| Action | Mental Retardation/Intellectual Disability Waiver Changes |
| Stage | Proposed |
| Comment Period | Ended on 12/9/2011 |
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31 comments
Completely align Individual Supported Employment (ISE) under the Waiver with ISE as it is administered by the Department of Rehabilitative Services. Specifically, Allowable Support Activities need to be aligned with those allowed by DRS including "non-face to face" documented interventions and collateral contacts including but not limited to Meetings & Set Up, Travel, Job Development, Indirect Advocay and Narratives & Reports. Note: ISE cannot be provided to the extent necessary to achieve the desired outcome for the persons served without providing all of the essential ISE functions such as those allowed by DRS. Supported Employment providers cannot provide these functions without being compensated by DMAS in the same manner in which they are compensated by DRS. Failure to make the recommended changes will result in many individuals who are eligible to receive ISE under the Waiver to be denied the services they deserve.
I am serving on the Prince William Commission on Aging and also serve as the Board President of the Independence Empowerment Center-Center for Independent Living. I am actively involved with the ADRC work both here in Virginia, and four other States I consult in with other entities.
Virginia continues to delay deleting the term Mental Retardation (or its abbreviation) and not using Intellectual & Developmental Disability as noted by two previous commentors. Developmental Disability is clearly defined in Section 102 of the Developmental Disabilities Assistance & Bill of Rights Act of 2000 (42 U.S.C 15002). That definition also is comparative to one used for Intellectual Disabilities. Additionally, the U.S. Department of Housing & Urban Development, in revising the rules under 24 CFR Parts 91, 576, 582, and 583 with relation to the 2009 HEARTH Act in order to define "Homeless", uses the terms "Developmental Disabilities" and "People with Disabilities" although the latter does not go in depth as to carryover Section 102 definition.
Continuing to use the outdated term and trying to make MR and ID interchangeable is not in accordance with current Federal Law, and does not support the Consumer Directed and Person-Centered/Patient-Centered initiatives occuring in the Commonwealth.
Stop and pause and consider: If the Arc of Virginia and the various local Arcs are no longer using their beginning name of "Assocation of Retarded Citizens" and simply using "Arc", is it not time for the Commonwealth to consider removing a term with negative connotations? I have not looked to see what impacts continued use of an outdated term would have in terms of Civil Rights, but a "label" that is outdated may be such an instance.
Overall, there is an impression that some of the information in the proposed regulations is inconsistent. There is also confusion since emergency regulations, which have already expired, are being replaced so there is a lack of clarity as to dates that changes are effective. Since some of these changes were recently legislated by the General Assembly, there is even greater confusion when date ranges span fiscal years, calendar years and the previous practice of individualized service plan years (PCP years). Since these proposals are being reviewed in December, there is a significant amount of confusion and anxiety expressed by recipients and families as to what will be effective in a few weeks, on January 1, 2012.
There is confusion regarding Assistive Technology/Environmental Modification (ATEM) and Respite regulations due to the recent legislative action by the VA General Assembly. This is further complicated by emergency regulations, which have already expired. In any case, the question being raised is whether the legislative action taken by the General Assembly to reduce ATEM and Respite Services is accurately described in the proposed regulations.
At the same time that the General Assembly (GA) voted to reduce the maximum annual allotments for ATEM and Respite, there was also a change in the definition of a year from the “PCP year” (the cycle based on the date of the annual consumer plan) to a calendar year for ATEM. It is our understanding that effective 1/1/2012, DMAS will continue a calendar year measurement. This causes confusion for service recipients and families as to how much service they may request. The GA reduced the annual amount of ATEM from $5,000 to $3,000. Since this time period spanned two fiscal years, a service recipient may have had $5,000 authorized for a six-month period and an additional $5,000 for a second six-month period. Recipients and families are now asking whether their authorization effective January 1st will be $3,000 or $5,000 for the calendar year.
Similarly, the wording for the new Respite limits proposes a limit of 240 hours in each of two six month increments which is different than 480 total hours for a year (respite running per fiscal year). Having multiple authorizations, expired emergency regulations and recent legislative action have cumulatively caused this confusion. In some cases, families may have used an amount greater than 240 hours of respite in a six-month period based on their family schedule. Similarly a family may have requested and spent more than $3,000 in a designated time frame for ATEM due to the actual cost of the item and the timing.
We request that simple examples be developed in conjunction with CSB staff and DBHDS staff to illustrate various authorization scenarios spanning these effected time periods. These examples or alternative interpretive language are critically needed ASAP since service planning for the time period beginning January 1, 2012 is now occurring.
On Page 105, there is new language regarding service initiation.
9. If services are not initiated by the provider within 30 days of receipt of enrollment confirmation from DBHDS, the case manager shall notify the local department of social services so that a re-evaluation of eligibility as a noninstitutionalized individual can be made.
This replaces the current time frame of 60 days and the current total time frame of 6 months to 5 months to get the ID Wavier initiated. If this is the correct understanding of this regulation, it is our contention that a loss of 30 days is too short for many recipients and families and may therefore restrict and inhibit their choice. They may not have sufficient time in 5 months to evaluate the options and details of service options and therefore cannot decide within that time frame since some have struggled within 6 months. The timeframe to initiate Waiver slots is in need of clarification.
On Page 103, there is new language on eligibility specific to diagnosis.
a. Individuals qualifying for MR/ID Waiver services shall have a demonstrated need for the service due to significant functional limitations in major life activities. The need for these waiver services shall arise from either (i) an individual having a diagnosed condition of MR/ID or (ii) a child younger than six years of age being at developmental risk of significant functional limitations in major life activities;
This language does not specify that the diagnosis of MR/ID must be made prior to age 18. Is there a reference anywhere that limits the diagnosis of MR/ID to individuals aged 18 or younger (with the clause for those under age 6)? The issue is that many families seek Waiver services for adults who may not have the requisite diagnostic documentation dated prior to the individual’s 18th birthday. Without clarity in the regulations, these families may infer that they may present their family member for Waiver eligibility regardless of the date of the MR/ID diagnosis.
On Page 67, the requirement for a SIS is introduced in the Summary section.
The proposed amendments (i) require the use of a statewide Supports Intensity Scale form, an assessment instrument, to comprehensively assess individuals' needs for supports and services received through the waiver every three years;
There is clarity needed as to whether the 3-year frequency mentioned also applies to children. There had been verbal comments made previously, which suggested that the frequency for administering a SIS for children should be every 2 years instead of 3. Additionally, the language describing the need for more frequent administration of the SIS is very vague and could be open to interpretation by audits and reviewers who could challenge why a SIS was not administered each time a person moves, for example, even though the move was very routine and did not have significant clinical impact on the recipient. Finally, since these are Waiver regulations, there is no discussion about the administration of the SIS for residents of Training Centers. This mention may be worthwhile, however, due to the emphasis on transitioning residents of Training Centers to community based and Waiver funded services. The issue is for planning by community providers so they understand the frequency of SIS administration of Training Center residents.
While Support Coordinators are paid a monthly fee and this would include the time involved with the SIS, other service providers are paid for time increments and therefore it is recommended that service providers who participate in the assessment process resulting in a SIS score are compensated through Waiver reimbursement.
There is a concern that VA will base future reimbursement rates or levels based on SIS “scores” or results. If this is in fact the intent of the State then this fact should be disclosed now so providers and recipients can prepare or offer testimony.
There would be a cost incurred by both CSBs and service providers to fulfill the requirements for electronic information exchange among DMAS and local Departments of Social Services. There is a history of unfunded mandates imposed by DMAS and DBHDS for which no reimbursement is available.
While the leveraging of EPSDT funding for children who are Waiver recipients is cost effective and logical proposal, the details of the process are confusing. It had previously been the practice for DBHDS staff to extract those authorizations for children eligible for EPDST funding and then divert those authorizations directly to EPSDT. That process only required the Support Coordinator to submit one authorization and allow DBHDS to direct or divert as needed. The new proposal places the responsibility on the Support Coordinator to initially decide to whom the authorization should be submitted. Text on Page 129, which discusses Skilled Nursing is the best example of how this language is presented while page 107 describes the submission process. The issue is whether the Support Coordinator is advised if an authorization is denied for EPSDT in a timely manner so he/she can resubmit to DBHDS through the Waiver process.
Is it possible to include the language on the use of EPSDT funds but retain that decision process within DBHDS and not assign it to CSBs?
On Page 65, the Opt Out of service facilitation process is described. It is our contention that the prevalence estimates presented are inaccurate. While the prevalence estimate of those opting out is presented as a few, the reality is that just within Fairfax-Falls Church, there is evidence if a larger number.
The following comments are specific to day services.
DAY SUPPORT services have been redefined and the PREVIOUS (and now repealed) definition stated:
A. Service description. Day support services shall include a variety of training, assistance, support, and specialized supervision for the acquisition, retention, or improvement of self-help, socialization, and adaptive skills. These services are typically offered in a nonresidential setting that allows peer interactions and community and social integration.
The proposed NEW regulations eliminates the words training and assistance---and substitutes “skill building, supports and safety supports”. This seems acceptable as long as the level of assistance typically provided to recipient can now be defined as supports and safety supports.
Also, community integration is now REMOVED from the definition—does this present problems for providers and recipients who benefit from community integration activities or can these be “rebranded” in service plans as skill building?
A unit block has replaced the unit. Providers have continuously requested a definition of “rounding” when increments of time are provided. The new regulations seem to be logical and easy to implement in that a unit block is ANY time from one hour through 3 hours and 59 minutes. So if a recipient receives 65 minutes of service each day for five days, the provider can bill for 5 unit blocks.
“Service providers shall be reimbursed only for the amount and level of day support services included in the individual’s approved Plan for Supports based on the setting, intensity and duration of the service to be delivered.”
This would suggest that any PREPARATION such as administering and analyzing the SIS would NOT be reimbursable BUT there we contend that there could be some room for interpretation if the Plan for Supports (which is submitted to DBHDS and approved by them) references the SIS development as a key component of the service plan.
For a number of day services (including day support, pre-vocational and supported employment, there is new language which states essentially that DMAS will over these services (in other words purchase) ONLY after determining that this service is not available from DRS for this Waiver individual. This sounds logical and in fact the current practice has been embedded in the actual Waiver application wherein DRS makes a statement then that as a co requisite to Waiver enrollment, DRS is affirming that this person would not be served by DRS because of the severity of their need and therefore are “cleared” for Waiver enrollment. The question is: will this practice continue wherein that DRS “disclaimer” is solicited at the initiation of the Waiver by the Support Coordinator OR is there now a new requirement for EACH time that a day service is being requested?
The regulations are silent on the fact that for individual supported employment, the DRS rates are accepted and are specific to each provider. On the rate schedule that DMAS publishes, this statement is made. Could this statement be in the regulations so that it is clear that for Individual SE, the Waiver reimbursement rate is specific to each provider as approved by DRS?
We contend that the Therapeutic Consultation service language revision needs to be expanded. It is still limited to just the consultation and DOES NOT include the actual therapeutic intervention recommended by the consultation. This severely impacts the services providers who implement costly behavioral or other therapeutic intervention programs without additional compensation.
The Virginia Medicaid Waiver Network offers the following public comment on proposed changes to the Intellectual Disability (ID) Waiver regulations.
General comment regarding the term mental retardation
The final regulations should refer to the waiver as the Intellectual Disability Waiver. Maintaining the inappropriate term of mental retardation is demeaning and antiquated as well as inconsistent with the Commonwealth’s commitment to the use of person-centered language.
12 VAC 30-120-1000 DEFINITIONS
In-home residential support
Recommendation
Include a definition of this service.
Rationale
The regulations include definitions of congregate residential support and residential support services. In-home residential support is a distinct service.
Residential support services
Recommendation
The definition should clarify how residential support services are different from congregate and in-home residential services. Or if this definition is intended to only be a description of congregate and in-home residential services, the definition should clearly delineate this.
Skilled nursing services
This modified definition is clear and improved over current regulations.
Transition services
Recommendation
Expand the definition to include the first sentence of 12VAC30-120-2010 and maintain the reference to that regulation. The new definition would be as follows: Transition services “means set-up expenses for individuals who are transitioning from an institution or a licensed or certified provider-operated living arrangement to a living arrangement in a private residence, which may include an adult foster home, where the person is directly responsible for his own living expenses.”
Rationale
The one sentence definition will help to clarify that these services are for individuals who are either transitioning from “an institution or licensed or a certified provider-operated living arrangement.”
12 VAC 30-120-1005 WAIVER DESCRIPTION AND LEGAL AUTHORITY
1005 D. (evaluation before the age of seven)
Recommendation
Allow a standardized developmental assessment to substitute for a psychological evaluation for children who are not yet seven years of age.
Rationale
The proposed regulation states, “Psychological evaluations confirming diagnoses must be completed less than one year prior to transferring to the IFDDS Waiver.” A few sentences further into the proposed regulation is the following statement: “The case manager shall submit the current Level of Functioning Survey, Individual Support Plan, and psychological evaluation (or standardized developmental assessment for children under six years of age) to DMAS for review.” This language indicates that DMAS will allow a standardized developmental assessment to be used in place of a psychological assessment. Accepting the standardized developmental assessment will minimize the number of evaluations the child will be required to participate. This will reduce stress for the child and family, save the Commonwealth resources, and eliminate delays in the waiver process.
1005 D. (transfer from ID Waiver to DD Waiver)
Recommendation
Include a clear timeline for DMAS to make a determination of whether an individual is appropriate for transfer to the Individual and Family Developmental Disability Support (IFDDS) Waiver and if an IFDDS Waiver slot available for the child.
Rationale
Without a timeline, individuals, their families and case management organizations are unaware of whether or not the process is proceeding in a timely manner.
1005 F. (use of the term “waiver”)
Recommendation
Clarify that an individual cannot be enrolled in or simultaneously receive services from more than one home and community based waiver program.
Rationale
Individuals can be enrolled in the Ticket to Work program and other waiver programs while they are simultaneously enrolled in a home and community based waiver. The regulation should clarify that individuals cannot be enrolled simultaneously in more than one home and community waiver program.
1005 H. (process before services initiated)
Recommendation
Clarify whether or not services can be reimbursed before approval and authorization of services has been completed.
12 VAC 30-120-1010 INDIVIDUAL ELIGIBILITY REQUIREMENTS
1010 (informed consent)
Recommendation
The regulation should include specifics regarding when and how informed consent is required before services are provided or revised. Terminology relating to consent throughout the regulations should be changed to “informed” consent.
1010 C.4. (waiting list – written notice)
The waiting list process is improved with the proposed regulatory language. Requiring written notice when someone is placed on the waiting list is important because it lets the individual and case manager know where the individual is in the process.
1010 C.4. (enrollment)
Recommendation
Establish a timeline for DBHDS to respond to a request by the case manager to enroll an individual in the ID Waiver.
1010 C.4. (annual waiting list contact)
Recommendation
The proposed regulation will require case managers to annually contact individuals on the waiting list to provide a choice between ICF/DD and the ID Waiver. This annual contact is important. We recommend that in addition to providing annual choice, the case manager should be required to assess the individual’s current needs and their placement status on the urgent or nonurgent list.
Rationale
Without current information, case managers cannot adequately determine if someone has an urgent need or the extent of an urgent need.
1010 C.4. (waiting list written notification)
Recommendation
Add a requirement that written notification be provided to the individual if their waiting list status is changed from urgent to nonurgent or nonurgent to urgent.
1010 D.3.a. (medical examination)
Recommendation
If an individual does not have Medicaid or private insurance, a medical examination should not be required until the individual is enrolled in Medicaid and adequate time is provided to schedule the exam and for the provider to write the examination report.
Rationale
Individuals should not be required to pay for requirements established by DMAS in order to receive Medicaid services. If the individual is not enrolled in Medicaid prior to waiver enrollment or if the individual’s private insurance requires a deductible that has not yet been met or a co-payment, the requirement for a medical examination should be delayed until the individual is enrolled in Medicaid.
1010 D.5. (patient pay)
Recommendation
If the designated collector of patient pay is the employer of record (EOR) for consumer-directed services, the case manager should be required to periodically monitor for changes in patient pay. If there are changes in patient pay, the case manager should notify the EOR.
Rationale
The EOR does not have access to the DMAS system and cannot monitor for changes in patient pay. The EOR depends on the case manager to inform him or her of any change to the patient pay.
1010 E.1.a. (informed consent for services)
Recommendation
Include a statement that the individual’s initial plan for services requires an agreement in writing by the individual (informed consent).
1010 E.1.c. (informed consent for services)
Recommendation
Include a statement that any modifications to the amount or type of services requires an agreement in writing by the individual (informed consent).
12 VAC 30-120-1020 COVERED SERVICES; LIMITS ON COVERED SERVICES
1020 A.4.(b) (health, safety and welfare guarantee)
Recommendation
Replace the following sentence: “The health, safety, or welfare of the waiver individual cannot be guaranteed or a back up emergency plan cannot be developed” with the following: “A back up emergency plan cannot be developed.”
Rationale
Health, safety and welfare cannot be “guaranteed” for anyone and requiring this is impractical. If this term must remain in the final regulations, this “guarantee” should be required for all services.
1020 B.2. (year for assistive technology)
Recommendation
Continue to authorize assistive technology by the plan year. Do not change the year to a calendar year.
Rationale
The proposed regulation would have individuals receiving services via three different cycles: plan year for most services, calendar year for assistive technology and environmental modifications, and state fiscal year for respite. These different year definitions will be confusing and cumbersome. Currently, requests for assistive technology and environmental modifications are spread throughout the year based on plan year dates. If these services were put on a calendar year cycle, assessors, case managers and providers will be overwhelmed during the last quarter of the year with requests for these services. Services authorizations should all be by plan year to avoid this possibility and to reduce confusion and additional cumbersome processes.
1020 B.2.a. (assistive technology limit)
Recommendation
Correct the annual limit to $5,000.
1020 C.1. (companion services)
Recommendation
Add the word routine to the last sentence in the following manner: The provision of companion services shall not entail routine hands-on care.
Rationale
Companion services should allow for unforeseen or occasional assistance with hands-on care. For example, an individual who typically would not need assistance in the bathroom, may need assistance if they develop an unforeseen illness, such as the flu. Another individual who typically does not need assistance with dressing may need assistance with a piece of clothing such as a coat if they become frustrated with the task.
1020 E. (institutionalization standard for assistive technology)
Recommendation
Remove the following language from the first sentence in the service description: “and without which the individual would require institutionalization.”
Rationale
All waiver services meet this standard – if the service is not needed, it should not be provided. All waiver services are provided to prevent institutionalization.
1020 F.2.b. (environmental modifications limit)
Recommendation
Correct the annual limit to $5,000.
1020 F.2.b. (case management required)
Recommendation
Remove “in addition to MR/ID targeted case management pursuant to 12VAC30-50-450.”
Rationale
This statement is not unique to environmental modifications. People who use ID Waiver services must also receive State Plan ID targeted case management.
1020 F.2.b. (year for environmental modifications)
Recommendation
Continue to authorize environmental modifications by the plan year. Do not change the year to a calendar year.
Rationale
The proposed regulation would have individuals receiving services via three different cycles: plan year for most services, calendar year for assistive technology and environmental modifications, and state fiscal year for respite. Currently, requests for assistive technology and environmental modifications are spread throughout the year based on plan year dates. If these services were put on a calendar year cycle, assessors, case managers and providers will be overwhelmed during the last quarter of the year with requests for these services. Services authorizations should all be by plan year to avoid this possibility and to reduce confusion and additional cumbersome processes.
1020 F.2.f. (Fair Housing Amendments Act)
Recommendation
Add “modifications required by an entity to comply with the Fair Housing Amendments Act” to the list of excluded modifications.
1020 F.4.c. (upkeep and maintenance of environmental modifications)
Recommendation
Allow the upkeep and maintenance of an item not purchased under the ID Waiver to be covered as an environmental modification service.
Rationale
It may be more cost effective and otherwise preferable to maintain an item than to purchase a new item, regardless of how the item was initially funded (payment source).
1020 G.3.b. (back-up plan for personal assistance)
Recommendation
Remove “and family/caregiver” from this item.
Rationale
The family and/or caregivers may be the ones serving as the backup.
1020 G.3.c. (personal assistance)
Recommendation
Allow personal assistance services to be provided to people who live in congregate residential settings and to people who need skill development.
Rationale
Just as companion services can be provided to someone who typically lives in a congregate setting, personal assistance services may be needed while the individual is away from the congregate residential setting.
If the individual needs significant assistance with activities of daily living or instrumental activities of daily living, they may need routine hands-on support when they are temporarily away from the congregate residential setting.
1020 J. (residential services)
Recommendation
Add language that describes the differences between congregate and in-home residential services.
1020 J. (room and board)
Recommendation
Add language explaining how room and board arrangements would include residential supports and why they would do so.
Rationale
The separation of housing from services is important to many individuals and their families who do not want to be beholden to the provider of their housing if they elect to change service providers or vice versa. It is also the policy direction that the Commonwealth has taken.
1020 J.2.b. (personal assistance)
Recommendation
Allow individuals to receive personal assistance services when they are away from the congregate facility.
1020 K.3.b. (services provided to avoid institutionalization)
Recommendation
Remove the following language from the first sentence: “in order to avoid institutionalization of the individual.”
Rationale
All waiver services meet this standard – if it is not needed, it should not be provided. All waiver services are provided to prevent institutionalization.
1020 K.4. (respite authorization in six month increments)
Recommendation
Maintain the current policy of allowing people to use respite hours when needed throughout the year. Remove the proposed language that would only allow individuals to use 240 hours of respite every six months.
Rationale
Presently, many people only use respite when needed resulting in a bank of hours that can be used, if needed, for emergencies or other unforeseen circumstances. If hours will be lost after the first six months of every State fiscal year, people will be encouraged, by this new policy, to use the hours before the end of the six months rather than bank the hours for possible later needs. If those needs do not materialize close to the end of the respite year, the hours may not be used. This would result in a cost savings to the Commonwealth which would be negated by the proposed regulation.
1020 K.5. (respite standards)
Recommendation
Remove this item.
Rationale
This subsection covers both agency and consumer-directed respite services. If the statement remains, an additional sentence should be added to clarify that agency directed respite services shall meet the same standards as consumer-directed respite.
Recommendation
Add language stipulating the responsibilities of the employer of record should the individual elect not to use services facilitation.
1020 L.6. (review of timesheets)
Recommendation
Remove the language requiring that services facilitators review timesheets.
Rationale
The timesheets may be submitted electronically and unavailable when the home visit occurs.
1020 L.11. (term “case manager”)
Recommendation
Clarify whether the term “case manager,” when used in the context of the proposed regulation, refers to the individual who is the staff person or to the CSB/BHA that provides case management.
1020 L.11. (case manager and services facilitator)
Recommendation
Allow the individual’s case manager to be the services facilitator if preferred by the individual.
Rationale
Individuals may prefer to have the case manager perform the services facilitation duties to minimize the confusion between services and to eliminate extra staff involvement in the individual’s life.
If individuals elect not to use services facilitation, the case manager will need to complete some of the tasks that would have been completed by the services facilitator.
1020 L.11. (role of case manager)
Recommendation
Describe the role of the case manager if the individual elects not to use services facilitation.
1020 L.14.c. (reference checks)
Recommendation
Modify the requirement that the employer of record check references of assistants.
Rationale
While it is generally best practice to check employment references, if the employer of record is hiring a family member or well known acquaintance, the employer may not feel it is necessary to check employment references.
1020 L.14.c. (hiring packets)
Recommendation
Add a requirement that the employer complete required hiring packets.
1020 L.14.d. (management training)
Recommendation
Clarify how management training for consumer-directed services will occur if the individual opts not to receive services facilitation.
1020 M. (home health criteria and skilled nursing)
Recommendation
Update the service description to clarify that individuals who meet home health criteria may also need ID Waiver skilled nursing services.
1020 P.2. (transition services)
Recommendation
Replace the word “funding” with “services.”
12 VAC 30-120-1040 GENERAL REQUIREMENTS FOR PARTICIPATING PROVIDERS
1040 C.6. (Fair Housing Amendments Act)
Recommendation
Add the Fair Housing Amendments Act to the list of statutes with which providers must comply.
1040 H.5.(b) (cost of services during appeal)
Recommendation
Replace the word “shall” with “may” at the end of the second sentence to read as follows:
“…the individual may be responsible for the costs of his waiver services incurred by DMAS during his appeal action.”
12 VAC 30-120-1060 PARTICIPATING STANDARDS FOR PROVISION OF SERVICES; PROVIDERS’ REQUIREMENTS
1060 B. (documentation in absence of services facilitation)
What entity will maintain the listed documentation if there is no services facilitation?
1060 B.2.(d) (identifying assistants)
Recommendation
Remove the requirement that the services facilitator maintain “identifying information for the assistant or assistants.”
Rationale
The employer of record is responsible for hiring staff and maintaining documentation. The services facilitator does not need to know who the employer is hiring. It is important to maintain clear separation of roles to reinforce the responsibilities of each entity.
1060 E.4.a., I.10.a., M.11. (objective written documentation for consumer-directed services)
Recommendation
Retain current language that makes it the responsibility of the services facilitator to document why other providers are not available if family members living under the same roof are going to provide companion services. If the individual elects not to receive services facilitation, then the individual forfeits choice and must use the case manager.
Rationale
The services facilitator could be seen as more objective since individuals have choice of providers. Individuals can choose their services facilitation provider; they cannot choose their case management organization.
1060 I.1. (clarify reference to agency directed requirements)
Recommendation
Clarify that the language in this subsection only applies to agency directed personal assistants. Insert “agency-directed” after “All.”
1060 E.3., I.8., M.8. (background checks)
Recommendation
Add the requirement for consumer-directed personal assistants to submit documentation for background checks with the State Police and Child Protective Services.
Rationale
The requirements for these background checks can be found in 12VAC30-120-1020. However, since these lists are included in subsection 1060, the lists should be complete to ensure compliance.
1060 I.8.e., M.10.b. (waiver requirement reference)
Recommendation
Provide a citation to where the reader can find the referenced “DMAS’ MR/ID Waiver requirements.”
1060 E.8.(3), I.14, M. (employee management training documentation)
Recommendation
The requirements for documentation of employee management training should be the same in each of these subsections.
1060 E.3., I.8., M.8. (consumer-directed requirements)
Recommendation
Standardize the requirements for all three consumer-directed services.
1060 K.7., P.2. (prevocational and supported employment services not available through IDEA)
Recommendation
Modify the regulatory language to reflect that the requirement is to document that the individual is not eligible for prevocational or supported employment services through IDEA.
Rationale
This should be an individual determination about eligibility for the service through IDEA. These services are available “through the IDEA.” Depending on the individual’s educational needs, the service may not be available to that particular individual. IDEA services are provided based on an individual determination. An individual may not be eligible for the services through IDEA even though the services are “available.”
1060 M.6.a. (respite period)
Recommendation
Define “respite period” used in this paragraph.
1060 Q.4. (informed consent for changes to the plan)
Recommendation
Changes to the plan should be agreed to by the individual, not just reviewed with the individual.
12 VAC 30-120-1070 PAYMENT FOR SERVICES
1070 C.1. (Fair Housing Amendments Act)
Recommendation
Add that services will not duplicate services required by the Fair Housing Amendments Act.
12 VAC 30-120-1088 WAIVER WAITING LIST
1088 B.2. (urgent category request)
Recommendation
Add a description as to how applicants are notified about the ability to request assignment to the urgent waiting list category.
1088 B.2.e. (term “children”)
Recommendation
Change “children” to “individuals.”
Comment submitted by the following organizations in collaboration as the Virginia Medicaid Waiver Network:
Autism Society, Central Virginia
Center for Family Involvement
Parent to Parent of Virginia
Peninsula Autism Society
Virginia Association of Centers for Independent Living
Virginia Board for People with Disabilities
Virginia Office for Protection and Advocacy
12VAC30-120-1005
12VAC30-120-1020
Page 115
On behalf of The Arc of Virginia, which represents people with intellectual and developmental disabilities and their families across the Commonwealth, the following comments are submitted to the Virginia Department of Medical Assistance Services regarding the proposed regulations for the Intellectual Disability Waiver Regulations.
Assistive technology is a critical support that allows individuals to live successfully in the community vs. an institution.
Environmental modifications are a critical support that allows individuals to live successfully in the community vs. an institution.
1020 F.2.b Recommendation: Authorize environmental modifications by the plan year not the calendar year.
The proposed regulations have services received on three different cycles. There is the plan year for most services, the calendar year for assistive technology and environmental modifications and the state fiscal year for respite. Having so many different year definitions is confusing and hard to manage for the recipients, family and service providers. Assistive technology and environmental modifications requests are currently based on plan year dates and occur throughout the year. If assistive technology and environmental modifications are put on a calendar year, case managers and providers will be overwhelmed at the end of the year with requests. To avoid this and to reduce confusion for all involved, services authorizations should all be by plan year.
1020 K.4 Recommendation: Maintain the current policy that allows people to use respite hours throughout year when needed is critical. Remove the proposed language that would only allow individuals to use 240 hours of respite every six months.
The current policy is person-centered and responsive to the needs of individuals and families, allowing them flexibility to plan and be prepared for emergencies depending on individual circumstances. Circumstances such as school schedules and employment demands require that respite hours be available on a calendar year so that they can be available and used to care for an individual when it is most needed. When individuals with the waiver experience illness or decline, respite is the support that often maintains the individual and family through the illness. Families who are caregivers have to deal with their own illnesses or there may be sudden death necessitating immediate respite. These are crisis situations that cannot be scheduled according to a limited amount of respite available every six months. Without this flexibility it is very likely that there will be more crisis situations resulting in increased costs and hospitalizations.
From a financial standpoint it would be to the Commonwealth’s advantage to maintain the current policy so that people will bank hours for an emergency rather than using their hours up every six months. When hours are banked and then not used entirely there is a cost savings to the Commonwealth. However as proposed, people will be encouraged to use up the hours at the end of six months and there would be less of a cost savings.
The Arc of Virginia endorses the public comments from the Virginia Medicaid Waiver Network.
Definitions:
QMRP - Question: Will current QMRPs who do not meet the new qualification be grandfathered in? Request: Provide parameters around that process.
Services Facilitator: Request: In the definition for Services Faciliator add language that ensure collaboration with the case manager.
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MR/ID shall not be offered outside of the Commonwealth:
Question: Does this preclude in the future interstate compact between DSS in different states?
30 day time frame to complete the SIS
Request: Change the language to begin to initiate the SIS within 30 days or give a longer time frame to complete the SIS such as 60 days.
DMAS -225
Request: Define “periodically” for monitoring DMAS designated system for changes. Question: Is this process consistent with every Social Services Department across the state? It is our experience that every Social Services does things differently. Request: Please inform Social Services of this request.
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Covered Services |
Involuntary disenrollment of services by the Services Facilitator |
Request: Add language that ensures that the case Manager is made aware whenever the Services Facilitator is initiating involuntary enrollment of services. |
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Covered Services |
Management Training |
Question: Who provides the management training for the EOR if there is no Services Facilitator? |
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Covered Services |
Supported Employment Support |
Question: What is the definition of intermittent? What do you mean by ongoing? Comment: Intermittent seems to limit the support you can provide for employment. More guidance is needed. |
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General Requirements |
Immediate notification to DMAS and DBHDS |
Request: Immediate notification to DMAS and DBHDS is required, further information is needed to clarify “any change”. Comment: This is extremely broad and is in need of clarification. |
Regulation Area
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Brief statement of Concern |
Comment/Suggestions/Recommendations |
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General Requirements |
Immediate notification to DMAS and DBHDS |
Request: Immediate notification to DMAS and DBHDS is required, further information is needed to clarify “any change”. Comment: This is extremely broad and is in need of clarification. |
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Case Managers responsibility for the Medicaid Long-Term Care Communication Form (DMAS-225) |
Documentation Requirements |
Request: Further clarification is needed regarding what the “date of documentation completed means” The requirement is unclear. |
I am the parent of a severely disabled 31 year-old child. My husband and I care for him in our home. I am very concerned about the proposed new regulations splitting our respite hours into 2-6 month blocks, with no carry-over. First, our available respite hours were slashed by 1/3. Then, the amount of money paid to caregivers was reduced. Now we are being further restricted by not being able to use our hours as we see fit. This seems counter to the concept of Person-Centered Planning. Families know best when respite is needed and they should be allowed to use their respite hours as seems best for them.
All of these changes are making it harder for families to find and keep reliable, quality caregivers. The Waiver is supppsed to be helping families continue to care for their loved ones in their own homes. These changes are putting up roadblocks to that goal and imposing unnecessary stresses on families who are in these situations through no fault of their own. It is not to Virginia's advantage to stress families to the point where they begin to consider alternative placements for their children. I respectfully ask that you reconsider your plan to split respite hours into 6 month blocks.
I am the parent of a severely disabled 31 year-old child. My husband and I care for him in our home. I am very concerned about the proposed new regulations splitting our respite hours into 2-6 month blocks, with no carry-over. First, our available respite hours were slashed by 1/3. Then, the amount of money paid to caregivers was reduced. Now we are being further restricted by not being able to use our hours as we see fit. This seems counter to the concept of Person-Centered Planning. Families know best when respite is needed and they should be allowed to use their respite hours as seems best for them.
All of these changes are making it harder for families to find and keep reliable, quality caregivers. The Waiver is supppsed to be helping families continue to care for their loved ones in their own homes. These changes are putting up roadblocks to that goal and imposing unnecessary stresses on families who are in these situations through no fault of their own. It is not to Virginia's advantage to stress families to the point where they begin to consider alternative placements for their children. I respectfully ask that you reconsider your plan to split respite hours into 6 month blocks.
Page 115
SE Services
N. “Intensive” is not the appropriate word to be used here. Ongoing supports may be intensive or may be periodic depending upon the individual’s circumstances and employer requirements and/or changes.
DELETE “Intensive”. CHANGE to – “These services shall consist of intensive, ongoing supports that enable individuals…….”
As the overall definition for both individual and group - it should be as flexible as possible to allow fluctuations in service needs.
Page 115
SE Services
N.2.a. “Intermittent” is not the appropriate word to be used in regards to individual supported employment. The definition for “intermittent” in Webster’s is “occurring at irregular intervals”. We don’t believe this is what should be the definition of “support”.
DELETE “Intermittent”. CHANGE to – “Individual supported employment shall be defined as intermittent support, usually provided……” We recommend “support” or “ongoing support” which provides flexibility to accommodate individualized support according to the needs of the individual on the job which can change at any time. Support can continuously change depending upon changing job requirements, site movement, employer needs as well as the individual’s circumstances. The definition of support can be further defined in the Manual.
Page 115
SE Services
N.2.a. “collateral contacts by providers”
This term/phrase needs to be further defined in the Manual. Inconsistent interpretations & TA have been provided to providers.
Page 115
N.2.b. “Eight or fewer” is problematic and rigid to some employment circumstances (i.e. grounds maintenance, building maintenance, etc.)
DELETE “eight or fewer” in the regulations.
CHANGE to - “Group supported employment shall be defined as continuous support provided by staff to eight or fewer individuals with disabilities ……” Further define in manual to provide flexibility for ever-changing employment opportunities and circumstances as well as staff to client ratios.
Page 115
SE Criteria
N.3.a. The wording in this section is problematic and does not allow for maximum flexibility in job development tasks on behalf of an individual. Regulations should be as broad as possible to allow further definition in Manual to correspond to SE best practices with allowable activities accepted by DRS SE practices and CARF accreditation in SE.
DELETE “specifically include” and “search”. CHANGE to – “Only job development tasks that specifically include are specific to the individual shall be allowable job development search activities under the ………..”
Job search is only one aspect of job development.
Page 115
SE Service Units and Definitions
N.4.c. The regulations specifically mention compensation for “group models of SE” and the DMAS fee schedule. However, no mention of Individual SE hourly rates based upon provider specific rates authorized by DRS.
ADD – Individual SE rate statement
“Individual supported employment rates are provider specific based on rates authorized by the Department of Rehabilitative Services (DRS)’)
This statement is already used on the DMAS rate schedule and differentiates between the Group and Individual SE services.
Page 115
SE Service Units and Definitions
N.4.d. Should be “minutes” versus “seconds”.
Should be “a period of time from one hour through three hours and 59 seconds minutes.”
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