I am submitting this public comment regarding the proposed amendments to Virginia’s CCC+, Community Living (CL), and Family and Individual Supports (FIS) Waivers. I work directly with individuals with disabilities and their families who rely on consumer-directed services, and I am deeply concerned about several of these proposed changes, particularly the elimination of Services Facilitation as a standalone service and the implementation of a 56-hour soft cap on personal assistance.
I support appropriate oversight, accountability, and responsible use of Medicaid funds. However, changes intended to improve efficiency should not reduce individual choice, access to services, continuity of care, or protections for people with significant disabilities.
I strongly urge DMAS to reconsider incorporating Services Facilitation into a statewide Support Broker model operated through the Fiscal-Employer Agent and eliminating independent Services Facilitation.
Services Facilitators do far more than complete paperwork. We develop ongoing relationships with individuals and families, conduct assessments, observe individuals in their homes, identify changes in functional needs, assist with service authorization issues, educate Employers of Record, explain Medicaid requirements, help resolve problems, and advocate for services that accurately reflect an individual’s needs.
For individuals with significant intellectual, developmental, physical, behavioral, and medical disabilities, continuity matters.
A Services Facilitator who has worked with an individual over time understands that person beyond what appears on an assessment form. We may know why bathing takes significantly longer than expected, why an individual requires extensive toileting or incontinence assistance, why feeding requires prolonged supervision, why behavioral support is necessary during daily activities, or why someone cannot safely be left alone.
That historical knowledge is extremely important when assessing medical necessity and developing an appropriate plan of care.
I am concerned that moving these responsibilities into a large statewide Fiscal-Employer Agent structure could result in higher caseloads, less individualized attention, less continuity, and fewer opportunities for families to choose the professional who assists them.
Consumer direction is supposed to promote individual choice and control. Eliminating independent Services Facilitation appears to move in the opposite direction.
Rather than eliminating Services Facilitation, DMAS should consider allowing individuals to choose between qualified independent Services Facilitators and the new Support Broker model.
If the Support Broker model provides better service, families should be able to choose it. But families who value their existing Services Facilitator relationship should not automatically lose that option.
I am also concerned about combining service-broker responsibilities with the Fiscal-Employer Agent structure.
DMAS should clearly explain what safeguards will ensure that Support Brokers are able to independently advocate for the individual when problems involve the Fiscal-Employer Agent itself. There should be clear standards regarding independence, qualifications, caseloads, response times, continuity, supervision, complaint procedures, and conflict-of-interest protections.
Before eliminating an established statewide network of Services Facilitators, DMAS should demonstrate that the replacement system will provide at least the same level of individualized assistance, accessibility, oversight, continuity, and consumer protection.
Quarterly Support Broker visits may not adequately address the needs of every individual receiving consumer-directed services.
Problems do not occur once every three months.
Individuals are hospitalized. Medical and behavioral conditions change. Attendants quit. Employer of Record arrangements change. School schedules change. Service authorizations are reduced or denied. Families receive confusing notices. New Medicaid requirements are implemented. Individuals may suddenly require significantly more assistance.
Families need to know that someone familiar with their situation will be available when these issues occur.
DMAS should establish clear standards regarding assistance between quarterly visits, maximum response times, continuity of assigned Support Brokers, caseload sizes, and procedures for urgent situations.
I am also concerned about implementing a 56-hour soft cap on personal assistance under the CL and FIS Waivers.
I understand that DMAS describes this as a “soft cap” and that individuals may request additional hours. However, safeguards are necessary to ensure that 56 hours does not gradually become a de facto maximum.
Fifty-six hours per week equals eight hours per day.
Disability does not operate on an eight-hour schedule.
Some individuals require assistance from the time they wake until they go to bed. They may require hands-on assistance with bathing, dressing, toileting, incontinence care, grooming, feeding, transfers, mobility, communication, medication routines, and other disability-related daily needs.
Some activities also take considerably longer for individuals with significant disabilities than they do for people without disabilities.
An individual may require prolonged feeding because of swallowing difficulties or behavioral and sensory needs. Bathing may require extensive physical assistance. Toileting may occur repeatedly throughout the day. Transfers and mobility may require two-person assistance or specialized equipment. Individuals with intellectual disabilities may require extensive caregiver involvement to safely complete daily routines.
Those needs do not disappear after eight hours.
Authorization decisions should continue to be based upon documented medical necessity and individualized functional need—not an arbitrary number of hours.
If Virginia implements the 56-hour soft cap, the exception process must be clearly defined, accessible, timely, and fair.
Families should know exactly what documentation is required to request more than 56 hours.
Individuals with lifelong and significant disabilities should not repeatedly be required to prove that their disability continues to exist simply because their assessed needs exceed 56 hours per week.
DMAS should also monitor and publicly report:
The number of requests exceeding 56 hours;
The number approved and denied;
The average number of hours requested and authorized;
Processing times;
Reasons for denials; and
Appeal outcomes.
Without this information, there will be no meaningful way to determine whether the “soft cap” is truly functioning as an administrative review threshold or has effectively become a hard cap.
The individuals most likely to exceed 56 hours are often those with the most significant disabilities.
These may include individuals who cannot safely be left alone, individuals with significant intellectual disabilities, individuals who are nonverbal, individuals with severe autism, people with mobility limitations, and individuals with complex behavioral or medical needs.
These individuals are able to remain in their homes and communities because appropriate supports are available.
Reducing access to personal assistance does not eliminate the underlying need. It simply transfers the responsibility elsewhere—often to unpaid family caregivers.
If families cannot sustain that responsibility, the consequences may include caregiver burnout, loss of employment, worsening health conditions, emergency department utilization, hospitalization, or pressure toward more restrictive settings.
Virginia should ensure that HCBS policies continue to support people in their homes and communities rather than unintentionally creating barriers for individuals with the greatest needs.
I also urge DMAS to proceed carefully with the proposal allowing an individual receiving services to serve as his or her own Employer of Record while designating another person to perform some or all EOR responsibilities.
For some individuals, this may appropriately increase autonomy and self-direction.
For individuals with significant intellectual disabilities, communication limitations, or impaired decision-making abilities, however, the arrangement could create confusion regarding who is actually responsible for employer duties.
DMAS should clearly establish who is responsible for hiring and supervising attendants, approving time, ensuring compliance with program requirements, addressing attendant performance issues, and responding to suspected fraud, abuse, neglect, or exploitation.
Increasing autonomy should never come at the expense of safeguards for vulnerable individuals.
I am also concerned about removing the requirement that DMAS staff perform higher-level reviews when an individual is determined to no longer meet the level of care necessary to remain on the CCC+ Waiver.
Loss of waiver eligibility can have enormous consequences.
For some individuals, waiver services are what allow them to remain safely in their homes rather than requiring institutional care.
A determination with consequences this significant deserves meaningful oversight.
If DMAS removes the higher-level review requirement, the agency should clearly explain what safeguard will replace it and how incorrect level-of-care determinations will be identified before an individual loses critical services.
I respectfully ask DMAS to reconsider eliminating Services Facilitation as a standalone service and instead preserve meaningful consumer choice between qualified independent Services Facilitators and Support Brokers.
If DMAS proceeds with the Support Broker model, strong requirements should be established regarding qualifications, independence, caseloads, continuity, accessibility, response times, conflict-of-interest protections, and assistance between quarterly visits.
I also ask DMAS to ensure that the proposed 56-hour soft cap never becomes a hard cap and that individuals can receive hours above 56 when supported by documented medical necessity and functional need.
The exception process should be transparent, timely, and accessible, and DMAS should publicly monitor approval and denial patterns for requests exceeding the cap.
Finally, I ask DMAS to maintain meaningful safeguards before individuals lose waiver eligibility and to carefully evaluate how all of these changes will affect people with the most significant disabilities.
Virginia's Medicaid waiver programs exist to allow individuals with disabilities to live safely and meaningfully in their homes and communities.
Program integrity and fiscal responsibility are important, but so are continuity, individual choice, adequate support, and protection of vulnerable individuals.
Please do not measure the success of these changes solely by administrative efficiency or cost savings. Measure them by whether people with disabilities remain safe, supported, and able to live in their communities—and whether families can realistically sustain the responsibilities placed upon them.
Thank you for considering my comments and for considering the voices of the individuals, families, caregivers, and professionals who work with Virginia's waiver programs every day.