Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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6/12/23  3:41 pm
Commenter: Rachel Evans

Comments on the Entire Draft Manual

Italicized comments are quotations and the manual page number being referenced is in bold.

Page 1: Certified Brain Injury Specialist (CBIS) means a certification through The Academy of Certified Brain Injury Specialists that includes 500 hours of direct work with patients, giving staff ample experience in the core disciplines of behavior, speech, cognitive challenges, physical therapy, & community reintegration. Certification is valid for three years, requiring staff to renew their status & stay current with treatment issues & protocols in the process. For more information go see nto,for%20individuals%20with%20brain%20injury.

CBIS certification is valid for ONE year. The included link is to “” but that is just a blurb about the C.B.I.S. certification; Neuroskills does not provide or administer the credential. The correct link is to the Academy of Certified Brain Injury Specialists (ACBIS), which goes through the Brain Injury Association of America: . Also, all of the other defined terms are in quotation marks; “Certified Brain Injury Specialist (CBIS)” should be also as this is the Definitions section.

Page 3: “Home & Community Based Services (HCBS)” or "waiver services" means the range of community services approved by CMS pursuant to § 1915(c) of the Social Security Act to be offered to persons as an alternative to institutionalization. They provide opportunities for Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted populations groups, such as people with intellectual or developmental disabilities, physical disabilities, &/or mental illnesses.

This appears to answer the question of whether it matters which waiver an organization is providing services under, as it says HCBS Services is the full range of Medicaid community services regardless of targeted population groups. This seems to exclude all CSBs (& any other providers who provide services under any CMS waiver) from TCM provision.

Page 4: “Plan of Care (POC)” means a comprehensive, person-centered plan that sets out the supports & actions to be taken during the year by each provider, as detailed in each provider's plan for supports to achieve desired outcomes & goals.

“Plan of Care” is an institutional & medicalized term for an Individual Support Plan (ISP) that is outdated & inappropriate here.

Page 4: “Qualified Brain Injury Support Provider (QBISP)” means certification in a training program through the ©Neurobehavioral Training Institute that promotes practical education for direct care staff that is supported by daily supervision to enhance care for persons with behavioral challenges. Training information can be found here:

As the DMAS definition clearly states, the QBISP is a certification intended for Direct Care staff supported by daily supervision. The provided link also clearly states this: The mission of the QBISP program is to improve the lives of persons with neurobehavioral challenges by providing direct care staff with practical skills, & by training supervisors to use a model for daily mentorship that reinforces these skills. THIS IS A DIRECT CARE LEVEL CERTIFICATION, intended to be used UNDER DAILY SUPERVISION, & it is not appropriate for a specialized ABI case manager & not equivalent to the far more rigorous CBIS certification.

Page 5: CARF requirement for providers – no ‘grace period’ is included in the manual (DMAS had indicated there might be a ‘grace period’ of time to allow new providers to obtain CARF accreditation). This did not make it into the Manual.

Pages 5 – 6: 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 & qualified entity to provide case management &/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.

This directly contradicts the information DMAS provided at the May 2, 2023, Steering Committee meeting. It is critically important that DMAS have one clear consistent written standard addressing & informed by the CMS rules regarding conflict of interest in case management/support coordination. How the requirements are implemented will have a significant impact on many potential & current provider entities & it is inappropriate to provide inconsistent &/or contradictory guidance.

Page 6: States that BI Case Managers must have knowledge of “Treatment modalities & intervention techniques, such as positive behavior supports, person-centered practices, independent living skills training, community inclusion/employment skills, supportive guidance, family education, crisis intervention, discharge planning, & support coordination.” Page 7 states BI CMs must have skills in “Identifying services within the established service system to meet the individual’s person-centered needs & preferences.”

The above references in the BI CM required qualifications section appear along with many other required qualifications but they are the only mention of person-centeredness qualifications/skills on the list. Considering the unique & often challenging nature of the brain injury survivor population & the fact that a person-centered plan of care is CENTRAL to the activities of the CM, there should be a stronger requirement that BI CMs complete person-centered thinking/planning/practices training at least annually (including prior to delivering services to this population). Current state-contracted providers of brain injury services are contractually required to demonstrate that this training takes place for all staff annually; providers of HCBS supports should have at least the same requirement. A person-centered focus is neither automatic nor guaranteed in a CM; training is required to ensure that “person-centeredness” does not become a box that is checked off or meaningless language that is not reflected in individual’s lives.

Page 6: BIS case managers must either hold at least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling OR be licensed by the Commonwealth as a registered nurse. BIS case managers must be certified as a Qualified Brain Injury Services Provider (QBISP) or a Certified Brian Injury Specialist (CBIS) prior to independently delivering billable BIS case management services.

There are 2 concerns here. #1: the degree requirement language feels arbitrary & limiting & will lead to established ABI case managers not qualifying to be TCM providers despite their experience because their degree is not in one of the 7 listed areas. The ID/DD waiver uses language like this: completion of at least a bachelor's degree in a human services field, including, but not limited to sociology, social work, special education, rehabilitation counseling, or psychology & that would be more inclusive & appropriate ("including but not limited to" is important language). We have a CM with dual degrees in neuroscience & in psychology but if he only had neuroscience he’d be ineligible for TCM & that makes zero sense. A solution might be to grandfather in existing CMs with noncompliant degree fields &/or to allow the substitution of experience hours plus a non listed degree area.

#2: The QBISP certification is NOT equivalent to ACBIS certification & should not be presented as if it is. Per the DMAS definition on Page 4 & per the QBISP information at the link provided, the QBISP is a DIRECT CARE level certification intended for people working UNDER SUPERVISION. The case manager in TCM is not a direct care level position, it is the individual responsible for support coordination & survivors of ABI deserve fully qualified professionals overseeing their support plans, not people who have completed a 2 day direct care level certification class in house. Equating the CBIS (with a rigorous exam & contact hour requirement) with the QBISP is a false equivalency that will do a disservice to survivors. If DMAS wants an “easier” & quicker training requirement like the QBISP because the CBIS is too rigorous then the QBISPs should have to be under the supervision of a CBIS. The QBISP intends for supervision to be in place; it is not a higher level professional certification. ABI survivors are a unique & challenging group & they deserve & require truly qualified specialized brain injury oversight (as is the case with other specialized populations such as mental health).

Page 9: “Additionally, the case manager must complete the Mayo-Portland Adaptive Index-4 screening to determine whether the member meets the required severity threshold for BIS case management service.

The Manual doesn’t specify whose perspective is to be used in completing the MPAI-4, which is designed to accommodate 4 different perspectives (one per assessment: single professional, professional consensus, person with brain injury, or significant other).
Having the CM who will be getting paid for service delivery also complete the assessment determining eligibility opens the door to a significant conflict of interest – an unethical provider could manipulate responses to get the required T-score.

Page 10: Under Covered Services it states, “Linking individuals to needed services such as through a waiver, other State Plan services, as well as medical, social, educational & other direct service activities; & coordinating & monitoring those services. • Identifying a course of action to respond to the assessed needs of the eligible individual. Referral & related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services, including activities that link the person with medical, social, educational providers, or other programs & services that are capable of addressing identified needs & achieving goals specified in the plan of care.

It is not clear in the description that, with survivors of brain injury, the scope of services provided may need to include more than “scheduling appointments” or linking people to other providers. “Referral & related activities” must include accompanying individuals to medical & other services as an option when needed. There is further language in the Manual such as “Assist the individual with locating, identifying, obtaining, or scheduling needed services & resources. Aid the individual in accessing appointments & community resources, such as enabling their access to care & receipt of services. This may include finding & locating provider & service resources, including the use of MCO supports; help with completing appointments; & coordination with other service providers to ensure appropriate supports are in place.” & “Assist the individual to participate in appointments & community resources to ensure access to care & successful facilitation of service delivery.” It should be clarified if this language means the CM is permitted to physically accompany individuals to access supports where necessary.

Page 11: “Notifying the MCO Care Coordinator of concerns about the status of the health & welfare of member that require attention.” & “Alerting other providers of observed concerns as needed & related to other areas of specialty when an individual’s health, safety & welfare are compromised.

Does the Manual need language addressing the identification of risks/safety concerns, communication of same to the individual, & the rights of individuals to accept the dignity of risk & choose not to address identified safety concerns after being apprised of risks & possible mitigation action? BI survivors need protection in the form of a procedure to identify non-mandatory safety needs (identified needs the member chooses not to address).

Page 12: “Case managers are responsible for identifying when a participant is residing in a provider owned or controlled service setting that does not meet the Home & Community Based Services settings requirements.

Will DMAS be doing quality reviews on this? Does the CM specifically address this in the “POC”? Will DMAS be providing a specific checklist? In our region, private provider owned group homes often violate the HCBS Settings rules without consequences (i.e., “closing” kitchens at certain times which restricts an individual’s access to food, instituting a house-wide “bedtime”, etc), even when reported to DMAS Human Rights &/or the CSB. Does this give the CM the authority to identify a setting as non-compliant &, if so, how would that be enforced?

DMAS indicated at a recent Steering Committee meeting that some Assisted Living Facilities (ALFs) could qualify as HCBS settings. The availability of waiver/HCBS supports to individuals residing in ALFs in Virginia has been the subject of much discussion. The DMAS guidance on this needs to be thorough, particularly as individual CMs will be responsible for making HCBS compliance determinations. There needs to be uniformity & universal clearly written criteria.

Page 13: “Monitoring the person-centered plan of care will be completed by the case manager in a face-to-face contact every 60 days from the date of the initial plan of care”.
“Every 60 days” might be better replaced by “within 60 days” or “at least every 60 days” (it does not have to be on the 60th day). This 60 day requirement, which also appears on page 10, is contradicted by a 90 day requirement on page 168. Documentation must demonstrate that the case manager provides active case management monthly & a face-to-face contact with the individual occurs at least once every 90 calendar days.”

Page 13: “Person Centered Planning Requirements

The section is called Person Centered Planning Requirements but it doesn’t directly address person-centeredness, other than to use the phrase. Making reference to person-centeredness/using the term does not actually equate to person-centeredness. Given the absence of any specific person-centered practices training requirement, it is critically important that person-centered planning requirements be spelled out in greater detail. Just calling it a person-centered plan does not make it one & it needs to be clear to any provider using the Manual what is entailed. What makes the plan person-centered beyond the title? If this is not included or documented BI CM will suffer from the same lack of genuine person-centeredness that permeates many supports under other waivers. This is not a population where paying lip service to person-centered thinking will suffice; all supports must be genuinely person-centered & it should be a requirement that the person-centered planning aspect be clearly both required & documented.

Page 17: “9. The case manager must revise the plan of care whenever the amount, type, or frequency of services rendered by the individual service provider’s change. When such a change occurs, the case manager must involve the individual or the individual’s authorized health care representative in the discussion of the need for the change.”

Is there a time frame in which the POC must be revised? Understanding that the individual or their authorized representative must be involved in the change, is the revision required within days or within weeks? Within 14 days? Within 30 days? At the next quarterly review? More specificity is required.

Other Questions/Comments:

-  Will there be a required software or will providers be able to choose their own? The current network of state-funded BI providers uses Brain Injury First (BI 1st) software. Will that be allowed or will there be a new software (& will there be an associated cost?)?

- There does not appear to be any sort of grievance or complaint procedure for survivors of BI who believe their rights, choices or needs are not being respected or any requirement that persons served be aware of & educated on their human rights & what to do if they feel they are violated. This should exist & the information should be cognitively accessible & readily available. Given that this is a new service and a newly targeted population there should be clear specific grievance/complaint/oversight processes identified.

CommentID: 217194