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🚨 Speak Up Now: Make Your Voice Heard — Public Feedback Is Needed 🚨
Waiver Changes &
✅ How to Submit Your Public Comment (It’s Easy!)
We’ve made this as simple as possible—just follow the steps below to speak up:
Click on the Pre-Generated Template Link
Scroll through the options and choose the one that best fits your role or concern (caregiver, provider, case manager, etc.).The Full Comment Will Open Automatically
Each link opens a complete, ready-to-send email in your browser or email app—all the talking points are already filled in for you.Review and Personalize (Optional)
Feel free to add a personal sentence or two at the top if you’d like to share your story or perspective—but you don’t have to.Click Send
Double-check the email address and subject line (already pre-filled), then hit send! That’s it—you’ve submitted your comment.
🕓 Deadline to submit is August 8, 2025. Don’t wait!
Pre-Generated Templates for the Current Waiver Changes
Health & Wellness / TBI / Pathways Waivers
Structured Family Caregiving
New SFC requirements would add excessive oversight, take away virtual options, and pile on more documentation and in-person training—even for experienced caregivers.
Structured Family Caregiving
New SFC requirements would add excessive oversight, take away virtual options, and pile on more documentation and in-person training—even for experienced caregivers.
🔹 Main concerns:
Too many required home visits, including by a nurse
No option for virtual check-ins
8-hour in-person training with no flexibility
Mandatory digital-only paperwork, leaving some caregivers behind
Increased daily documentation, even about medications
Agencies must write quarterly reports duplicating case manager work
Risk of caregiver stipend cuts due to added unfunded responsibilities
Ask the state to reduce red tape, keep caregiver pay strong, and support flexibility in how families meet program requirements.
“Extraordinary Care” Definition Is Too Medical
Redefines extraordinary care to mean only skilled nursing tasks (like ventilators/trachs) — cutting off support for people who need hands-on or supervisory help.
🔹 Affects: Attendant Care (ATTC) & PAC
🔹 Excludes: People with high behavioral, cognitive, or functional needs
🔹 Suggests: A fair, function-based definition
Limits on Relatives as Paid Caregivers
Limits on Relatives as Paid Caregivers
New rules would limit which relatives can be paid caregivers and cap their hours at 40 per week, even when more care is needed.
Expands the definition of relative to include aunts, uncles, cousins, and in-laws — then limits what care they can provide
Makes it harder for families who rely on trusted extended relatives
Introduces these changes without properly listing them in the public summary
Could force families to choose between trusted care and access to service
Attendant Care
Option 1 – Personal & Direct (Plain Language)
Attendant Care
Option 1 – Personal & Direct (Plain Language)
Written like a caregiver talking directly to the state
Focuses on just two main issues:
→ The hourly progress note requirement
→ The 40-hour cap on family caregiversEasy to read, emotional, and relatable
Best for caregivers who want to share their voice but don’t want to dive into technical language
Attendant Care
Option 2 – Personal + System Impact
Attendant Care
Option 2 – Personal + System Impact
Blends caregiver experience with broader system concerns
Highlights how the changes will:
→ Increase caregiver burnout
→ Leave out key daily living supports
→ Limit family choice and create care gapsMore detailed than Option 1 but still accessible
Great for people who want to explain why the policy just won’t work
Attendant Care
Option 3 – Legal & Policy-Focused
Attendant Care
Option 3 – Legal & Policy-Focused
Most technical and detailed version
Cites federal law and HCBS regulations (like Olmstead, ADA, and CMS rules)
Discusses deeper concerns like:
→ Documentation burdens tied to EVV systems
→ Violation of participant choice
→ Gaps in allowed Attendant Care services
→ Structural barriers caused by requiring denials from schools or State Plan servicesIdeal for advocates, providers, or policy-savvy caregivers
Family Support / CIH Waiver
Limits on Music Therapy
Limits on Music Therapy
The overarching message is that the proposed changes are restrictive, burdensome, and violate federal regulations, ultimately harming individuals who rely on waiver services.
This comment advocates for:
Removing the 6-hour monthly cap on Music Therapy.
Reducing excessive documentation requirements.
Reaffirming Music Therapy as a habilitative (life skills/support) rather than strictly clinical (medical treatment) service.
Limits on Recreation Therapy
Limits on Recreation Therapy
The overarching message is that the proposed changes to Recreational Therapy are overly restrictive, administratively burdensome, and conflict with federal HCBS requirements, ultimately harming individuals who rely on this service for community participation, emotional regulation, and life skills development.
This comment advocates for:
Removing the 6-hour monthly cap on Recreational Therapy,
Reducing excessive quarterly documentation requirements
Reaffirming Recreational Therapy as a habilitative service that supports inclusion, independence, and functional skill-building—not just as a medically-coded service constrained by clinical standards.
Comments on Day Habilitation
Comments on Day Habilitation
The overarching message is that the proposed changes to Day Habilitation are overly burdensome, restrict flexibility, and undermine person-centered, community-based care. Excessive documentation requirements, rigid service planning rules, and limits on real-world activities shift the focus away from inclusion and skill-building toward compliance and paperwork.
This comment advocates for:
Simplifying daily and quarterly documentation expectations
Allowing support for real-life skills like shopping, errands, and appointments
Covering reasonable participation costs for inclusive community activities
Supporting emerging interests without requiring pre-approved PCISP entries
Preserving provider flexibility to deliver meaningful, person-centered services in natural settings
Excessive Documentation & Risk of Reduced Pay for PAC services
Excessive Documentation & Risk of Reduced Pay for PAC services
Indiana is proposing new rules for Participant Assistance and Care (PAC) that would severely disrupt access to care and hurt caregivers.
Indiana is proposing new rules for Participant Assistance and Care (PAC) that would severely disrupt access to care and hurt caregivers.
🔹 Require a nurse on staff or on-call
Even though PAC is a non-medical service, the new rule misclassifies it as clinical—adding unnecessary cost, liability, and barriers for small providers.
🔹 Mandate hour-by-hour documentation, including:
▫️ A detailed summary of tasks completed
▫️ The outcomes of those tasks
▫️ Exact start and end times with a.m./p.m.
▫️ Note any medical, behavioral, or other unusual events that occurred
▫️ Two signatures—for every single hour of service provided
📉 The waiver includes no increase in reimbursement to offset this massive new administrative load—meaning caregiver pay will almost certainly drop as more time will need to go to admins verifying paperwork is correct.
⚠️ These changes:
– Shift focus away from the individual’s needs
– Create unrealistic burdens for family caregivers and small providers
– Will make it harder for people with disabilities to remain safely at home
Changes with Behavioral Support Services:
Changes with Behavioral Support Services:
Only one type of support (like consultation or FBA) can be billed per month—even if the person needs more help that month
Strict yearly time limits for a behavior assessment
Excessive paperwork and template uploads required for every service
The state is eliminating Intensive Behavioral Intervention (IBI), a high-level support for people with severe behavior needs
Changes with Extended Services:
Changes with Extended Services:
This template highlights 5 key concerns with Indiana’s proposed Extended Services waiver changes — and offers specific solutions to fix them.
Documentation Overload – Too much paperwork, even for stable jobs
Group Size Limits – Restrictive ratios that hurt peer learning
No Transportation Help – No mileage or job-related ride support
No Volunteer/Intern Support – Blocks transitional job opportunities
Remote Work Barriers – Vague rules may exclude home-based self-employment
Changes with Facility-Based Support Services:
Changes with Facility-Based Support Services:
The proposed Facility-Based Support Services in Indiana’s December 2025 waiver draft raise serious concerns, including segregation from the community, inadequate staffing ratios, exclusion of real-life skill-building activities, and an unsustainable $2.51/hour reimbursement rate.
This template calls for:
✔️ Reducing excessive and redundant paperwork
✔️ Community integration
✔️ Lower staff-to-participant ratios
✔️ Coverage of activity costs
✔️ A reimbursement rate that ensures safety, access, and quality
Medicaid Waiver Provider Drafts & Concerns
PROVIDER: Attendant Care (Detailed)
PROVIDER: Attendant Care (Detailed)
Written For: Agency administrators and provider organizations
🔹 Key Concerns:
Narrowed definition of care
40-hour cap on family caregivers
Burdensome hourly progress notes
Duplicative quarterly reports
Forced denials from other programs
Audience: Ideal for providers or directors who are actively involved in advocacy or policy discussions and want their comment to carry more weight.
PROVIDER: Attendant Care (Brief)
PROVIDER: Attendant Care (Brief)
Written For: Agency administrators and provider organizations
🔹 Key Concerns:
Narrow definition excludes essential ADL/IADL supports.
40-hour weekly cap on family caregivers is too restrictive.
Hourly documentation requirements are unworkable.
Quarterly narrative reports duplicate case manager duties.
Requirement to first be denied by other programs is inequitable.
Audience: Ideal for busy agency providers who agree with the concerns and want to voice opposition quickly without customizing a letter.
PROVIDER: Structured Family Caregiving (In-Depth)
Written For: Agency administrators and provider organizations
🔹 Key Concerns:
Calls to clarify stipend-based model to reduce the risk of caregiver reclassification as employees
Unfunded mandates (monthly nurse visits, daily logs, in-person training)
Respite policy confusion and unclear agency responsibilities
Below-minimum compensation for 24/7 care
Burdensome documentation and oversight requirements
PROVIDER: Structured Family Caregiving (Brief)
Written For: Agency administrators and provider organizations
🔹 Key Concerns:
Opposing unfunded mandates (e.g., RN visits, in-person training)
Pushing for flexibility in documentation and oversight
Clarifying non-employment status of caregivers
Addressing duplicative responsibilities and burdens
Case Management – For Case Managers
Case Management – For Case Managers
Written from the viewpoint of a current case manager
Focuses on 3 major concerns:
→ Excessive documentation expectations without added support
→ Clinical and medical oversight duties being pushed onto CMs
→ Legal, financial, and contractor-related tasks beyond the CM role
Best for case managers who want to speak out about unrealistic expectations and role overreach.
Information about the December 2025 Waiver Draft Proposals
Email your comments to:
Pathways: backhome.indiana@fssa.in.gov
Health & Wellness Waiver/TBI/CIH/Family Supports Waiver:
ddrswaivernoticecomment@fssa.in.gov
Mention which waiver you are commenting on in the subject line!
Fact Sheet Proposed Changes - Provided by FSSA
Fact Sheet Proposed Changes - Provided by FSSA
Points of Concern – Family Solutions Home Care (Julie McGill)
Summary of Main Proposed Changes & Program Failures of Structured Family Caregiving (SFC)
Unrealistic Daily Data‑Collection
Demands comprehensive daily logs requiring an excessive amount of datapoints (health, behavior, sleep, diet, medications*, activities) akin to clinical settings—unsustainable for family homes.
*Medication Logs raises legal concerns over medication monitoring by unlicensed caregivers.
Forces all daily notes and reports into digital systems, disadvantaging caregivers with poor internet access or low digital literacy.
Excessive In‑Home Oversight Requirements
Mandates one home visit/month—two by an RN/LPN annually—beyond existing case manager, nursing, and therapy visits.
No virtual‐visit option, creating unnecessary logistical, health, and equity barriers.
Duplicative Quarterly Progress Reports
Requires SFC providers to submit narrative outcome reports—duplicating case manager and other provider reviews and overstepping care coordination roles.
Rigid In‑Person Training Mandate
Requires 8 hours of in‑person training with no timeline, virtual alternative, or recognition of existing caregiver expertise.
Below‑Minimum Wage Compensation
Even at the top tier—with an 80% pass‑through of the $133.44 daily stipend—caregivers earn just $4.45 per hour for 24‑hour coverage (or $6.67 per hour based on a 16‑hour active shift), and they receive no overtime pay.
Summary of Main Changes in the Revised Attendant Care
Unprecedented Documentation Burdens
Mandates detailed hourly progress notes for every attendant hour (timeframe, tasks, issues, individual entries per staff), plus a duplicative quarterly outcomes report—far exceeding typical non‑clinical or clinical standards and creating serious operational and compliance risks.
Intensive Needs Can Use LRIs *RARE EXCEPTION*
Must need intensive nursing care needs such as: continuous ventilator care, tracheostomy care, or Total Parenteral Nutrition (TPN) to qualify.
Rigid 40‑Hour Cap on Family & LRI Caregivers
Imposes a blanket 40‑hour/week limit on services provided by relatives, legal guardians, or other legally responsible individuals—regardless of assessed need or local provider availability—undermining participant choice and forcing potential institutionalization.
Ambiguous “Hands‑On Nutrition” Restriction
Limits nutrition support to undefined “hands‑on” tasks (e.g., meal planning/prep), leaving out critical non‑touch assistance like verbal prompting, supervision for choking safety, or coaching for independence.
New Barriers & “Care Gaps” Through Exhaustion Requirements
Requires families to first exhaust EPSDT/FAPE and State Plan home‑health services (even when unavailable) before approving ATTC, and forbids waiver coverage for low‑risk tasks deemed “nursing only,” creating regulatory traps that delay or deny needed support.
Extraordinary Care Definitions for LRI allowances
1. Attendant Care (ATTC) & Participant Assistance & Care (PAC)
1. Attendant Care (ATTC) & Participant Assistance & Care (PAC)
Who Qualifies: Intensive nursing supports (ventilator, trach, TPN, etc.)
2. Structured Family Caregiving (SFC)
2. Structured Family Caregiving (SFC)
Who Qualifies: Those with medical conditions requiring non-medical ADL/IADL support, supervision, behavioral cueing, etc.
Key Concerns
Behavioral supervision, cueing, and 24/7 oversight are every bit as “extraordinary” as ventilator or tracheostomy care and should be included to reflect true service needs.
By tying “extraordinary care” solely to skilled medical tasks, the draft excludes individuals with high functional or behavioral needs—this contradicts 42 CFR § 441.301(c)(4)(iii), which bases service eligibility on assessed need, not on a medical diagnosis.
The waiver should harmonize the “extraordinary care” definition across SFC, ATTC, and PAC to prevent case‐by‐case confusion and inequitable access within the same program.
“Relative” Definition & Arbitrary 40-Hour/Week Cap
Now includes a overbroad “Relative” Definition
Expands “relative” to include distant and non‑household family members, then limits their ability to provide care—undermining trusted, qualified caregivers.
Parent of an Adult (natural, step, adopted, in‑law)
Grandparent (natural, step, adopted)
Uncle (natural, step, adopted)
Aunt (natural, step, adopted)
Brother (natural, step, half, adopted, in‑law)
Sister (natural, step, half, adopted, in‑law)
Child (natural, step, adopted)
Grandchild (natural, step, adopted)
Nephew (natural, step, adopted)
Niece (natural, step, adopted)
First Cousin (natural, step, adopted)
Arbitrary 40‑Hour/Week Cap
Imposes a flat limit on family‑provided Attendant Care regardless of assessed need, forcing some families toward more fragmented or institutional options.
Harmful Changes to Music Therapy
1. Drastic Reduction in Annual Service Limits
1. Drastic Reduction in Annual Service Limits
What’s Changing:
Music Therapy is being capped at 6 hours per month (down from ~20 hours/month in previous drafts).
💥 Why This Matters:
This is a significant cut in service availability, with no regard for individual need or therapeutic goals.
The new limit applies across the board—no mention of exceptions, prior authorizations, or tiered limits based on severity or progress.
Families may be forced to abandon or drastically scale back therapy targeting emotional regulation, communication, or sensory integration.
2. Documentation Requirements Create an Unsustainable Burden on Providers
2. Documentation Requirements Create an Unsustainable Burden on Providers
What’s Changing:
Each session must now include:
The specific goals addressed
The methods and activities used
Observed outcomes
Progress toward each goal
🛑 Why This Matters:
Providers will spend more time writing than engaging with participants.
Small agencies and solo practitioners may be unable to meet these new standards without sacrificing time or revenue.
No rate increase is proposed to reflect the added workload—therapists will effectively be paid less per hour of service.
📌 Recommendation:
Scale documentation expectations to align with HCBS’s intent of flexible, person-centered care—not medical-model charting.
3. Documentation Standards Shift Music Therapy Toward a Clinical Medical Model
3. Documentation Standards Shift Music Therapy Toward a Clinical Medical Model
What’s Changing:
Therapists must now document treatment-style data after every session, implying that services must produce clinical, measurable outcomes.
🛑 Why This Matters:
Not all participants use Music Therapy for medical or behavioral treatment.
Many rely on it for expressive, functional, or regulatory purposes—such as improving mood, communication, or focus.
The new standard suggests that Music Therapy must be medically justified, undermining person-centered flexibility.
🎯 Bottom Line:
This approach is inappropriate for many HCBS participants and contradicts the person-centered principles in 42 CFR §441.301(c).
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