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    Document Summary
    - Report Published -

    Report Document No. 76

    Document Title
    Review of Potential Waiver Changes and Associated Costs Related to Improving the Intellectual Disability (ID), Day Support (DS), and Individual and Family Developmental Disabilities Support (DD) Waivers

    Department of Medical Assistance Services

    Enabling Authority
    Appropriation Act - Item 297 BBBBB. (Regular Session, 2011)

    Executive Summary
    Section BBBBB of the 2011 Acts of Assembly directs the Departments of Medical Assistance Services (DMAS) and Behavioral Health and Developmental Services (DBHDS) to review of the current Intellectual Disability (ID), Day Support (DS) and Individual and Family Developmental Disabilities Supports (DD) Waivers to identify any improvements and report on the proposed waiver changes and associated costs. The language further requires that the Departments consult with appropriate stakeholders and national experts in order to increase the efficiency and cost effectiveness of the waivers, enable more individuals to be served, strengthen the delivery of person-centered supports, enable individuals with high medical needs and/or high behavioral support needs to remain in the community setting of their choice and provide viable community alternatives to institutional placement. This document is intended to meet the requirement of such a review.

    Virginia’s home and community-based services (HCBS) waivers are funded by the Medicaid program to enable individuals to receive long-term care services in a less restrictive community setting in a more cost effective manner than if the individual had been placed in an institution. Section 1915 (c) of the Social Security Act allows states, with the approval of the Centers for Medicare and Medicaid Services (CMS), to “waive” certain federal requirements in the provision of Medicaid services. The Commonwealth developed the ID, DS and DD Waivers to “target” services to individuals with developmental disabilities (DD), including intellectual disability (ID). The ID Waiver, serving individuals with intellectual disability, was created in 1991; the DD Waiver, serving individuals with a developmental disability over the age of six, was created in 2000; and the DS Waiver was created in 2005 to serve individuals with intellectual disability who were on the waiting list for the ID Waiver. The three waivers differ in size based on past decisions of state lawmakers; the ID, DS and DD Waivers are currently authorized to serve 8,937, 300 and 803 individuals, respectively (as of July 2011). Waiver “slots” are approved and funded by the Virginia General Assembly and subsequently approved by CMS to identify the number of individuals to be served and to draw down the federal matching funds. The ID and the DD Waivers have significant waiting lists, 5,825 and 1,127 respectively.

    Each waiver was originally designed to meet the specific needs of the individuals with ID or DD; however, as developmental disabilities is an umbrella term which includes individuals with intellectual disability, many states have reviewed the administration and array of waiver services available to individuals with DD, including ID, and designed a single comprehensive waiver covering both populations. Input from individuals with DD/ID and their families support an expanded array of available services and housing options. To this end, this report addresses these areas and frames improvements for the ID, DS and DD Waivers in short and long-term strategies.

    Short-term enhancements include options to adjust the Medicaid provider rates to increase availability of smaller residential settings (group homes of four beds or less and in-home residential supports); to enhance services to individuals with high medical and/or behavioral needs by creating an exceptional rate for individual receiving residential support services; and, to increase the number of services available in the DS Waiver. As any change to a HCBS waiver requires prior approval of CMS, amending the existing waivers is a less rigorous process than making major structural changes to a waiver (i.e. changing the target population, modifying the case management structure, adjusting the waiting list process, etc). Long-term enhancements are more appropriately handled through the waiver renewal process that could include the major structural changes mentioned previously, as well as realignment of the state responsibilities related to administrative oversight and financial accountability of the ID, DS and DD Waivers.