Family Support / CIH Waivers

Comments on this draft FS amendment will be accepted until 4:30 PM Eastern Time August 8, 2025, via email to DDRSwaivernoticecomment@fssa.IN.gov or via mail to the address below. FS Waiver Amendment Public Comment c/o Division of Disability and Rehabilitative Services 402 W. Washington St., #W453 P.O. Box 7083, MS26 Indianapolis, IN 46207-7083

Public Comment on December ‘25 Drafts of Indiana’s Family Supports & CIH Waivers

I am writing to express significant concerns regarding the proposed changes to Indiana’s Family Supports Waiver (FSW), as outlined in the December 2025 draft. While the waiver reflects some efforts to strengthen oversight and alignment with federal policy, several provisions—especially when contrasted with the July 2025 version—introduce excessive administrative burdens, reduce flexibility for families, and create potential legal and operational conflicts with federal Medicaid regulations and civil rights law.

These changes, taken together, represent a shift away from person-centered planning and equitable access, and toward a more institutionalized, compliance-driven model that risks reducing both quality and availability of services. Many of the new provisions appear to conflict with federal requirements outlined in 42 CFR §441.301, the Americans with Disabilities Act (ADA), and CMS’s own 1915(c) Technical Guide.

The following concerns highlight how the current draft would negatively affect individuals receiving care, their families, and the provider network tasked with delivering these essential services.

A. Limited Access for Individuals Transitioning from the Health & Wellness Waiver

The December 2025 draft again reserves only 100 slots for individuals losing Nursing Facility Level of Care (NFLOC) under the Health & Wellness Waiver, despite concerns raised in the previous waiver cycle. There is no evidence that this is sufficient for the large number of individuals expected to lose NFLOC eligibility on the H&W Waiver.

Without a clear justification or adjustment mechanism in Appendix B-3, this fixed cap risks delaying or denying access to eligible individuals who meet ICF/IID level of care—placing Indiana at odds with 42 CFR §441.302 and the Olmstead v. L.C. mandate to avoid unnecessary institutionalization.

B. Elimination of Intensive Behavioral Intervention (IBI)

The removal of IBI as a service under the FSW reflects a deeper systemic failure. IBI was effectively priced out of reach for most, then eliminated entirely before access could be equitably expanded. This decision was not due to a lack of need but a lack of investment. Commenters previously urged the state to fund IBI outside the cap; instead, the state acknowledged the concern, promised future consideration, and then removed the service without offering a meaningful alternative. Eliminating a clinically intensive service that was largely inaccessible does not resolve the underlying need—it merely removes the state’s obligation to address it..

C.  PAC Documentation and Oversight Requirements

Instead of enhancing flexibility and preserving natural supports, the proposed changes to PAC services introduce clinical-style oversight, excessive administrative burden, and restrictions that reduce access and equity—especially for family caregivers and small providers.

Most notably, the draft introduces hourly documentation requirements so excessive they surpass those used in many clinical settings. Every hour of PAC must now include The requirement for "detailed task summary," "outcome notes," and "progress toward outcomes and goals" on an hourly basis, along with dual signatures start and end times, service location, two caregiver/participant signatures, and credential verification. This level of micromanagement is unrealistic for natural supports, small agencies, and family caregivers—and it comes with no increase in reimbursement to reflect the new burden.

Instead of supporting caregivers, this framework will force agencies and families to divert time and resources away from direct care and into paperwork. The result is predictable: less time for care, lower caregiver wages, fewer participating providers, and diminished service quality.

PAC is designated under CMS service category 08: Home-Based Services, specifically as both 08010 (home-based habilitation) and 08030 (personal care). These are non-clinical, non-medical support services designed to assist with daily living, promote safety, and support basic skill maintenance within the home and community setting. This draft requires PAC providers to have a licensed nurse (RN or LPN) on staff or on-call—a drastic departure from the original intent of PAC as a non-medical service. Imposing licensed nursing oversight on non-medical services  far exceed what is appropriate for its federal classification and creates serious consequences:

• Drives up costs for small providers and family-run agencies.

• Adds an unnecessary clinical layer that deters providers and complicates service delivery.

Even more concerning, this change directly conflicts with the principle of self-direction. How can families be expected to self-direct PAC services if they are required to hire or contract with a nurse? This requirement undermines the intent of PAC, discourages flexibility and self-direction, and risks excluding capable caregivers who already provide high-quality personal support.

The inclusion of nursing requirements without medical necessity documentation may violate both CMS policy and the HCBS Settings Rule, which prohibits institutional features and unnecessary service barriers in community-based care (42 CFR §441.301(c)(4)).  

Finally, PAC remains one of the few services restricted to hourly billing. For families and providers coordinating care efficiently, PAC should be billed in 15-minute increments, like Attendant Care, to reduce service fragmentation and support flexible use. It is also unclear what documentation is required to support reimbursement for “participating on the IST for the development or revision of the PCISP.”

D. Structured Family Caregiving (SFC)

The SFC model under FSW has long been overly burdensome, requiring monthly in-home visits and nurse oversight regardless of the individual’s medical needs. Instead of revisiting and reducing these requirements to align with public comments requesting less intrusive models used in other waivers (H&W, TBI, PathWays), the state is attempting to expand this overly surveilled model system-wide.

The increased requirement for caregivers to log multiple data points (mood, nutrition, supervision, behavior, goals, etc.) every single day reflects a clinical oversight model, not a person-centered support framework. These expectations are unrealistic and misaligned with the day-to-day nature of family caregiving.

Mandatory Monthly Visits with Nursing Oversight: Requiring at least two RN or LPN visits per year for a non-medical service is unnecessary and costly. These rules may prevent SFC participation by agencies that do not employ licensed nurses—especially those operating in rural or underserved areas.

This is the wrong direction. Rather than using SFC in the FSW as a template for other waivers, Indiana should have reformed the FSW model to align with CMS guidance favoring person-centered, least-restrictive, non-duplicative care models (see 42 CFR §441.301(c)(1) and (4))

E. Music and Recreational Therapy: Arbitrary Caps and Excessive Documentation

 The December 2025 draft imposes arbitrary caps and burdensome requirements on both Recreational Therapy and Music Therapy services—proposals that conflict with person-centered planning principles and federal HCBS regulations (42 CFR §441.301 and §441.302).

• • Arbitrary 6-Hour Monthly Caps: Both services are capped at six hours per month, regardless of individual need, directly violating 42 CFR §441.301(c)(1), which requires service amounts to be based on assessed need. This also risks violating Olmstead by limiting access to supports necessary for community inclusion.

  • Excessive Documentation Requirements: Providers are expected to produce quarterly narrative reports, detailed system uploads, and—in the case of Music Therapy—session-by-session clinical charting. These are disproportionate for habilitative services, impose administrative burden, and discourage provider participation.

  • Mischaracterization of Purpose: Recreational and Music Therapy are habilitative services supporting social engagement, emotional regulation, and functional life skills. Forcing them into a rigid “medical” framework dilutes their value and restricts flexibility.

F. Behavior Support Services

The changes to Behavior Support Services in the December 2025 draft create too many restrictions and make it harder for people to get the help they need when they need it. Although the updated language talks about quality of life and person-centered goals, the way the service is set up does not match how support actually works in real life.

• • Only one kind of help per month: The draft says providers can only bill for one type of support each month (like consultation, an FBA, or ongoing support). But in real life, people often need more than one kind of help at the same time—especially during a crisis or big life change.

  • Tight limits on hours: There are strict yearly limits on how many hours a person can get for each type of service (like 20 hours for an FBA or 36 for consultation). These limits could leave someone without support later in the year, even if they still need it.

  • Too much paperwork: Providers are being asked to fill out multiple forms, collect signatures, and submit detailed reports that take a lot of time and don’t always improve care. This takes time away from helping people and adds pressure to small providers.

Behavioral support should be built around the individual—not a billing structure. These changes risk undermining person-centered planning and will make it harder for families to find qualified help and get the right support at the right time. 

G. Day Habilitation: Undermining Community Inclusion and Adding Burden

The proposed changes to Day Habilitation appear to increase oversight but actually undermine person-centered care, discourage community inclusion, and create unnecessary administrative burdens for providers and families. 

Daily logs, multiple signatures, and quarterly reports tracking staffing ratios and even “positive life events” turn habilitation into a paperwork exercise. These documentation demands reduce time for direct engagement and disproportionately burden small providers without improving actual outcomes.

Even more concerning is the exclusion of natural, real-world activities like shopping, banking, and errands—even when they align with an individual’s goals. These are some of the most effective ways to foster independence and community integration. Removing them strips the service of its most valuable teaching tools.

Compounding the problem, providers are prohibited from billing for basic participation costs like entry fees or tickets. This shifts financial responsibility to families, creating inequities and deterring participation—especially for lower-income individuals.

Requiring every activity to be pre-written into the PCISP further restricts flexibility. It prevents participants from trying new things, adjusting to their interests, or making spontaneous choices—undermining person-centered planning and natural autonomy.

Instead of supporting engagement, these changes emphasize compliance, restrict opportunities, and disconnect Day Habilitation from real life. The waiver should be revised to reduce administrative burden, restore support for authentic community-based activities, and allow flexibility that reflects the lived experience of the people it serves.

H. Prevocational Services – Excessive Reporting Burden

The draft introduces high-volume documentation for prevocational services, even though these are designed as habilitative and transitional supports. This discourages provider participation and shifts attention away from skill-building and engagement.

I. Extended Services: Barriers to Employment Success

While supporting competitive employment is vital, the proposed Extended Services model in the December 2025 waivers is fundamentally flawed. Its rules impose overly burdensome documentation and restrictive group sizes. Crucially, it fails to address transportation barriers and excludes vital transitional work experiences like internships. Moreover, ambiguous self-employment language risks limiting opportunities. These combined flaws will severely hinder access for individuals, deter essential providers, and ultimately undermine the very goal of successful, integrated employment.

J. Facility-Based Support Services: A Discredited and Harmful Model

The Facility-Based Support Services model, though technically available, is effectively unusable in practice—likely due to poor design, underfunding, and fundamental misalignment with HCBS principles

• • A 1:16 staffing ratio, which is unsafe for participants who need hands-on ADL or medication support.

  • Excessive documentation requirements, including daily logs, multiple signatures, and quarterly reports, which discourage participation by small and community-based providers.

  • No reimbursement for skill-building in the community or for transportation, limiting access to meaningful activities.

  • A reimbursement rate of only $2.51/hour, which is wholly insufficient to pay qualified staff or meet basic standards of quality and safety.

K. Extraordinary Care Definition

The use of a skilled nursing-based definition of “extraordinary care” within Participant Assistance and Care (PAC) under the Family Supports Waiver (FSW) is fundamentally misaligned with the intent of the service and the needs of the individuals it serves. The FSW is designed for individuals who meet the ICF/IID level of care as defined in 42 CFR § 440.150, which primarily includes people with developmental disabilities, such as autism, Down syndrome, cerebral palsy, and intellectual disabilities.

Most individuals in this population:

• Do not have medical devices like ventilators, tracheostomies, or TPN;

• Do require high levels of daily support, including total assistance with ADLs, behavioral supervision, and frequent redirection or cueing;

• Are not medically complex in the traditional sense, but are often functionally and cognitively dependent on caregivers to remain safely in the community.

If the PAC service is limited to those who meet a high-acuity medical standard—such as requiring skilled nursing tasks—it effectively excludes the entire intended population. The vast majority of individuals who rely on PAC would be disqualified under this definition, despite needing extraordinary levels of daily care and supervision to avoid institutionalization.

These needs may include:

• Full physical assistance with toileting, bathing, transferring, dressing, and eating;

• 1:1 supervision to prevent self-harm, elopement, or aggression;

• Constant redirection, emotional regulation support, or cueing for basic tasks;

• Assistance with navigating daily routines, medical appointments, and community outings.

The proposed definition dismisses these critical supports simply because they are not classified as “skilled medical”, despite being both intensive and essential. This is not consistent with the purpose of PAC and violates the principles of person-centered planning under 42 CFR § 441.301, which require that services be based on functional need, not on the presence or absence of specific medical procedures.

In effect, the definition implies: “Unless the person has a ventilator or trach, their care is not extraordinary.” This is not only inaccurate—it is harmful and devalues the lived experience of individuals with intellectual and developmental disabilities and their families. It renders a vital waiver support functionally inaccessible and invites inconsistent interpretation, ultimately placing individuals at increased risk of crisis or institutional placement.

L. Service Fragmentation in Workplace Support

The waiver unnecessarily splits job-related support across multiple services (PAC and Workplace Assistance), and explicitly prohibits Workplace Assistance providers from supporting job coordination or transitions outside of paid hours. This undermines the effectiveness of employment support, limits continuity, and contradicts CMS guidance encouraging integrated, individualized employment strategies. 

M. Home/Vehicle Modifications & Specialized Equipment

The requirement for two itemized bids creates access barriers in areas with limited vendors which even in a large city, there may only be 1 option. In practice, this results in delays, reduced provider participation, and higher long-term costs. Restricting selection to the lowest bid also risks poor-quality outcomes when providers with less experience are chosen solely due to price. Many other states have moved to a “best value” bidding model, which allows consideration of contractor qualifications, timelines, references, and prior experience with accessibility modifications to ensure safe, durable results.

A related equity issue arises when individuals purchase or move into new homes that require initial accessibility modifications. The current waiver framework does not clearly support modifications in newly acquired properties, which often forces families to try slightly improve an inaccessible home or absorb the full cost of adapting a new one. As a result, families are left trying to “make it work” in homes that were never designed to meet the individual’s needs—struggling up stairs, navigating narrow bathrooms, or sleeping in living rooms—when a safer, more suitable option could involve adding a bedroom, converting a garage into a first-floor living space, or building a more accessible home altogether.

Additional restrictions also undermine the long-term effectiveness of this service:

• • Second modifications are not supported, even after major life changes such as health decline, household transitions, or aging caregivers.

  • Accident-related repair or replacement costs are excluded, despite the fact that many individuals rely on modified homes and vehicles as their primary means of safe functioning and transportation. 

  • Pre-installed modifications in vehicles are not reimbursed, even when they offer a more cost-effective and immediate solution.

  • Therapeutic equipment such as lifts to safely access pools or spas, and adaptive bicycles or tricycles—is excluded under the current waiver, limiting opportunities for exercise, physical therapy, and increased quality of life.

N. Respite

Requiring detailed summaries of specific tasks and outcomes for each unit of respite care is not only unnecessary—it is fundamentally misaligned with the core purpose of the service. Respite is intended to provide temporary relief to caregivers, not to achieve habilitative or outcome-based goals. Imposing outcome documentation requirements on respite care transforms it into something it is not, creates unnecessary administrative burden, and may deter providers from offering this critical support. CMS has consistently recognized that respite is a caregiver support, not a skill-building or therapeutic service.

Additionally, the FSW explicitly excludes HHAs from providing respite, a critical inconsistency. Given that the H&W Waiver, serving a medically complex population, allows HHAs for respite, it is even more imperative for the FSW—which supports individuals with intellectual and developmental disabilities (I/DD) who often have significant and complex medical needs—to permit this provider type.

Allowing HHAs to provide respite in the FSW would expand access to qualified professionals, reduce caregiver burden, and ensure that individuals with I/DD receive the medically-informed support they often require, preventing unnecessary strain on families and promoting continuity of care. This change is essential for equitable access and high-quality, person-centered support.

O. Lack of Transparency and Reasonable Notice

FSSA's public input process is fundamentally flawed. I am concerned by the overwhelming volume of complex changes, inconsistent information dissemination, and severely limited public engagement (e.g., restricted live comments, inaccessible listening sessions). These systemic issues hinder meaningful stakeholder participation and risk policy outcomes that fail to truly meet Hoosiers' needs.

One of the waiver amendments carried an effective date of July 1, 2025, no announcement was made when it was approved and it was not posted publicly until July 14, but even then it was not announced to stakeholders until July 21. This timeline provided almost no opportunity for meaningful public review or input—especially troubling given that a new amendment was submitted almost immediately afterward.

Such rushed processes undermine transparency, violate the spirit of public engagement, and erode trust in the waiver development process. We urge FSSA to ensure all future amendments are posted, shared, and announced in a timely and accessible manner, with adequate time for stakeholder review before submission to CMS.

P. Case Management Caseload Language

While the waiver states that caseloads must average 45 individuals per full-time case manager, it fails to establish a firm maximum per individual. Without a hard cap, agencies may concentrate large caseloads on specific staff, leading to diminished service quality and burnout.

Q. No Added Funding for Added Burden

 A critical overarching concern is that none of the added oversight or administrative burdens come with additional funding or administrative support for agencies. Caregivers and providers are expected to do more, document more, and report more—with no increase in compensation or infrastructure support. This unsustainable approach risks driving dedicated providers and family caregivers out of the system.

R. Make All FSW Materials Plain Language

The Family Supports Waiver draft requires plain language for Service Plans—but that’s not enough. Families still struggle to understand waiver services, eligibility notices, appeals, and how to request support.

Confusing, technical documents keep families in the dark and block informed decisions.

Recommendations for Comprehensive Waiver Revision

To ensure Indiana's Family Supports (FS) and Community Integration and Habilitation (CIH) Waivers genuinely promote person-centered care, community integration, quality, and equitable access, we respectfully urge the FSSA leadership to implement the following critical revisions before submission to CMS:

I. Improve Public Input and Transparency:

• Extend and Reopen Public Comment Period: Immediately extend the public comment period for all December 2025 waiver amendments and concurrent rule changes, and proactively reopen it to allow adequate time for thorough review and meaningful feedback from all stakeholders.

• Ensure Timely and Consistent Information Dissemination: Clearly designate where all waiver materials will be publicly posted and ensure consistent, ongoing access. Provide sufficient advance notice when new waiver versions are approved, and make the full text available before any provisions take effect. All materials must comply with accessibility standards under 42 CFR §435.905(b), including prompt correction of broken links and removal of navigation barriers.

• Establish Responsive Inquiry Channels: Ensure stakeholders have clear and reliable ways to ask questions and receive timely, substantive responses. This includes reopening public comment features on informational videos, responding to submitted questions, and maintaining open channels for ongoing dialogue throughout the waiver amendment process.

• Conduct Genuinely Inclusive Engagement: Design and conduct future engagement opportunities that are truly accessible and inclusive, offering virtual options, varied scheduling (e.g., evenings), and locations that accommodate all Hoosiers, regardless of geography or work schedule.

• Enhance Transparency in Waiver Operations: Provide clear and public transparency regarding how structured family caregiving and other assessed service levels are determined and how scoring is applied.
  
  

II. Enhance Access and Ensure Seamless Transitions:

• Expand Reserved Capacity for H&W Transitions: Substantially increase the number of reserved waiver slots for individuals losing Nursing Facility Level of Care (NFLOC) under the Health & Wellness Waiver who still meet ICF/IID criteria. Provide clear numerical justification for the current cap or establish a dynamic mechanism to adjust for need, ensuring compliance with 42 CFR §441.302 (reasonable promptness) and the Olmstead mandate.

• Develop Robust Behavioral Support Options: Re-evaluate and implement a comprehensive approach to supporting individuals with intensive behavioral needs, either as a adequately funded standalone service, through coverage via EPSDT or Medicaid behavioral health, or via a high-acuity waiver tier.

• Proactive Planning for NFLOC Disenrollment: Ensure sufficient reserved capacity or a dynamic mechanism to prevent individuals losing NFLOC from being waitlisted or institutionalized, aligning with "reasonable promptness" and Olmstead.
  
  

III. Redesign Services to Promote Person-Centered Care and Reduce Burden:

• Revise Participant Assistance and Care (PAC) & Structured Family Caregiving (SFC) Documentation:

  • Scale back documentation to align with habilitative goals, prioritizing engagement and person-driven goals over clinical reporting.

  • Eliminate excessive, hourly "clinical-style" documentation (e.g., detailed outcome notes for every task) for non-medical personal support services, as it creates an undue burden on caregivers and agencies without improving care.  Ensure any documentation requirements are commensurate with reimbursement rates.

• Align PAC & Workplace Assistance Billing Increments: Allow PAC services & workplace assistance to be billed in 15-minute increments, mirroring Attendant Care, to reduce fragmentation and support flexible service utilization. 15-minute billing reflects the real-world nature of supported employment. It improves access, ensures fair compensation, and better aligns services with the needs of individuals and employers alike.

• Remove Unnecessary Nursing Oversight: Eliminate nurse oversight requirements for PAC, SFC, and other non-medical services. For individuals who require clinical supervision or skilled nursing tasks, referral should be made to appropriate Medicaid State Plan services (e.g., Home Health Aide under 42 CFR §440.70), wellness coordination or to the Health & Wellness Waiver if nursing supports are essential to meet their needs.

• Structured Family Caregiving:

  • Reduce the mandated frequency of home visits to quarterly for routine oversight—unless a higher frequency is clearly justified based on assessed individual needs within the person-centered service plan. This approach acknowledges the substantial cumulative oversight many SFC households already experience, including regular case manager contacts, nursing supervision through Home Health, and additional oversight from therapy, behavioral, or educational teams.

  • Authorize virtual or telehealth oversight visits when physical presence is not medically necessary and is consented to by the participant/caregiver, to enhance accessibility and reduce burdens for immunocompromised individuals, rural families, or those with complex schedules.

  • Permit training to be completed via virtual, hybrid, or self-paced online modules to accommodate caregivers who cannot leave home.

  • Recognize caregiver experience and provide alternatives (competency testing or prior documentation) to avoid unnecessary retraining and to satisfy the requirement.

  • Define SFC payments as stipends, not wages, explicitly stating that principal caregivers are not subject to Fair Labor Standards Act (FLSA) wage and hour requirements (e.g., minimum wage, overtime). Caregivers are not subject to payroll tax withholding or employment classification requirements to prevent unintended FLSA or unemployment insurance liability for provider agencies.

• Address Relative Hour Caps: Eliminate or raise the 40-hour/week cap on family-provided care services; if retained, include an explicit exception process for cases of high medical or behavioral needs especially when staff is limited.

• Reform Day Habilitation:

  • Reduce administrative documentation burdens (daily logs, quarterly reports) that detract from direct engagement.

  • Expand the definition of day habilitative tasks to include real-life activities (e.g., shopping, banking) that foster independence and community integration, even if they overlap with residential domains, when clearly tied to a habilitative goal in the PCISP.

  • Allow coverage of reasonable participation costs with Day Habilitation when necessary for skill-building in community settings.

  • Eliminate or revise the “strategy step” requirement to allow Day Habilitation to support emerging interests without needing a pre-written PCISP entry.

• Address Prevocational Services Reporting Burden: Streamline documentation for prevocational services to focus on skill-building and engagement, reducing administrative burden that discourages provider participation.

• Behavior Supports:

  • Restore flexibility by allowing multiple components (e.g., FBA + consultation) to be delivered and billed in the same month when clinically justified.

  • Adjust annual caps to allow individualized extensions based on assessed need and support continuity of care.

  • Simplify documentation requirements to focus on meaningful, person-centered outcomes rather than bureaucratic compliance artifacts.

  • Reintroduce an intensive behavioral support option, either by reconfiguring IBI or creating a carve-out mechanism to ensure access for those with high support needs without exhausting their entire waiver budget.

  • Expand provider capacity by permitting supervised bachelor’s-level staff, allowing telehealth delivery, and explicitly covering family and caregiver coaching as integral components of the service.

• Revise Music and Recreational Therapy Provisions:

  • Remove arbitrary 6-hour monthly caps to ensure service amounts are based solely on assessed individual need, as required by 42 CFR §441.301(c)(1).

  • Simplify documentation requirements (e.g., eliminate session-by-session clinical charting for habilitative services) to reduce administrative burden and encourage provider participation.

  • Ensure the purpose of these services is accurately characterized as habilitative and supportive of social engagement and life skills, not strictly clinical treatment, and recognize that not all disabilities involve measurable "progress" in a clinical sense.

• Improve Extended Services Design:

  • Reduce Documentation Burdens (e.g., tiered model for stable employment).

  • Loosen Group Ratio Restrictions.

  • Support Transportation Access (e.g., cover actual job-related transportation costs like bus fare or uber).

  • Include Transitional Employment Supports (e.g., time-limited support for unpaid work experiences).

  • Clarify Remote Self-Employment Eligibility (e.g., home-based/remote work qualifies when competitive).

• Reform Facility-Based Support Services (FS Waiver):

  • Eliminate or fundamentally redesign this service to genuinely promote community integration, or discontinue it if it cannot meet HCBS Settings Rule and Olmstead requirements.

  • Significantly increase staffing ratios to ensure participant safety and adequate support (e.g., higher than 1:16).

  • Significantly increase the reimbursement rate beyond $2.51/hour to a level that is economically viable for qualified staff and ensures quality, safety, and dignity.

  • Ensure reimbursement covers community-based skill-building activities and transportation.

• Clarify That Not All Disabilities Involve Measurable “Progress”: Waiver documentation and oversight requirements must recognize that many individuals with intellectual and developmental disabilities have lifelong conditions that do not follow a linear trajectory of improvement. Requiring constant measurement of “progress toward goals” can be inappropriate, misleading, and even harmful when applied to individuals whose needs are based on maintenance, stability, or prevention of regression. Federal HCBS policy (42 CFR §441.301(c)(1)) requires services to be based on assessed need—not on presumed ability to improve. Documentation expectations must reflect this reality and avoid penalizing individuals for the nature of their disability.
  
  

IV. Ensure Equitable Access and Fair Requirements:

• Broaden "Extraordinary Care" Definition for LRIs: Redefine “extraordinary care” to reflect the full scope of extensive, non-medical support needs of individuals with I/DD, ensuring equitable compensation for family caregivers.

• Improve Workplace Support Integration: Allow Workplace Assistance to cover transitional tasks around paid hours and basic job maintenance support. This aligns with person-centered planning, prevents service fragmentation, and supports real employment outcomes. Promote continuity through integrated support planning and ensure Workplace Assistance can be billed in 15-minute increments.

• Modernize Home and Vehicle Modifications:

  • Permit “best value” bidding for home/vehicle modifications and allow exceptions where multiple bids are not feasible, to ensure quality and address vendor limitations.

  • Clearly support modifications in newly acquired properties.

  • Allow for second modifications after major life changes.

  • Cover accident-related repair or replacement costs for essential modifications.

  • Reimburse for pre-installed vehicle modifications when cost-effective.

  • Include therapeutic equipment (e.g., lifts for pools, adaptive bicycles) as eligible for reimbursement.

• Revise Respite Care Provider Qualifications: Allow Home Health Aides (HHAs) to serve as qualified respite providers under the FSW, just as they are under the Health & Wellness Waiver.

• Simplify Documentation: Ensure that documentation requirements are not overly burdensome, do not demand outcomes for non-goal-based support, and are fundamentally aligned with the purpose of the service. Additionally, imposing clinical tracking expectations in habilitative services where there is no goal of measurable “progress” (e.g., in cases of lifelong, stable disability) is medically inappropriate and administratively burdensome.
  
  

V. Strengthen Administrative Oversight and Support:

• 1. Establish Firm Case Management Caseload Caps: Clarify case manager caseload limits by establishing a firm, enforceable individual cap per full-time staff member to ensure service quality and prevent burnout.

  2. Eliminate Duplicative Oversight Reports: Streamline reporting requirements by removing redundant data-driven oversight provider reports that replicate existing case management and monitoring efforts.

  3. Provide Added Funding for Added Burden: Recognize that none of the added oversight or administrative burdens can be implemented without additional funding or administrative support for agencies and providers. Ensure new requirements are matched with appropriate compensation or infrastructure support.

  4. Require Plain Language for All FSW Materials: Mandate plain language for all FSW documents, including service descriptions, notices, appeals, and outreach materials, to ensure families can make informed decisions.
     
     

I urge the Division of Disability and Rehabilitative Services (DDRS) and the Centers for Medicare & Medicaid Services (CMS) to reject the proposed changes that increase administrative burden, restrict service flexibility, or limit access to necessary supports. Instead, I respectfully request that Indiana revise the Family Supports Waiver to reflect federal HCBS requirements under 42 CFR §441.301–302, uphold the integration mandate of the ADA and Olmstead, and center the needs, voices, and lived experiences of individuals with disabilities and their families. True person-centered care cannot be achieved through systems that prioritize paperwork over people.

Thank you for the opportunity to submit these comments.

Julie McGill