Page 14 – Frequency of Visits (30/60 Days Unless Written Justification for Medical Need)

The guidance states that face-to-face visits must occur at least every 90 days and visits every 30 or 60 days require written medical justification. Clarification is needed regarding what qualifies as medical justification, as personal care and respite services in the consumer-directed model are not medical services.

This would negatively impact families because the need for additional Service Facilitator contact is often related to service management challenges, not medical issues, such as:

• Supporting Employer of Record (EOR) responsibilities by providing tools, guidance, and resources to assist with hiring, retaining, and managing attendants.

• Service Facilitators also help address scheduling challenges and service coverage gaps, including discussing potential Plan of Care adjustments and assisting families in navigating Managed Care Organization (MCO) or Fiscal Agent changes that may occur between visits.

Families rely on Service Facilitators for guidance in these situations. Limiting additional visits to medical justification may create barriers to timely support and increase the risk of service disruptions.

Clarification is needed on what qualifies as medical justification, and whether additional visits may occur when families face challenges that threaten service continuity.

Page 17 – Management Training (MT)

Clarification is needed regarding when Management Training can be provided and how it should be documented.

EORs often need training during visits when Service Facilitators identify issues or when families request assistance. It is important to note in these cases there would not be any emails or call logs if the request is made during the visit. Requiring extensive documentation, such as emails or call logs, may delay the ability to provide the training needed.

This could negatively impact families who rely on Service Facilitators to help them understand:

• Employer responsibilities

• Policy changes from the state or Fiscal Agent

• Attendant management and compliance requirements

• And when EVV issues are identified.

Clear guidance is needed on how Management Training should be documented when it is identified or provided during a visit.

Page 33 – Legally Responsible Individual (LRI)

The document states that notes from “providers” confirming therapy or diagnosis are not sufficient justification, but the term “provider” is not clearly defined.

In the consumer-directed model, “provider” could refer to:

• Physicians or medical professionals

• Service Facilitators or Agencies 

• Attendants

Lack of clarity may cause confusion for families regarding what documentation is required and could delay services. The term provider should be clearly defined.

Pages 38–39 – Respite Documentation

The key issue is not the term “supervision,” but the requirement for separate documentation from the PCA to justify respite services, even when reviewed alongside personal care.

This raises operational questions: 

• Does this require a separate DMAS-99? 

• Or will the existing DMAS-99 be revised to include a respite-specific section?

• What exactly needs to be reviewed for respite?

Page 45 – Electronic Visit Verification (EVV)

It is the Service Facilitator’s (SF’s) responsibility to ensure that the EOR is adequately trained to confirm that tasks reported in EVV align with the Plan of Care. While the EOR may require this training, they are unlikely to request it independently.

Would training provided by the SF to meet this requirement mandated by DMAS be considered Management Training? If so, there would typically be no email or phone request from the EOR, particularly when the need for training is identified during an in-person visit and time sheets are reviewed on-site.

Service Facilitators do not currently have access through PPL to verify EVV usage, which limits their ability to monitor compliance.

Clarification is needed regarding EVV expectations.

Pages 94–95 – Critical Incidents

Clarification/Training is needed regarding what qualifies as a critical incident.

Some individuals receiving services experience falls or seizures as part of their baseline condition. Without clear definitions, families/SFs may feel required to report events that are routine for the individual.

Clear guidance should distinguish between:

• Expected events related to an individual’s condition, and

• Incidents that represent a significant health or safety concern.

The term “provider” is used throughout the document and refers to several different entities (Physicians, Service Facilitator, Attendant, etc). Using the same term “provider” for multiple different roles can create confusion for readers.

99509

With the new cardinal care contract risk stratification, many of our members are now receiving one face to face contact per year. We have concerns with the frequency of routine visits being specific to medical needs. There are many situations that can lead to a need for adjustments to the plan of care such as changes in support system changes and health related social needs that may not otherwise be identified short of the providers routine visits. 

S5116

Where should the outcome of a work hour verification be appropriately documented and billed when additional education for the EOR is identified as necessary, but the S5116 code is limited to use only when the EOR explicitly requests education?

Specifically, if education is required based on findings during verification (rather than by request), what is the correct mechanism for capturing both the intervention and associated staff time to ensure compliance and accurate documentation?