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Department of Medical Assistance Services
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Board of Medical Assistance Services
chapter
Waivered Services [12 VAC 30 ‑ 120]
Action Three Waivers (ID, DD, DS) Redesign
Stage Final
Comment Period Ends 3/31/2021
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3/30/21  3:14 pm
Commenter: Saundra Ward, Dominion Youth Services

Three Waivers (ID, DD, DS) Redesign Pt. 1
 

Dominion Youth Services puts forth the following COMMENTs and recommendations in reference to Three Waivers (ID, DD, DS) Redesign”

  General Comments:

Applying to all references to lengths of time: add language to indicate and clarify if it is business days or calendar days (see 12vac30-50-440, 12vac30-122-190C.2.e for examples)

 

12VAC30-122-20. Definitions

"Service authorization" means the process to approve specific services for an enrolled Medicaid individual by a DMAS service authorization designee prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS requirements for reimbursement. Service authorization does not guarantee payment for the service.

 

COMMENT:  Remove word “medically.” While DD waiver services are all Medicaid-funded services, not all services authorized or funded under the Waiver are medical in nature, e.g., ordered by a physician (e.g., employment, community engagement, etc.). Services are developed in accordance with the person-centered plan.

 

12VAC30-122-20 - Definitions

Comment: “Progress Notes” - DELETE language indicating that progress notes are signed and dated on the day the supports were provided and REINSTATE previously utilized language that indicates “progress notes are signed and dated as soon as is practicable but no longer than one week after the referenced services”. It is unrealistic and impracticable to expect that documentation shall be entered, dated and signed on the date that supports are delivered for most services.

 

 

12VAC30-122-190

Subsection: C.2.a

2. Components of annual person-centered plan review.

a. The support coordinator shall complete a reassessment annually, at a minimum, in coordination with the individual and the individual's family/caregiver, as appropriate, providers, and others as desired by the individual. The reassessment shall be signed and dated by the support coordinator and shall include an update of the level of care  [ (VIDES) ] and personal profile, risk assessment, and any other appropriate assessment information. "Risk assessment" means an assessment used to determine areas of high risk of danger to the individual or others based on the individual's serious medical or behavioral factors and shall be used to plan risk mitigating supports for the individual in the individual support plan.

COMMENT: clarify “Risk Assessment” and change the wording to the “Risk Awareness Tool (RAT)” as currently the Risk Assessment is only completed with SIS completion and not during the annual person- center plan review.

12VAC30-122-400-Group and Individual Supported Employment

Subdivision C 4:

COMMENT: This revision helps with clarity. Strike the word “service” after employment, and strike “in combination with other day service or residential service” and revise to “concurrently with other waiver services for purposes of job discovery.” The updated sentence would read as follows: “For time limited and service authorized periods (not to exceed 24 hours) individual supported employment service may be provided in combination with concurrently with day service or residential services for purposes of job discovery.” 

 

12VAC30-122-90 Waiting list; criteria; slot assignment; emergency access; reserve slots.

Subsection: E.3. 3.  The individual who has the highest need as designated by the committee shall be recommended for the available waiver slot. DBHDS shall make the final determination for slot assignment [and to the most appropriate waiver to address the assessed needs of the individual. FIS slots will be offered unless the individual demonstrates an immediate need for sponsored residential, group home residential, or support living which are only offered in the CL waiver ]

 

COMMENT: Supported living is available in the FIS waiver.

 

12VAC30-122-120 Provider Requirements

10. ] Submit reimbursement claims to DMAS for the provision of covered services and supplies for individuals in amounts not to exceed the provider's usual and customary charges to the general public and accept as payment in full the amount established by the DMAS payment methodology from the individual's authorization date for that waiver service.

COMMENTShould read services and supports.

 

12VAC30-122-200 Support Intensity Scale

Subsection 2.a.: 4 years between SIS assessments for ages 22 and over.

COMMENT: This distance of time between assessments is detrimental to assuring proper care of individuals.  Currently, requests for re-evaluation are limited and difficult to obtain approval, even when there have been changes to medical or behavioral needs.  This time frame remain 3 years. In addition, requests for reassessment (due to changes in support needs, outcome of RAT, and other life changes) be made easier and allowances be make for appeal of results when the team does not feel the level reflects need.

 

12VAC30-122-200.

Subsection B.2. Notations of exceptional medical/behavioral needs will be investigated and may or may not lead to obtaining the exceptional level of services.

 

COMMENT:  Increased transparency in the scoring of SIS assessments and how the levels are determined would be beneficial to providers, case managers, and the individual in having fully informed decision making and understanding of their services, level of need, and supports intensity.  In all other assessments and evaluations, scores are shared with the person being assessed along with determination summary.  Since adopting SIS scoring for rate setting, scoring and interpretation has changed multiple times without transparency. 

Dominion Youth Services echoes and supports VaSRPG in requesting the following:
- scoring and determination criteria be posted,

- justification of any change (especially reduction) in level or tier be sent to the individual,

- and an avenue for appeal be provided to the individual who wishes to appeal the determination, as is the right of all service recipients related to their diagnosis and treatment assessing and planning. 

 

Dominion Youth Services would like to echo recommendations and comments submitted by the Virginia Board for People with Disabilities:

 

12VAC30-122-450 Peer support service

Subsection D 2: During the comment period for the proposed regulations, this section was reserved, for this reason, comment has been taken on this service. 

 

The Board recommends allowing this service to be provided virtually. Requiring this service be “provided face-to-face” is unnecessarily limiting. During the past year, we've learned a lot about the benefits of virtual and tele-health options that people with disabilities have experienced. Allowing a virtual option would also mitigate barriers such as transportation and better support statewide availability.

 

The Board recommends broadening the qualifications for a peer mentor to include competitive integrated employment, or demonstrated leadership abilities and activities. A peer mentor could be a person who chooses to live with their family, is competitively employed and actively involved in the community with a robust social life.  Requiring a peer mentor to have "Lived independently in the community for one year" is overly restrictive.  The Board recommends modifying as follows: “Peer mentor supports shall be provided by an individual with a developmental disability who has lived independently in the community for at least one year, or has been competitively employed for at least one year, or has been in a leadership role in a community or other organization demonstrating self-advocacy and leadership skills and is or has been a recipient of services, including to publicly-funded housing, Medicaid waiver services, work incentives, and supported employment.”

 

 Dominion Youth Services echoes and supports the recommendations and comments submitted by VNPP:

12VAC30-122-390  includes  language which appears to be a substantive addition and revision since the publication of this section in the “proposed stage.”  The language restricts the number of licensed beds in a setting reimbursed for group home residential to 6 (six) or fewer.  We do not support large congregate settings, however, we are mindful that the level of support needed by individuals in any size home is dependent on many factors out of the immediate control of the provider.  Those factors include;

    • the reimbursement rates paid by Medicaid which are directly controlled by the General Assembly
    • wage or benefit mandates imposed by law or regulation that drive costs higher
    • other inflationary factors including housing costs, insurance costs or utility costs

Providers have experienced years of rate stagnation while trying to accommodate the rising costs – the only remedy  has been to increase the number of operating beds in the home  to gain some economy of scale – the only  alternative is to close the home and remove an option for community living.  Since 1990, the Code of Virginia at §15.2-2291 has supported Group Homes of 8 beds of fewer by classifying them as “single family residences.”  To impose a regulatory limit that is more restrictive is both short-sighted and unnecessary. 

The rate structure, which makes smaller homes financially more practical,  has brought down the number of people living in a home  as it was intended to do, without imposing a top limit. 

Therefore, based on the fact that imposing a restriction which limits a provider’s ability to conduct business in “final” regulations and limiting the opportunity for COMMENT by affected parties:

    • will pose a potential threat to the entities which are the subject of the regulation
    • in a substantive change from the previous version of the regulation, and
    • is likely not necessary to achieve the goal of reducing the size of Group Home Residential settings in the long term

We object to the inclusion of this provision as a substantive change not previously reviewed as part of public COMMENT, however, recognize that requesting further opportunity for COMMENT is unlikely to change the outcome.  We will strongly request modifications of the language in the Manual to mitigate the most damaging impact.

Dominion Youth Services echoes and supports recommendations and COMMENTs submitted by VaSRPG:

 

12VAC30-122-390 - Group home – 6 bed max on group homes. 

COMMENT:  VaSRPG recognizes that residential settings of 6 or fewer beds are the preference for community based services, however, we support COMMENTs posted by VNPP which acknowledges ”Providers have experienced years of rate stagnation while trying to accommodate the rising costs – the only remedy  has been to increase the number of operating beds in the home  to gain some economy of scale – the only  alternative is to close the home and remove an option for community living.  Since 1990, the Code of Virginia at §15.2-2291 has supported Group Homes of 8 beds of fewer by classifying them as ‘single family residences.’  To impose a regulatory limit that is more restrictive is both short-sighted and unnecessary.”

 

 

12VAC-30-122-370.7. Environmental Modification

COMMENT:  Environmental Modification Services need to be allowed for sponsored residential services and group homes in cases in which a person has been living in the home for a lengthy period of time without the need for such modifications and has had a significant change in medical status or mobility/accessibility.

 

12VAC-30-122-390.

Subsection D.1.e. e. A written review supported by documentation in the individuals' record will be submitted to the support coordinator at least quarterly with the plan for supports, if modified.  [ For the annual review and every time supporting documentation is updated, the supporting documentation shall be reviewed with the individual or family/caregiver, as appropriate, and such review shall be documented. ]

 

COMMENT: Clarification as to how the “review” of documentation should be documented

 

12VAC-30-122-530

Subsection: C.1. C. Service units and limits.

1. The unit of service shall be one day and billing shall not exceed 344 days per ISP year, as indicated in the plan for supports of the individuals who are authorized to receive this service.

COMMENT:  21 days is an excessive number of non-service days for the great majority of people in Residential services who do not have alternatives to paid supports.  Care providers continue to provide services during this time as well as pay for additional DSPs and relief staff, though they are unable to receive reimbursement for those non-billable days.  Additionally, assurances that a full year of funds are encapsulated in the 344 days of approved services fails to reflect the additional costs to providers brought on by many of the other regulatory changes such as loss of environmental modifications, risk management and quality improvement requirements, and competency requirements.  The determination of 21 non-billable days as a blanket requirement does not take into consideration the individualized and various life situations of those in services and is based on an assumption that people have family to visit, or are able to/want to attend camp or be away from their home for 21 days out of the year.

Re-evaluation of the 21 non-service days is requested with recommendation to include provisions allowing justification for full year service days.

 

550.B.2.i - Therapeutic Consultation - Telehealth and phone options for visits to be permanent.

COMMENT:  Thank you for this!  Telehealth has allowed us to be able to connect with those we are supporting much more frequently and effectively! Love this change.

550.C.5.a,b,and c - Initial SARs will be approved for only 180 days after which point a new SAR will need to be submitted with accompanying documentation including baseline Data.  Annual renewals will need to have an annual summary of quarterly data.

COMMENT:  Though we understand that the purpose is to assure that plans are meeting the expectation of content, resubmission of a plan for support at 180 will cause delays in continuation of services.  In multiple areas of Virginia, we are unable to receive approval for a Plan for Support on a plan renewal in less than 60 days.  If it is pended, it will be delayed longer.  In addition, initial PFSs will often take 60 to 90 days for authorization.  In these cases, we cannot start services until they are approved which is 3 months into the requested plan time and we will have only 3 months of data or information to submit.  Followed by further delays in Plan renewal authorization at the 180 day end-date.   

We request the removal of the 180 day resubmission requirement and request that the accompanying documentation be required for annual renewal.  

550.E.e.(1)and(2) - quarterlies must include graphs and charts 

COMMENT:  We request that this be modified to read that quarterlies must include summary of progress which may include charts and graphs.

PBSFs rely on team participation for data collection. Surveys within the PBSF community rate data collection as the #1 barrier to plan completion and cite that data is often not completed at all or is completed incorrectly. PBSFs often have to resort to record reviews of alternative documentation that the residential provider uses internally, direct observation during visits/telehealth, and anecdotal reports to measure progress and response to interventions.  Broadening the scope of this requirement to include a summary of progress will allow for presentation of data as it is available and will afford the PBSF opportunity to document on the quarterly the barriers with obtaining proper data so the team can measure progress with team participation.  In addition, it will avoid delay of services to the individual due to pending of authorization by PA when the charts and graphs do not look a particular way.

In addition, VaSRPG would like to advocate that LPCs and LCSWs who are endorsed to provide Positive Behavioral Supports are able to bill at the highest rate along with “Therapist and BCBAs” as follows: 

97139 Therapeutic Consultation, Therapists/Behavior Analysts/Rehab. Engineers

LPCs and LCSWs who provide Therapeutic Consultation for behavior supports are restricted to billing under 97530 as "other professionals" because we are not considered as qualified to provide Therapeutic Behavioral Consultation as a BA. 

Licensed Professional Counselors are Master’s level licensed professionals, completing 4000 supervised clinical hours with 200 direct supervision hours under an LPC.  Likewise, LCSWs are Master’s level licensed professionals, completing 3000 supervised clinical hours with 100 direct supervision hours under an LCSW. In addition to clinical experience, LPC or LCSW with endorsement as a PBSF holds specialized training in evidenced based behavioral support.

Our state struggles to provide quality mental health support to individuals with Developmental Disabilities that also have comorbid conditions related to mental health. In addition to being able to provide interventions for behavioral needs and address behavioral emergencies, PBSFs who are LPCs and LCSWs are uniquely able to integrate resources and strategies related to diagnosed mental health disorders which are contributing to the behavioral needs of the individual as well as evidence based behavioral strategies for behavioral support. 

LPCs and LCSWs holding endorsement as a PBSF offer a specialized level of professional qualification to meet highly complex behavioral and mental health comorbid needs and should be able to bill accordingly.

Overall Comments

SUBSTANTIVE CHANGE - not authorized by Virginia Statute
Supported Employment - Required Staff competency Training & Monitoring -
DBHDS and DMAS have no authority to require Supported Employment providers to adhere to proposed staff competency requirements if SE providers are DARS vendors of SE services and are CARF accredited. This is protected by statute originally adopted by the General Assembly and signed by the Governor under Chapter 854, Acts of the Assembly 2019. We have included language deletion in Section 122-180 (Orientation Testing, Professional Competency et.al) and language amendment inserting this exception in Section 122-400 - Group and Individual Supported Employment.   

One Plan of Supports per Individual to Streamline Quarterly Reviews: DMAS and DBHDS should create the option for a single organization to have one Plan for Supports per individual regardless of the number of individual services are provided to an individuals in order to streamline documentation and to reduce the number of quarterly reviews per individual required. This was a unanimous recommendation of the DBHDS’s own Provider Issues Resolution Workgroup (PIRW) in its report published August 2018. This recommendation has also been proposed and documented in many workgroup recommendations and previous Town Hall public comment opportunities.

CommentID: 97558