12VAC30-122-90. Waiting list; criteria; slot assignment; emergency access; reserve slots.

• C.1.a. – Following care for the individual   add “a primary care giver who is 70 years of age or greater”. While we recognize that the age criterion was removed during the “redesign,” we feel that the impact has been significant on older families. It also limits the family’s ability to assist their adult children to make life decisions before it is an emergency.
• C.1.a- Following there are no strike “other” 
• C.1.b.(1)- Following effectively managed strike “by the primary caregiver or unpaid provider”. Not everyone has a primary caregiver.
• C.1.b.(2)- Following managed strike “by the primary caregiver”
• C.1.d- Following IDEA services and strike “is transitioning to independent living” and add “has expressed a desire to live independently”
• E.3- Strike “A regional WSAC session will then be held for the remainder of available slots, reviewing those individuals meeting criteria for the Priority Two and then Priority Three.”  We feel strongly that all slots should be for the Priority 1 list – if the service array in the BI Waiver is not attractive to those on Priority 1 then either the slots should be re-purposed or the service array should be changed.

12VAC30-122-120. Provider requirements.

• A.4.- Change “30 calendar days” to “90 calendar days” (See comment above in Section 80)
• A.5.- Strike “medically necessary services and supplies” and add “services and supports”
• A.6.- Strike “supplies” and add “supports”
• A.10.d- Strike “Such documentation shall be written on the date of service delivery.” This is not in keeping with the definition of Progress Note in 122-20 and as referenced earlier in comments.
• A.10.d- Strike “medical” in the first sentence
• A.10.f- Add “if applicable” within the parenthetical phrase “including specific timeframe”
• A.13- Change 37.2-600 to 37.2-607
• A.14- Strike “-s of Licensing and”. Abuse and neglect are reported to the Office of Human Rights not the Office of Licensing.
• D- Strike “may” add “shall” in last sentence.  If the purpose is to improve or remove poor providers - then this should not be an option.

12VAC30-122-180. Orientation testing; professional competency requirements; advanced competency requirements.

• A.2. refers to the standardized test as “DMAS approved” while the 2016 version of the regulations refers to the test as “DBHDS” approved.  Please clarify which agency must approve the test, describe the process of approval, and include a list of approved standardized tests and resources for providers. 
• C5. The orientation is a knowledge-based assessment, while the competencies are both knowledge and action based. On many of the competencies, you are required to assess action and knowledge. Where I have found the deficiencies to be is in the action part of the competencies. Therefore, retaking the orientation test is not a valid way of training for action. Having statewide readily available online training tools for the competencies from department would be helpful. 
• D.1- The reference should to the “personnel file” not the “provider record”
• D.2- Change sentence to “Completed documentation from the online certificate shall be maintained in the Personnel File.”
• E.7- Add “only” before specific to the needs; and following specific to the needs strike “and level”
• E.8- add “only” before “specific to the needs”; strike “and service levels”. These changes clarify the intent have the advanced competencies applicable as the needs of the individual requires.

12VAC30-122-190. Individual support plan; plans for supports; reevaluation of service need.

• A.8- Add “by the support coordinator” before with a copy of the. This clarifies that the support coordinator is responsible for providing a copy of the ISP to the individual family.

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 regulation 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.