Thank you for the opportunity to comment on the proposed amended applications for the following 1915(c) Home and Community Based Services (HCBS) Medicaid Waivers: Commonwealth Coordinated Care Plus (CCC+), Community Living (CL), and Family and Individual Supports (FIS) Waivers.

We understand the need for sporadic adjustments to procedures and policies to maintain program effectiveness and sustainability, however we do have a few specific questions to the proposed changes (as they are presented in the General Notice):

Implementing a 56-hour soft cap limit on personal care/assistance with exceptions to request more hours to mirror the CCC+ Waiver (CL, FIS; Appendix C-1/C3):

The use of the term “application” throughout the General Notice is ambiguous.  It can be referenced as simply exercising new policies and procedures into processes and procedures, or “application” could be referencing the actual/formal Application itself.  This is important, specific to the 56 hours “soft cap”, because it is unclear if this new standard is generally going to be “applied” to all current/existing waivers, or is it being implemented  exclusively for new/initial “Applications”? Some clarity would help inform and support more comprehensive feedback.  

The current methodology for calculating needed hours (for non CCC+ waivers) is detailed, objective, and already reviewed and approved by DMAS officials.  Inserting a “soft cap” of 56 hours, only on the merits of reflecting consistency with CCC+ (interpreted based on the language used in the General Notice), appears at the surface to be an arbitrary and unnecessary layer.

Incorporating services facilitation into the statewide service broker model via the Fiscal-Employer Agent contract and eliminate services facilitation as a standalone service (CCC+, CL, FIS; Transition Plan, Appendix E).  Details of the transition are also available on the DMAS waivers page.

12VAC30-122-500 provides clear annotation of current Service Facilitator roles and responsibilities.  “Service Broker models” is not specifically mentioned or alluded to in 12VAC30-122-500.  The General Notice does not provide sufficient detail to assure that new models and procedures will align with existing regulations.  If significant deviations were to occur, should 12VAC30-122-500 first be amended?   

Personal experience with Service Facilitators over the past 11 years has been overwhelmingly positive.  With the lack of information in the General Notice, it is difficult to discern what corrections/improvements this new broker model will provide (over the existing Service Facilitator model).

Concluding thoughts:

It is important to stress (again) that we understand the need for adjustments/refinements to policies and procedures.  The overarching concern is lack of full clarity with the proposed changes as they notated in the General Notice.  Specifics of where and how 56 hour “soft caps” will be “applied”, and how new service broker models will operate (and whether they impact existing statute) are unclear.  

More comprehensive information will better assist with either supporting or questioning the proposed changes.  These are very high consequence decisions that have direct impact on physical lives.  A more comprehensive explanation, coupled with with Impact Assessments, and further assurances that critical care will not be disrupted, would be a more prudent approach to proposing and implementing change; and would further reduce litigative risk to the State.

Very respectfully submitted.