I am submitting this public comment regarding the proposed amendments to Virginia's Medicaid Home and Community-Based Services waivers.
I have serious concerns about several of the proposed changes, particularly: (1) implementation of a 56-hour soft cap on personal care/assistance; (2) elimination of Services Facilitation as a standalone service and incorporation of those functions into the statewide Service Broker model through the Fiscal-Employer Agent; and (3) the cumulative effect these and other changes may have on individuals with significant disabilities and their families who depend upon consumer-directed services to remain safely in their homes and communities.
I support efforts to make Virginia's Medicaid waiver system more efficient and easier to navigate. However, administrative efficiency should never come at the expense of individual need, continuity of care, consumer choice, independent advocacy, or health and safety.
I am concerned about establishing 56 hours per week as the presumptive limit for personal care or personal assistance services.
The number of hours an individual receives should be based upon that person's actual disability, functional limitations, health and safety needs, and person-centered service plan—not an arbitrary numerical threshold.
Individuals with significant disabilities do not become less disabled after 56 hours of care in a week.
Although the proposal describes this as a "soft cap" and provides an exception process for individuals who require additional hours, the practical implementation of that process is critical. A soft cap can effectively become a hard cap if exceptions are difficult to obtain, require repeated documentation, are inconsistently approved, or take so long to process that services are interrupted.
Individuals with permanent or long-term disabilities should not have to repeatedly prove the existence of the same disability or the same continuing need for assistance merely because their care exceeds 56 hours per week.
I ask DMAS to ensure that:
Individual need remains the controlling factor in determining authorized hours;
Exceptions above 56 hours are accessible, timely, transparent, and based upon documented individual need;
Individuals with permanent or substantially unchanged conditions are not subjected to unnecessary repetitive documentation requirements;
Existing authorized hours continue while an exception request, renewal, reconsideration, or appeal is pending; and
Families receive clear written notice explaining the criteria for obtaining hours above the soft cap and their rights when additional hours are denied.
No individual should experience an interruption in necessary care simply because an administrative exception has not been processed.
I am particularly concerned about eliminating Services Facilitation as a standalone service and incorporating those functions into a statewide Service Broker model through the Fiscal-Employer Agent.
Services Facilitators do much more than complete paperwork.
They can serve as an important resource, educator, problem-solver, and advocate for individuals with disabilities and their families. They help families understand Medicaid requirements, navigate consumer-directed services, address problems involving attendants and authorizations, and identify issues that could jeopardize an individual's services or ability to remain safely in the community.
Services Facilitators may also bring valuable lived experience to this work. Some have family members with disabilities or have personally navigated Medicaid, waiver services, special education, disability services, and other complex systems.
That lived experience matters.
Someone who has personally navigated disability systems may understand challenges that cannot be learned solely through a training manual or administrative contract.
Eliminating this independent role raises a fundamental question:
Who will independently advocate for the individual receiving services?
The Fiscal-Employer Agent performs important administrative and fiscal functions. The individual and Employer of Record may sometimes need assistance precisely because they are experiencing a problem with those administrative functions.
There may be payroll problems, attendant enrollment problems, administrative delays, disagreements regarding requirements, authorization problems, documentation disputes, or other issues affecting the individual's services.
If the person expected to help the individual navigate or resolve those problems works within the same structure responsible for administering the program, families may reasonably question whether that person is truly independent.
An advocate should not be structurally dependent upon the same administrative system about which the individual may need to raise a concern.
This does not mean that a Support Broker will necessarily act improperly. Rather, the proposed structure itself creates legitimate questions about independence, accountability, and divided responsibilities that DMAS should address before eliminating the existing model.
DMAS should clearly explain:
Who employs the Support Broker?
Who supervises and evaluates the Support Broker?
To whom does the Support Broker owe his or her primary responsibility—the individual receiving services, DMAS, or the Fiscal-Employer Agent?
Can a Support Broker freely challenge or advocate against an action or decision of the Fiscal-Employer Agent on behalf of an individual?
What protections will prevent institutional or financial pressures from influencing the assistance provided to individuals and families?
What independent avenue will exist when an individual or family disagrees with the Fiscal-Employer Agent or Support Broker?
Will individuals and families have the right to select or change their Support Broker?
What caseload limits will apply?
What training and disability-services experience will be required?
How will DMAS preserve the institutional knowledge and lived experience currently provided by experienced Services Facilitators?
These questions should be answered publicly before the existing Services Facilitation system is eliminated.
Consumer direction should mean more than permitting an individual or Employer of Record to hire an attendant.
True consumer direction requires meaningful choice, access to understandable information, assistance navigating the system, and the ability to raise concerns without being entirely dependent upon the same entity administering the program.
Families caring for individuals with significant disabilities already carry substantial responsibilities. They may be coordinating attendants, medical appointments, therapies, transportation, medications, Medicaid requirements, service authorizations, timesheets, payroll issues, benefits, and many other aspects of daily life.
Independent Services Facilitators can provide an important layer of support between the family and a complicated government system.
If DMAS believes the statewide Service Broker model will provide better services, it should demonstrate how the new model will preserve or improve this independent advocacy function rather than simply eliminate it.
At a minimum, DMAS should establish a meaningful independent advocacy and problem-resolution mechanism outside of the Fiscal-Employer Agent structure.
The 56-hour soft cap, elimination of standalone Services Facilitation, changes to the Employer of Record structure, changes affecting legally responsible individuals, and other proposed modifications should not be evaluated solely as separate administrative provisions.
Families will experience these changes together.
For an individual with significant disabilities, even a temporary interruption in personal assistance can have serious consequences. A missed administrative deadline, delayed authorization, payroll problem, difficulty reaching a Support Broker, or misunderstanding concerning a new requirement can mean that an attendant does not get paid or that necessary care is disrupted.
Virginia should not transfer the administrative burden of system reform onto individuals with disabilities and their families.
If DMAS proceeds with these changes, there should be meaningful protections during the transition.
Existing service authorizations should remain in effect while new requirements are implemented. Families should receive clear advance notice written in understandable language. There should be adequate staffing and telephone assistance available when problems arise.
No individual should lose authorized services because of confusion, processing delays, staffing shortages, technological problems, or administrative errors associated with the transition.
DMAS should also establish a rapid escalation process for situations in which a transition problem threatens an individual's health, safety, attendant payment, or continuity of care.
Implementation should not be considered successful merely because the administrative transition is completed.
DMAS should track and publicly report whether these changes result in:
Reductions in authorized personal-assistance hours;
Numbers of requests for exceptions above 56 hours and the outcomes of those requests;
Processing times for exception requests;
Interruptions in personal-assistance services;
Attendants leaving because of payroll or administrative problems;
Delays in attendant enrollment or payment;
Complaints involving Support Brokers or Fiscal-Employer Agents;
Increased Medicaid appeals;
Increased caregiver burden;
Increased emergency-room utilization or hospitalization associated with gaps in care; and
Individuals entering institutional care after losing or experiencing interruptions in community-based services.
The ultimate measure of success should be whether people with disabilities remain safe, supported, and able to live in their homes and communities.
People who use waiver services and the families who support them have practical knowledge of how these programs function in real life.
Their experiences should not be treated as anecdotal obstacles to administrative reform. They are essential information for determining whether the system actually works.
Before eliminating a longstanding service model, DMAS should meaningfully consider what will be lost along with what may be gained.
Experienced Services Facilitators, individuals receiving services, Employers of Record, attendants, parents, guardians, and other family caregivers should have a meaningful role in designing and evaluating the replacement system.
Virginia's Medicaid Home and Community-Based Services waivers exist to help individuals with disabilities remain safely in their homes and communities.
Every proposed change should therefore be evaluated against that fundamental purpose.
I respectfully ask DMAS to reconsider eliminating independent Services Facilitation as a standalone service and to carefully examine whether placing the support function within the Fiscal-Employer Agent structure adequately protects independence and avoids actual or perceived conflicts of interest.
I also ask DMAS to ensure that the proposed 56-hour soft cap never becomes a de facto hard cap and that individuals whose disabilities require additional assistance have a fair, timely, and accessible process for obtaining the hours they need.
Administrative efficiency is important. Fiscal responsibility is important. But neither should override individualized need, continuity of care, consumer choice, independent advocacy, or the health and safety of Virginians with disabilities.
The Commonwealth should strengthen consumer-directed services while preserving the fundamental principle behind them:
The individual with a disability—not the administrative system—should remain at the center of the decision-making process.