200.2.A - This will move the SIS to being completed "At least every four years for those individuals who are 22 years of age and older"
Comment: Our agency typically works with more complex needs and has seen [historically] that as status changes occur, reassessments are not easily obtained and when [if] they are, Level/Tier changes are not approved. The prior three-year period proved to be difficult to provide supports financially; a 4-year period would be even more challenging. 200.2D could potentially remedy this (see below).
200.2.D - Reassessment can be requested "For a, b, and c of this subdivision A 2, when the individual's support needs have been deemed to have changed significantly for a sustained period of at least six months."
Comment: This should allow for immediate change/reassessment for diagnosed life-long conditions or newly identified exceptional support needs. Supporting documentation from an approved source (i.e., PCP, Psych., QMHP, etc...) should suffice in proving the need for immediate reassessment.
200.3.C - "The results of the SIS®, Virginia Supplemental Questions, and, as needed, a document review verification process shall determine the individual's required level of supports. The results of the SIS®, other assessment information, and the person-centered planning process shall establish the basis for the individual support plan."
Comment: An appeals process should be defined when an individual/guardian and/or support partner disagree with the findings of the assessment. The process should identify all steps affiliated with an appeal as well as with specified timelines. This should be covered under 122-200, not just as a broad appeal in 122-220, which provides little guidance or directive.
12VAC30-122-210 Payments for covered services (tiers)
210.4.E: Customized Rates reviewed at least annually.
Comment: Most of the justification for CR approvals comes directly from the exceptional medical or behavioral supports identified in the SIS. If 4-year SIS assessments are [likely] being implemented, the approval period for a CR should also be reconsidered to be extended. For example, if an individual has a life-long medical exceptional support need identified, the CR approval could be longer than the standard approval period that requires resubmission of documentation to verify the need.
12VAC30-122-390 Group home residential service
390.A - "The number of licensed beds in a setting reimbursed for group home residential services shall not exceed six."
Comment: While GN does not offer congregate supports in homes larger than 6, there are many factors that attribute to providers needing to do so. Furthermore, restricting this would impede the individual's choice - especially considering that if "a group home larger than six licensed beds changes ownership, the group home will be considered a new setting and the licensed bed capacity limit of six beds shall apply for Medicaid reimbursement purposes." This would force individuals to find alternate placement and disrupt the quality of care received from a stable, familiar setting/provider.