Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
Waivered Services [12 VAC 30 ‑ 120]
Action Change Administration of DD Waiver and Other Technical Corrections
Stage Final
Comment Period Ended on 4/9/2014


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4/9/14  11:59 pm
Commenter: James Engram






a. The case manager shall develop the plan of care, implementing a person-centered planning process with the individual, his family/caregiver, as appropriate, other service providers, and other interested parties identified by the individual and/or or family/caregiver, based on relevant, current assessment data. The plan of care development process determines the services to be provided for individuals, the frequency of services, the type of service provided, and a description of the services to be offered. All plans of care written by the case managers must be approved by DMAS DBHDS prior to seeking authorization for services. DMAS is the single state authority responsible for the supervision of the administration of the home and community-based waiver.
J. Changes or termination of care. It is the DMAS DBHDS staff's responsibility to authorize any changes to supporting documentation of an individual's plan of care based on the recommendations of the case manager. Waiver service providers are responsible for modifying the supporting documentation with the involvement of the individual or his family/caregiver, as appropriate. The provider shall submit the supporting documentation to the case manager any time there is a change in the individual's condition or circumstances that may warrant a change in the amount or type of service rendered. The case manager shall review the need for a change and shall sign the supporting documentation if he agrees to the changes. The case manager shall submit the revised supporting documentation to the DMAS DBHDS staff to receive approval for that change. The DMAS staff or its agent or DBHDS has the final authority to approve or deny the requested change to individual's supporting documentation. DMAS DBHDS shall notify the individual or his family/caregiver, as appropriate, in writing of their theright to appeal the decision or decisions to reduce, terminate, suspend, or deny services pursuant to DMAS client appeals regulations, 12VAC30-110, Eligibility and Appeals.

3. The DMAS termination of eligibility to receive home and community-based waiver services. DMAS shall have the ultimate responsibility for assuring appropriate placement of the individual in home and community-based waiver services and the authority to terminate such services to the individual for the following reasons:

As to I myself am confused somewhat still by the selection of the text above

Here is a SAMPLE letter that could be written  regarding the waiver below:


Dear Department of Behavioral Health and Developmental Services
Office of Developmental Services

I am writing in regards to IFDDS Waiver participants rights.

Application for 1915(c) Home and Community-Based Services Waiver
Individual and Family Developmental Disabilities Support (IFDDS) Waiver VA.0358
Participant Rights.Appendix F specifically states:

IFDDS Waiver individuals may register a grievance or complaint with DMAS.
The individual is informed that they may file a grievance or make a complaint upon entrance into the waiver through correspondence from DMAS and through meetings with their Case Manager and SF when reviewing their service plan.
If a service provider has an internal appeal process, the participant need not utilize the provider's in-house appeal process as a prerequisite to filing for a fair hearing directly with DMAS.  The participant can utilize the provider's appeal process or appeal directly to DMAS or participate in both processes simultaneously.

Individuals may request a fair hearing at any time.  They need not file a complaint or grievance first.

IFDDS Waiver participants may register the following types of grievances/complaints:

1.  Safety, endangerment, or welfare issues;
2.  Suspicion of Medicaid fraud;
3.  Violations of Medicaid regulations, policy, or Code of Virginia, including HIPPA;
4.  Issues regarding DMAS contractors for pre-admission screening, pre-authorization, or fiscal management services;
5.  Issues related to parties other than parents, such as social worker, doctor, therapist;
6.  Issues related to a provider of Consumer Directed Services Facilitation;
7.  Difficulty with services and/or provider agencies.
DMAS staff respond to and log the grievance/complaint and resolution within a reasonable timeframe based on the type of grievance/complaint filed and enter the information into the Waiver Services Database.

Furthermore, individuals shall have the right to appeal adverse actions taken by DMAS that deny, suspend, delay, reduce or terminate services
Individuals' appeals shall be considered pursuant to 12VAC30-110-10 through 12VAC30-120-370.
DMAS shall provide the opportunity for a fair hearing, consistent with 42 CFR Part 431, Subpart E. "Appeal" means the process used to challenge adverse actions regarding services, benefits, and reimbursement provided by Medicaid pursuant to 12VAC30-110, Eligibility and Appeals, and 12VAC30-20-500 through 12VAC30-20-560 and
as 12VAC30-120-420 concerning the appeal process.


At this present time I am utilizing the aforementioned right(s) in order to make a complaint(s)/grievance(s).
My some of my complaints regard case management services waiver support. 
My case management organization is
The difficulties encountered with this organization include lack of contact with a case manager or social worker due to ‘staff changes’ as evident with no new reassigned person or entirely new person to work on  Plan of Care (POC).
(POC) [service plan] as well as a determination for Medicaid eligibility was not completed. This was evident as
Local Department of Social Services (LDSS) seemly has no information to share.
Any plan of care for home and community based waiver services (HCBS) must be pre-approved by DMAS prior to Medicaid reimbursement for waiver services.
All plans of care written by case managers must approved by DMAS prior to seeking authorization for services.
A case manager should have notified (LDSS) [as well as DMAS] by submitting DMAS-122 DMAS-225 and Level of Care [level of function] form after the initial Plan of Care is developed.
A case manager does not contact me as stated by 12VAC30-50-490 [face to face meetings] nor are
annual level of care reviews/annual comprehensive reassessment completed as stated by 12VAC30-120-720.
Also, the case management organization has not provided the yearly DD waiver waitlist update [number] for me.
In conclusion, this correspondence serves as the start complaint/ grievance process. 
Depending on the nature and extent of this complaint [supporting documentation],  if Department of Medical Assistance Services is not the proper agency,  a referral to another agency [e.g. DBHDS Office of Developmental Services, DBHDS of Licensing, Department of Social Services, other DMAS units] may be necessary  and such a response may include follow-up by phone, letter, etc.


My thoughts are while the waiver unit in DHBDS ODS could the enforcement mechanism of appelas be confused as such by the inter workings of the agreement between DMas dbhds


CommentID: 31569