As one of 17 Virginia nonprofit community-based volunteer organizations (commonly known as Villages) that coordinates caregiver-like services to older adults, LOWLINC (Lake of the Woods Living Independently in Our Community) endorses Option 6 in the JCHC ‘Report on Strategies to Support Aging Virginians in Their Communities.’ Since 2016, LOWLINC has provided a range of volunteer services to older adults at Lake of the Woods in Orange County, allowing them to remain in their homes and avoid the need to access state-provided home caregiving services. LOWLINC services include transportation, light home maintenance, check-in calls and friendly visits, tech support and social/educational activities. We are also a referral source for screened service providers such as plumbers and electricians, and we assist members with meals and other support as they transition home after hospitalization. LOWLINC members, most of whom are not Medicaid eligible, pay a modest annual fee with subsidized memberships available for those with demonstrated need. LOWLINC is supported primarily through these membership fees, donations and small grants. The Village Model works! LOWLINC members, like older adults in other Villages, consistently report significant positive impact on their well-being and quality of life as a direct result of their participation in the Village. Starting a Village typically takes about two years of planning and a financial investment to cover marketing, website, insurance and other start-up costs. A grant program such as proposed in Option 6 would enable LOWLINC to expand the continuum of our home-based care services with care coordination that includes personal care, companion, and homemaker services. It also would provide support for extending the Village model to new and under-resourced communities, including in rural areas, with home and community-based care for older Virginians. Respectfully submitted, Emily Slunt, LOWLINC President, and Mary-Jane Atwater, LOWLINC Co-founder

Change Medicaid Rule so that eligibility for Community Based Care is the same for Nursing Facility Care The Department of Medical Assistance Services (DMAS) policy differentiates how it determines income spend-down for nursing facility care versus community-based care (CBC). This rule limits many applicants with higher incomes from accessing community-based care. It unnecessarily forces applicants for Medicaid coverage of long-term care into nursing facilities. This has a negative impact in two ways. First, these applicants would much prefer to receive long-term care services in their home and they have the social means to keep them safely at home. Second, the cost of care for Medicaid community-based care is less costly than nursing facility care. Therefore, there is a negative budget impact because of this rule. Medicaid policy under M1460.710B as interpreted by the Virginia Medicaid Manual is the issue. It states: The spenddown procedures for facility patients differ from the spenddown procedures for CBC patients. The expected cost of facility care is projected at the beginning of the month. The cost of care is not projected and must be deducted daily as incurred. This difference in the projection of the cost of care between facility patients and CBC patients denies access to CBC to many applicants. CBC patients rely on home care agencies that are willing to accept for payment the low Medicaid rates. Each month the patient must calculate the monthly home health care cost at the private rate, submit that to Medicaid, and hope for Medicaid approval for that month of care. Home health care agencies must bill at a private rate and submit the bill to the patient. The home care agency must then wait while DMAS compares the private rate cost of care to the patient’s monthly income. Only then does DMAS pay the home care agency. Home care agencies do not want to bill at a private rate that they will never receive and do not want to wait retroactively for payment. This must occur every month. Home care agencies are unwilling o provide services under this rule. This prevents many applicants from obtaining CBC coverage. The only exception to this rule is for applicants with a monthly income less than 300% of the SSI rate or about $2,250. These applicants are allowed to project expenses and therefore automatically receive Medicaid coverage for CBC. Home Care agencies are paid without delay. Applicants with higher incomes should be treated no differently. If the projected cost of monthly home care is greater than the applicant’s monthly income, then eligibility should be automatically provided all other criteria for eligibility is met. VAELA has confirmed with CMS that no federal rule or law prevents this proposed Virginia Medicaid change in policy. VAELA proposes the following: The spend-down procedures for CBC patients shall not differ from facility patients. The expected monthly cost of home care shall be projected at the beginning of the month.