I respectfully ask DMAS to reconsider whether eliminating Services Facilitation is the appropriate way to streamline Virginia's Medicaid waiver system.

If the goal of the proposed Support Broker transition is to reduce duplication, improve accountability, or lower administrative costs, DMAS should first conduct a transparent review of the overlap between Managed Care Organization care coordination and Services Facilitation.

Virginia's Medicaid system already contains multiple layers of coordination.

Individuals receiving CCC+ waiver services may have an MCO care coordinator while also working with a Services Facilitator for their consumer-directed personal care or respite services.

Both roles involve assessment, monitoring, communication, care planning, identifying changes in needs, and coordination of services.

However, the roles are not interchangeable.

Services Facilitators work specifically within the consumer-directed service model.

They help individuals and families understand Employer of Record responsibilities, assess personal assistance needs, develop consumer-directed plans of care, determine the number of hours necessary to meet documented functional needs, submit service authorization requests, conduct required monitoring, identify changes in condition, and assist families when problems arise with consumer-directed services.

This specialization matters.

The consumer-directed model is complicated, particularly for families caring for individuals with significant intellectual, developmental, physical, behavioral, or medical disabilities.

An experienced Services Facilitator frequently develops a detailed understanding of the individual's daily routines, functional limitations, caregiver circumstances, and history over many years.

That knowledge cannot necessarily be replaced by assigning the member to another employee within a large statewide administrative structure.

At the same time, CCC+ Managed Care Organizations already employ care coordinators who perform broad care-management responsibilities.

MCO care coordinators communicate with members, participate in assessments, monitor services and outcomes, facilitate referrals, coordinate interdisciplinary care teams, and maintain individualized care plans.

For individuals receiving HCBS waiver services, MCO care coordinators are also required to maintain regular contact.

This raises an important policy question:

If DMAS believes Virginia's waiver system contains too many layers of coordination, why is the state proposing to eliminate the specialized consumer-directed Services Facilitator rather than examining whether some MCO care-coordination responsibilities could be consolidated, reduced, or redesigned?

Before eliminating Services Facilitation, DMAS should conduct a member-level study examining how families interact with each layer of the system.

For individuals receiving consumer-directed services, DMAS should determine:

• How often members contact their MCO care coordinator;

• How often members contact their Services Facilitator;

• What types of problems each professional resolves;

• Which professional assists with service authorization problems;

• Which professional assists with EOR and attendant issues;

• Which professional identifies changes in functional need;

• Which professional assists families when hours are reduced or additional documentation is requested;

• Member satisfaction with each role;

• Average caseloads for MCO care coordinators and Services Facilitators; and

• The administrative cost associated with each model.

DMAS should publish this analysis before eliminating one of these roles statewide.

Consider Redesigning MCO Care Coordination Rather Than Eliminating Services Facilitation

Federal Medicaid requirements understandably require managed care organizations to maintain responsibility for coordination and continuity of medical care.

However, that does not necessarily mean Virginia must maintain every existing layer of duplicative LTSS administrative activity in exactly its current form.

DMAS should examine whether MCO responsibilities could be redesigned so that MCO care coordinators remain responsible for broader medical and managed-care coordination while qualified independent Services Facilitators retain responsibility for the specialized consumer-directed component of waiver services.

For example, the MCO could continue coordinating:

• Primary and specialty medical care;

• Pharmacy and behavioral health services;

• Hospital transitions;

• Managed-care benefits;

• Medical referrals;

• Broader interdisciplinary care; and

• Other health-plan responsibilities.

Meanwhile, the Services Facilitator could remain the primary professional responsible for:

• Consumer-directed personal assistance and respite;

• Employer of Record education and support;

• Functional assessment related to consumer-directed services;

• Development of the consumer-directed plan of care;

• Service-authorization documentation;

• Monitoring personal assistance needs;

• Changes in functional status affecting authorized hours;

• Attendant and EOR issues; and

• Ongoing consumer-directed program support.

This division of responsibility may create clearer accountability while preserving the specialized provider relationship that families already rely upon.

DMAS should also explore whether qualified Services Facilitators could perform certain LTSS care-coordination functions on behalf of the managed-care system.

Federal Medicaid rules require coordination of care, but they allow states and managed-care entities flexibility in how coordination is structured.

Rather than creating another statewide Support Broker workforce while eliminating an existing network of experienced providers, Virginia should examine whether Services Facilitators could be integrated into the broader care-coordination structure.

For example, Services Facilitators could potentially serve as contracted community-based LTSS coordinators for individuals who use consumer-directed services while the MCO retains oversight and responsibility for medical managed care.

Virginia's previous CCC+ contract has itself contemplated partnerships with community-based organizations to perform local care-coordination functions.

That concept deserves serious consideration before Virginia dismantles the current Services Facilitation network.

DMAS should also provide a direct financial comparison between the alternatives.

The public should know:

• How much Virginia currently spends on MCO care coordination for waiver members

  • How much Virginia currently spends on Services Facilitation;

  • How much the new Support Broker system will cost;

  • How much Fiscal-Employer Agents will receive to administer the Support Broker workforce;

  • Expected Support Broker caseloads;

  • Expected MCO care-coordinator caseloads;

  • Whether any functions will continue to be duplicated under the new model; and

  • The projected net savings from each possible restructuring.

• If the state is attempting to eliminate duplication, it should identify exactly where that duplication exists and determine which structure provides the greatest value to the member.

  Virginia should not assume that eliminating independent Services Facilitation is the only way to streamline Medicaid administration.

  There may be other approaches that reduce duplication while preserving member choice and continuity.

  DMAS should evaluate at least the following alternatives before proceeding with statewide elimination:

  1. Maintain Services Facilitation and narrow duplicative MCO LTSS care-coordination functions for members using consumer-directed services.

  2. Allow qualified Services Facilitators to perform designated LTSS care-coordination functions under arrangements with MCOs while MCOs retain responsibility for broader medical coordination.

  3. Preserve independent Services Facilitation while offering Support Brokerage as an optional alternative.

  4. Pilot the Support Broker model and compare it with the existing Services Facilitation model before eliminating Services Facilitation statewide.

  5. Establish clear divisions of responsibility between MCO care coordination and Services Facilitation to eliminate duplication rather than eliminating either function unnecessarily.

  Ask the Individuals and Families Which System Works

  Most importantly, DMAS should ask individuals receiving services which professional actually helps them navigate their care.

  Administrative organizational charts do not necessarily reflect how the system operates in a family's home.

  For many individuals using consumer-directed services, the Services Facilitator may be the professional who knows the individual's daily support needs, caregiver situation, authorized hours, attendant arrangements, and functional history most closely.

  If Virginia intends to eliminate that relationship, it should first demonstrate that another system will provide equal or better support.

  My Request

  I respectfully request that DMAS pause the elimination of standalone Services Facilitation and conduct a transparent analysis of the entire care-coordination structure surrounding waiver members.

  Specifically, DMAS should examine whether duplication between MCO care coordination, Services Facilitation, Fiscal-Employer Agents, and the proposed Support Broker system can be reduced without eliminating independent Services Facilitators.

  The goal should not simply be to reduce the number of provider types.

  The goal should be to create the simplest system that provides individuals with disabilities the strongest combination of consumer choice, expertise, continuity, accountability, and access to assistance.

  Before Virginia eliminates Services Facilitation, it should determine whether the better solution is to preserve the specialized consumer-directed provider while redesigning other administrative layers around it.

  Please evaluate these alternatives and publish the financial and programmatic analysis before making an irreversible statewide change.