While we understand the desire of the Agency to “streamline” the regulations, we want to point out the following reasons why the MR and Day Support Waiver regulations should remain entirely separate beginning with 12 VAC 30-120-211 through 12 VAC 30-120-249 and 12 VAC 30-120- 1500 through 12 VAC 30-120-1550:

·        The HCBS Waivers which are currently approved for Virginia fall into two categories – those which are primarily designed to prevent or postpone admissions to or allow discharge from nursing facilities and those which prevent or postpone admission to or allow discharge from ICFs-MR.  The only similarity between the two is that they are Long Term Care facilities; otherwise you are comparing the proverbial apples and oranges.

·        The philosophical basis for and the approach to services provided under these two Waivers is significantly different from that of the others.  For example, “care” is provided in the EDCD Waiver, “services” or “supports” are provided in the MR and Day Support Waiver. 

·        The MR Case Management system and role, the assessment process and instruments used, the preauthorization process and authority, the criteria used in the development and the management of the waiting list(s), and the process for offering the right to appeal are among the unique features of these two Waivers.

·        These Waivers are also unique in their oversight; the Department of Mental Health, Mental Retardation and Substance Abuse Services is the agency designated as responsible for the daily policy development and management of these Waivers.  This partnership of DMAS and DMHMRSAS is a unique relationship that blends the policy and operational expertise in mental retardation of DMHMRSAS and the Medicaid program experience of DMAS.

·        Among other functions outlined within the DMAS-DMHMRSAS Interagency Agreement, the Agreement specifies that DMHMRSAS is responsible for the development of policy and regulations; the integration of the regulations into an Omnibus Regulation would result in virtually all sections of the regulations being opened each time either agency needed to suggest changes and would, therefore, add to the burden of participants, advocates, and providers (not to mention Agency staff) in being involved in a nearly continuous regulatory process.  Under the current configuration, changes which need to occur in one Waiver can be reflected in the regulations more readily without opening all sections of 12 VAC 30-120.

·        There are certainly changes which should be made to the regulations for both the MR and the Day Support Waivers, however, the creation of an Omnibus Regulation which eliminates “inconsistencies” in definitions and program requirements will inevitably eliminate the unique characteristics of the two Waivers mentioned above.  Virginia public policy leaders have affirmed many times their desire to preserve these unique characteristics

·        For the most part recipients, providers and stakeholders are concerned with only one of the waivers; having the regulations (for example, 12 VAC 30-120-211 through 249) speak to that Waiver alone is far easier for that constituency to read, understand and use as a reference.  It would seem that an Omnibus Regulation would only satisfy the needs of Agency staff. 

SUBJECT:     VACSB Comments Regarding NOIRA to Publish Omnibus Waiver Regulations

On behalf of the Virginia Association of Community Services Boards (VACSB), thank you for the opportunity to comment upon the intention of DMAS to publish Omnibus Waiver Regulations. 

The VACSB appreciates the intention to streamline regulations; however, it is our strong and enduring belief that, while there may be some cause for certain components of the Regulations to be consolidated, the MR Waiver and MR Day Support Waiver regulations should remain entirely separate beginning with 12 VAC 30-120-211 through 12 VAC 30-120-249 and 12 VAC 30-120- 1500 through 12 VAC 30-120-1550.

The VACSB has been an active and critical participant in the development, design, implementation, and revisions of the MR Waiver and, more recently, the MR Day Support Waiver.  These Waivers have many unique and significant features that must be retained.  Additionally, these two Waivers have figured highly in public policy discussions and decisions made by Virginia’s elected officials since the MR Waiver was first developed in the early 1990’s. 

The MR Waiver, at the direction of the General Assembly and the Administration, was developed by DMHMRSAS, in consultation with CSBs, DMAS, and advocates.  Within DMHMRSAS resided the experience and leadership for services for persons with Mental Retardation.  As a result, the MR Waiver was intended to offer services and supports for people with Mental Retardation who could and chose to live in their communities and was based upon the best expertise and knowledge of the needs of individuals with Mental Retardation.   The history of its development, oversight, and implementation, all of which occurred in the public eye and was the focus of two important legislative subcommittees, is too lengthy to describe in these comments. The results of this history constitute the reasons why these Waivers should be entirely separate:

• Among the very unique features of the waivers include the assessment process and instruments used in assessment, the preauthorization process and authority, and the criteria used in developing and managing the waiting lists.
• Unique is the MR case management system and roles played by the Case Managers.  If any citizen is seeking information regarding the MR Waiver or the MR Day Support Waiver, a separate set of regulations is going to be most helpful and will assist in that citizen’s understanding of the Waiver features. 
• The oversight of the MR Waiver and the MR Day Support Waiver is unique.  The Virginia General Assembly mandated a secure partnership between DMAS and DMHMRSAS.  Each agency has roles specific to these Waivers and which are outlined within the DMAS-DMHMRSAS Interagency Agreement.  Such roles have been affirmed time after time by Virginia’s elected leaders.
• Since responsibility is shared for the implementation, administration, and oversight of the MR Waiver and the MR Day Support Waiver, integration of the Waivers into Omnibus regulations would result in all sections of these Waivers being opened each time the agency needed to suggest changes to any Waiver, for example, the AIDS Waiver.  Such a continuous regulatory process would result in a burden upon the agencies, consumers, advocates, families, and providers.  Instead of streamlining anything with regards to these Waivers, the result would be increased process and work for everyone involved, including the very DMAS staff proposing such a move.  As the regulations are constructed at present, changes needed in one Waiver can occur with no need to open all sections of 12 VAC 30-120.
• While there may be exceptions, most families are concerned with only one Waiver and separating those Waivers by section would appear to be the most informative and user-friendly way to accomplish information sharing.
• The history of the MR Waiver and MR Day Support Waiver, with its legacy of strong interest and affirmation by Virginia’s elected leaders, should indicate that the very features that have made them vital and effective Waivers, whether they are phrased as “inconsistencies” or by any other term, cannot be lost if the Waivers are to remain strong systems of support for citizens of Virginia and their families.
• Are the Waivers complex?  Yes.  Can the complexity be managed?  Yes.  Through confusing Omnibus Regulations?  No, emphatically No!

Thank you again for this opportunity.

 For simplicity and clarity, it is necessary to keep  the regulations for MR Waiver and MR Day Support waiver as separate entities.  The MR Waiver includes  many services, one being is a Day Support component. The Day Support Waiver regulations specify a different slot distribution method to implement for eligible consumers.  The MR Waiver service, Day Support, uses a different method of slot distribution.

Thank you for the opportunity to comment on the intention of the Department of Medical Assistance Services (DMAS) to publish Omnibus Waiver Regulations. 

Danville-Pittsylvania Community Services (DPCS) appreciates the intention to streamline regulations; however, it is our belief that while there may be some cause for certain components of the regulations to be consolidated, the Mental Retardation (MR) Waiver and MR Day Support Waiver regulations should remain entirely separate beginning with 12 VAC 30?120-211 through 12 VAC 30-120-249 and 12 VAC 30-120-1500 through 12 VAC 30-120-1550.  These two Waivers have many unique and significant features that must be retained.  In addition, these Waivers have played a major part in public policy discussions and decisions made by Virginia’s elected officials since the MR Waiver was first developed in the early 1990’s. 

The Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) developed the MR Waiver, at the direction of the General Assembly and the Administration, in consultation with Community Services Boards, DMAS, and various advocates.  Within DMHMRSAS resided the experience and leadership for services for persons with Intellectual Disabilities.  As a result, the MR Waiver was intended to offer services and supports for people with Intellectual Disabilities who were able and chose to live in their communities, and it was based upon the best expertise and knowledge of the needs of individuals with Intellectual Disabilities.   The history of the MR Waiver’s development, oversight, and implementation, all of which occurred in the public eye and was the focus of two important legislative subcommittees, is too lengthy to describe in these comments.  The results of this history, listed below, constitute the reasons why the MR Waiver and the MR Day Support Waiver should be entirely separate:

• Among the very unique features of the Waivers are the assessment process and instruments used in assessment, the preauthorization process and authority, and the criteria used in developing and managing Waiver waiting lists.
  
  
• The MR Case Management system and the roles played by Case Managers are unique.  If any citizen is seeking information regarding the MR Waiver or the MR Day Support Waiver, a separate set of regulations will be most helpful and will assist in that citizen’s understanding of the Waiver’s features. 
  
  
• The oversight of the MR Waiver and the MR Day Support Waiver is unique.  The Virginia General Assembly mandated a secure partnership between DMAS and DMHMRSAS.  Each agency has roles specific to these Waivers which are outlined within the DMAS-DMHMRSAS Interagency Agreement.  Such roles have been affirmed time after time by Virginia’s elected leaders.
  
  
• While there may be exceptions, most families are concerned with only one Waiver, and separating the Waivers by section would appear to be the most informative and user-friendly way to accomplish information sharing.
  
  
• The history of the MR Waiver and MR Day Support Waiver, with its legacy of strong interest and affirmation by Virginia’s elected leaders, should indicate that the very features that have made these Waivers vital and effective, whether they are phrased as “inconsistencies” or by any other term, cannot be lost if the Waivers are to remain strong systems of support for citizens of Virginia and their families.

Thank you again for this opportunity to offer comments.

Our division has extensive experience with the MR, MR Day Support, IFDDS,, and ECDC Waivers, it is obvious that any attempt to streamline all  waivers to eleminate inconsistencies would wreck havoc on the provider community, totally disregard the uniqueness/diversity of each targeted group, and provide no help to families in navigating these waivers.  It would, however, serve to say...."we consolidated as requested". 

Waviers are designed for specifc targeted groups of individuals who have very specific needs (i.e. Aids,MR, DD, Elderly, etc) .  Consequently, by  target specific conditions/groups of individuals, assessment tools unique to these conditions/groups are required.  Language used to describe services are also unique to secific groups.  Because of the uniqueness , monitoring and oversight needs also to be very specific and should be conducted by agencies having experience with specific conditions;  a generic format will not work.

Regardless of the disability field, our task is to look at people as individuals first.  By consolidating all the waivers, we would lose sight of this uniqueness.  VAPPis correct.  An apple is an apple and an orange is an orange.  We get that and so do the people who are the recepients of these waivers.

On behalf of the Chesterfield Community Services Board, thank you for the opportunity to comment upon the intentions of DMAS to publish Omnibus Waiver Regulations.

While appreciating the effort to streamline regulations and find efficiencies wherever possible, Chesterfield CSB strongly believes that the MR Waiver and MR Day Support Waiver regulations should remain entirely separate beginning with 12 VAC 30-120-211 through 12 VAC 30-120-249 and 12 VAC 30-120-1500 through 12 VAC 30-120-1550.

These two MR Waivers have evolved with significant unique features that respond to the special circumstances in Virginia and the population being served.  Managing these MR Waivers without respect to those unique features will create a significant risk to the population that is targeted for services.  Among the most important unique features are:

• The assessment process and instruments, preauthorization process and authority, and the overall management of the significant waiting lists are accomplished through cooperative agency activities
• The role of the CSB case managers in managing both the waiver access and the needs of consumers in conjunction with state agencies
• The unique shared authority of the DMHMRSAS and DMAS in the oversight of the MR Waivers
• The historical understanding of the state leaders concerning the value of the MR Waiver and its use as a benchmark for state support for that population

Essentially unlike other Waiver tools, the MR Waivers have been developed over time to be managed in a manner that best meets the needs of the families and consumers who relate to their individual local CSB.  To do that, it required teamwork and coordination among state and local agencies.

It is the concern of all involved, the CSB board, service staff, consumers and families that it has taken time and effort to create a system to effectively manage the distribution and use of the MR Waivers.  We respectfully request that the existing sytem be respected and maintained.

Sincerely

George Braunstein

Therefore, Region Ten Community Services Board encourages you to decline moving forward with Omnibus Regulations..

As a consumer of the Developmental Disabilities Waiver, I enjoy the flexibility and the freedom of making all of the decisions regarding  my Personal Care Attendants. On this 232nd birthday of America, please don't take away the freedom of choice that the DD waiver provides to it’s consumers.

The MR Waiver and MR Day Support Waiver regulations should remain separate beginning with 12 VAC 30-120-211 through 12 VAC 30-120-249 and 12 VAC 30-120- 1500 through 12 VAC 30-120-1550.

These Waivers have many unique and significant features that must be retained.  Additionally, these two Waivers have figured highly in public policy discussions and decisions made by Virginia’s elected officials since the MR Waiver was first developed in the early 1990’s. 

Among the very unique features of the waivers include the assessment process and instruments used in assessment, the preauthorization process and authority, and the criteria used in developing and managing the waiting lists.

Unique is the MR case management system and roles played by the Case Managers.  If any citizen is seeking information regarding the MR Waiver or the MR Day Support Waiver, a separate set of regulations is going to be most helpful and will assist in that citizen’s understanding of the Waiver features.

The oversight of the MR Waiver and the MR Day Support Waiver is unique.  The Virginia General Assembly mandated a secure partnership between DMAS and DMHMRSAS.  Each agency has roles specific to these Waivers and which are outlined within the DMAS-DMHMRSAS Interagency Agreement.  Such roles have been affirmed time after time by Virginia’s elected leaders.

Since responsibility is shared for the implementation, administration, and oversight of the MR Waiver and the MR Day Support Waiver, integration of the Waivers into Omnibus regulations would result in all sections of these Waivers being opened each time the agency needed to suggest changes to any Waiver.  Such a continuous regulatory process would result in a burden upon the agencies, consumers, advocates, families, and providers.  Instead of streamlining anything with regards to these Waivers, the result would be increased process and work for everyone involved, including the very DMAS staff proposing such a move.  As the regulations are constructed at present, changes needed in one Waiver can occur with no need to open all sections of 12 VAC 30-120.

While there may be exceptions, most families are concerned with only one Waiver and separating those Waivers by section would appear to be the most informative and user-friendly way to accomplish information sharing.

The history of the MR Waiver and MR Day Support Waiver, with its legacy of strong interest and affirmation by Virginia’s elected leaders, should indicate that the very features that have made them vital and effective Waivers, whether they are phrased as “inconsistencies” or by any other term, cannot be lost if the Waivers are to remain strong systems of support for citizens of Virginia and their families.

Although these Waivers are complex, they can and are being managed as is. 

Thank You for the opportunity to Comment on this intended regulatory action.

Comments from Harrisonburg-Rockingham Community Services Board, Harrisonburg, VA

(David Shue, Director of Community Support Services) – July 7, 2008

We appreciate the intent of streamlining the various DMAS waivers.

We oppose inclusion of the MR Waiver and the MR Day Support Waiver in a consolidated package for the following reasons:

-                     There are unique and significant features that have been specifically designed to meet the unique needs of individuals with mental retardation (or intellectual disability). 

-                     Unique features have been crafted and refined over many years through excellent collaboration of CSBs, DMAS, advocates, and in full sight of the General Assembly.  The waivers may not be simple, but they work because they have been carefully crafted.

-                     Expertise in mental retardation is strongest at DMHMRSAS and, locally, at CSBs.  The role of MR case managers is critical, and again has been developed and refined over a period of years through collaborative processes.

-                     Oversight of waiver services is strengthened by the partnership of DMAS and DMHMRSAS.

-                     Inconsistencies, while often troublesome, are in this case the reflection of necessary attention to the unique needs of Virginia’s participants in the MR Waiver and MR Day Support Waiver.

Thank you for the opportunity to comment.

District 19 would like to offer comments regarding the streamlining of waiver regulations.  While the attempt to streamline the requlations is apprciated, it is not believed that this effort wil accomplish the intended goal.  The MR and Day Support waivers have a uniqueness that does not lend them to be bundled with other waiver regulations.  Some of those unique characteristics are outlined below:

*   The assessment process and preauthorization process used with these two waivers differs from other waivers.

*   The management of the wait list (and the fact that there is a wait list) is unlike other waivers.

*   The integrated, intense role of MR case management in these waivers strengthens consumer understanding of service choices, service satisfaction, and timely resolution of any issues that may arise.

*   The relationship between DMAS and DMHMRSAS is specific to these two waivers.  The collablration of these two agencies has resulted in an evolving waiver that has been responsive to consumer needs and sensitive to redesigns to better, more quickly meet those needs.

While it understood there is some duplication in the various requlations, it is belived it would be quite cumbersome and convoluted to try to combine them and still have a clear understanding of the unique differences in administrative process, populations, assessment requirements, etc.  It is hoped that DMAS will reconsider pursuing the Omnibus Regulations.  Thank you for the opportunity to express our concerns regarding this effort.

 encompassing role of the CSB case managers has been successful in managing both the waiver access and the needs of consumers in conjunction with state agencies

In addition, an unequaled system for developing, managing and maintaining a statewide-but-locally-driven Waiting List has been established and tested over the past 18 years. Given the chronic state-wide shortage of slots, this system has proven essential in securing Waiver services for persons with Intellectual Disabilities in as fair a manner as possible.

The Virginia Board for People with Disabilities will be submitting public comment on the proposed Omnibus regulation during the formal public comment period after the draft regulations are published.  We hope that there will be significant stakeholder involvement during the development of the draft regulations.  The Board also hopes that any proposed regulatory changes in definitions or related to service provision will be focused on ensuring person centered practices and maximum flexibility for consumers and families.  The goal of any regulatory changes should be to “do no harm.”  The Board would be very concerned with any proposed changes that weaken rather than strengthen consumer direction or which move the Commonwealth backward to a more medical vs. consumer directed model of services, including what appear to be potential new excessive credentialing requirements for service facilitators (i.e., having a nursing credential),  If an Omnibus regulation continues to be pursued, the focus should be solely on coming into compliance with any specific CMS requirements or corrective action requests and on providing consistency in financial agreements, terminology and definitions which vary from one waiver to another.  Identical services available under more than one waiver should be defined in the same manner and the same set of rules should apply to those services.  If for example, an individual transitions from one HCBS Waiver to another they should be able to maintain a service in the manner in which they are currently using it and maintain their providers without having to wade through confusing and differing requirements--other than those requirements that are uniquely specific to the Waiver itself (such as eligibility, alternate institutional placement, or entirely different services), etc. The Board understands the need for regulatory review of waivers, but hopes that time and effort will also be devoted to development of a plan to improve and expand waiver services, including expanding consumer directed options, improving information available to consumers and families, improving the administration of consumer directed payroll services, and enhancing quality control mechanisms.

At The Arc of Loudoun (Larc) we are disability advocates who work with persons who have many different types of disabilities. We provide waiver and other information to them, and, therefore, we appreciate the complexity of assessment, eligibility, services available, and the unique populations that each waiver serves. Larc supports the definition change to “Intellectual Disability” and the inclusion of person-centered language proposed. We ask that any clustering of terminology and language clarification and consistency proposed will facilitate understanding, yet not minimize individual choice or unique characteristics and needs of people with different types of disabilities who receive waiver services.

There are some areas where we have specific concerns:

1. Requirements for Service Facilitators to be a nurse and/or have a certain type of degree:  With the current shortage of nurses, we have concerns about a nurse requirement. It is difficult for individuals receiving waiver services here in Northern Virginia to obtain the number of skilled nursing service hours that they need.  Also, there are individuals who may be more than qualified with experience to do service facilitation who have a different type of degree.kz

2. Nurse delegation for certain types of services e.g. G-Tube feedings should allow for training of non-LPN or RN staff (including consumer-directed providers) with oversight so that waiver participants with these types of needs have choice and community living maximized;

3. Because Loudoun County borders Maryland and West Virginia, more flexibility and outreach to out-of-state providers by DMAS would be helpful;

4. DD Waiver participants should be able to continue Sponsored Residential types of placements with sponsoring individuals and families. These living situations are NOT group homes and they provide additional supports to individuals with developmental disabilities who are not able to afford an apartment with only SSI income or just need to be in a more supported setting in the community.

5. Individuals who receive a funded waiver slot should be given additional time to find providers before waiver termination notices are sent. In Northern Virginia and other areas, there are few Medicaid providers and it may take time for individuals and families to advertise and find consumer-directed service providers.

Thank you for this opportunity to comment.

Virginia Association of Personal Care Assistants (VAPCA) is interested in the proposal to consolidate Medicaid home and community based waivers into an omnibus regulation.  VAPCA is a statewide organization of personal care assistants whose mission is to create a voice for quality care through quality jobs in the Commonwealth.