Preamble

Community Engagement and Community Guide are swapped – FYI only

General Comments

Benefits Planning, Community Guide, Non-medical Transportation, Peer Support are not included; we recognize that including them at this stage is a substantive change, however, to continue on without regulatory authority is unacceptable

20 – Definitions

• Assistive Technology- add following environment “, actively participate in other waiver services which are part of their plan.”; delete “in which they live”
• Community Coaching – add following participating “or to support an individual  when there is an ongoing barrier to participation . . .”    [This is a issue of access to the Community Engagement service; individuals with chronic medical, sensory or mobility issues, challenging behavioral issues or a condition which is progressively more debilitating will be barred from Community Engagement as 1:1 staff exceeds the parameters of the service.]
• Community engagement – delete “one staff person to” or change the last sentence to  “Community Engagement Services shall be provided in groups no larger than 3 individuals with a minimum of one staff” [This should be self evident!]
• Positive Behavior Supports – use the definition of the American Association for Positive Behavior Supports and delete the language provided [This will bring the service in line with the national standard]
• Progress Note – We support this definition as written and object to the variations contained in the Provider Requirement sections of the several service descriptions.
• QDDP – add a reference to all sections in this regulation which permit “QDDP” for the purposes of developing service plans and/or the supervision of staff to be defined in accordance with 12VAC35-105; while it is not necessary for the purposes of the definition, it will add clarity to the regulations.
• Face-to-face visit- add following support coordinator “or shared living administrative provider” [Face-to-face is the term used for the periodic meetings required in that service]
• Independent Living – Add a definition
• Service Authorizations- Strike the word “medically” [While we understand the Medicaid standard of “medical necessity” for payment, it implies that services must have a physician’s order and not be developed by the Person-Centered planning process]
• Supported living residential- delete following a service “taking place in an apartment setting”; add following operated by a DBHDS-licensed provider, “taking place in an individual’s own home” [There is no operational reason to limit the choice of the type of living arrangement]

60 – Financial eligibility standards

• B.3.a.(1) and B.3.b.(1) Delete following employed “at least 8 hours but” [Individuals who work fewer than eight hours per week are unnecessarily disadvantaged by the limitation]
• Recommend Spend-down for all Long-Term Care waiver categories.  This language is already in the CCC+ waiver.  This language should be moved to all categories.
• Recommend that Patient Pay be considered an Income Related Work Expense (IRWE). IRWEs are already considered when countable earned income is considered.  Reasoning - without waiver services, an individual would not be earning at the level they are earning. But, earning at a higher level is forcing them to incur a Patient Pay. This is a disincentive to earn wages at a higher level.
• Recommend Special Group Category Consideration – SSI/SSDI waiver recipients increasingly have retired, disabled or deceased parents and the waiver recipient’s income increases because their parent’s FICA account is opened and a portion of this account is received by the waiver recipient.   This amount (now SSDI) often puts the waiver recipient over the 300% gross income limit.  The first thing the individual does is quit work if working. These individuals should be put in a “protected category” which will disregard the amount of the new income (SSDI) that will cause them to become ineligible for waiver services. This protection is considered when looking at continued Medicaid eligibility.
• Recommend Subsidies and Special Conditions as deduction for wages earned (per SSA definitions). If the individual is not fully earning his or her wages because the work is performed under special conditions (e.g. close and continuous supervision, on the job coaching, etc), then we should deduct that part of his or her wages that are not “earned” by the individual from his/her average gross wages.  This is true whether or not the employer or someone else provides the special on-the-job conditions. Most work supports that an individual receives in order to earn income is provided under LTC (i.e. transportation, personal attendant services, job coaching, etc).  However, under current Medicaid LTC regulations, if they earn over 300% of federal benefit rate (FBR), they are penalized.  Many individuals do not have the out-of-pocket expenses that are needed to bring down countable earned income due to the LTC supports that they are receiving at no cost to them.  However, they would not be earning at the level that they are earning without the waiver provided supports.  Subsidies and Special Conditions would give value to the supports that are provided to the individual that enables them to work and earn income.

80 – Waiver approval process

• C.3.- add at the end “and other service plans as applicable.”
• C.4.- Following intiated within change “30 days” to “90 days,” [Taking into account the existing workforce recruitment timeframes, training requirements, etc. services can not realistically be initiated in only 30 days.  If there are other requirements to notify DSS within that timeframe then the 30 day requirement in line 4 will have to remain]
• C.6.c.- Following approve change “suspend” to “pend”

90 – Waiting list

• 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 families 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 repurposed or the service array should be changed!]

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]
• 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]

180 – Orientation testing

• C.1.- The reference should to the “personnel file” not the “provider record”
• 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 to have the advanced competencies applicable as the needs of the individual requires.]

190 – Individual support plan

• A.8- Add “by the support coordinator” before with a copy of the

200 – Supports Intensity Scale® requirements

• 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; the text (Appendix D-1) from the most recent Waiver Application is:

“To assess other support needs, each individual 22 years of age and older has the Supports Intensity Scale® (SIS®) completed every four years or when the individual's needs change significantly.

• A.2.a - Change “three” to “four” to stay consistent with the CL application
• A.4.- The specific scoring protocol should be in a Medicaid Memo, not in the regulations.
• D - Strike entre paragraph
• 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 support coordinator 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.”

210 – Payment for covered services

• A.4.e.- Change “individuals” to “each individual’s needs”