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Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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11/4/21  5:56 pm
Commenter: Virginia Association of Centers for Independent Living, Maureen Hollowell

DD Waivers Manual, Chapters II, IV and VI, Appendix B

Chapter 2, Page 5, Fingerprinting
Include the exemption for fingerprinting of services facilitators as the Code of Virginia does not include a provision allowing for these employee background checks to include finger printing.
Include the exemption for fingerprinting of consumer-directed staff. The fiscal agent nor the employer of record obtain this level of back ground check.

Chapter 2, Page 5, CD Employee Responsibility to Notify of Convictions
Clarify what the Employer of Record is to do if an employee reports a conviction.

Chapter 2, Page 31, Sleeping or Living Units
Provide a definition of a living unit including how this is different from the sleeping unit.

Chapter 2, Page 32, Accessibility
Include in the examples of required accessibility, all features of the kitchen and outdoor areas used by the individual.

Chapter 2, Page 36, Support Coordination for People with DD Other Than ID
Clarify that the “provider” is the CSB or BHA, not the contractor. Not all of the requirements listed can be achieved by the contractor due to CSB and BHA structures and DBHDS licensing requirements.

Chapter 2, Page 50, Transition Services
Can these services be provided by any Medicaid targeted case management provider or only DD and ID case management?

Chapter IV, Page 6, Patient Pay Consumer-Directed Services
Include the process to notify the individual and employer of record about patient pay.

Chapter IV, Page 9, Removal from Waiting List
Regarding the last sentence of the first paragraph, what must the CSB do with the provided Choice forms?

Chapter IV, Page 13, CL Waiver Requirement for Group Home or Sponsored Residential
This description of CL Waiver assignment is unclear. Is the individual expected to use group home or sponsored residential within a certain timeframe in order to be assigned a CL Waiver?

Chapter IV, Page 40, Likely to Have an ID Diagnosis
The assumption that people have ID has been problematic for people with DD for many years. Using this likely assumption in the Manual is inappropriate. Most people with DD do not have an ID diagnosis. In the past, an ID diagnosis was sought by some parents and providers due to funding levels for case management, previous requirements to have an ID diagnosis for some waiver services, and other antiquated perceptions about abilities and services.

Chapter IV, Page 40, Spina Bifida
Correct the spelling of spina bifida in the fourth paragraph.

Chapter IV, Page 52, AT Service Exclusions
The exclusions listed in the last paragraph are concerning. These, and similar items, often have significant therapeutic value depending on the needs and preferences of the person with a disability.

Chapter IV, Page 66, EM Exclusions
Multiple wheelchair ramps in the same residence may be necessary to ensure a safe exit from the home. For example, one entrance may be blocked by a fallen tree during a storm or unusable due to snow.

Previous modifications to the same room should be allowed. People use Waiver services for years – entire lifetimes. It is unrealistic to expect a previous modification to remain useable or appropriate for the individual for a lifetime. Previous modifications to the same room should be allowed.

Chapter IV, Page 76, Locks
Clarify that locks must be on livable areas such as bathrooms and bedrooms.

Chapter IV, Page 93, Benefits Planning Service Limitations
Individuals have the right to choose their employment network (EN) provider. Granted most people choose DARS. However, for individuals who choose a different EN, it does not matter if the benefits planning is available through DARS.

Chapter IV, Page 111, Employment and Community Transportation Requirements
Clarify that the provider does not attend the annual plan meetings. The rate of reimbursement for this service does not include plan meetings.

Chapter IV, Page 133, Private Duty Nursing
Private duty nursing providers often refuse to provide personal care services. Personal care attendants may not make medical judgements or be involved with vents, trachs and other sterile techniques, even with nurse delegation (as explained further in this Manual). This limits personal care to a period of time when the nurse is not present if something were to become dislodged with the ventilator or other device that requires the use of a sterile technique.

Chapter IV, Page 182, Companion Services Criteria
The fifth paragraph appears to be an incomplete sentence. Is the intent to state that companion services are limited to no more than eight hours in a 24-hour period?

Chapter IV, Page 195, Consumer-Directed Documentation by the Personal Assistant
There is no requirement for the documentation in the second and third bullets. While some employers of record may want to require this documentation, there is no program requirement for this.

Chapter IV, Page 200, CD Employees Working 16 Hours or More
In the first paragraph, clarify if this is a limitation based on employer of record or a limitation of the assistant, regardless of how many employers they work for.

Chapter IV, Page 204, Using CD Without Services Facilitation
The Manual should include guidance on how this is to be done.

Chapter IV, Page 204, Selection of EOR
Include the use of the DMAS-95. This was previously done by the services facilitator, but will now need to be done by the case manager since the case manager now decides if the EOR is appropriate.

Chapter IV, Page 209, CD Monitoring
Clarify that the phone contact to conduct the monitoring to prepare the quarterly report is a billable service
Clarify whether a quarterly monitoring is required for companion services or if it remains a semi-annual monitoring timeframe.

Chapter VI, Quality Management and Utilization Reviews, Page 6, VIDES timeline
Clarify what timeline DMAS expects for the “annual” VIDES. Is it within 365 days of the last review, a specific timeframe before the annual Waiver plan development, or other timeline?

Chapter VI, Quality Management and Utilization Reviews, Page 7, Evaluations
The language used, “psychological or other evaluation” is good. Too often people with DD have unnecessarily gone through psychological evaluations when their DD diagnosis is better determined, or already appropriately determined, by other evaluations.

Chapter VI, Quality Management and Utilization Reviews, Page 8, Plan for Supports, Case Management
As is written in the fifth clear bullet, it appears that Case Management is a waiver service. Clarify that case management is a state plan service.

Chapter VI, Quality Management and Utilization Reviews, Medical Evaluation, Page 9
The assumption that all people with DD need an annual physical is not is not a Medicaid requirement. The Manual correctly states that a medical examination should occur whenever needed. Further clarification should be included in the Manual to guide a better understanding of this matter and minimize unneeded medical examinations.

Chapter VI, Quality Management and Utilization Reviews, Page 11, Plan of Support
Clarify the development of plans of support (Part V) for consumer-directed services. The provider is responsible for working with the team to develop the plan. In the case of consumer-directed supports, the provider is the direct staff (attendant, companion or respite provider). They currently do not develop plans of support and should not. This exception should be included in the Manual.
For individuals who choose to use consumer-directed supports without services facilitation, if the final decision is to require the development of plans of support for consumer-directed services, this will be the responsibility of the case manager and should described in the Manual.

Chapter VI, Quality Management and Utilization Reviews, Page 11, Service Documentation
In reference to the last bullet on page 11, clarify that this documentation does not exist for consumer-directed services. This bullet requires the case manager to look at documentation that is not available to them.

Chapter VI, Quality Management and Utilization Reviews, Page 17, Patient Pay with Consumer-Directed Services
The Manual should include a description of how the assignment of patient pay occurs for consumer-directed services, including notification to the employer of record and the individual, if different.

Chapter VI, Quality Management and Utilization Reviews
The Manual should include details about case management responsibilities and documentation requirements when an individual who uses consumer-directed services elects not to use services facilitation.

Appendix B, EPSDT, Page 5, Assistive Technology
In the second paragraph of this section:
An IEP is an individualized education program, not a plan.
Assistive technology required by an IEP is an allowable school-related Medicaid funded service. See the EPSDT Manual, Appendix A, page 5.

Appendix B, EPSDT, Page 6, Nursing Services
Add clarification that the individual must be receiving one of the DD Waivers services in order to continue eligibility for their Waiver. If a child develops the need for nursing services subsequent to receiving and using the Waiver, they must continue to use a Waiver service to maintain their Waiver.

CommentID: 116635