Meredith Lee, PRME Division

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, VA 23219

Re: Public Comments -  Draft Telehealth Services Provider Manual Supplement

disAbility Law Center of Virginia (dLCV) is the designated protection and advocacy (P&A) agency for the Commonwealth of Virginia. See, Va Code § 51.5-39.13. As the designated P&A, dLCV establishes annual goals with input from the public. One of our goals is to ensure people with disabilities have equal access to healthcare.

Unfortunately, people with disabilities regularly encounter accessibility barriers when seeking healthcare. These barriers include physical accessibility and effective communication issues, among other things. The use of telehealth modalities during the COVID-19 pandemic and beyond has reduced access barriers in some respects and created altogether new barriers in others.

To combat these barriers, the Departments of Justice and Health and Human Services recently released “Guidance on Nondiscrimination in Telehealth: Federal Protections to Ensure Accessibility to People with Disabilities and Limited English Proficient Persons.” This guidance can be accessed online at https://www.ada.gov/telehealth_guidance.pdf.

We ask that you take proactive steps to ensure Virginia Medicaid’s fee-for-service and managed care providers are familiar with and in compliance with this important federal guidance. This should include updating your provider manual to more explicitly reference relevant federal civil rights requirements related to assistive technology, effective communication, and reasonable modifications.

If you have questions regarding these comments, please contact Robert Gray, Director for Compliance and Quality Assurance, at robert.gray@dlcv.org or 804-662-7188.

Sincerely,

Colleen Miller

Executive Director

People with disabilities or medical, behavioral, and developmental conditions that otherwise qualify them for Home and Community Based Services (HCBS), referred to as HCBS eligible members experience disproportionate barriers to accessing healthcare and medical services across all settings, including telehealth. Telehealth is uniquely able to prevent or reduce risks of costly service utilization, institutionalization, and/or premature death. For example, people with intellectual and developmental disabilities (I/DD) are ten times as likely to expire during a COVID infection than those without IDD because they are unable to self-assess and report, and their support providers are unable to observe health indicators and early warning signs compared to their non-HCBS member counterparts.

Pg 6 of 22, Remote Patient Monitoring (RPM) eligiblity criteria excludes members without 2 or more recent hospitalizations or ER visits, which represents a disproportionate healthcare access barrier for HCBS eligible members. Their risk of institutionalization is significantly greater after even one ER visit compared to non-HCBS eligible members. Furthermore, HCBS eligible members are more likely to have cognitive conditions that interfere with their ability to effectively self-report change in status or to initiate medical attention early enough to prevent avoidable and costly negative outcomes. Please consider not only allowing, but promoting RPM for HCBS eligible members.

Pg 9 of 22, Telemedicine Originating Site fee is payable to a provider whose presence is medically necessary for the member to participate in a synchronous telehealth visit. Please consider waiving the exclusion criterion for the member's residence if the member's residence is a licensed HCBS residential facility. The exclusion of a home setting for originating site support requires the member to leave their licensed residential service setting in order to receive a telehealth service. If that were possible, they wouldn't need a telehealth service in the first place.

Pg 12 of 22, Telehealth Equipment and Technology. Without adequate funding and access to telehealth equipment and technology, HCBS eligible members will continue to experience significant administrative barriers to accessing telehealth services that can prevent or mitigate risks of ER visits, hospitalization, institutionalization, and premature death. HCBS members need specialized or adaptive equipment and technology to access telehealth, which is only allowable for adults age 21 and older if it meets criteria for durable medical equipment (DME) under the state plan or assistive technology (AT) under HCBS; and for children if it meets criteria for EPSDT. Please consider additional guidance that will allow state plan, HCBS, and EPSDT service authorization of equipment and technology necessary for medically necessary telehealth services as defined in this manual.

The Arc of Virginia appreciates the opportunity to review and comment on the Draft Telehealth Services Provider Manual Supplement. 

Due to the difficulties that people with Intellectual and other Developmental Disabilities face, the implementation of an effective and accessible Telehealth system is essential for Virginians.  

The Arc of Virginia supports the disAbility Law Center of Virginia's comments to combat the barriers that people with IDD encounter when trying to obtain healthcare.  

People with Medicaid Waivers are at very high risk of hospitalization.  Accessing telehealth has the potential of reducing health care costs and most importantly better health outcomes.  There are several areas in the draft that raise questions and additional clarification would be helpful.  They are:
Why is Remote Patient Monitoring limited to people who have at least 2 or more hospitalizations or Emergency Dept. visits?

Are people who live in licensed HCBS residential homes/facilities excluded from using telehealth if the residence is the originating site?

Will Medicaid regulations and authorization requirements allow people to access funding for technology and equipment necessary for HCBS users to access telehealth? 

Thank you for considering these comments.

Pg 9 of 22, Telemedicine Originating Site fee is payable to a provider whose presence is medically necessary for the member to participate in a synchronous telehealth visit. Please consider waiving the exclusion criterion for the member's residence if the member's residence is a licensed HCBS residential facility. The exclusion of a home setting for originating site support requires the member to leave their licensed residential service setting in order to receive a telehealth service. If that were possible, they wouldn't need a telehealth service in the first thing.