Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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11/4/21  4:25 pm
Commenter: Karen Tefelski - vaACCSES

COMMENTS - DD Waiver Manual - Chap 4 #1 of 2

DD Waiver Manual - Chapter 4 Part #1 - vaACCSES

  1. Purpose of Manual to provide explanation, clarification, definition, examples, possible service scenarios, and interpretation for providers to deliver consistent implementation of quality services, documentation and required reports across the Commonwealth. However, we have found that there are numerous items in the Manual that are more prescriptive than what is included within DD Waiver regulatory authority - which is problematic. The Manual should not be more prescriptive than regulations since the governing authority are the regs. The addition of regulatory citations would help as reference throughout the Manual as appropriate.  
  2. Consistency between Regulations and Manual is critical.  There are multiple examples throughout the Manual of inconsistencies between licensing regulations, DD Waiver regulations and what’s required by DMAS in the Provider Agreement.  All of this makes it confusing for the provider and creates additional administrative burden.  It also complicates the rules for providers that provide “unlicensed services”.  Because the service is unlicensed, it makes it difficult to know and fulfill requirements that refer to the licensing regulations and/or to forms referenced.
  3. Chart with “Corresponding Regulations” and BI, FI and CL columns are a helpful visual and provide clarity regarding regulation reference at the beginning of each service.  We recommend that a chart be used for all services in Chapter 4. (See page 78 as example).
  4. There is an overall need to clearly delineate the responsibilities and requirements for support coordinator actions versus service provider actions.  Ideally, support coordination would either have a companion Manual or minimally, within the Waiver manual, have clear sections within chapters and/or services. Possibly, even a separate chapter with ONLY the Support Coordination requirements and responsibilities. The lack of separation and specificity are confusing regarding responsibility and requirements of “providers” throughout the Manual.  The question asked often throughout is “which provider is responsible”.
  5. We request that overall instructions on how providers should round any fractions of service hours provided for billing purposes. This is not included in the current Manual but would be very helpful as an overall instruction to provide specification and consistency. In the past when we asked, we were told that these instructions were to be included in the future Manual in a chapter for “other services”.  It would of course be efficient to include this information within the Waiver manual.


Table of Contents & Service Option Charts:
Corrections Needed:

  • Individual & Family/Caregiver Training is incorrectly marked as included in the BI waiver - should be FIS Waiver
  • Workplace Assistance Services is incorrectly marked as only being included in the FIS Waiver - it is also included in the CL Waiver.

Page 1 - Criteria to Be Eligible -
Comment:  What if they do not have "functional limitations in major life activities" - but might need Companion Care or Sensory Equipment (AT or DME)?

Diagnostic Eligibility

Page 2, paragraph 1:
COMMENT:  Correction Needed. Paragraph refers to “three of more criteria described in (1) through (5) above…”  Please change bullets to numbers for clarity.

Day Assessment Service Authorization Requests

Page 22:

Comment:  Would prefer that the language used provide additional clarity than the 60-day assessment is an option (“may”) - but not required. Recommend - “Provider has the option to request a 60-day assessment prior to initiating plan for supports.”


Page 23:  Provider Discontinuation of Services.

Comment: Regarding 10 business days advanced notice in writing. This is not always possible. Individual Supported Employment (ISE) services, for example, will end when an individual quits or is terminated from a position and DARS categories are open. Would prefer language that better reflects that this is best practice when possible but not required. Additionally, it indicates that in a situation in which health/safety concerns are the reason for discharge, DBHDS must be notified – who at DBHDS is to be notified?


Assistive Technology (AT)  

General Comment: Assistive Technology (AT) is an HCBS waiver benefit that all recipients of DD waivers and CCC+ waivers are equally entitled to access in accordance with regulations at 12VAC30-122-270. Although there is only one regulation for AT, guidance for administration of it is inconsistent. AT requests for people with a DD waiver are approved by DBHDS according to the DD Waiver Manual Chapter IV and AT requests for people with the CCC+ waiver are approved by the MCO or KePRO according to the Durable Medical Equipment (DME) and Supplies Manual Chapter IV. Review of both manuals find extensive differences and variations, and both manuals are more restrictive than the AT regulations they are purported to clarify.


These contradictions and inconsistencies represent the root causes of many of the barriers that individuals, providers, and DMAS are experiencing as reported by the HB2197 working group that DMAS was charged with hosting to identify barriers to accessing AT and related services as well as options for removing them. Making the administrative manual changes recommended below will remove many of these barriers that impact over 30,000 people with disabilities. Only the DD Waiver Manual is open for public comment; the DME Manual was closed in June 2021 after receiving zero comments. We strongly urge DMAS to revise both Manuals to appropriately reflect the AT regulations at 12VAC30-122-270. Suggested revisions for both manuals are provided below.

Relevant Regs at 12VAC30-122-270.


Page 49 - Service Description - 2nd to last sentence
Comment:  Assistive technology devices are portable and authorized per calendar year” is inconsistent with the regulations, which do not require AT devices to be portable. Recommend DELETE “are portable and” to retain the calendar year portion of the sentence, which is consistent with the regulations.


Page 50 - Examples - Allowable Equipment Table

Comment:  Lists allowable equipment and activities that may include a limited list that does not fully reflect the allowable scope of AT in the regs because it lists both types of AT and purposes of AT. Specifically, the allowable list in the manual does not reference AT that enables an individual to actively participate in other waiver services. This purpose of AT is referenced in both the regulations and in the manual on the previous page that lists what AT is supposed to enable.

Recommend replacing the allowable equipment and services list on page 50 about the types of allowable AT to, “Allowable equipment and activities may include specialized medical equipment and ancillary equipment; durable or nondurable medical equipment and supplies; adaptive devices, appliances, and controls; and other equipment, devices, items, and software that meets the service definition.”


Page 51

Comment: This is a stand-alone exclusion that is neither supported by the regs nor referenced in the allowable items section of the regs or the manual, “Items such as furniture shall not be approved if they are of general utility and are not of direct medical benefit.” The regulations require an independent professional consultation that should determine on its own merit if the AT is needed to, “enable an individual to be independent in areas of personal care and ADLs, to communicate more effectively, or to participate in other waiver services. (12VAC30-122-270),in order for the AT to be approved, making this additional stipulation unnecessary.

Recommend deletion of the entire sentence.


Page 51 -
Comment:  Sentence about software compatibility is more restrictive than regulations, “AT providers must ensure that requests for software are compatible with the individual’s current computer.” This assumes all individuals have a computer at all, let alone one that is compatible with every type of software that might be evaluated as necessary AT by an independent professional’s recommendation. The regulations are clear that the independent professional shall determine the most appropriate item(s) for the individual’s needs, which may be compatible with a device that they already own or may require upgrades, enhancements, or a separate device.

Recommend deletion of the entire sentence.


Page 51 - Service Units and Service Limitations - 1st Bullet
“for a specific timeframe” does not clarify the implementation of the regulation. The only timeframe specified in the regulations at (12VAC30-122-270) is the budget limit for a calendar year, and many prior authorization systems only accept a 1-month service period for the AT code used for service authorization requests.

Recommend either deleting “for a specific timeframe” or revising to, “for the timeframe specified by the service authorization system.”


Page 52 - Service Units and Service Limitations Bullet about AT

Comment: under EPSDT for children is vague, confusing, and is more restrictive than the regulation. The regulation at (12VAC30-122-270) C.4. Service units and limitations says, “Requests for AT service via a DD Waiver shall be denied if the AT service is available under EPSDT.” Nowhere in any of the regulations are children under 21 limited to only AT available under EPSDT. Instead of instructions and guidance about how to coordinate the AT benefits that children are eligible to receive under both EPSDT and HCBS in order to comply with the regulation if the requested AT is not available to the child under EPSDT, the proposed manual language only says, “AT for individuals younger than 21 years of age must be accessed through the EPSDT benefit,” indicating children may only access AT under the EPSDT benefit.

Recommend revision: “AT for individuals younger than 21 years of age may be requested via a DD Waiver if the AT is not available to the child under EPSDT.”


Page 52 - Service Exclusions - 1st Bullet
Comment:  Assumes all of the items listed will only ever be for the purposes of convenience, restraint, or recreational or leisure purposes. This administrative declaration circumvents and undermines the fundamental requirement for an independent, professional consultation/evaluation, and could restrict individuals from accessing the least expensive, most cost-effective manner of meeting the regulatory purpose of AT, “to enable individuals to increase abilities to perform ADLs; to perceive control, or communicate with their environment; to actively participate in other waiver services; or are necessary for the proper functioning (12VAC30-122-270) of other equipment. As drafted, the manual permits service authorization staff to overrule the independent professional if any item related to those excluded, regardless of compliance with the regulations. Blanket exclusions are unnecessary and contradictory to the several pages of criteria, guidance, exclusions, and instructions in the manual that safeguard the AT fund for appropriate and compliant utilization.

Recommend deletion of the entire first bullet.


Page 53 - Last Bullet - Service Exclusions
Comment:  Same as regulation. Additional explanation or guidance would be appreciative. It is about duplication of payment for services that are reasonable accommodation requirements of the ADA and other Acts. What constitutes a duplication of payment? If an AT service is otherwise paid by whom? The HCBS AT budget? The Waiver? A Waiver provider? The State Plan? Another State entity? If the individual already has the AT that provides reasonable accommodation, then the independent professional would not recommend it as a needed item. Please describe a real-world example of a duplicate waiver payment for AT that supports this restriction.

Recommend revision with example that provides a better understanding of the regulation.


Page. 54 - Provider Documentation Requirements
states Documentation in the Support Coordination record of notification by the individual or individual’s representative family/caregiver of satisfactory completion or receipt of the service or item.” This is supported in the regulations but is not a requirement that the AT provider can fulfill.

Recommend removing this bullet from the Provider Documentation Requirements and consider adding a separate Support Coordinator Requirements list and/or adding it to the Support Coordination Manual also currently open for public comment.


Page 54 Provider Documentation Requirements - Last Bullet -
Comment:  States for the Support Coordinator to perform and document a face-to-face visit to assure that the individual can use the AT safely and appropriately.” Overly burdensome. This is not a requirement for provider documentation and is not supported in the regulations at (12VAC30-122-270). The other documentation requirements listed in the manual are copied from the regulations without additional detail or guidance, but this particular bullet does not reflect any requirement in the regulations for a face-to-face visit or assurance of safe and appropriate use. Only a professional trained in the AT item could make an assurance that the individual can use the AT safely and appropriately, which is part of the required independent professional consultation/evaluation.

Recommend deletion of the entire sentence.


Community Guide Services

Page 59 - 3rs Bullet - Documentation Requirements
States “Observations of the individual’s responses to the service must be available in at least a daily note”. Community Guide services are not necessarily provided on a daily basis.  Is this needed and realistic. Recommend deleting “daily” from note.


Electronic Home-Based Supports (EHBS)

General Comment:  The regs and the manual are aligned with one another in a way that only makes sense for equipment. In order for providers to deliver services under EHBS, the unit of service cannot be limited to only one.
Recommend Additional Language Be Added: "Only one unit of service is only appropriate for equipment or items that are delivered once. Services that include ongoing monitoring and other supports delivered electronically occur periodically and routinely as needed by the individual, similar to therapeutic consultation. Please consider separating administration of EHBS coverage of equipment from EHBS coverage of services to allow for appropriate and compliant service authorization and billing for ongoing services."

Page 63 - Service Documentation Requirements - Bullet #2
  This documentation is the requirement of the Support Coordinator and not the EHBS provider.

Individual and Family Caregiver Training

Page 70:
Indicates that contact notes, monthly notes, and quarterly reports must be completed. This is more than the regulations require.  Is also duplicative. It is also more information than is required for other services.  Other services require a quarterly review. Clarification is needed if monthly summaries are needed when there is a quarterly review being completed.


Transition Services

Page 74 Paragraph 1 and Page 75 Last Paragraph - Inconsistent language
  Page 74 includes language that an “individual has 30 days after transitioning to apply for Transition Services”.  Page 75 states that “service authorization must be obtained within 30 days of discharge.  Recommend clarification and consistent language be used to avoid confusion.


Benefits Planning
Page 90: Criteria/Allowable Activities
1st Paragraph
Comment:  DELETE “or” before “employment status” and ADD “or need for work incentives”.

Page 94:
Paragraph 1:  Indicates that this service requires face to face contact.
Comment:  Regulations do not specify that this be a face-to-face contact.  Alternative options must be available including telehealth and virtual options. Overly prescriptive and not included in regulations.


Page 95: Mid-page - Bullet 1 -
Comment:  ADD “or is not available” after “have been explored and exhausted”.  Also, please clarify what documentation is needed to fulfill the requirement of “explored or exhausted”.

Page 95: Mid-page - Bullet 2 - Indicates there should be documentation of “All correspondence to the individual and the individual's family/caregiver, as appropriate, the support coordinator, DMAS, and DBHDS”
Comment:  Should also include “DSS and SSA as appropriate” for this particular service.


Community Engagement

Page 102 - Criteria/Allowable Activities
Paragraph 1 - Last Sentence
  Underlined sentence is confusing.  Should “community engagement” be substituted for “supported employment”?

Page 104 - 7th Bullet:
Comment:  ADD “independent” before “living skills”

Group Day Services

Page 112 - Service Definition/Description
1st Paragraph - Last Sentence:
  DELETE “these services”.

Page 114:  Semi-Predictable Events
Paragraph 1:  States “The provider may request between 3-5 hours of additional “community engagement” per week that will allow the individual to choose additional community outings.
Comment:   Shouldn’t this read:  “The provider may request between 3-5 hours of additional “group day” services per week that will allow the individual to choose additional “group day activities.  It is not clear.  If Community Engagement - then it should be included in the Community Engagement service section,


CommentID: 116626