Brief Waiver Description, page 4
In this item and in other locations in the draft Application, choice of support coordination/case management is described. The Department of Medical Assistance Services (DMAS) has not taken action to ensure there is choice of developmental disability (DD) private case management by individuals. There has been a significant reduction in the availability of private DD case management, severely limiting choice and resulting in no choice in the majority of the Commonwealth.
RECOMMENDATION: DMAS should clarify that choice is not viable in almost every locality in the Commonwealth.
Attachment #1: Transition Plan, page 10
Check box nine in the list of this item: “Making any change that could result in some participants losing eligibility or being transferred to another waiver under 1915(c) or another Medicaid authority.” Some minor-aged children who are receiving personal assistance from their parent may request transition to the Medicaid Community Living (CL) Waiver if the parent of the minor-aged child is not able to continue the practice allowed with Appendix k to provide paid support to their minor-aged child in a consumer-directed model. DMAS may anticipate that personal care agencies in all regions of the Commonwealth may be willing to hire the parent of a minor-aged child to provide personal assistance. However, there is no data or notation in the Application indicating that this is the case.
RECOMMENDATION: Do not require parents of minor-aged children and spouses who provide Medicaid-funded personal assistance to use the agency-directed model of service. If DMAS decides to remove the consumer-direct model for parents of minor aged children and spouses who are or will be paid caregivers, include in the Application how DMAS has determined that there is adequate capacity of personal care agencies to become employers of assistants who are paid providers for their minor0aged child or spouse.
Communication with Stakeholders, 1st full paragraph, page 16
The Settlement Agreement Stakeholder group has not met quarterly for several years and it is unlikely the group will resume quarterly meetings, if they meet at all, as there has been no indication from the Virginia Department of Behavioral Health and Developmental Services (DBHDS) that future meetings are scheduled.
RECOMMENDATION: Remove “quarterly Settlement Agreement Stakeholder meetings”. RECOMMENDATION: Add the DMAS DD Waivers Advisory Committee to this item.
Appendix A: Waiver Administration and Operation, 2. Oversight of Performance, b. Medicaid Agency Oversight of Operating Agency Performance, item 7, page 21
DBHDS does not “maintain a listing of providers licensed by DBHDS on their website”. The DBHDS website is outdated, incomplete and difficult to navigate. There is no effective, accurate listing of providers on the DBHDS website.
RECOMMENDATION: Commit to developing and maintaining an accurate, usable listing of providers including the geographical areas served by the providers. Or remove item 7 from the listing.
Appendix A: Waiver Administration and Operation, 2. Oversight of Performance, b. Medicaid Agency Oversight of Operating Agency Performance, item 13, page 21
The statement that DBHDS may “convene and serve as lead of advisory committees that pertain to these waivers” reflects that DBHDS facilitates several groups focused on the three DD Waivers. DMAS convenes the DD Waivers Advisory Committee. Among other issues, this Advisory Committee addresses deficiencies in DBHDS operations.
RECOMMENDATION: Correct item 13 to reflect current responsibility for the Advisory Committee and to maintain this as a DMAS role.
Appendix A: Waiver Administration and Operation, 6. Assessment Methods and Frequency, page 26
The draft Agreement lacks assessments that represent input from individuals. There are options and methods that have not been fully explored or seriously considered for individuals to express their own voice, choice, and experiences. The national average for people with disabilities who report they are satisfied with the type of community interactions they have is only 57.6%, satisfied with the frequency of their community interactions is only 36.7%, respected is only 48.8%, and treated fairly is only 49.3%, according to the 2023 Personal Outcome Measures® Data Digest from the Council on Quality and Leadership (CQL). Yet, most of the assessments required by DOJ and DMAS, including the Monthly Onsite Assessment Tool for people who live in group homes, report close to 100% individual satisfaction and met needs, based entirely on how their Support Coordinator/ Case Manager reports it, even with evidence to the contrary, such as adult protective services referrals, evictions, encounters with law enforcement, suicide attempts, and emergency room visits.
RECOMMENDATION: Methods used to measure consumer satisfaction with waiver services and the waiver planning process should be added to this item. The methods should be independent of DBHDS, Community Services Boards (CSB), or waiver service providers.
Appendix A: Waiver Administration and Operation, Quality Improvement: Administrative Authority of the Single State Medicaid Agency, a.1. Performance Measures, page 27
The Agreement lacks Performance Measures representing input from individual.
RECOMMENDATION: Add a Performance Measure that will capture the timeliness of the slot allocation process. This should be based on the date of services authorization completion, and not the date the award was assigned. Something such as, “Percentage of slots allocated to CSBs that were awarded and at least one service authorized for each individual who received a slot within 60 days of the CSB being awarded the slot.”
Appendix B: Participant Access and Eligibility, B-3: Number of Individuals Served (2 of 4); c. Reserved Waiver Capacity, Purpose, Waiver Movement and Emergencies, Page 37
The description of the purpose of reserve slots in this specific Application is to indicate the purpose of reserved of Family and Individual Support (FIS) Waivers. However, in the first paragraph of this item the purpose is described as moving “to the Community Living waiver”. Are the slots in the table on page 38 FIS or CL Waiver reserve slots that are reserved?
The pool of reserved FIS Waiver slots are for people using the Building Independence (BI) Waiver who need the additional supports provided by the FIS Waiver. It is highly unlikely, that FIS Waiver reserved slots would be used by people who are using the CL Waiver, unless it is determined that the individual using the CL Waiver is not using group home or sponsored residential services (the only two services available in the CL Waiver that are not available in the FIS Waiver).
RECOMMENDATION: Clarify whether the slots listed in the chart are FIS or CL Waiver slots.
RECOMMENDATION: If these are FIS Waiver slots in the chart, clarify that the FIS Waiver slots would likely be used by people currently using the BI Waiver or those using the CL Waiver who are not using group home or sponsored residential.
Appendix B: Participant Access and Eligibility, B-3: Number of Individuals Served (3 of 4); e. Allocation of Waiver Capacity, 4th paragraph, 6th line, Page 39
The statement, “documented needs for a residential services only available in the CL waiver, such as group home individual” could be misleading. The only two services in the CL waiver that are not available in the FIS Waiver are group home and sponsored residential. Other residential services are available in the FIS Waiver including in-home residential, shared living, supported living, personal assistance, companion and respite. It is important to change the approach used to describe supports individuals can receive in their home to include these other services as “residential” services: services that can be used in one’s residence. Support Coordinators and providers who do not have experience working with individuals to plan for comprehensive, integrated living situations may think narrowly about services available to support an individual in their home. DMAS should use language in a manner that expands this narrow thinking about options to ensure group homes and sponsored residential are not thought of as the only options for individuals who need extensive support services in the home and community.
RECOMMENDATION: Change “(e.g., individuals with documented needs for a residential service…) to e.g., taking into consideration the FIS Waiver supports that can be used in the individual’s residence.
Appendix B: Participant Access and Eligibility, B-3: Number of Individuals Served (3 of 4); f. Selection of Entrants to the Waiver, 7th paragraph, Page 40
The FIS Waiver and the CL Waiver are primarily different by the provision of group home and sponsored residential only being available in the CL Waiver. The decision to live in a group home or sponsored residential home is typically a choice made by the individual’s parent(s) due to their understanding that these two settings are the only means to achieve 24-hour support or because the parent wants to be the paid sponsored residential provider. Misperceptions are often due to the lack of information provided by the support coordinator, desire to have one provider, and/or perceptions and experiences the parent(s) received from others using Waiver services.
The decision to use a CL Waiver is often the result of a lack of information, not the level or intensity of support needs. Both the FIS and CL Waivers can provide services to address intensive medical, residential, behavioral and other support needs.
To make needed changes in service authorization and delivery, to change the perception of support coordinators, and to encourage integrated living situations, even for those individuals with high level and intensity of need, the Commonwealth needs to use language that clarifies service delivery and supports, regardless of level or intensity, can be provided for in integrated living experiences.
RECOMMENDATION: Change the three bulleted items in this paragraph to reflect that the individual may be considered for the CL Waiver if the individual or their guardian chooses them to live in a group home or sponsored residential setting AND FIS Waiver residential and other support service providers are not available.
Appendix B: Participant Access and Eligibility, B-6: a. Reasonable Indication of Need for Services, i. Minimum number of services, page 48
DMAS has selected the minimum number as one.
RECCOMEDATION: Clarify that some services are not considered stand-alone services. This may increase the minimum number to two or more.
Appendix B: Evaluation/Reevaluation of Level of Care, page 52
The draft Agreement lacks of assurances from individuals.
RECOMMENDATION: Solicit input regarding evaluation for FIS Waiver eligibility from people with disabilities and their families. Include feedback on ease of establishing an appointment for initial evaluation, quality of information provided to the individual during the intake and assessment process, and annual understanding about the waiting list process and priority levels. Solicit annual feedback about the ongoing process to maintain waiting list status and understanding of the slot assignment process, particularly the support coordination role in determining needs and status.
Appendix C: Participant Services, C-1/C-3: Services Specification, Service Definition, all service sections, starting page 64
The Service Definition narratives among the 29 services do not capture details about telehealth allowances in a clear manner.
RECOMMENDATION: Following the format DMAS uses in the service narratives for customized rates, develop a similar format for telehealth services to describe telehealth allowances, when allowed, for each service. For example:
Telehealth is not permitted for this service. OR Telehealth is allowed for this service as described below.
Then state components of the service that can be provided by telehealth. Any limitations or conditions that telehealth would be allowed in this service. The number of hours or percentage of billed units a month that the service can be provided by telehealth.
Appendix C: Participant Services, C-1/C-3: Services Specification, Service Definition, all service sections, starting page 64
The Service Definition narratives among the 29 services do not capture details about back up plans required of the individual.
RECOMMENDATION: Following the format DMAS uses in the service narratives for customized rates, develop a similar format for back up plans that are required for each service. For example:
Back-up plans are required for this service. OR The back-up plan for this service is a requirement of (the individual, the provider, something else.) Back-up plans must be documented (where).
Then state specific back-up plan requirements for this service (if back-up is required).
Add what the procedure is if a back-up plan cannot be identified.
Appendix C: Participant Services, C-1/C-3: Services Specification, Verification of Provider Qualifications, Entity Responsible for Verification, all licensed service sections, starting on page 67
The draft Application lacks consistency in this item. The same three requirements apply to all licensed FIS Waiver services – provider enrollment, licensure verification, and quality management reviews.
RECOMMENDATION: Use language similar to Group Day Services requiring the provider enrollment, licensure verification, and quality management reviews for all licensed services.
Appendix C: Participant Services, C-1/C-3: Services Specification, Verification of Provider Qualifications, Frequency of Verification, all licensed service sections, starting on page 67
The draft Application lacks consistency in this item. There should be an initial verification for all services.
RECOMMENDATION: Use language similar to Group Day Services requiring the verification initially and then a statement about how often after initial verification.
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (2 of 8), b. Service Plan Development Safeguards, narrative, 3rd paragraph, 1st sentence, page 195
This item requires the case manager to “offer choice among all providers serving the area in which the individual desires services”. This is not currently being offered as there is no reliably current and usable database or document for the case manager to locate this information. DMAS currently requires use of the Virginia Informed Choice form to document that choice has been given. The form is inadequate for this and other purposes.
RECOMMENDATION: DMAS should develop a database of FIS Waiver providers listed by service that includes the name of the provider agency, contact information for the agency, geographical area the agency will provide services, and for licensed agencies, if the agency has a provisional license.
Appendix D: Participant-Centered Planning and Service Delivery, D-1: Service Plan Development (4 of 8), d. Service Plan Development Process, narrative, 7th paragraph, page 197
DMAS proposes to continue use of the Virginia Informed Choice form to document choice of services and providers. The form is inadequate.
RECOMMENDATION: Redesign the Virginia Informed Choice Form or a companion guide to include a description of services, eligibility, and applicable processes and timelines for each service the individual is eligible to request, including exclusion criteria. The names of providers who are included in a DMAS-maintained database as enrolled, qualified, and offering the service should be listed on the Virginia Informed Choice Form. There should also be a place to describe how the SC/CM ensured the individual understands their options and expressed their choice.