Dear Ms. McClellan,

The disAbility Law Center of Virginia (dLCV) respectfully submits the following public comments regarding the DMAS proposed High Needs Support (HNS) Benefit Delivery System Design. dLCV commends the Department's efforts to enhance the service delivery system for high needs Medicaid enrollees through the development and implementation of new housing and employment support options. Below, we have highlighted a few areas in which the Department can further strengthen and enhance services for people with disabilities through this initiative.

As Virginia's federally mandated protection and advocacy agency, dLCV's comments are submitted on behalf of our broad constituency, which includes individuals with brain injuries, mental health support needs, developmental disabilities (DD), and complex medical considerations. dLCV also fully supports and echoes the comments submitted by our fellow DD network member organization, the Virginia Board for People with Disabilities.

Brain Injury Considerations:

Historically, adults with traumatic and acquired brain injuries have been underserved by Virginia's 1915(c) Medicaid waivers. As such, we applaud DMAS for explicitly including brain injury as a HNS eligibility employment risk factor. DMAS should similarly include brain injury as a HNS eligibility housing risk factor to ensure brain injury survivors have meaningful access to both service options where appropriate. The Brain Injury Association of Virginia  and the Brain Injury Services Coordination Unit within the Department of Aging and Rehabilitative Services are well versed in specialized housing and employment needs of Virginians with brain injury and should be actively included in the forthcoming stakeholder engagement efforts.

Stakeholder Involvement:

In addition to brain injury stakeholders, DMAS should take great care to ensure Medicaid enrollees with high needs have meaningful and ongoing opportunities to inform the design of the HNS benefit delivery system. Tapping into the established mental health peer recovery and support network, along with the forthcoming DD peer mentor network, will empower those most likely to utilize HNS benefits to influence the process directly.

Based on our prior experiences representing individuals with high needs, dLCV believes stakeholders who directly work with individuals in institutional settings should be meaningfully included as well. For community transition services to be successful, gatekeepers in these institutional settings (such as social workers in state operated psychiatric hospitals, case managers in psychiatric residential treatment facilities, and social services staff in nursing facilities ) will need to buy into and help facilitate the process

No Wrong Door:

DMAS has emphasized an intention to employ a "no wrong door" approach to HNS participant identification and enrollment, and dLCV fully supports such an approach in theory. Unfortunately, Virginia's disability support systems remain largely siloed and plagued with fractured information sharing networks. This issue has been amplified by DMAS's move in recent years towards an increasingly managed care landscape. Medicaid enrollees, families, providers, and advocates now must be adept at navigating six different managed care organizations with six different approaches to fulfilling their responsibilities. Role diffusion and confusion are omnipresent for many, especially for those with the most intensive support needs. As such, we urge DMAS's HNS planning and implementation staff to carefully align their efforts with best practices promulgated by the Administration for Community Living (see https://nwd.acl.gov/).

Due Process & Quality Assurance:

One approach DMAS has successfully employed to address the challenges associated with Virginia's transition to managed care has been the ongoing partnership with the Office of the State Long Term Care Ombudsman (LTCO). The LTCO's CCC Plus Advocate services are available to CCC Plus enrollees at no cost and allow individuals to receive assistance with a wide range of due process and quality assurance concerns. We strongly urge DMAS to actively plan for the expansion or replication of existing CCC Plus Advocate Services to coincide with the HNS benefit start date. Some individuals will inevitably be subjected to improper HNS service delays and/or denials and should have access to timely support from qualified advocates when seeking to resolve these issues.

dLCV strongly supports DMAS in your stated goal to provide high quality supports to Medicaid enrollees with high needs. The above comments reflect a shared commitment to that goal. We look forward to continued opportunities to contribute to the HNS benefit delivery system design.

Sincerely,

Colleen Miller

Executive Director