The Arc of Virginia appreciates the opportunity to comment on the proposed amendments to the Community Living (CL), Family and Individual Supports (FIS), and CCC Plus waivers. We appreciate the work of the Department of Medical Assistance Services (DMAS), the Department of Behavioral Health and Developmental Services (DBHDS), and the many people across these agencies who work to improve Virginia's Medicaid system.
Through our Information and Resources work, we hear regularly from people with developmental disabilities and their families who are trying to navigate a complicated system while getting the support they need to live their lives. We recognize that the system needs improvement. There are too many layers, overlapping responsibilities, and processes that can be difficult for people and families to navigate.
We support efforts to make the system more efficient, consistent, and responsive. But improvements should be measured by whether they make the system work better for people receiving services, not simply whether they change the administrative structure.
Our greatest concern with these amendments is the lack of meaningful stakeholder engagement before the proposals were developed. The Arc of Virginia was not involved in designing or evaluating the proposed support-broker model, considering how it would work in practice, or planning for its implementation. We are concerned that people with disabilities, families, and organizations working directly with them have not had a meaningful opportunity to help shape these decisions.
A 30-day public comment period is important, but it should not replace engagement throughout the development process. We appreciate that DMAS has documented and responded to public comments in previous waiver applications. However, we would like greater transparency about how stakeholder feedback influences substantive policy decisions, not just technical or language changes. More importantly, public comment should not be the first meaningful opportunity for people with disabilities and families to help shape significant changes to the services they rely on.
The timeline makes this especially concerning. CMS review and approval take time, yet implementation of the support-broker model is scheduled to begin in March 2027. While DMAS has outlined some advance communication and transition protections, we question whether there is adequate time for meaningful engagement, education, training, and resolving problems before implementation.
People and families are also navigating other significant changes in Virginia's waiver system. We need to be thoughtful about the cumulative impact of asking them to adjust to additional requirements and new processes, particularly when those changes affect essential services.
The Arc of Virginia does not oppose the concept of a support-broker model. In fact, we believe there are opportunities to improve the current consumer-directed system.
Today, individuals and families may work with a Support Coordinator or Care Coordinator, a Services Facilitator, a Fiscal/Employer Agent, and an Employer of Record. These roles serve important purposes, but there are overlapping responsibilities, multiple assessments and plans, and too many layers in some processes.
There are real opportunities to simplify the system, reduce duplication, improve coordination, and make it easier for people and families to navigate.
However, based on the proposed amendments, it is not clear that the support-broker model will accomplish those goals. It appears to replace Services Facilitators with Support Brokers operating through the Fiscal/Employer Agent structure while leaving the other roles and much of the existing work in place.
We question what problem this restructuring is intended to solve and what evidence DMAS has that it will produce better outcomes for people receiving services.
Will it reduce duplicative assessments, service plans, monitoring, and paperwork? Will people and families have fewer contacts to navigate? Will it improve the time it takes to resolve payroll and authorization problems? How will DMAS measure whether the change has actually improved people's experiences?
We also have questions about independence and choice. How will Support Brokers provide independent assistance when a problem involves the Fiscal/Employer Agent through which they work? Will individuals have meaningful choice in selecting or changing their broker? What qualifications, caseload standards, and accountability measures will be required?
These are questions that should have been explored with stakeholders before the model was developed.
We recognize that DMAS has included important transition protections. The amendments describe advance communication, continuation of existing attendants, transfer of assessments and service plans, extensions of existing authorizations to allow time for broker visits, and continued Services Facilitation during the transition. These are positive steps.
However, the protections outlined in the applications do not replace the need for a comprehensive implementation plan developed with stakeholders.
People need more than a notice that their Services Facilitator is being replaced. They need to understand who their broker will be, what that person will do, what will change, what will stay the same, and where to turn when something goes wrong.
We are also concerned about the loss of established relationships. Many Services Facilitators have worked with individuals and families for years and understand their needs. A transition plan should address how that knowledge will be preserved and how individuals will receive consistent support if their current Services Facilitator leaves before the transition is complete.
We urge DMAS to establish a stakeholder workgroup that includes people receiving services, families, self-advocates, Services Facilitators, Support Coordinators, Fiscal/Employer Agents, and advocacy organizations. The group should help evaluate the model, clarify responsibilities, identify potential problems, and develop a realistic implementation plan.
We also urge DMAS to reconsider the implementation timeline and not eliminate Services Facilitation until the operational details are clear, people have received meaningful notice and training, and the state can demonstrate readiness in each region.
The goal should not simply be to replace one administrative structure with another. We should be able to show people how this change will make their lives easier.
The Arc of Virginia has significant concerns about the proposed implementation of a 56-hour soft cap for personal assistance in the CL and FIS waivers.
We recognize that DMAS has outlined a phased implementation process, including education, an opportunity to request exceptions, and appeal rights. We also recognize that some individuals may benefit from a different combination of waiver services.
However, the proposed amendments include language requiring existing personal assistance authorizations of 57 hours or more per week to be automatically adjusted to 56 hours following the exception-review phase, unless an exception has been approved.
We strongly oppose automatic reductions of previously authorized services based on a new administrative threshold.
These individuals have already been assessed and approved for their current level of support. A change in policy should not automatically undo those determinations without an individualized review of whether the person's needs have changed.
We appreciate that DMAS has included an exception process, but the proposed approach places a significant burden on individuals, families, and Support Coordinators to identify the need for an exception, gather documentation, and obtain approval within a relatively short period.
Some individuals may not understand the new requirements, receive adequate notice, or have the assistance needed to complete the process. Others may have difficulty obtaining the necessary documentation or navigating the review process before their existing authorization is reduced.
We urge DMAS to remove the automatic reduction provision and work with stakeholders to develop an individualized transition process for people with existing authorizations above 56 hours.
At a minimum, individuals and families should receive clear advance notice, accessible information about exception criteria, and direct assistance with documentation and authorization requirements.
For individuals who may benefit from other waiver services, Support Coordinators should help them explore whether a different combination of supports could better meet their needs. This should be based on the individual's preferences, assessed needs, and the actual availability of appropriate services, not simply an effort to reduce personal assistance hours.
We also ask DMAS to review whether the exception criteria used in the CCC Plus waiver are appropriate for people receiving DD waiver services. The populations and service systems are not identical, and the exception process should reflect those differences.
Most importantly, existing authorized hours should remain in place while necessary reviews, exception requests, and planning are completed. No one should lose essential care simply because they could not navigate a new administrative process in time.
The Arc of Virginia opposes removing the automatic higher-level review when a Level of Care Eligibility Re-determination Instrument (LOCERI) indicates that someone no longer meets CCC Plus waiver eligibility criteria.
We recognize that individuals would retain appeal rights. However, an appeal is not the same as an automatic internal review intended to identify potential errors before an adverse determination is finalized.
Removing this safeguard shifts more responsibility to individuals and families to recognize a possible error, understand the appeal process, and initiate a challenge.
That is particularly concerning for people with significant disabilities, complex medical needs, or limited assistance navigating the Medicaid system.
We understand the need to improve administrative efficiency. However, when an incorrect determination can result in the loss of essential waiver services, an additional level of review is an important protection.
We urge DMAS to retain the higher-level review requirement and examine opportunities to make the process more efficient without removing this safeguard.
We also ask DMAS to explain how it will continue to monitor the accuracy of negative level-of-care determinations and identify errors before individuals lose services, particularly given the proposed changes to associated quality measures.
The Arc of Virginia supports efforts to provide greater flexibility and control in consumer-directed services, but clarification is needed regarding the proposed changes to Employer of Record responsibilities and Employer Identification Numbers.
Under the proposed amendments, individuals may serve as their own Employer of Record while designating someone else to carry out some or all employer responsibilities. The amendments also identify circumstances in which an Employer Identification Number may be assigned to someone other than the individual receiving services.
These changes may have practical, tax, administrative, and legal implications for individuals and the people assisting them.
There is already considerable confusion about the responsibilities of individuals receiving services, Employers of Record, designated representatives, attendants, Services Facilitators, and Fiscal/Employer Agents. Greater flexibility is welcome, but it needs to come with clear guidance.
We ask DMAS to provide plain-language guidance explaining which responsibilities can be delegated, which cannot, who remains legally responsible for each function, how liability is handled, and what happens when someone cannot fulfill their employer responsibilities.
This guidance should be reflected in consumer-directed service manuals, training materials, and other public resources. We also encourage DMAS to involve individuals and families in developing the guidance and provide practical examples of how these arrangements will work.
We recognize the potential benefit of moving responsibility for reviewing managed-care-developed service plans to the DMAS Office of Community Living.
Independent state oversight can be an important safeguard, particularly when decisions affect the services and supports people receive.
We ask DMAS to explain how this change will strengthen oversight, ensure timely reviews, and maintain accountability without creating additional delays for people receiving services.
We also encourage DMAS to identify how it will monitor the effectiveness of the new review process and address problems as they arise.
Although the new Electronic Visit Verification requirement for live-in caregivers is not part of these proposed amendments, we want to reiterate The Arc of Virginia's strong opposition to Virginia's decision to impose this requirement.
The requirement took effect October 1 despite significant concerns raised by families, caregivers, and advocates. Virginia chose to require EVV for live-in caregivers even though federal EVV requirements do not apply when the caregiver and the person receiving services live together.
We raise this here because it is part of the larger picture. Families are already navigating a significant change in how they must document care, with unresolved questions about how EVV works when paid and unpaid support are provided throughout the day.
These changes do not happen in isolation. Each new requirement adds to the responsibilities of people and families already managing complicated systems of care. The cumulative impact matters, and it makes meaningful engagement, clear guidance, and realistic implementation timelines even more important.
The Arc of Virginia supports efforts to improve Virginia's Medicaid waiver system. We recognize opportunities to reduce unnecessary duplication, strengthen accountability, improve coordination, and make services easier for people and families to navigate.
But efficiency should be measured by whether the system actually works better for the people using it, not simply whether the state has changed its administrative structure.
We urge DMAS to meaningfully engage people with disabilities, families, and other stakeholders in designing and implementing significant changes; demonstrate how proposed reforms will improve outcomes; provide adequate notice, accessible training, and realistic transition timelines; and preserve essential protections against unnecessary service reductions or loss of eligibility.
We also ask DMAS to provide greater transparency about how stakeholder comments influence substantive policy decisions and what changes are made before applications are submitted to CMS.
People with disabilities and their families should not be expected to repeatedly adjust to major system changes without having a meaningful voice in how those changes are developed.
We appreciate the work of DMAS and DBHDS and want to continue working together to build a better system. That requires involving the people who know it best from the beginning.
Thank you