Subject: Public Comment on 1915(c) HCBS Waiver Amendments — 56-Hour Cap and Services Facilitation
Subject: Public Comment on 1915(c) HCBS Waiver Amendments — 56-Hour Cap and Services Facilitation
To the Virginia Department of Medical Assistance Services:
I am writing to comment on the proposed amendments to the Commonwealth Coordinated Care Plus, Community Living, and Family and Individual Supports Medicaid waivers. I am particularly concerned about the proposed 56-hour weekly cap on personal care/assistance services and the proposal to incorporate services facilitation into a statewide service broker model through the Fiscal Employer Agent contract.
I am directly affected by these proposed changes. I am the caregiver of an adult son with special needs who relies on personal care services for many basic activities of daily living. His care needs include bathing, dressing and undressing, toileting and incontinence care, transferring, eating, turning and changing position, personal grooming, supervision, meal and snack preparation, cleaning up after meals, changing his bed, shopping, laundry, transportation to medical appointments and social activities, and medication support.
For my son, these are not extra services or conveniences. They are necessary supports that allow him to remain safe and participate in daily life.
A 56-hour weekly limit could have a very concrete impact on him and on our family. It could mean fewer safe transfers, going without bathing or meals, being left alone at unsafe times, relying more heavily on an already exhausted family caregiver, missing work or medical appointments, or facing an increased risk of nursing-facility placement. These are serious consequences that cannot be reduced to a number on a service authorization.
As a caregiver, I oppose the proposed 56-hour weekly cap on personal care/assistance under the 1915(c) HCBS waivers. A blanket cap does not account for the fact that waiver participants have different disabilities, health needs, living situations, schedules, and amounts of available unpaid support. What one person needs in eight hours may be very different from what another person needs.
Eight hours per day may not meet the needs of someone who requires assistance in the morning, throughout the day, in the evening, overnight, or during unpredictable health or safety-related events. Personal care needs do not disappear simply because an individual has reached an administrative hourly limit. When services are reduced below what a person actually needs, the consequences can include unmet basic needs, caregiver burnout, preventable medical crises and hospitalizations, loss of independence, and unnecessary institutionalization.
I recognize that the proposed amendments may provide an exception process. However, an exception process is only meaningful if it is simple, timely, transparent, consistently available, and based on documented individual need. People should not have to repeatedly fight for services that their assessments and care plans show they require.
If DMAS moves forward with the 56-hour cap, it should include strong protections, including:
• Individualized service authorizations: Service authorizations should remain based on each person's documented functional and health needs rather than a blanket hourly limit.
• A transparent exception process: DMAS should publish clear eligibility standards, provide a simple application process, make prompt decisions, and provide written explanations for any denial or reduction.
• Continuation of services during appeals: Existing services should continue while an exception request or appeal is pending so that individuals do not lose critical care during the review process.
• Meaningful appeal rights: Individuals and their representatives should receive adequate notice, have access to the records used to make decisions, and have an opportunity for independent review.
• Recognition of different types of care needs: The policy should account for overnight, intermittent, and safety-related needs that may not fit neatly into a weekly hourly cap.
• Public reporting: DMAS should publicly report the number of people affected, exception requests and their outcomes, appeals, service reductions, and any associated changes in hospitalizations or institutional placements.
• Meaningful stakeholder involvement: Waiver participants, family caregivers, direct support professionals, disability advocates, and service coordinators should have a direct role in developing, implementing, and monitoring the policy.
Services Facilitation and the Proposed Statewide Service Broker Model
I am also concerned about the proposal to incorporate services facilitation into the statewide service broker model through the Fiscal Employer Agent contract and to eliminate services facilitation as a standalone service.
This change could undermine consumer direction by taking away independent, participant-centered support and replacing it with a more centralized administrative structure.
People who direct their own services often need ongoing, trusted assistance—not simply a call center or standardized broker process. They may need help finding and keeping attendants, understanding employer responsibilities, managing schedules, resolving payroll problems, arranging backup support, responding to worker turnover, and protecting their ability to make decisions about their own care.
These needs are personal and sometimes urgent. They may also require someone who understands the participant's individual circumstances rather than someone working from a standardized statewide process.
I am also concerned about the potential for a conflict of interest. The entity responsible for administrative functions, including Fiscal Employer Agent functions, should not become the only source of assistance that participants rely on to understand their options, challenge decisions, or resolve problems. Participants need access to assistance that is genuinely independent and accountable to them, rather than assistance that may be influenced by the priorities of the system administering payments, contracts, or service processes.
DMAS should preserve services facilitation as a separate, participant-chosen, conflict-free service. If DMAS proceeds with the statewide broker model, participants should be able to choose an independent facilitator or advocate, retain existing trusted support relationships, and receive timely, local, accessible, and culturally responsive assistance.
Participants should also be able to appeal or resolve problems without interruption to their workers or essential care. DMAS should publicly monitor and report whether the transition results in delayed payroll, loss of workers, missed shifts, reduced participant choice, complaints, or people being forced out of consumer-directed services.
For families like mine, these proposed changes are not simply administrative changes. They affect whether our loved ones can receive the assistance they need to live safely in their own homes and whether families can continue providing care without becoming overwhelmed.
Virginia should protect people's health, safety, dignity, independence, and ability to live in the community. Essential services should be based on individual need, and people who direct their own care should have meaningful access to independent support and genuine choice.
