9 October, 2026

Dear DMAS Representatives,

Thank you for the opportunity to provide public comments regarding General Notice 3470 and the proposed changes to Virginia’s Medicaid waiver programs. I recognize the importance of improving administrative efficiency and accountability. However, changes affecting essential services should be developed with meaningful input from the individuals and families who depend on them. My concerns involve public notification, family choice, independent assistance, potential conflicts of interest, medical decision-making, and continuity of care. Meaningful Public Notice and Family Participation. Before addressing the proposed changes themselves, I respectfully ask DMAS to explain how affected families were informed about these proposals and their opportunity to participate. The public comment period opened on September 17, 2026. As of October 9, more than three weeks have passed, representing over seventy percent of the comment period. Yet an important question remains: How many affected families actually know that these changes are being considered? As a family member participating in consumer-directed services, I did not receive direct notification from DMAS or from my Service Facilitator about this public comment opportunity. I learned about it through my own research. I am concerned that many, possibly a majority of affected families, may still be unaware of the proposed changes. I respectfully request specific answers to the following questions: How many individuals and households are directly affected by the proposed amendments? How many affected households received direct notification? What notification methods were used, and on what dates? Were notices provided in appropriate languages and accessible formats? Were Service Facilitators, care coordinators, MCOs, or Fiscal/Employer Agents instructed to notify families? If Service Facilitators were not asked to provide neutral notices during their regular contact with families, why was this existing communication channel not used? Can DMAS document whether at least a majority of affected households were directly informed about the opportunity to comment? How many unique individuals or households submitted comments, to the extent that this can reasonably be determined? The number of published comments does not necessarily represent the number of participating families. More importantly, the absence of a comment does not establish that a family was informed and chose not to participate. The existence of a public comment period does not necessarily mean that affected families know it exists. Service Facilitators already maintain direct relationships with many participating households. They could distribute simple, neutral information about proposed changes and public comment opportunities without advocating for or against any proposal. I respectfully request that DMAS disclose its notification methods and documented outreach. If substantial gaps are identified, DMAS should provide direct notice and consider extending or reopening the comment period before implementing the changes. Family Choice and Continuity of Service Facilitation. The proposed transition from independent Service Facilitators to Support Brokers raises important questions about family choice and continuity of care. Families may have established relationships with Service Facilitators who understand their individual needs, communication requirements, and service histories. Before implementation, DMAS should clarify: Who will select the Support Broker—the individual receiving services, the family, or an administrative organization? Will families be able to change Support Brokers when necessary? Will there be restrictions on how frequently a broker may be changed? Will existing Service Facilitators be eligible to transition into Support Broker positions while continuing to serve their current families? What procedures will protect families against interruptions in services when a broker resigns, becomes unavailable, or must be replaced? If independent Service Facilitation is eliminated, what equally independent assistance will remain available? I respectfully request that DMAS publish clear procedures governing broker selection, replacement, and continuity of services before implementation. Financial Independence and Potential Conflicts of Interest. A central concern involves the employment, compensation, supervision, and accountability of Support Brokers. I respectfully request that DMAS explain the proposed financial and administrative structure. Who will directly employ and compensate Support Brokers? Will they be employed or contracted through a Fiscal/Employer Agent, Managed Care Organization, or another entity? Who will determine their compensation, evaluate their performance, and make decisions regarding continued employment? Will compensation depend on the number of families served, administrative performance, service utilization, or financial savings? These questions matter because families may need assistance challenging decisions or administrative actions involving organizations with which their Support Broker has a financial or contractual relationship. If a broker depends financially on an organization whose actions a family needs to challenge, how will that broker’s independence be protected? What safeguards will prevent retaliation against brokers who assist families with complaints or appeals? Will families have access to an independent complaint process outside the organization involved in the dispute? Will DMAS conduct independent oversight of potential conflicts of interest? I respectfully request that DMAS establish clear protections for both families and Support Brokers. Service Reductions, Appeals, and Independent Assistance. Consider a beneficiary whose authorized personal care hours are reduced following reassessment despite continuing documented functional needs. The family may need assistance understanding the decision, obtaining assessment records, submitting medical evidence, and pursuing an appeal. My own experience illustrates why these protections matter. Previously authorized personal care hours were reduced despite continuing care needs. Following an appeal, the decision was reconsidered and additional hours were authorized. This experience raises practical questions about the proposed Support Broker model. Who will help families understand an adverse decision? Who will assist them in obtaining relevant records and identifying possible assessment errors? Will Support Brokers be permitted and expected to explain appeal procedures and assist families in accessing available review mechanisms? If a broker has a conflict of interest or declines to help, what independent assistance will be available? How will families be informed about applicable appeal deadlines and any available right to continued services during an appeal? If a reduction is overturned, what remedies are available for services that were not provided during the disputed period? Families should not lose access to independent assistance precisely when they need it most. Treating Physicians and Independent Medical Review. Another important concern involves the weight given to medical evidence when previously authorized personal care services are reduced. A treating physician may have examined and cared for a beneficiary over many years and may possess detailed knowledge of the individual’s medical history and functional limitations. An MCO medical reviewer may reach a different conclusion based primarily on records, without personally examining the beneficiary. I respectfully ask DMAS to clarify: What weight is given to the treating physician’s documented findings and recommendations? If the treating physician confirms that the beneficiary’s condition and functional limitations have not improved, what evidence may justify reducing previously authorized hours? When an MCO reviewer disagrees with the treating physician, must the MCO explain the specific medical and functional evidence supporting its determination? Is consultation with the treating physician required or available before a substantial reduction? What independent medical review procedures are available when medical opinions conflict? Can a treating physician initiate or request an independent reviews and how can the family access that process? I respectfully ask DMAS to consider a safeguard under which substantial reductions that conflict with documented treating-physician findings receive independent medical review before taking effect, where consistent with applicable Medicaid requirements. Treating physicians’ findings should receive substantial consideration, and disagreements affecting essential services should be subject to transparent, appropriately qualified review. An independent medical review mechanism would not replace independent Service Facilitation. Families may need both medical and administrative assistance. Accountability and Protection Against Service Disruptions. DMAS should clarify who will independently oversee Support Brokers. If a family believes that its broker is not providing appropriate assistance, who will investigate? Will families be able to contact DMAS or another independent oversight entity directly? Can they request a different broker without jeopardizing their services? What enforceable procedures will address unresolved complaints, service interruptions, and potential conflicts of interest? I respectfully request that these procedures be published before the transition. Related Waiver Amendments and Beneficiary Safeguards. Several other proposals in General Notice 3470 raise related questions about oversight and beneficiary protections. Proposed 56-hour soft cap. DMAS should explain how exceptions will be evaluated, what evidence families must submit, who will make determinations, and what review or appeal protections will apply. Individualized assessments should remain central to determining necessary services. Removal of Higher-Level DMAS Reviews. Regarding the proposed change to additional DMAS reviews when a CCC Plus beneficiary is determined no longer to meet waiver level-of-care requirements, what independent safeguards will remain? How will incomplete assessments, missing medical evidence, and conflicting clinical findings be identified and addressed? How will affected beneficiaries receive notice and access available appeal procedures? Changes to Service Plan Quality Reviews. Regarding the proposed changes to MCO participation in certain CCC Plus service-plan quality reviews, which entity will assume responsibility for the affected reviews? How will DMAS ensure continued accountability, independence, and correction of identified deficiencies? I respectfully ask DMAS to explain how these changes, considered together, will preserve meaningful oversight and protect beneficiaries from unnecessary disruptions in essential services. Requested Action. Before implementing the proposed Support Broker transition, I respectfully request that DMAS disclose the number of affected households and document the methods and reach of direct public notification; provide additional meaningful opportunities for public participation if substantial notification gaps are identified; publish clear procedures governing Support Broker selection, replacement, compensation, supervision, and accountability; explain how potential conflicts of interest will be prevented, identified, and independently reviewed; preserve access to independent Service Facilitation or establish an equally independent alternative; clarify the responsibilities of Support Brokers when families challenge service reductions, administrative errors, or adverse determinations; ensure meaningful consideration of treating physicians’ findings and identify independent medical review procedures for disputed decisions; explain the beneficiary protections that will remain under the related waiver amendments. I appreciate DMAS’s consideration of these questions and respectfully request substantive written responses in the public record. Families should have meaningful notice, a genuine opportunity to participate, and clear information about their rights before changes affecting essential services are implemented. Thank you for your consideration. 
Respectfully, Larisa (mother of a child with disabilities)