Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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6/9/23  2:35 pm
Commenter: Jodi Judge, Brain Injury Services of SWVA

Response to TCM draft

Crisis Services-

The draft states that one of the agency requirements is to "guarantee that individuals have access to emergency services on a 24-hour basis. This may be done via a phone answering service and/or coordination with other MCOs and DBHDS administered crisis services." Further clarification is needed to describe what qualifies as “guaranteeing” this requirement.  We are not crisis providers and make sure our consumers have the emergency services contact information for a variety of assistance that may be needed should a crisis occur.

Brain Injury definition-

The Code of VA defines “Brain injury" as an injury to the brain that occurs after birth that is acquired through traumatic or non-traumatic insults. Non-traumatic insults may include but are not limited to anoxia, hypoxia, aneurysm, toxic exposure, encephalopathy, surgical interventions, tumor, and stroke. "Brain injury" does not include hereditary, congenital, or degenerative brain disorders, or injuries induced by birth trauma. The current definition included in the draft is lacking and absent of qualifying injuries.

Face-to-face visit requirements-

Under the "Documentation Requirements" section- item #8 stating a 90 day face-to-face requirement contradicts what is stated as a 60-day face-to-face requirement earlier in the draft under "Covered Services" on page 10 and "Person-Centered Planning" on page 13. Please clarify.


QBIS and CBIS are not comparative to one another.  QBIS doesn’t require any experience with the brain injury population and is a training that when completed provides a certificate.  CBIS requires extensive contact (500 direct hours) with individuals with brain injury prior to being eligible to sit for the exam, provides certification, and requires that to be renewed annually (not every three years as listed in the draft).  

Another certification that is somewhere in the middle of the two should be considered.  BIAV is able to establish for all providers.

If QBIS is left as appropriate, QBIS should only be allowed as sufficient for a small period of time, such as 6 months, as new hires or existing providers, work towards something more substantial.  During this time, QBIS providers should be required to be supervised under staff that hold a CBIS certification.

Staffing requirements-

If an agency has current staff that do not hold either a degree in one of the named fields or has no degree, how will this be handled in the eyes of DMAS?  Will existing staff be grandfathered in?  

Will experience with human services or work within the brain injury population be considered in lieu of a degree?  Can the requirements be listed as such-for example- staff must hold a bachelor’s degree in a relevant human services field or have X number of years of case management/human services/brain injury field experience? My recommendation would be two years of experience in lieu of.

The language regarding degree requirements are extremely restrictive, especially in the current market.  The State of VA has changed their hiring guidelines beginning 7/1/2023 to not require a four-degree and look at experience as an acceptable replacement for a degree.

Additionally, the named specific degrees are quite limited.  Including language that is sufficient for ID/DD service provision might be considered.  Language such as “including but not limited to” the following degrees (insert what is already in the manual).  

Conflict of Interest-

Please clarify what is considered "conflict of interest" (COI) in providing services.  In the draft it states the following:

"Pursuant to 42 CFR 441.301(c)(1)(vi), providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the person-centered plan of care, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered plan of cares in a geographic area also provides HCBS.  In order to meet this requirement an individual that provides case management services must not be employed (directly, or as a contractor) by an entity that provides other HCBS services.  Furthermore, an individual or entity that provides case management/support coordination services must not have an interest (as defined in 42 CFR 411.354) in a provider of other HCBS services."  

Throughout the development of these services the stance has been that an agency can't provide TCM services and waiver services.  In our most recent meeting with DMAS what was communicated was that an agency could provide both TCM and waiver services however they couldn't be the provider of both to the same individual.  

These are two very different stances which affect services among existing providers and providers that would seek to provide services.  Clarification is needed, as well as uniform enforcement across ALL agencies providing TCM services.


Consideration to changing "Plan of Care" (POC) to Individualized Service Plan (ISP).  This term is considered more person-centered even in it's wording and is the terminology that is used by CARF, which is also an accreditation requirement listed in this draft.

Neuropsychological Evaluation-

This instrumental evaluation needs to be included in the acceptable documentation of BI , as well as, a covered service to establish documentation.

CommentID: 217163