PHOTO: Medicaid expansion

Gov. Ralph Northam speaking on the steps of the State Capitol before signing budget bills that expanded Medicaid.

MY colleagues and I at Virginia’s Medicaid agency have heard from members who experienced a reduction in personal care hours for services in their home, including meal preparation and bathing, due to recent policy changes.

We’ve been working to find solutions, and I’m happy to report that we have achieved some meaningful progress.

Our agency recently reached agreement with the Centers for Medicare and Medicaid Services (CMS) to reverse a policy implemented last year that impacted some of our young members under age 21 who receive personal care services.



In September 2018, Virginia Medicaid was instructed to begin evaluating personal care hours based on criteria established in our Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. As a result of this policy change, decisions about the number of personal care hours approved for individual members were strictly focused on an assessment of medical necessity.

Of the members who saw a change under this policy, 5 percent experienced an increase in the number of personal care hours available to them, while nearly 12 percent saw a decrease in hours of care.

We were concerned about the impact of this policy change, and the letters we received from our members validated those concerns. With these powerful testimonials in hand, we went back to CMS officials and reached agreement to return to our previous policies for determining personal hours of care.

Starting May 1, 2019, our agency is once again evaluating the number of personal care hours required for our members based on criteria outlined in our Commonwealth Coordinated Care Plus (CCC Plus) Waiver.

Rather than a rigid measure of medical necessity, these criteria are based on an assessment of the services needed for members to remain in their homes and their communities if they choose that option over institutional care.

We have reached out to our existing providers and members to let them know that they can request a review of decisions made prior to May 1.

We are gratified to know that we have been able to offer relief for children and young people who rely on us for this important health benefit.

But we realize we have only partly resolved the challenges related to personal care. Some of our adult members have also seen their personal care hours reduced. In these cases, the solution is more complex and will require individual review to make the right decisions.

The Virginia Department of Medical Assistance Services has a duty to the commonwealth’s taxpayers to make sure the dollars they invest in our program are spent wisely. We have implemented policy and budget actions to strengthen protections against fraud.

There are cases in which a reduction in hours is appropriate and legally necessary, but we want to ensure that services meeting the criteria are kept in place and, most important, that we are helping to improve the health and wellness of Medicaid members.

Moving forward, we are working to improve our data analytics tools so that we can be vigilant in preventing fraud while ensuring that decisions are made based on a holistic understanding of each member’s needs.

I am proud of Virginia’s decision to expand eligibility for Medicaid, a decision that has given more than 280,000 men and women life-saving health coverage.

This transformational change in our program has inspired us to become a more member-focused Medicaid agency. We are pursuing that goal through more open communications with our members, a new member advisory committee and other policies. We still have a lot of work to do, and we value the feedback we receive from our members.

Our goal as an agency is to do a better job every day and to always do what is right for our members. Let us know how we are doing.

I promise you, we will be listening.

Dr. Jennifer S. Lee is director of the Virginia Department of Medical Assistance Services.