I am writing to provide comments on behalf of the Virginia Board for People with Disabilities (the Board) regarding the increase in FMAP for spending on Medicaid Home and Community Based Services (HCBS) by 10 percentage points. As you know, this funding is dedicated to expanding and strengthening Medicaid Home and Community-Based Services (HCBS). This system has been under tremendous stress during the pandemic: providers have shut down programs, workers have been laid off, people with developmental disabilities haven’t had the supports they need, and their families have been left to fill the gaps.

Based on information from the Kaiser Family Foundation, Virginia is estimated to receive $213,363,000 in enhanced FMAP. The law requires states to use the funds to "supplement, and not supplant, the level of State funds expended for home and community-based services for eligible individuals through programs in effect as of April 1, 2021." The Board proposes standalone recommendations to enhance HCBS as well as recommendations included in its Assessments of Residential, Employment and New Day Services in the DD Waivers. Both sets of recommendations promote access to integrated services, support building provider capacity, and facilitate enhanced opportunities that empower individuals and their families.

Support individuals with returning to the community. The number of people with disabilities who have been placed in nursing facilities or other institutional settings due to the pandemic is not readily known. DMAS should prioritize identify individuals who were relocated to an institutional setting during the pandemic and provide needed services and supports to ensure their return to the community setting of their choice. This includes waiving the one-time expenditure of $5,000 in Transition Service if the cost of transition back to the community is a barrier.         

Support Family Caregivers: Family caregivers have been impacted significantly during the pandemic. DMAS should consider additional supports to family caregivers by providing services that prevent burnout and address the mental and physical health needs of family caregivers and individuals receiving DD waiver services. In addition, expand access to respite and/or paid caregiving roles for family members (i.e., hiring legally responsible individuals).

Implement a Time-limited Pilot Program for Assistive Technology. The pandemic has shed light on the isolation and exclusion experienced by many people with disabilities. It has also demonstrated the resilience of people with disabilities and the benefits of connecting virtually. With the increased in FMAP, DMAS should consider developing and implementing a pilot program providing Assistive Technology (including laptops with cameras and microphones, hotspots, and other needed adaptive equipment to support access) and Training services for the purpose of social connection with natural and other supports, access to information and resources, and developing self-advocacy skills. Such a pilot project could provide evidence and information necessary to further the modernization of Virginia’s system of services and supports for individuals with developmental disabilities.

Additionally, in its Assessments of Residential, Employment and New Day Services in the DD Waivers, the Board recommends ways to increase access to integrated living, employment and day options and achieve the goals of waiver redesign. The Board is sharing select recommendations for funding consideration. The full Assessments will be shared with DMAS and posted on the Board’s website. The FMAP increase provides opportunities to incentivize new waiver services, increase provider capacity, and empower self-advocates with the DD service system.

Increase Provider Capacity to Offer New Day Services through Incentives

Assessment Recommendation 9 (Integrated Day Services): The Departments of Medical Assistance Services and Behavioral Health and Developmental Services should develop provider capacity benchmark goals based on service need estimates regionally for Workplace Assistance, Community Guide and Community Coaching and develop incentive options and other strategies to increase provider capacity to meet the benchmark goals.

 Invest in Knowledge Development to Improve Shared Living and Employment Services

Assessment Recommendation 8 (Shared Living): DBHDS should implement a pilot project with providers interested in becoming an administrative provider of shared living services. These providers should receive training and technical assistance as they move through the process of supporting individuals to transition to shared living and providing the administrative services. There should be a strong research and evaluation component to the pilot project to: 1) identify and address barriers and 2) identify needed modifications and innovations to policy and practice to ultimately increase provider capacity and service utilization. DMAS and DBHDS should directly address provider concerns about their exposure to risk and liability based on the responsibilities and expectations of the administrative Shared Living provider outlined in regulations. Incentives should be provided to participating providers to reimburse them for their time and expertise.

Assessment Recommendation 2 (Competitive Integrated Employment): The Department of Behavioral Health and Development Services should invest in training and resource development to cultivate a pool of supported employment subject matter experts who can provide technical assistance to support coordinators and others navigating the complex processes for accessing supported employment services

Invest in Individual Empowerment in the DD Services System

Recommendation A: The Department of Behavioral Health and Developmental Services should incentivize Community Service Boards, possibly through a pilot project, to incorporate self-advocates in paid positions to bring perspective and experience to the training of support coordinators, including adding a self-advocate-led module in the required support coordinator training modules. The self-advocates can provide guidance through lived experience on the education of individuals and families about services and supports and advise on the principles of person centered planning and individualized supports.

This is a critical opportunity to build the HCBS system to support families and people receiving home and community-based services. The Board looks forwarded to continuing to work with DMAS, DBHDS, and other stakeholders on the HCBS services system. Thank you for the opportunity to provide input.