VIRGINIA ASSOCIATION OF CENTERS FOR INDEPENDENT LIVING, www.vacil.org
Comment on the Virginia Medicaid Family and Individual Support Waiver Renewal Application
The Virginia Association of Centers for Independent Living (VACIL) is a private, non-profit, consumer-directed, statewide association of the 17 Virginia Centers for Independent Living. VACIL advocates for the integration and inclusion of people with disabilities into all aspects of society.
The term “individual” is used throughout this comment to mean the individual receiving supports or their substitute decision maker.
2. Brief Waiver Description, narrative, 6th paragraph, page 4
In this item and in other locations in the draft Application, choice of case management/support coordination 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, limiting choice and resulting in no choice in many communities.
RECOMMENDATION: Clarify that choice of DD private case management is not viable in most localities in the Commonwealth.
Attachment #1: Transition Plan, page 10
Item nine in this list is, “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 draft 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-directed model for parents of minor-aged children and spouses who are or could in the future 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 minor-aged child or spouse.
Additional Needed Information (Optional), 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, narrative, item 7, page 21
DBHDS does not maintain a listing of providers on their website. The listing on the DBHDS website is only of providers licensed by DBHDS and not the many other waiver providers. Individuals need provider information for all provider types. The information on the DBHDS website is not current, outdated, incomplete and difficult to navigate. There is no accurate listing of providers on the DBHDS website that can effectively be used by individuals and case managers/support coordinators.
RECOMMENDATION: Commit to developing and maintaining an accurate, usable listing of providers including the geographical areas served by the providers with agency contact information. Alternatively, remove item 7 from the listing in this narrative.
Appendix A: Waiver Administration and Operation, 2. Oversight of Performance, b. Medicaid Agency Oversight of Operating Agency Performance, narrative, item 13, page 21
The statement that DBHDS “will 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.
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.
RECOMMENDATION: Methods used to measurer 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), and 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 draft 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, not the date the award was assigned to the individual. 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); Purpose, narrative, 1st paragraph, page 37
The description of the purpose of reserve slots in this draft Application are slots for the Family and Individual Support (FIS) Waivers. However, the purpose is described as moving “to the Community Living waiver”. Are the slots in the table on page 38 FIS or Community Living (CL) Waiver reserved slots?
The pool of reserved FIS Waiver slots are primarily for individuals 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 individuals transitioning from the CL Waiver, unless it is determined that the individual using the CL Waiver is not using group home or sponsored residential services (the two services available in the CL Waiver 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, narrative, 4th paragraph, 6th line, page 39
The statement, “documented needs for a residential service only available in the CL waiver, such as group home residential” could be misleading. The two services in the CL waiver that are not available in the FIS Waiver are group home and sponsored residential. Other services provided in a residential 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. Case managers/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 their residence and in the 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 case manager/support coordinator, desire to have only one provider, and/or perceptions and experiences the parent(s) learned 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 case managers/support coordinators, and to encourage integrated living situations, even for those individuals with high level and intensity of need, DMAS should encourage the use of language that clarifies service delivery and supports, regardless of level or intensity, can be provided for in integrated living settings.
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 nor preferred by the individual.
Appendix B: Participant Access and Eligibility, B-6: Evaluation/Reevaluation of Level of Care, a. Reasonable Indication of Need for Services, i. Minimum number of services, page 48
DMAS has selected the minimum number of services 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, Quality Improvement: Level of Care, a. Methods for Discovery: Level of Care Assurances/Sub-assurance, page 52
The draft Agreement lacks methods to assure the satisfaction of individuals with the level of care they receive.
RECOMMENDATION: Solicit input regarding evaluation for FIS Waiver eligibility from individuals, and when appropriate their families. This should include information about their experience of establishing an appointment for initial evaluation, quality of information provided to the individual during the intake and assessment process, and understanding about the annual 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 case management/support coordination role in determining needs and status.
Appendix C: Participant Services, 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. Include any limitations or conditions that telehealth would be allowed in this service. Include the number of hours or percentage of billed units a month that the service can be provided by telehealth.
Appendix C: Participant Services, all service sections, starting page 64
The Service Definition narratives among the 29 services do not adequately 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 any back-up plans that are required for each service. For example:
Back-up plans are not 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: Service Specification, Group Day Services, Service Definition, page 65
A back-up plan is not stated as a requirement Group Day Services. Individuals using the FIS Waiver could be living in their own home and require daily intensive supports. If a Group Day Services provider closes due to weather or other unforeseen circumstances or the individual does not go to Group Day Services on a scheduled day or time, the individual may need to have a back-up plan in place to ensure they receive needed supports.
RECOMMENDATION: Clarify that a plan for Group Day Services should include a back-up plan.
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, 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: Provider Specifications for Service, 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 C: Participant Services, C-1/C-3: Service Specification, Individual Supported Employment, Service Definition, narrative, 1st paragraph, last sentence, page 73
The lack of assistance to use the restroom, to eat and drink, and to remove outdoor garments are significant ongoing, pervasive employment barriers. Assistance with these functions is difficult to schedule, the functions are typically brief, and not always performed at specific times during working hours. The draft Application states, “Personal assistance is not part of individual supported employment.” Page 170 of the draft Application goes on to limit personal assistance through Workplace Assistance if personal assistance is the sole purpose of Workplace Assistance. These service limitations leave an individual with one option, personal assistance services. However, personal assistance is difficult to schedule in brief 30-60 minute increments during the individual’s work hours. Individuals with DD are not able to predetermine exactly when they will need to use the restroom any more than an individual who is not disabled. Limiting their ability to use the restroom to a predetermined schedule is impractical, cruel, and shortsighted. Prohibiting Individual Supported Employment staff from providing this needed assistance when the staff are already present on the job site is a poor use of resources. The distinct FIS Waiver service of personal assistance services may be appropriate for the workplace, depending on the frequency, length of time and nature of the assistance. Each individual’s needs and circumstances are unique. However, an outright prohibition of these supports by Individual Supported Employment providers is inappropriate.
RECOMMENDATION: Individual Supported Employment should include assistance with personal assistance support, when needed, if the Individual Supported Employment staff are present when the assistance is needed. Personal assistance support should not be a significant percentage of time included in the individual’s plan for Individual Supported Employment. However, it should be permitted as one model to meet the personal assistance needs of individuals in their work place.
Appendix C: Participant Services, C-1/C-3: Service Specification, Individual Supported Employment, limits on the amount, frequency or duration of this service, 2nd paragraph, page 74
Individual Supported Employment is to be denied if the individual is “eligible for or receiving supported employment” funded by the Rehabilitation Act or the Individuals with Disabilities Education Act. There are individuals who may be eligible for supported employment through the Rehabilitation Act. These same individuals who are eligible, may be wait listed due to an order of selection process established by the Virginia Department for Aging and Rehabilitative Services (DARS) due to federal and/or state funding constraints.
RECOMMENDATION: FIS Waiver supported employment services should be provided to, if they are eligible for DARS supported employment services, but unable to access these services through DARS due to the lack of DARS funding.
Appendix C: Participant Services, C-1/C-3: Service Specification, Personal Assistance Services, Service Definition, narrative page 76
State Code allows personal assistance services to include some skilled nursing tasks through nurse delegation (54.1-3000).
RECOMMENDATION: Include language for nurse delegation, when appropriate, that follows the provisions in State Regulation 18VAC 90-19-240.
Appendix C: Participant Services, C-1/C-3: Service Specification, Personal Assistance Services, Service Definition, narrative, page 76
The draft Application states that individuals who elect to use consumer-directed services may choose a services facilitator to provide training and guidance. When an individual elects to use consumer-directed services, but does not choose a services facilitator for training and guidance, services facilitation is not required.
RECOMMENDATION: Include the process for the individual to initiate and continue consumer-directed services in the absence of services facilitation. This process should include a description of the role of the employer of record and role of the case manager/support coordinator.
Appendix C: Participant Services, C-1/C-3: Provider Specifications for Service, Consumer-Directed Attendant Care, Other Standard, narrative, 1st paragraph, 2nd sentence, page 79
The employer of record may be anyone qualified and chosen by the individual or other if the individual has a guardian.
RECOMMENDATION: Clarify that family members and caregivers are not the only persons who can be the employer of record for the individual. A friend, neighbor or other may serve as the employer of record.