15 comments
On page two of Appendix A there is mention of mitigating circumstances in which a pend would not be denied on the third pend. I would reccomend examples be provided in this manual so that it is not soley the discretion of DBHDS Service Authorization. This could adversely affect providers and individual if there are not some flexibitiies outlined so everyone is on the same page.
We, the Public Policy Committee of the Virginia Association for Behavior Analysis, have the following comments on the Draft Development Disabilities Waivers Appendix A Provider Manual. We thank you for the opportunity and partnership. Many of our members are providers of Therapeutic Consultation as Licensed Behavior Analysts and Licensed Assistant Behavior Analysts.
On page 60, the section titled Therapeutic Consultation, Occupational Therapists, Physical Therapists, Speech- Language Pathologists, Board Certified Behavior Analysts, Licensed Behavior Analysts, and Rehabilitation Engineers:
In the title, we respectfully ask that you delete the reference to Board Certified Behavior Analysts and list Licensed Behavior Analysts and Licensed Assistant Behavior Analysts. In the Commonwealth of Virginia, Board Certified Behavior Analysts are not permitted to practice unless licensed.
The unit of service is currently 1 hour. However, a 15 minute-unit would be more efficient and less open to waste. Frequently, providers of therapeutic consultation provide services over or under the hour mark and then must adjust for billing purposes. Often this results in the provider not being paid for services provided under 30 minutes or the provider being paid for services not provided but rounded up to the next hour.
Please clarify that since ABA is not covered under the State Option Plan, as Speech, OT, and PT are, that waiver recipients should be able to access ABA through EPSDT AND Therapeutic Consultation.
On page 63, the section titled Therapeutic Consultation Behavioral Services:
There is a need to define who is legally able to provide this service. “Behaviorist” as a term is undefined in Virginia Code including DMAS and DBHDS regulations. It should be made clear that only professionals who have been trained to perform a functional assessment and have the services in their scopes of practice should be allowed to perform these services.
We thank you for the opportunity to comment and welcome your continued partnership.
Page 5 Bullet #7
“The authorized start date of services will not be prior to the date the service authorization request is initially submitted to DBHDS for an eligible individual…… it is recommended to be submitted at least 30 days prior to the requested start of services….”
Comment: Providers have been directed not to schedule annual review meetings. They are told it is the responsibility of the CSB. There have been times when the individual is not aware of who his/her support coordinator is at the time, and they are not contacted or have a meeting scheduled until 1-2 weeks prior to the plan turning over in WaMS. Even after an annual plan meeting is held, providers are at the mercy of the Support Coordinator to submit the Part III in WaMS and “assign” the provider to specific outcomes. We have experienced that not happening until less than 3 days ahead of the new plan starting. Once a provider submits information into the WaMS system, they are again beholden to the Support Coordinator to push the submission button to lock in a date. Even after multiple phone calls and emails, this has still been an issue for providers. This has increased with the high rate of turnover in the Support Coordinator role.
Recommendation: Add a 10 business day grace period for authorization start dates.
Page 17 in the 4th paragraph
“Community Guide activities conducted not in the presence of the individual, such as researching and contacting potential sites, supports services and resources, shall not comprise more than twenty-five percent of authorized plan for support hours.”
Comment: Allowing only 25% of the research and contacts to be outside of the presence of the individual is not reasonable in today’s housing climate or the current paperwork procedures for individuals utilizing the SRAP or Housing Choice voucher programs. (I know this is a Waiver manual requirement, but I want them to hear this one as often as possible.)
Recommendation: This piece should be increased to 50% of the allowable hours and should allow phone/telehealth meeting options to increase efficiencies. Not doing so will mean the potential for individuals with disabilities to miss out on important options and/or providers to discontinue providing this support.
Page 34, Last paragraph
“When the provider anticipates a need for an increase in service hours due to holiday, doctor visits, closure of day or employment sites, for which the back-up plan is not an option, the provider may submit an authorization request that includes (1) an explanation of the insufficiency of the back-up plan……
Comment: This requirement to discuss why a back-up plan is not sufficient is not listed in regulation, nor should it be the provider’s responsibility to research and investigate why a back-up plan is not an option for an individual. The individual utilizing supports are also not required to ask someone named in a back-up plan prior to utilizing supports that have been vetted and awarded to them based on need by the Medicaid Waiver program. This is an egregious overstepping of boundaries and a waste of resources that could be used to simply support the individual in need.
Recommendation: Strike this paragraph from the manual. It should not be a pre-requisite to check with the person named in the back-up plan if a planned service is not available and another provider/service is able to step in and meet the need. The same is expense is being utilized, and the most important factor is that the individual has the safety supports he/she needs immediately.
I have provided details directly to DMAS to edit for spelling, duplications, and general lack of clarity. Substantive issues include:
Lack of consistency - eg. the description, approval and use of semi-predictable or "flexible" hours, references to when "family" can or cannot provide services, etc.
The formatting is very difficult and makes reading the document challenging
The taxonomy codes and specialty codes for each service should be included - it would be a useful reference
"Family/caregivers acting as the employer on behalf of the individual (EOR) may not also be the CD employee. The primary caregiver shall not be authorized to serve as the paid CD employee for this service."
- Even well prior to the pandemic many families had little to no access to care providers for children. The entire system is overwhelming, and we are not only caring for our children, including multiple Doctor/Therapy/ER/Urgent Care/Hospital visits, but endless phone calls (on hold often for an hour or more). Many parents cannot work due to the high level of care their children require, AND have to deal with endless paperwork, screenings, etc. We need to be able to be paid for this. Why should families go broke trying to care for our children with disabilities? We have no help, especially throughout the pandemic because for the raid paid for care providers, they have all left for other more lucrative employment. Please help us!
Service Facilitators get paid a lot while families of children with disabilities suffer with lack of sustainable, properly trained, reliable care providers, and some service facilitators like Toddlers to Grandparents and Moms in Motion, who, upon failing their own responsibilities to children, fail to accept an ounce of responsibility and then blackball innocent children out of their organizations. Fund the families! WE are strapped with medical bills until we are broke and on Medicaid. Service Facilitation should be an INTERNAL (much as I almost hate to say it) government service like case management. (like CSA and CSB) Wherein hopefully there is accountability and focused, concise, reliable, factual information provided to families on Waiver Services. Children and families deserve better when independent service facilitators fail. Get rid of them and replace them with a 3 to 5 year transparent, actionable plan. Save the added expenses. Invest directly into our families and children in need, please.
Families should not have to go broke to care for their disabled kids, (ID/DD Waivers, etc.) especially when there is no help anyhow. Pay family caregivers. The qualifications for care providers are so ridiculously strict anyhow to keep people from 'cheating the system' there is no good reason not to authorize permanently parent/live-in caregivers for kids. In fact, we should be paid something for all the ridiculous, constant phone calls and paperwork and evaluations, etc. etc. and all the work we have to do to fight for our children's needs in the schools, and medically? All of this work with no income for people who CAN'T work due to their childrens' needs, but would like to...why NOT pay us for all we do just because we're related to our children and love them more than anyone else ever would. Why does it matter that they are not 18? That's discrimmination, period.
Please streamline the entire process and create a centralized department in each Virginia region to specifically do facilitation work. Continue to allow video visits when needed, but if local case managers are seeing their cases monthly, let them report that they've seen the client to the newly established facilitation divisions. Save the taxpayers the $$$ sent to external resources and do it in-house more efficiently. Thank you.
Appendix A text: The maximum service authorization duration is 6 months, and in accordance with the ISP’s effective from and through dates. The ISP Parts 1-4 and provider’s Part 5 and a CMS 485, signed by a physician/nurse practitioner and a schedule of the proposed delivery of hours are to be submitted by the support coordinator in WaMS with supporting documentation/justification for this service. Services are authorized for the length of the physician’s orders up to 6 months.
enCircle comment: This process is already very tedious, and we have ongoing challenges with receiving orders from Physicians and Nurse Practitioners in a timely manner. Our nurses spend significant time calling and faxing physicians. Changing this to every six months creates an even greater burden on an already overworked and underfunded nursing workforce. The medical field is generally maxed out due to the on-going stress of the pandemic, asking physicians and medical offices to provide more frequent documentation seems like an unnecessary burden on them as well.
COMMENTS: vaACCSES
DD Waiver Manual - Appendix A Draft (Service Auth) for Public Comment
GENERAL COMMENT:
While Service Facilitation does not require service authorization under the DD Waivers, it is a listed BI/FIS/CL Waiver Service in the regs and should be listed in the section of this Appendix where all other Waiver Services are listed. It is mentioned in the CD sections of this appendix, but it is not specifically listed as its own waiver service, and it should. We have billable codes just like every other service on these waivers. This manual should spell out who can and cannot be an SF, when it's appropriate to engage an SF (CD services only, for example), and what the minimum requirements are in order to provide SF services, etc.
ASSISTIVE TECHNOLOGY
Page 2-3. “Pend for Additional Information”
Page 5. “To assure the provider that the individual is eligible and that services are authorized as requested, it is recommended that the required documents be submitted at least 30 days prior to the requested start of services.”
Page 6. “Review Process: The DBHDS has 10 business days to review a request for service authorization… Upon the receipt of a response to a pend, DBHDS has 10 additional business days to process the request.”
Page 7:
Page 8-9. “For children under the age of 21 – EPSDT ASSISTIVE TECHNOLOGY (T5999) over $5000…. T5999 code for requests over $5000.”
Page 9. “A 30% markup based on the provider cost is required.”
Page 9. “Items covered under DME cannot be considered as AT, if the AT item doesn’t meet the EPSDT criteria, then the item cannot be approved under the waiver.”
Page 10. “Requests for new Assistive Technology devices must contain the following: Provider to submit quote, showing cost and if request approved, then markup cost 30%.”
Page 18, COMPANION SERVICES:
Page 20:
ELECTRONIC HOME BASED SUPPORTS
Page 23. “Service authorization request must include a description of the item requested by the support coordinator… A preliminary needs assessment shall be completed by an independent technology specialist (cannot be employed by the requesting provider) to determine the best type and use of technology and overall cost effectiveness of various options.”
INDIVIDUAL SUPPORTED EMPLOYMENT
Page 33 – Individual SE – Paragraph 3
Page 33 – Individual SE – Paragraph 6
Page 52 - CD Respite:
THERAPEUTIC CONSULTATION
Page 64 – Therapeutic Consult – Bullet Point 3
DD Waiver Manual - Appendix A Draft (Service Auth) for Public Comment
GENERAL COMMENT:
While Service Facilitation does not require service authorization under the DD Waivers, it is a listed BI/FIS/CL Waiver Service in the regs and should be listed in the section of this Appendix where all other Waiver Services are listed. It is mentioned in the CD sections of this appendix, but it is not specifically listed as its own waiver service, and it should. We have billable codes just like every other service on these waivers. This manual should spell out who can and cannot be an SF, when it's appropriate to engage an SF (CD services only, for example), and what the minimum requirements are in order to provide SF services, etc.
ASSISTIVE TECHNOLOGY
Page 2-3. “Pend for Additional Information”
Pended requests from DBHDS and responses from SC/CM and Provider should be documented as part of the person’s records that are accessible to DMAS because DMAS receives consumer and provider complaints and appeals that often involve SA request pends.
Page 5. “To assure the provider that the individual is eligible and that services are authorized as requested, it is recommended that the required documents be submitted at least 30 days prior to the requested start of services.”
Please add, “but not required” or remove the entire recommendation. Providers are able to verify service eligibility in near real-time with DMAS information systems. In addition, there are several processes that have to occur before “the required documents” can be created for services that require SA, including meeting, consultation, and sometimes assessments by an independent clinician. These processes often take 30 days or more to complete before they can be submitted for SA. This current guidance recommends delaying a service start date by another month unnecessarily.
Bullet 6 and bullet 8 are redundant.
Bullet 9, which carries into the next page is more restrictive than the regulations, which do not stipulate that an individual MUST try to find an attendant first that lives outside of the home before hiring someone that lives "under the same roof". https://law.lis.virginia.gov/admincode/title12/agency30/chapter122/section460/ section C is where the regs talk about who can and cannot be a PCA and nowhere in the regs does it say that the PCA cannot live under the same roof. The regs do not even mention the words "Objective Documentation" anywhere. My opinion is that this bullet in the manual should be removed or language that matches the regs should be used in its place, such as Section C-9 in the regs.
Page 6. “Review Process: The DBHDS has 10 business days to review a request for service authorization… Upon the receipt of a response to a pend, DBHDS has 10 additional business days to process the request.”
Please add guidance for similar timeframe expectations for the SC/CM to submit requests and responses to DBHDS. Complaints about SC/CM refusals and delays in submitting requests and
responses to pends to DBHDS are increasing while DMAS regulations and guidance are silent. Please consider guidelines for the SC/CM or CSB responsibilities for providing appeal information and rights if they cannot submit requests or pend responses within 5 business days of receiving the required documents and/or response from the provider.
Page 7:
AT Only (T1999) is missing the 30% markup for providers.
Page 8-9. “For children under the age of 21 – EPSDT ASSISTIVE TECHNOLOGY (T5999) over $5000…. T5999 code for requests over $5000.”
Please correct this to clarify that all AT for children under the age of 21 uses code T5999. As stated, it sounds like only costs or requests over $5,000 are covered by EPSDT when the regulations and DMAS memos clearly designate all AT for children is coded as T5999 EPSDT AT, and none of it is designated as waiver AT with code T1999.
Page 9. “A 30% markup based on the provider cost is required.”
The 30% markup above the provider cost for EPSDT AT for children under 21 is not required. It is allowable if the provider is not also the manufacturer of the AT.
Page 9. “Items covered under DME cannot be considered as AT, if the AT item doesn’t meet the EPSDT criteria, then the item cannot be approved under the waiver.”
Please clarify this sentence that conflates two separate ideas. Suggest, “Items with a designated DME billing code and established rate cannot be considered for AT approval. AT requests for children under the age of 21 may only be approved under EPSDT AT and may not be approved under the waiver even if it doesn’t meet the EPSDT AT criteria.”
Paragraph 2 following the bullets, "Therefore, services that do not involve directly support the individual or environmental services dealing exclusively with an individual's surroundings rather than the individual are not covered." This language does not appear anywhere in the regulations: https://law.lis.virginia.gov/admincode/title12/agency30/chapter122/section270/ - section C. This is an interpretation by DMAS that is not supported by regs and is more strictive than the regs.
Page 10. “Requests for new Assistive Technology devices must contain the following: Provider to submit quote, showing cost and if request approved, then markup cost 30%.”
This sequence, adding 30% markup cost if the request is approved, will result in a claim submission that is 30% higher than the approved amount. Please revise to, “Provider to submit quote, showing cost and markup of 30% if the provider is not the manufacturer of the item.”
Page 18, COMPANION SERVICES:
"Documentation submitted with the service authorization request must confirm that the service is not purely recreational in nature." What does that even mean? How is that defined? I have the same comment for Page 19 under CD Companion Services, paragraph 3.
Page 20:
Paragraphs 2 and 3 are redundant
ELECTRONIC HOME BASED SUPPORTS
Page 23. “Service authorization request must include a description of the item requested by the support coordinator… A preliminary needs assessment shall be completed by an independent technology specialist (cannot be employed by the requesting provider) to determine the best type and use of technology and overall cost effectiveness of various options.”
These two statements are contradictory to one another and does not provide guidance for instances where the support coordinator does not agree with the needs assessment completed by an independent professional as required in the regulations. Suggest revision of, “Service authorization request must include a description of the item requested by the support coordinator and recommended by the independent professional assessment.”
INDIVIDUAL SUPPORTED EMPLOYMENT
Page 33 – Individual SE – Paragraph 3
Would like clarifying information indicating if requiring the contact name at DARS/the school is the SC or provider’s responsibility
Is this asking for above and beyond what the regulations require?
Page 33 – Individual SE – Paragraph 6
Would recommend adding that personal assistance can overlap
Page 52 - CD Respite:
CD Respite, paragraph 2, typo in the sentence, "...reminders to take self-administered medication or other medical needs, or monitoring OR her health status or physical condition." The word "OR" could probably be "OF".
THERAPEUTIC CONSULTATION
Page 64 – Therapeutic Consult – Bullet Point 3
Would recommend modifying the language to include “most recent completed period.” Quarter 4 data is not available at the time of submission as submission occurs prior to the end of the quarter.
Page 5 Bullet #7: “The authorized start date of services will not be prior to the date the service authorization request is initially submitted to DBHDS for an eligible individual…… it is recommended to be submitted at least 30 days prior to the requested start of services….”
Although this is ideal situation the ongoing staffing overturn in support coordination (SC) continues to hinder providers ability to do this effectively as it is difficult to make contact with "whomever might be the current support coordinator" and depending on the location of how soon the SC is setting up team meetings being inclusive of all providers. There needs to be some flexibility and or accountability on the SC side as per recommendation of SC accountability in the review process on page 6 or approving from time provider submits to the SC.
Page 6. “Review Process: The DBHDS has 10 business days to review a request for service authorization… Upon the receipt of a response to a pend, DBHDS has 10 additional business days to process the request.”
(Agreement with vaACCSES ) Please add guidance for similar timeframe expectations for the SC/CM to submit requests and responses to DBHDS. Complaints about SC/CM refusals and delays in submitting requests and responses to pends to DBHDS are increasing while DMAS regulations and guidance are silent. Please consider guidelines for the SC/CM or CSB responsibilities for providing appeal information and rights if they cannot submit requests or pend responses within 5 business days of receiving the required documents and/or response from the provider.
Page 17 in the 4th paragraph:“Community Guide activities conducted not in the presence of the individual, such as researching and contacting potential sites, supports services and resources, shall not comprise more than twenty-five percent of authorized plan for support hours.”
Comment: (Agreement with Hope House Comment) -Allowing only 25% of the research and contacts to be outside of the presence of the individual is not reasonable in today’s housing or community climate as we are slowly returning to non-pandemic realm and the documentation processes that need to occur.
Recommendation: This piece should be increased to 50% of the allowable hours and should allow phone/telehealth meeting options to increase efficiencies.
Also would recommend a better delineation of Community Guide service definition as some interpret it as all about housing vs the option of community connections and that a provider might only be doing one part vs. another.
GENERAL COMMENT:
While Service Facilitation does not require service authorization under the DD Waivers, it is a listed BI/FIS/CL Waiver Service in the regs and should be listed in the section of this Appendix where all other Waiver Services are listed. It is mentioned in the CD sections of this appendix, but it is not specifically listed as its own waiver service, and it should. We have billable codes just like every other service on these waivers. This manual should spell out who can and cannot be an SF, when it's appropriate to engage an SF (CD services only, for example), and what the minimum requirements are in order to provide SF services, etc.
ASSISTIVE TECHNOLOGY
Page 2-3. “Pend for Additional Information”
Page 5. “To assure the provider that the individual is eligible and that services are authorized as requested, it is recommended that the required documents be submitted at least 30 days prior to the requested start of services.”
Page 6. “Review Process: The DBHDS has 10 business days to review a request for service authorization… Upon the receipt of a response to a pend, DBHDS has 10 additional business days to process the request.”
Page 7:
Page 8-9. “For children under the age of 21 – EPSDT ASSISTIVE TECHNOLOGY (T5999) over $5000…. T5999 code for requests over $5000.”
Page 9. “A 30% markup based on the provider cost is required.”
Page 9. “Items covered under DME cannot be considered as AT, if the AT item doesn’t meet the EPSDT criteria, then the item cannot be approved under the waiver.”
Page 10. “Requests for new Assistive Technology devices must contain the following: Provider to submit quote, showing cost and if request approved, then markup cost 30%.”
Page 18, COMPANION SERVICES:
Page 20:
ELECTRONIC HOME BASED SUPPORTS
Page 23. “Service authorization request must include a description of the item requested by the support coordinator… A preliminary needs assessment shall be completed by an independent technology specialist (cannot be employed by the requesting provider) to determine the best type and use of technology and overall cost effectiveness of various options.”
INDIVIDUAL SUPPORTED EMPLOYMENT
Page 33 – Individual SE – Paragraph 3
Page 33 – Individual SE – Paragraph 6
Page 52 - CD Respite:
THERAPEUTIC CONSULTATION
Page 64 – Therapeutic Consult – Bullet Point 3
Service authorizations lasting only 6 months is too short for medical care plans. It’s difficult getting necessary health care providers to sign off and we’re at their mercy when we get them back. Our constant paperwork is why some doctors don’t want to serve our individuals.