Scenario Question:  Say an individual qualifies for the CCC+ services and thus the proposed HNS Benefits because of complex medical needs and high risk of becoming homeless.  Suppose that this same individual also qualifies for the DD Waiver (DDW) due to their diagnosis of DD and Autism.  Their Support Coordinator and a MCO help the individual get HNS Benefits through CCC+, but the individual expresses their desire for the DDW.  So the Support Coordinator makes sure that the individual remains on the DDW Waitlist until funds for a slot can be procured.  Will receiving CCC+ Waiver HNS Benefits while still on the DDW Waitlist prolong their wait time? If so, that's unethical.  An individual on the DDW waitlist and desperately needing HNS benefits should not have to wait longer. What will DMAS do to ensure that the individual's DDW waitlist prioritization is changed to a higher level (Priority 1 from Priority 2)?

November 12, 2020

The Honorable Karen Kimsey, Director

Department of Medical Assistance Services

Department of Health and Human Resources

RE: DMAS Seeking Public Comments on High Needs Support Benefit Delivery System Design

The Virginia Commonwealth University Health System Authority (VCU Health System) appreciates the opportunity to comment on the Department of Medical Assistance Service's (DMAS) High Needs Support Benefit Delivery System Design General Notice.

Based in Richmond, VCU Health System is the academic medical center for Virginia Commonwealth University (VCU), one of the Commonwealth of Virginia’s premier public research universities. VCU Health System’s mission is to preserve and restore health for all people in Virginia, and it is committed to leading the nation in quality, affordability, and impact as a trusted and preferred academic health system.

VCU Health System is the primary provider of services to Medicaid beneficiaries and uninsured individuals in central Virginia. It is comprised of VCU Medical Center (the region’s safety net and No. 1-ranked hospital), the Children’s Hospital of Richmond at VCU, Community Memorial Hospital in South Hill, Virginia, two nursing homes, and two physician practice plans.

VCU Health System commends DMAS’s work to implement the High Needs Supports (HSN) benefit program for high need Medicaid enrollees and for acknowledging the need to address enrollees' social determinants of health. The HSN benefit program will have an especially significant impact during economic downturns like the current recession. It will also improve enrollees’ health outcomes and promote equitable access to needed services.

Addressing the Social Determinants of Health

A growing body of research shows that the social determinants of health - the conditions in which people are born, grow, work and age - are key drivers of health outcomes (World Health Organization, 2011). There is also growing consensus that clinical care accounts for only 20 percent of the modifiable contributors (or factors) to health outcomes

for a population (National Academy of Medicine, 2017). Health behaviors, social and economic factors, and the physical environment account for the other 80 percent (Hood et al., 2016). Food insecurity, lack of stable housing, and inadequate access to transportation are just a few social determinants that influence health outcomes.

While medicine has made extraordinary advances in the past century, less attention has been paid to the social determinants of health. Although the United States spends far more than any other country on health care as a share of Gross Domestic Product (GDP), it spends only a modest amount on social needs. The result is discouraging – Americans, even those with comprehensive health insurance, suffer from alarmingly high rates of health-related social needs. According to recent data published by the Centers for Medicare and Medicaid Services, 67 percent of Medicare and Medicaid beneficiaries with high Emergency Department utilization struggle with food insecurity; 47 percent struggle to maintain stable housing; and 41 percent do not have adequate access to transportation (CMS, 2020).

Addressing the Social Determinants of Health at VCU Health System

As the primary provider of services to Medicaid beneficiaries in central Virginia, VCU Health System experiences in its daily work the importance of social determinants of health and is a leader in addressing them. VCU Health System participates in CMS's Accountable Health Communities model that tests "whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services" will improve health outcomes and reduce costs (CMS, 2017). VCU Health System also partners with many community organizations to help patients resolve their health-related social needs.

These efforts have improved health outcomes. As part of VCU Health System's health equity initiative, a pilot program was launched in one of VCU Medical Center's General Medicine inpatient units to screen inpatients for health-related social needs, provide heart-healthy food boxes upon discharge, and connect them to community resources. During the first year of this pilot, readmission rates among the intervention population dropped compared to the readmission rate for the unit as a whole. VCU Health System's partnership with Virginia Supportive Housing's New Clay House provides supportive housing and care management services for 10 VCU Health System patients with complex care needs - including five patients with sickle cell disease. Thus far, the partnership has yielded a 30 percent decrease in the cost of care for these patients at VCU Health System and a 75 percent decrease in 30-day inpatient returns over six months.

The Importance of a High Needs Support Benefit

Unfortunately, these partnerships are difficult to scale and sustain during economic downturns. Many organizations that address health-related social needs rely on local government support, nonprofit grants, and private donations, which often dry up during recessions. Some partners need to institute waiting lists or cut services to stay afloat. Others simply do not survive, creating major service gaps. The result is that there are fewer services at the same time more people need them.

The Department of Medical Assistance Service's High Needs Supports Benefit is a significant step toward alleviating these challenges. The benefit will provide a sustainable source of funding to supportive housing and employment organizations. It will help Medicaid enrollees' address their health-related social needs and ultimately improve health outcomes while reducing health care costs. VCU Health System thanks DMAS for advocating for this benefit through the Section 1115 waiver process.

HSN Benefit Program Considerations for Supportive Housing and Employment Entities

It is VCU Health System’s understanding that supportive housing and employment entities, not clinical providers, will primarily furnish the HSN benefits. To incentivize participation, VCU Health System urges DMAS to set adequate reimbursement rates for organizations furnishing supportive housing and employment benefits. It should also streamline reporting requirements to the minimum necessary to ensure program integrity. To participate in Medicaid, providers must keep detailed records, comply with HIPAA, and implement claims billing software among other costly requirements. If DMAS establishes inadequate reimbursement rates or overly burdensome administrative requirements, supportive housing and employment entities may not be able to justify the costs to participate in the program.

VCU Health System also urges DMAS to develop credentialing criteria for supportive housing and employment agencies that are not overly restrictive. This is critical because these organizations may not be able to participate in the program if the credentialing costs are too high. While VCU Health System acknowledges the importance of only credentialing qualified entities, it urges DMAS to set reasonable criteria and to do so in a transparent manner.

HSN Benefit Program Considerations for Clinical Providers

While VCU Health System expects supportive housing and employment entities will furnish the HSN benefits, clinical providers will be needed to identify Medicaid enrollees’ health-related social needs and navigate them to these entities. VCU Health System urges DMAS to consider the following questions as it implements the HSN benefit program:

1. Under the program, MCOs will be responsible for screening Medicaid enrollees for housing and employment needs. However, clinical providers regularly screen patients for health-related social needs. Will there be a process for aligning these screening tools and data collection?

2. In the table under Section XIV of DMAS’s HSN program policy paper, there is a notation that states “Identifying individuals eligible for High Needs Supports benefit through mechanisms such as claims and encounter data analysis.” However, there is no consistent mechanism for providers to identify health-related social needs. Does DMAS expect to require clinical providers to document ICD-10-CM Z Codes to identify housing and employment needs?

3. MCO care coordinators and care coordinator extenders will be responsible for identifying eligible enrollees and navigating them to supportive housing and employment entities. Will DMAS allow MCOs to subcontract with clinical providers that conduct health-related social needs screenings to capture this information at the point of care? Will there be a process for clinical providers to refer patients to supportive housing and employment entities?

4. Will Medicaid enrollees’ utilization of supportive housing and employment benefits be documented in a platform that clinical providers can access? Such access will be critical for clinical providers who focus on connecting patients with housing and employment resources as a part of their population health initiatives.

Finally, VCU Health System encourages DMAS to continue prioritizing the social determinants of health as it develops other payment and delivery policies. As mentioned above, doing so will improve beneficiaries' health outcomes and promote health equity.

Please do not hesitate to contact Karah Gunther, Executive Director of Government Relations and Health Policy, at klgunther@vcu.edu or 804-828-6879 should you have any questions.

November 10, 2020

TO:    Emily McClellan, Regulatory Manager, Division of Policy and Research, Department of Medical Assistance Services

FROM: Teri Morgan, Executive Director, Virginia Board for People with Disabilities

RE:    Public Comment on the High Needs Support Benefit Delivery System Design

The Virginia Board for Disabilities serves as Virginia's Developmental Disabilities (DD) Council. Part of federally-funded network in every state and territory of the United States, Councils work for the benefit of individuals with DD and their families to identify needs of people with disabilities and help develop policies, programs and services that will meet these needs in a manner that respects dignity and independence.

The Board has reviewed DMAS’ policy paper, High Needs Supports: Operational Design and Implementation Planning, detailing the High Needs Supports (HNS) benefit, which will provide housing and employment support services to the Commonwealth’s high-need Medicaid enrollees as part of Virginia’s Section 1115 Medicaid demonstration. As advocates for people with disabilities, the Board supports a HNS program that empowers individuals to fully participate in their communities through stable housing and integrated employment.

Based on our review of the policy paper, we seek additional clarification from DMAS in the areas described below.  Answering these questions will help provide clear guidance about the program’s proposed eligibility and implementation.

ELIGIBILITY

1. Page 3: The policy paper states individuals must be enrolled in the CCC Plus program to be eligible for the HNS benefit. However, it does not mention individuals enrolled in the CCC Plus Section 1915(c) waiver for HCBS. Are CCC Plus Waiver participants eligible to participate in this program?

2. Page 3: The HNS benefit could improve housing and employment outcomes for eligible individuals with intellectual and developmental disabilities. The policy paper states that individuals on the DD waivers waitlist are eligible for the HNS benefit; however, the impact on their waitlist status is not discussed. What will the impact of HNS program participation be on their waitlist status?

3. Page 5: In defining eligibility, the paper states that “[i]ndividuals must meet at least one health needs-based criteria, at least one housing or employment specific risk factor, and be expected to benefit from supports necessary to obtain and maintain stable housing or employment, as summarized below and further detailed in the appendix.” What factors will be considered when determining if someone is “expected to benefit?”

4. Question: One of the outcomes of HNS participation is stable, competitive employment. Is the High Needs Supports benefit compatible with the Medicaid Works program, which has flexible income requirements for employed participants? If no, why not? If yes, can more details be provided?

DISENROLLMENT

5. Question: Based on the policy paper, it is unclear if the HNS benefit is time-limited. Is there estimated amount of time an individual will be enrolled in the program? Has DMAS identified criteria for disenrollment such as securing competitive employment or achieving stable secure housing?

NETWORK ADEQUACY & COMPLIANCE STANDARDS

6. Page 8: Currently, there are areas of the state that lack provider capacity. What, if any, incentives are being considered to increase provider and network adequacy for the High Need Supports benefit?

7. Page 7: Training on the HCBS Setting Rule was referenced on page 7 of the policy paper. Can DMAS confirm that housing and employment options will be in compliance with the HCBS Setting Rule requirements?

ASSESSMENT AND REASSESSMENT

8. Pages 10-12: The policy paper references Person-Centered planning activities. The Board has concerns about quality assurance regarding the development and delivery of these plan. Will there be a standardized template for the person-centered care plan? Will care coordinators be required to complete training on person-centered practices and person-centered care planning? How will care coordinators track implementation, adequacy and progress? Will providers be required to report to care coordinators on a monthly and/or quarterly basis? Clarifying these questions will ensure the planning process is truly and consistently person-centered.

COVERAGE POLICIES

9. Page 11: On page 11, the paper states “MCOs will be required to provide services at least in equal amount, duration, and scope as available under Medicaid FFS, and any service limits will be placed in a manner that is no more restrictive than FFS.” It’s unclear if this statement is referring to the HNS services specifically or broader Medicaid service options.   A clear explanation of the coverage policy with examples would be helpful.

QUALITY IMPROVEMENT

10.  Page 13: The Board recommends DMAS identify measures that reflect the quality of services provided. To evaluate these measures, DMAS could implement an annual survey of service recipients on, for example, satisfaction, positive outcomes, and barriers addressed.  Currently, the measures provided focus more on processes than quality and impact.

The Board appreciates the opportunity to comment on the HNS program, which will help Virginians secure stable housing and integrated employment. In addition to the comments above, we echo and support the comments of our colleagues at the disability Law Center of Virginia.

Please do not hesitate to contact Clare Huerta, Deputy Director of Policy and Legislative Affairs, at clare.huerta@vbpd.virginia.gov if you have additional questions. Thank you for the opportunity to provide input.

Public Comment on High Needs Support Benefit Delivery System Design

From:  Karen Tefelski, Executive Director, Virginia Association of Community Rehabilitation Programs Dba vaACCSES

We have reviewed the Operational Design and Implementation Planning paper and have the following preliminary comments.  We look forward to working with DMAS as they move forward with designing this program.

Further clarification needed:

• Is the program time limited? 
• What is the process in determining which individuals receive slots?
• Specific eligibility for the program is not clear.  Does it include DD Waiver participants in CCC+?
• States that individuals on the DD Waiver waitlist are eligible for the HNS program.  What impact will that have on the individual’s waitlist status (i.e. Priority1 status)?
• What is meant by “expected to benefit from supports” eligibility criteria?
• Interaction with DARS and an ESO and the program referral process, service process and follow along process and funding need to be further clarified.  How do ESOs get referrals?  How do individuals have true “choice” for employment and/or housing providers?

Additional Service Needs to be Added:

• Benefits Assistance and Work Incentives Counseling Services need to be added if employment services are provided under this program.  Historically, individuals are afraid to work for fear of losing medical and housing benefits.  Counseling on both federal and state work incentives as well as the impact of work on SSA benefits and housing benefits is critical.  Benefits planning queries (BPQY) need to be obtained from SSA to verify benefits and work history.  Individuals need to be informed regarding the impact of work on benefits and what work incentives are available to help them maintain employment. There is no way of knowing an individual’s entitlement continuum and work history without this information.  Social Security Administration certified Work Incentives & Planning Assistance (WIPA) Community Work Incentives Counselors (CWIC) and DARS certified Work Incentive Specialist Advocates (WISA) should be added as qualified providers of this service.  SSA CWICs hold a level 5 federal security clearance and are required to have 18 hours of specialized training each year to hold their certification.   See DD Waiver Benefits Planning and Assistance Counseling service.

Employment Provider Rates - Individual Competitive Supported Employment (ISE) rates in Virginia have been established by the General Assembly to be the ISE rates established by the Virginia Department for Aging and Rehabilitative Services (DARS).  Virginia procurement law states that an identical service provided to different state agencies must be provided at the same rate.  The paper talks about establishing rates and further states that the MCOs would be able to negotiate rates with providers.  This would not be allowable under current procurement law.

Please do not hesitate to contact me at ktefelski@vaaccses.org or 703-200-7660.  We welcome active involvement in the development of this program.  Non state agency stakeholders need to be more actively involved in the development of this program.

VaACCSES is a statewide association of quality community-based providers supporting individuals with  DD/ID, autism, mental illness, substance use disorders, physical disabilities, blind and visually impaired, deaf and hard of hearing and other disabilities.  Our members are CARF accredited and provide all types of residential services, group day services, Community Engagement, Community Coaching, In-Home Support Services, Respite, Benefits Counseling and Employment.   The association started as an organization of employment providers in the mid-1970s.  Although we represent a multitude of other providers, we are considered the primary advocacy organization representing employment providers and promoting employment policy for Virginians with disabilities in Virginia.

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