Date: October 15, 2026

To: Virginia Department of Medical Assistance Services (DMAS)

Subject: Opposition to the Proposed 56-Hour Weekly Soft Cap and Restrictive Exception Criteria for Developmental Disabilities Waiver Services

To Whom It May Concern:

I am submitting this formal public comment in opposition to the proposed 56-hour weekly soft cap on personal assistance services under Virginia’s Developmental Disabilities (DD) Waiver program, including the Family and Individual Supports (FIS) and Community Living Waivers.

I am the parent of an adult son with significant developmental disabilities who receives services through Virginia’s FIS Waiver. These services help protect his health and safety, support personal care and community participation, and allow him to continue living at home.

I recognize the importance of responsible Medicaid spending and effective program administration. However, a standardized weekly threshold should not override an individual’s documented functional limitations, disability-related support needs, health and safety risks, or ability to participate in daily life. I urge DMAS to preserve individualized, needs-based service authorizations.

1. The 56-Hour Threshold Does Not Reflect Individual Needs

People with developmental disabilities have widely varying support needs. Some require assistance with scheduled activities, while others need frequent prompting, redirection, hands-on assistance, behavioral support, or intervention throughout the day and night.

My son requires substantial direct assistance with daily living, mobility, and health and safety. His needs illustrate why a uniform weekly threshold cannot account for the frequency, intensity, and cumulative impact of support required by individuals receiving DD Waiver services.

A person may be physically capable of performing part of a task but still unable to complete it independently, safely, or reliably. Assessments must therefore consider cognitive, behavioral, adaptive, mobility, personal-care, and safety-related needs—not only narrowly defined physical dependence.

The number of authorized hours should be based on a comprehensive assessment of actual needs, not an arbitrary weekly benchmark or a separate nursing-related eligibility test.

2. Nursing Care Should Not Be Required for Additional DD Waiver Hours

I am particularly concerned that the proposed policy would apply exception criteria currently used under the Commonwealth Coordinated Care Plus (CCC+) Waiver to individuals receiving services through the FIS and Community Living DD Waivers.

Under 12VAC30-120-927, an individual seeking personal care hours above 56 per week must meet a specified nursing-related level-of-care requirement and at least one additional qualifying condition. The criteria focus on medical or skilled nursing needs, specified activities-of-daily-living dependencies, behavioral and orientation dependencies, or qualifying Adult or Child Protective Services documentation.

I strongly oppose using these nursing-oriented criteria as the gateway to additional personal assistance hours for people with developmental disabilities. 

The need for skilled nursing and the need for extensive personal assistance are not the same. An individual may not require skilled medical nursing but may still need substantial support because of intellectual or cognitive disabilities, impaired danger awareness, elopement, behavioral challenges, physical limitations, or difficulty completing daily activities safely and reliably.

The central question should be whether the individual’s documented disability-related needs justify the requested hours—not whether the individual meets a separate nursing-care threshold.

I urge DMAS to develop DD-specific exception criteria that allow authorization above 56 hours whenever an individualized assessment establishes that additional assistance is necessary. Eligibility should not depend exclusively on physical dependence, a nursing assessment, or the existence of a protective-services case.

3. Existing Services Must Be Protected

The introduction of a new threshold should not automatically reduce an individual’s authorized hours. Any proposed reduction should be based on an individualized assessment of current needs, accompanied by appropriate notice, a clear written explanation, and access to applicable appeal rights.

Individuals and families must have a meaningful opportunity to challenge decisions that do not accurately reflect support needs. Essential services should continue during reviews or appeals when required by applicable law and procedures so that families are not placed at risk by administrative delays.

4. Exception Procedures Must Be Accessible and Transparent

A “soft cap” could become a hard cap if the exception process is restrictive, burdensome, inconsistent, or slow. DMAS should establish a process that includes:

• Clear, publicly available criteria tailored to developmental disabilities.
• Consideration of cognitive, behavioral, adaptive, physical, personal-care, and safety-related needs.
• Reasonable and transparent decision timelines.
• Written explanations for denials or reductions.
• Accessible reconsideration and appeal procedures.
• Protection against unnecessary interruptions in essential services.
• Transparent reporting of exception requests, approvals, denials, appeals, and reductions.
• Limits on repetitive documentation when a person’s underlying condition and support needs have not materially changed.

DMAS should also explain who will make exception decisions, what documentation will be required, and how families can challenge unfavorable decisions. Exceptions are meaningful only when people with legitimate needs can realistically obtain them.

5. Family Caregiving Is Not a Substitute for Authorized Support

My wife is my adult son’s live-in caregiver and intends to continue providing care. Our family is committed to supporting him at home and helping him participate in the community. He participates in activities including Special Olympics bowling, daily walks, music therapy, church services, volunteering, shopping, gym visits, and other community activities that contribute to his quality of life and social engagement.

Our willingness to provide care should not be treated as evidence that he needs fewer authorized hours. Family members already provide extensive unpaid assistance, but their availability does not eliminate the individual’s need for services or establish that the family can safely and sustainably meet every need without paid support.

Assessments should consider the individual’s actual needs and the caregiver’s circumstances rather than assuming that family caregiving can replace authorized assistance.

6. Services Facilitation Changes Must Not Create Additional Barriers

I also ask DMAS to consider the effect of proposed changes to Services Facilitation and the transition to Support Brokers for individuals using consumer-directed services.

DMAS proposes incorporating Services Facilitation into a statewide service-broker model through the Fiscal-Employer Agent and eliminating Services Facilitation as a standalone service. 

Any transition should preserve access to knowledgeable assistance, provide clear guidance, and prevent disruptions in arranging and maintaining services. DMAS should explain how the transition will be implemented, what support will be available to families, and how continuity of care will be protected.

7. Requested Actions

I respectfully urge DMAS and the Commonwealth of Virginia to:

1. Reject the proposed 56-hour soft cap as a standard that could restrict individualized personal assistance.
2. Authorize hours according to each individual’s documented needs, including needs exceeding 56 hours per week.
3. Do not require professional nursing care or a nursing-related level-of-care determination for additional DD Waiver hours.
4. Establish DD-specific criteria that recognize cognitive, behavioral, adaptive, physical, personal-care, and safety-related needs.
5. Require assessments to consider the frequency, intensity, and cumulative impact of assistance throughout the day and night.
6. Protect existing authorizations from automatic reductions based solely on the new threshold.
7. Create a timely, transparent, and accessible exception, reconsideration, and appeal process.
8. Recognize family caregiving without treating it as a substitute for necessary paid support.
9. Ensure that changes to Services Facilitation and Support Brokers do not create barriers or disrupt essential services.
10. Provide a meaningful opportunity for individuals, families, advocates, and providers to comment before finalizing and implementing these changes.

Conclusion

My adult son deserves appropriate personal care, safety, community participation, and the opportunity to live with dignity at home. His family deserves a waiver system that recognizes his actual needs and supports sustainable caregiving.

Virginia should maintain an individualized, needs-based approach rather than allowing an arbitrary weekly threshold or nursing-based eligibility test to determine access to essential support.

I respectfully request that DMAS reconsider the proposed policy, revise the exception criteria, protect existing services, and ensure that individuals with developmental disabilities can receive the assistance their documented needs require.

Please include this comment in the official public record and consider these concerns before finalizing the proposed changes.

Thank you for your consideration.

Respectfully submitted,

A Parent and Family Advocate
Virginia