On behalf of the Board of Directors and Membership of The Arc of Virginia, the following comments are in response to the request for public comment on Virginia’s Three Waivers Redesign Regulations.

The Arc of Virginia continues to support the spirit and intent of Waiver Redesign to create a system that supports people to live more integrated, independent and autonomous lives with the supports needed to do so in the community.  

The following is a list of questions or comments intended to help ensure that Virginia is accomplishing its’ goals of building a strong and robust community system of supports.  

Community Living (CL) Waiver Descriptions - Introduction

In the introduction to the new waivers, the language on the CL waiver should be more inclusive of all living situation types.  While nothing in the wording prohibits someone living in their own home using the CL waiver, we believe the term “24/7 residential support” could be mistaken to only mean group home settings.  There are many people using the CL waiver now, living in their own home and receiving 24/7 support services.

The Arc of Virginia suggests clarifying in the description of CL Waiver, that any setting may be included.  Recommend “This amended waiver will remain a comprehensive waiver that includes the option of 24/7 support services in a person’s residence”.   

Definitions - Assistive Technology

Assistive Technology can help a person to be more independent in any setting or environment, including home, work, school, social activities, etc….

The Arc of Virginia recommends changing the definition of Assistive Technology to include any place a person may be.  

Definitions - Positive Behavior Support

The Arc of Virginia recommends replacing this definition with the definition by the American Association of Positive Behavior Supports.  

Definitions - Service Authorization

The term “medical necessity” can be misinterpreted to mean that a service must be ordered by a physician rather than being developed by the person-centered planning process.  Medical necessity as required by Medicaid is already established in Medicaid regulations and should not be included in references to service authorization.

The Arc of Virginia recommends striking the work “medical”.  

Definitions - Supported Living

This definition refers to services taking place in an apartment setting.  There are people living in their own house receiving Supported Living services, this edit would just ensure regulation is not too prescriptive.  

The Arc of Virginia recommends editing definition to say “a service taking place in a person’s own home operated by a DBHDS licensed ….”

Waiting List Criteria - 12VAC30-122-90

We understand that the age of the caregiver was removed during waiver redesign, and we agreed that the age was too low.  However, many individuals/families know that the only way their adult child will get a waiver is when they die. Parents and individuals on the waiting list should not have to face this reality, they should be able to plan with for the future.  At some age, regardless of health, end of life becomes a reality, and families need to be able to prepare. Doing so saves the family in human costs, and saves the Commonwealth in financial cost by avoiding crisis scenarios.

The Arc of Virginia recommends that having a caregiver that is 70 or older, meets criteria for Priority One.

Assistive Technology - 12VAC30-122-270

This service can be invaluable in helping a person gain independence and access to opportunities to be included.  The use of AT is an investment that has potential for a high return on investment for the State. Some forms of AT can increase a person’s independence and decrease their need for staffing, thereby saving an ongoing cost from a one time investment.  There are currently examples of this in Virginia, where AT has been purchased for around $20,000 that resulted in an ongoing savings that is much higher. Most of these technologies will cost more than the $5,000 limit. Writing the regulation with such a hard stop, stifles innovation and misses the opportunity for ongoing costs savings year after year when a person’s need for staff is decreased.  Additionally, the benefit to the person using services is tremendous when the insertion of people into their home and lives can be decreased.

The Arc of Virginia recommends allowing the option to spend over $5,000 by submitting for approval a detailed Cost Benefit Analysis that outlines the anticipated savings following the initial investment.  Additionally, it is important to allow for creative AT that is part of today’s everyday advances in technology, not just disability-specific technology.

In Home Support Services - 12VAC30-122-410 - Section C2

The reference to medically necessary again may be misinterpreted to mean a physician order is necessary for this service to be provided for 24 hours when briefly needed.  The need for the 24 hour support should be documented in the person centered plan.

The Arc of Virginia recommends deleting “medically”, in “medically necessary”.  

In Home Support Services - 12VAC30-122-410 - Section C5

“The individual shall have a back-up plan for times when in-home supports cannot occur as regularly scheduled”.  First, this assumes that every person needs back-up when in-home supports has to be cancelled. For some people simply rescheduling the in-home service will work well for them.  Second, some people do depend on the supports for daily needs, and may not be able to make their own backup plan and would instead depend on the agency to provide a backup plan.

The Arc of Virginia recommends including agency backup plans for this requirement.  

Shared Living Support Services - 12VAC30-122-510

This is a service that has had a difficult time getting off the ground, but it is an excellent service that could benefit some people.  However, the administrative payment to the provider does not cover the services they are asked to provide in this definition. In the regulation is it unclear how often the provider is eligible for the flat fee noted.  

The Arc of Virginia believes in the value of this service and recommends that the method for administrative fees be reconsidered.  Similar to the Federal program Ticket to Work, an up front small payment to a provider for beginning a case with someone, followed by subsequent lump payments upon evidence of the desired outcome, could incentivize providers to innovate.  Additionally we recommend a minimum of $5,000 per year for the administrative fee.

Thank you for your consideration of these matters,

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