Behavioral Health Navigators Center (BHNC) respectfully submits this public comment regarding the proposed amendments to Virginia's 1915(c) Home and Community-Based Services waivers, specifically the proposal to incorporate Services Facilitation into a statewide Support Broker model through the Fiscal-Employer Agent (F/EA) contracts and eliminate Services Facilitation as a standalone Medicaid service.
BHNC is a Virginia nonprofit organization that provides Services Facilitation and works with Medicaid members, families, Employers of Record (EORs), attendants, healthcare providers, community organizations, and other stakeholders to help individuals remain safely in their homes and communities.
BHNC supports efforts to improve Virginia's consumer-directed services system, increase accountability, simplify administration, and ensure responsible stewardship of Medicaid resources. However, we have serious concerns about eliminating the existing Services Facilitation infrastructure without sufficient evidence that the proposed Support Broker system will provide equal or greater accessibility, continuity, responsiveness, participant choice, local knowledge, and individualized support.
Our primary concern is not simply the elimination of a provider category or its economic effect on organizations such as BHNC.
Our primary concern is what happens to the Medicaid members and families who currently depend upon these organizations.
We respectfully request that DMAS reconsider eliminating qualified Services Facilitation providers from the consumer-directed system and instead develop a model that preserves the experience, relationships, infrastructure, and community presence of qualified existing providers while implementing any Support Broker reforms required by Virginia law.
Services Facilitation should not be viewed merely as an administrative function.
Effective Services Facilitation requires knowledge of the participant, the participant's home environment, functional needs, authorized services, family circumstances, Employer of Record responsibilities, attendants, service plan, Medicaid requirements, and community resources.
Service Facilitators develop relationships with individuals and families over time.
Those relationships can allow a facilitator to recognize changes that may not be apparent from a telephone call, electronic record, or periodic administrative review.
Service Facilitators can also serve as an accessible point of contact when participants and EORs encounter problems navigating consumer-directed services.
The value of this relationship is particularly important for individuals who are elderly, medically fragile, living with disabilities, experiencing communication barriers, or relying heavily upon family members to navigate Medicaid requirements.
Virginia should carefully evaluate the consequences of replacing these established relationships before eliminating the current provider network.
Consumer direction should include meaningful consumer choice.
Under the existing structure, participants may select among qualified Services Facilitation providers.
Under the proposed structure, Support Brokers would be hired through the Fiscal-Employer Agents.
BHNC respectfully asks DMAS to explain how meaningful participant choice will be preserved under this model.
A participant should not simply be assigned to whichever Support Broker happens to be available.
Participants should have reasonable opportunities to select and, when necessary, change the individual or organization responsible for helping them navigate consumer-directed services.
We therefore recommend that DMAS establish explicit participant protections guaranteeing:
The ability to select among qualified Support Brokers whenever practicable;
The ability to request a different Support Broker without retaliation or interruption of services;
A clearly defined complaint and escalation process;
Timely reassignment when a Support Broker is unavailable or the relationship is unsuccessful; and
Accessible information explaining these rights before transition.
DMAS has proposed a regional transition from Services Facilitation to Support Brokers.
A regional transition does not, by itself, guarantee continuity.
For many Medicaid members, their Service Facilitator knows their history, authorized services, household circumstances, attendants, EOR, barriers to care, communication preferences, and previous administrative difficulties.
Those relationships represent institutional knowledge.
Eliminating them simultaneously across an entire region could create avoidable disruption.
BHNC therefore recommends that existing participants be permitted, whenever possible, to retain their current qualified facilitator during the transition, including where that facilitator becomes qualified to function as a Support Broker.
No participant should experience an interruption in consumer-directed services because of an administrative restructuring.
Virginia has already invested substantial resources in developing a network of Services Facilitation providers.
These organizations have trained personnel, compliance systems, community relationships, documentation processes, Medicaid experience, and established participant caseloads.
Dismantling that infrastructure and attempting to recreate it within two Fiscal-Employer Agent systems may result in the unnecessary loss of experienced professionals.
BHNC respectfully recommends that DMAS establish a pathway through which qualified existing Services Facilitation agencies may participate in the Support Broker model.
For example, DMAS could authorize PPL and CDCN to contract with qualified existing Services Facilitation agencies to perform Support Broker functions under written agreements and DMAS-established performance standards.
The F/EA could remain accountable to DMAS while qualified community organizations perform designated Support Broker functions.
This approach would allow Virginia to modernize the program without discarding an experienced workforce.
Virginia is geographically and demographically diverse.
The needs and resources available to individuals in Southwest and Western Virginia may differ substantially from those available in Northern Virginia, Central Virginia, or Hampton Roads.
Community-based providers understand local healthcare systems, transportation barriers, workforce shortages, social-service organizations, community resources, and other regional challenges.
BHNC is particularly concerned that centralizing Services Facilitation functions could unintentionally reduce local accessibility.
A statewide administrative structure should not result in a one-size-fits-all service model.
DMAS should require the Support Broker system to demonstrate adequate geographic coverage and local accessibility before transitioning any region.
DMAS currently proposes beginning the Support Broker transition in Western and Southwestern Virginia on March 1, 2027.
Because this region is scheduled to transition first, DMAS should establish objective readiness standards before implementation.
Residents of Western and Southwestern Virginia should not bear disproportionate risk merely because their region is first in the implementation schedule.
Before the March transition, DMAS should publicly demonstrate that sufficient Support Brokers have been hired, trained, screened, assigned, and made operational to serve the affected population.
If those standards are not satisfied, implementation should be delayed rather than risking interruption or degradation of services.
DMAS indicates that Support Brokers will conduct quarterly visits with consumer-directed individuals.
BHNC respectfully requests clarification concerning what happens during the periods between required visits.
Consumer-directed services do not operate only once every three months.
Participants and EORs may experience problems involving attendants, service authorizations, hospitalizations, changes in condition, documentation, payroll, enrollment, Medicaid eligibility, service-plan changes, or other issues requiring prompt attention.
DMAS should therefore establish enforceable response standards.
We recommend requiring Support Brokers to acknowledge routine participant inquiries within one business day and establish procedures for urgent matters requiring more immediate attention.
Quarterly required visits should represent the minimum scheduled contact—not the maximum level of assistance available to a participant.
BHNC respectfully requests that DMAS disclose the anticipated Support Broker caseload.
Without caseload standards, it is difficult for participants, providers, CMS, or the public to determine whether the proposed system can realistically provide individualized assistance.
DMAS should establish maximum caseload standards based upon participant complexity, geography, travel requirements, and other workload considerations.
DMAS should also disclose:
The projected number of consumer-directed participants requiring Support Broker services;
The number of Support Brokers required statewide and by region;
Minimum staffing requirements;
Supervisor-to-Support-Broker ratios;
Minimum training and competency requirements;
Required response times;
Backup coverage requirements;
Vacancy contingency plans; and
Procedures for managing unexpected workforce shortages.
The existing Services Facilitation network should not be terminated until sufficient replacement capacity has been demonstrated.
Services Facilitation currently provides a distinct function within the consumer-directed system.
Under the proposed structure, Support Brokers would operate through the Fiscal-Employer Agent structure.
BHNC respectfully asks DMAS to explain how functional independence will be maintained.
A participant experiencing a problem involving the fiscal agent should have access to assistance that can objectively identify and escalate that problem.
DMAS should establish clear separation of responsibilities, escalation procedures, independent complaint mechanisms, and protections against conflicts of interest.
At minimum, participants should have direct access to DMAS or another independent escalation mechanism for matters they believe have not been adequately resolved within the F/EA structure.
Effective HCBS services require more than administrative efficiency.
Virginia serves individuals from different racial, ethnic, linguistic, socioeconomic, geographic, and cultural communities.
Support Broker standards should therefore include requirements regarding cultural competency, disability competency, communication accessibility, language access, and person-centered practices.
Community-based organizations often possess relationships and cultural knowledge developed through years of service.
DMAS should preserve and utilize this community capacity rather than unnecessarily eliminating it.
BHNC asks DMAS to clarify whether Support Brokers will maintain meaningful local, face-to-face relationships with participants or whether substantial functions will be centralized through telephone or electronic systems.
Technology can improve efficiency, but it should supplement—not replace—human relationships when serving vulnerable populations.
Participants should continue to have access to a knowledgeable individual who understands their circumstances and can provide personalized assistance.
Before transferring a participant from Services Facilitation to a Support Broker, DMAS should require an individualized transition process.
The transition should verify that the Support Broker has received necessary information, understands the participant's current services, knows the EOR and relevant contacts, and can identify outstanding issues.
No existing Services Facilitator relationship should terminate until the receiving Support Broker is operational and responsibility has been affirmatively transferred.
Participants should receive written notice identifying their Support Broker, contact information, effective date, complaint rights, emergency/escalation contacts, and procedures for requesting reassignment.
If Virginia implements this major structural change, DMAS should measure whether the new system actually improves services.
We recommend public reporting during at least the first two years concerning:
Support Broker vacancies and turnover;
Average caseloads;
Missed or late required contacts;
Participant complaints;
Complaint-resolution times;
Support Broker reassignment requests;
Authorization delays;
Attendant enrollment and payroll problems;
Interruptions in consumer-directed services;
Participant satisfaction;
Regional disparities; and
The number of participants leaving consumer-directed services following implementation.
These measures would allow DMAS, CMS, the General Assembly, participants, and taxpayers to determine whether the new model is achieving its stated objectives.
BHNC strongly recommends that DMAS consider a hybrid implementation model.
Rather than eliminating existing qualified agencies from the system, DMAS could establish statewide Support Broker standards while permitting qualified Services Facilitation organizations to participate through contracts or subcontracts with the F/EAs.
Under such a model:
Existing providers could be required to satisfy uniform Support Broker qualifications, training, background checks, documentation requirements, performance standards, audits, privacy requirements, and quality measures.
The Fiscal-Employer Agent could retain contractual accountability to DMAS.
DMAS could retain regulatory and programmatic oversight.
Participants could retain access to experienced community-based organizations.
Virginia could therefore obtain the administrative advantages it seeks without unnecessarily destroying existing provider infrastructure.
BHNC also recommends a reasonable grandfathering or expedited credentialing process.
Individuals who are currently qualified and successfully performing Services Facilitation should not automatically become ineligible to serve simply because the program changes the title of the position.
Existing qualified Service Facilitators should be offered an expedited pathway to meet Support Broker requirements.
Similarly, established Services Facilitation agencies with satisfactory compliance histories should receive a meaningful opportunity to qualify as organizational Support Broker partners.
The proposed change affects thousands of vulnerable Virginians and fundamentally restructures consumer-directed services.
BHNC recommends that Virginia consider a limited demonstration or pilot before permanently eliminating Services Facilitation statewide.
DMAS could compare participant satisfaction, responsiveness, administrative efficiency, service continuity, complaint rates, workforce capacity, and costs under the two approaches.
Evidence from actual implementation would provide a stronger basis for statewide policy than assumptions about how a new administrative structure will perform.
Before implementation, BHNC asks DMAS to publish an analysis addressing:
The number of existing Services Facilitation agencies affected;
The number of Service Facilitators currently serving participants;
The number of participants affected by region;
Projected Support Broker caseloads;
Projected administrative savings or additional costs;
Expected workforce displacement;
Rural-access implications;
Effects on participant choice;
Transition risks;
Measures DMAS will use to determine whether the new model is successful; and
The alternatives DMAS considered before determining that standalone Services Facilitation should be eliminated.
The public should be able to evaluate the factual and operational basis for such a substantial restructuring.
BHNC respectfully recommends that DMAS not eliminate the existing qualified Services Facilitation workforce from participation in Virginia's consumer-directed system.
If Virginia proceeds with the Support Broker model, we recommend that DMAS:
Permit qualified existing Services Facilitation agencies to contract or subcontract with PPL and CDCN as Support Broker providers;
Establish expedited credentialing for experienced Service Facilitators;
Preserve meaningful participant choice among qualified Support Brokers;
Permit continuity with an existing facilitator whenever that facilitator meets Support Broker requirements;
Establish maximum caseload standards;
Establish enforceable participant-response standards;
Require adequate regional staffing before implementation;
Create an independent complaint and escalation mechanism;
Require individualized transition plans;
Protect rural and underserved communities;
Require public performance reporting;
Establish cultural-competency and accessibility requirements;
Implement the model through a measured pilot or phased demonstration with objective readiness criteria; and
Delay a regional transition whenever adequate staffing, systems, or continuity protections have not been demonstrated.
This approach would permit Virginia to implement the Support Broker concept while retaining experienced professionals and community organizations already serving Medicaid members.
Before implementation, BHNC respectfully requests written responses to the following:
1. How many Medicaid participants currently receive Services Facilitation in Virginia?
2. How many active Services Facilitators and Services Facilitation provider agencies currently serve those individuals?
3. How many Support Brokers does DMAS estimate will be required statewide and within each transition region?
4. What maximum caseload will apply to each Support Broker?
5. What minimum qualifications, training, supervision, and experience will Support Brokers be required to possess?
6. Will existing qualified Service Facilitators receive priority or expedited consideration for Support Broker positions?
7. Will existing Services Facilitation agencies be permitted to contract or subcontract with PPL or CDCN to provide Support Broker functions?
8. Will participants be permitted to choose among Support Brokers?
9. Can a participant request a different Support Broker?
10. What response-time standards will apply when participants need assistance between quarterly visits?
11. What happens when a Support Broker resigns, is unavailable, or exceeds a reasonable caseload?
12. What independent complaint mechanism will exist when the participant's concern involves the Fiscal-Employer Agent itself?
13. What objective readiness criteria must be satisfied before DMAS transitions a region?
14. Will DMAS delay a regional implementation date if adequate Support Broker staffing has not been demonstrated?
15. What safeguards will ensure that no participant experiences an interruption of authorized consumer-directed services because of this administrative transition?
Behavioral Health Navigators Center supports responsible improvements to Virginia Medicaid and recognizes DMAS's responsibility to administer public resources efficiently.
However, efficiency should not be achieved at the expense of continuity, accessibility, participant choice, community relationships, accountability, or individualized assistance.
Virginia already possesses an experienced Services Facilitation workforce.
That workforce should be treated as an asset in the redesign of consumer-directed services rather than as infrastructure that must simply disappear.
BHNC respectfully asks DMAS to preserve a meaningful role for qualified existing Services Facilitation agencies and professionals within the Support Broker model and to establish enforceable participant protections before eliminating Services Facilitation as a standalone service.
If DMAS determines that implementation of a Support Broker structure must proceed, BHNC asks the Department to adopt a collaborative model that incorporates qualified existing providers, protects continuity of care, preserves participant choice, establishes reasonable caseload and responsiveness standards, and requires demonstrated regional readiness before transition.
The success of Virginia's Medicaid waiver programs should ultimately be measured not simply by administrative structure, but by whether individuals with disabilities and older Virginians can safely remain in their homes, exercise meaningful control over their services, and obtain timely assistance when they need it.
BHNC respectfully requests that DMAS carefully consider these recommendations before finalizing the proposed amendments.
Respectfully submitted,
Behavioral Health Navigators Center (BHNC)
Roanoke, Virginia
Bridging the Gaps in Healthcare and Social Determinants of Health
Authorized Representative: Bernice D. Griffin, DrPH (c)
Title: President
Date: _9.28.26