crisis. 12VAC30-122-310 - Community coaching service.

A- After barriers add “or to support an individual’s participation when there is an ongoing barrier to participation” See definition.

C.3- Strike “This service shall not be provided within a group setting.” This sentence is not necessary and has the potential the individual from learning how to interact and communicate with others in a community engagement setting – the entire purpose of the service. Requiring the service to be one-on-one is sufficient.

12VAC30-122-320 - Community Guide Service. (reserved);

This service is now available (Medicaid Memo Sept. 4, 2018). It should be included in the final DD Waiver regulations out for public comment.

12VAC30-122-340 - Companion service.

 C.1- Strike second sentence and limiting the service to eight hours per 24-hour day. While the occasions might be rare, this service can support those who can otherwise function reasonably independently at a modest cost – the 8 hour per day limitation can interfere with that. The waivers already allow a combination of various services to flexibly accommodate an individual’s needs. Companion services are inexpensive and there may be times when an individual requires more than eight hours of this service in a given day. The authorization should be an annual amount or hours that can be used as the individual needs them. Eight hours per day is an arbitrary cap.

 D.4.b- Replace with “Providers that are licensed by DBHDS, a supervisor meeting the requirements of 12VAC35-105 shall provide supervision of direct support professional staff.” This brings it in line with other similar services.

12VAC30 – 122-350 -

Crisis Support service. The three-levels described here are not included in the other two crisis support services – they should be consistent.

12VAC30 – 122-360 - Electronic Home-Based Support Service.

B.1.- STRIKE “physically”. The section notes that the individual must be “physically” capable of using the equipment provided via EHBS service. Some EHBS services may be voice activated and not require physical manipulation. Although voice activation could be considered “physical”, this provision could be misunderstood and, thus, misapplied by authorizers or auditors.

C.1. Recommend an increase to the cost of electronic home-based supports from the current maximum of $5,000 per calendar year. This limit is not sufficient for up-to-date technology as well as any associated monthly monitoring fees. The purpose of these supports is to enable individuals who so desire to live more independently with less staff intrusion into their lives. The benefit should be consistent with the average cost of this type of support. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new electronic home-based supports technology without raising the overall multi-year dollar limits.

12VAC20-122-370 - Environmental Modification Service.

C.2. Recommend an increase to the $5,000 annual limit for environmental modifications from the current maximum annual cap of $5,000 to a level deemed appropriate to the cost of such modifications. This limit is years old and it is increasingly difficult for families and individuals to secure modifications that will allow them to remain in their homes over their lifespan for this small amount of funding. If raising the overall limit is not feasible at this time, we recommend adopting a multi-year limit, such as $10,000 over the course of two years. This would allow greater flexibility for individuals to accommodate upfront costs of purchasing new environmental modifications without raising the overall multi-year dollar limits.

 C.6.- We recommend that an exception process be put into place for the uncommon circumstance in which the expansion of square footage to the home (which is prohibited) is an incidental result of a modification that will enable the individual to remain in the home ( e.g. a larger, accessible bathroom). Limits could be put into place for how much additional square footage would be allowable in an exceptions process.

12VAC30-122-380 - Group Day Service.

 B.1. Support the addition of the following that are included in the new CL waiver renewal application but are not currently included in the proposed final regulations: o Participation in community volunteer opportunities or education programs; o Staff coverage for transportation of the individual between service activity sites. Transportation is included as part of the service. The provider may be reimbursed for the time spent transporting the individual to community locations as part of the waiver billing o Personal types of activities (i.e. assistance with ADLs). These allowable activities are critical for individuals that need them but are not necessarily “skill building”. o Allowable activity of “providing safety supports in a variety of community settings”: This allowable activity is not included in the CL Waiver renewal application. Further, the CL renewal application includes “personal care types of activities (i.e. assistance with ADLs)” yet this allowable activity is not listed in either these proposed regulations nor in the “2016” version of regulations. These refer to activities rather than the requirement for skill-building; this phrase offers more flexibility for providers who are spending significant time in personal care than in skill-building. Consistent language should be included in these proposed regulations.

 C. Add 6. Recommend annual allocation for Group Day and Community Engagement hours to allow increased flexibility. Currently, Group Day hours and Community Engagement hours are authorized on a monthly basis with additional estimated “flex hours”. We recommend that there period of authorization be lengthened to allow more flexibility and consumer choice. For example, individuals choose whether they want to go out in the community or stay in a center on any given day. Because of weather or other personal circumstances of the individual, the individual may want to stay in the center more often in the winter and in the community more often in the Spring/Summer/Fall. Hours could then be drawn from a quarterly, semi-annual or annual “pool” of hours based on their person-centered plan.

 D.5. Supervision - There is NO reference to Licensing regulations to define “supervisor.” Licensing does not define a “supervisor” but does define a QDDP. The 2016 version of the Waiver regulations included the phrase “or a provider who has documented equivalent experience” to allow providers to substitute experience for a college degree, but this phrase is not included in either the new (2018) Licensing regulations or within the definition of QDDP in these Waiver regulations. Providers request consistency and clarity within and between regulations when defining QDDP since there are numerous QDDP responsibilities within these regulations.