I strongly oppose all eight proposed amendments to Virginia’s Community Living (CL), Family and Individual Supports (FIS), and Commonwealth Coordinated Care Plus (CCC+) Medicaid waivers under General Notice 3470. I respectfully request that DMAS withdraw all eight proposals because of their potential effects on Virginians with disabilities, their caregivers and families, providers, managed care organizations, hospitals, and the Commonwealth.
I am the parent of waiver service recipients, a caregiver, and a longtime disability advocate. My concerns come from firsthand experience navigating Medicaid waiver services, consumer-directed care, attendant services, and the difficulties of maintaining necessary support at home. I am not an attorney. My references to legislation, regulations, and court decisions reflect my good-faith understanding as a layperson, with supporting authorities identified so readers can examine them directly.
I am not asking DMAS merely to explain these changes more thoroughly, improve its guidance, or describe additional safeguards. Where I request information or discuss measures that might reduce harm, those requests do not mean that I accept the proposed changes. The same individual may experience several amendments simultaneously, together with the separately implemented live-in caregiver Electronic Visit Verification (EVV) requirement. Their cumulative impact matters just as much as their individual purposes, particularly when evaluating community integration, continuity of care, and the risk of destabilizing existing support arrangements.
A numerical threshold cannot substitute for an individualized assessment. Someone who needs help eating, bathing, toileting, dressing, transferring, communicating, or remaining safe does not suddenly need fewer hours because an administrative threshold has been established. Calling the threshold a "soft cap" does not eliminate the concern. An exception process can create additional administrative barriers and delays even when needs have already been established.
Families cannot simply be assigned the unpaid hours that disappear from an authorization. Federal HCBS regulations describe natural supports as voluntarily provided, and CMS explained when adopting the rule that the person-centered planning process must not compel unpaid services. Where a family member is also a paid attendant, the distinction between voluntary family assistance and compensable employment matters. Applicable federal wage-and-hour protections do not disappear because an employee is related to the individual receiving services. This does not mean every act of family support constitutes paid employment, but reducing authorized services does not create an unlimited supply of unpaid workers. (42 C.F.R. § 441.301(c)(2)(v); 79 Fed. Reg. 2948, January 16, 2014; U.S. Department of Labor home-care guidance.)
Reductions can force family caregivers to leave employment, destabilize attendant schedules, increase administrative appeals, and transfer costs to MCOs, hospitals, and institutional services. Community integration suffers when someone cannot attend school, work, medical appointments, or ordinary activities because assistance is unavailable. Continuity of care means necessary assistance is actually delivered, not merely authorized on paper.
I oppose establishing the threshold itself, not merely the administration of its exceptions.
Services Facilitation is more than processing forms. An established facilitator may understand an individual's communication needs, functional limitations, medical history, attendant arrangements, service authorizations, family circumstances, and available local resources. That knowledge cannot be transferred automatically by assigning a new contractor.
Concentrating planning-related assistance, enrollment, fiscal administration, and dispute resolution within connected organizational structures also raises legitimate ethical and conflict-of-interest concerns. When a participant has a complaint about the fiscal system, who independently represents that participant's interests? Federal HCBS regulations include conflict-of-interest protections for person-centered planning, including functional separation and accessible dispute resolution in circumstances covered by the rule. Internal separation within an organization does not necessarily provide the same independence as participant-selected assistance. (42 C.F.R. § 441.301(c)(1)(vi).)
Removing standalone facilitation may increase administrative demands on families, providers, support coordinators, DMAS, DBHDS-related systems, and MCOs. Records can be lost, authorizations delayed, and important changes in an individual's condition overlooked. Community integration depends on reliable, individualized assistance. Continuity of care depends on preserving established relationships and the knowledge necessary to maintain services.
I oppose eliminating standalone Services Facilitation. A promise of replacement assistance does not resolve the loss of independent consumer choice and existing support relationships.
Allowing a participant to serve as Employer of Record while delegating responsibilities does not automatically make complex employment duties accessible. Disability-related cognitive, communication, sensory, physical, or other limitations may affect a person's ability to manage payroll, hiring, tax documentation, electronic approvals, supervision, and urgent personnel decisions.
Delegation can also create conflicts or uncertainty when a participant, representative, attendant, Support Broker, and fiscal agent have overlapping financial or administrative responsibilities. Unclear authority can produce delayed wages, employment disputes, caregiver departures, and interruptions in necessary services.
Consumer direction should increase personal autonomy rather than transfer administrative responsibility to someone whose disability makes those duties difficult or impossible without support. Family members should not automatically inherit additional unpaid administrative obligations.
Community integration requires accessible consumer-directed services. Continuity of care requires preserving attendant relationships, lawful payment, and service delivery during administrative changes. I oppose this restructuring as proposed.
I acknowledge DMAS's explanation that the TWWIIA Basic Coverage Group provision was included in error or never operationalized. I am not suggesting that this proposal eliminates Medicaid Works generally.
However, removing eligibility language should not occur without considering whether it could affect current or future pathways to coverage. Virginians with disabilities should not have to fear that working, increasing earnings, or pursuing advancement may jeopardize the services that make employment and independent living possible.
Eligibility uncertainty creates complications for participants, families, benefits counselors, employers, eligibility workers, and MCOs. Incorrect determinations can produce administrative appeals, interruptions in coverage, and preventable healthcare expenses.
Employment is an important opportunity for community integration. Continuity of care requires that qualifying coverage and services remain available. Federal HCBS requirements recognize opportunities for employment and participation in community life. (42 C.F.R. § 441.301(c)(2)(i).)
I oppose removing this provision without establishing its full implications for present and future access.
I acknowledge DMAS's description that this transportation provision was not operationalized. That limits what can reasonably be claimed about current paid transportation arrangements. It does not establish that removing the option has no potential consequences.
Transportation for people with disabilities is not always interchangeable. Some individuals need wheelchair-accessible vehicles, assistance with medical equipment, communication accommodations, behavioral support, supervision, or transportation at times and locations poorly served by existing providers.
An alternative provider listed in a directory is not necessarily an available provider.
Without dependable transportation, someone may be unable to access employment, education, medical appointments, therapies, community programs, or ordinary social activities. Families may inherit transportation responsibilities they cannot safely or financially sustain. CSBs, MCOs, healthcare providers, employers, and community organizations may experience the resulting service gaps.
Community integration requires actual access to the broader community, not merely authorization for services that cannot be reached. Continuity of care requires dependable transportation arrangements.
I oppose eliminating this potential provider option without demonstrating that the change will not restrict meaningful access.
DMAS describes this proposal as correcting an enrollment-form reference because an enhanced agreement has been incorporated into the standard Fiscal/Employer Agent packet. I recognize that this is not presented as a general prohibition on paid family caregiving.
Nevertheless, families and paid attendants who followed previous agency instructions should not experience payment interruption, disqualification, or administrative penalties merely because Virginia changes its forms or procedures.
An administrative correction should not create payroll disputes, interrupt an established caregiver relationship, or shift previously compensated disability-related services onto unpaid relatives.
DMAS, MCOs, fiscal agents, and providers already face substantial administrative responsibilities. New paperwork requirements can generate additional corrections, claims disputes, appeals, and caregiver turnover.
Paid family caregivers may be essential to community integration and the ability to remain at home. Continuity of care requires preserving properly authorized services and lawful payment while paperwork is corrected.
I oppose adopting changes that could destabilize existing caregiver arrangements under the description of administrative cleanup.
An adverse level-of-care finding can determine whether someone retains the services necessary to remain safely in the community. Removing an established review checkpoint reduces the opportunity to identify overlooked evidence, assessment errors, or misunderstandings of complex disabilities before services are terminated.
Someone may appear stable precisely because existing assistance is working. Stability while receiving services is not evidence that the services are unnecessary.
Families and treating professionals need meaningful opportunities to present relevant evidence before an erroneous determination results in lost care. An appeal after services have been interrupted does not necessarily prevent the consequences of the interruption.
Errors can affect MCOs, providers, emergency departments, hospital discharge planning, and institutional-placement decisions. Medicaid notice and fair-hearing requirements remain important, but they do not make preventive review irrelevant. (42 C.F.R. Part 431, Subpart E.)
Community integration can be jeopardized when essential HCBS is lost. Continuity of care requires identifying and correcting erroneous determinations before preventable harm occurs.
I oppose removing the higher-level review.
Item 8 concerns changes to the CCC+ quality-improvement framework, including removing MCOs from performing specified service-plan quality reviews and removing references to higher-level LOCERI reviews. I understand that the proposed application assigns certain service-plan measure reviews to the State, and I am not claiming all quality monitoring would end. My objection concerns removing existing responsibilities and checkpoints within an already complicated system.
Service plans can omit assessed needs, rely on unavailable attendants, or become inaccurate when an individual's circumstances change. Quality review is an opportunity to identify those problems before they create medical emergencies or destabilize a person's living arrangements.
People with disabilities, families, and caregivers should not become the only means of identifying service gaps. Federal HCBS regulations require person-centered plans to identify responsibility for monitoring and provide for review and revision when appropriate. (42 C.F.R. § 441.301(c).)
Removing oversight can transfer responsibility and costs to DMAS, MCOs, providers, hospitals, appeals systems, and institutions. Federal managed-care quality requirements remain applicable, but their existence does not establish that eliminating a particular review responsibility is appropriate. (42 C.F.R. §§ 438.330 and 438.340.)
Community integration should be evaluated by whether people can actually participate in education, employment, healthcare, relationships, and community life. Continuity of care should be measured through services delivered rather than simply services authorized.
A person authorized sixty hours who receives only thirty-five because no attendant is available does not have sixty hours of care.
I am particularly concerned about the combined consequences of Items 7 and 8. Removing a higher-level review checkpoint and associated quality-monitoring measures affects both the opportunity to correct errors and the ability to examine whether that protection was functioning.
I oppose both changes. Reassigning administrative responsibilities does not, by itself, resolve my objection to removing established safeguards.
9. I also request separate public scrutiny of Virginia's live-in caregiver Electronic Visit Verification implementation.
I recognize that live-in EVV is not one of the eight proposed waiver amendments. However, its implementation affects the same people, attendants, and support systems.
Federal EVV legislation and CMS guidance do not establish EVV as a federal minimum requirement for qualifying live-in caregivers. Virginia's published regulation, 12VAC30-60-65(C)(4), also identifies live-in caregivers as exempt. DMAS nevertheless announced implementation effective October 1, 2026, under the 2026 Appropriation Act. My understanding is that this creates an important question concerning the relationship between the existing exemption, the separate budget authority, and the regulatory process. I am not asserting that the state categorically lacks authority to change its policy. I am requesting meaningful public scrutiny of how it has done so. (42 U.S.C. § 1396b(l); 12VAC30-60-65; DMAS September 9, 2026 EVV bulletin.)
Live-in caregiving frequently involves intermittent and urgent assistance rather than one continuous shift. App failures, GPS errors, inaccessible technology, missed clock events during emergencies, disputed plans of care, and correction or payroll delays can threaten the only caregiver available to a participant.
I request a separate, meaningful public-comment process capable of influencing this policy, a complete examination of its implementation authority, and a minimum six-month implementation period following that process for accessibility review, technical testing, training, correction procedures, and independent analysis. Existing caregiver relationships, lawful payment, consumer choice, community integration, and continuity of care must be protected throughout.
The financial consequences of these proposals also deserve closer examination.
Virginia's 2026–2028 budget materials projected approximately $44.85 million in biennial General Fund reductions from standardizing personal-assistance hours. Averaged across 21,079 authorized CL/FIS waiver slots, that is approximately $2,128 per slot over two years. That average is not the actual reduction experienced by any particular participant, and projected budget reductions are not demonstrated net savings.
Virginia's surveyed 2025 median annual costs were approximately $80,080 for 44 weekly hours of nonmedical home care and $123,005 for a semi-private nursing-home room, a difference of $42,925 annually. Those are market prices rather than Medicaid reimbursement rates, and 44 hours of assistance will not meet everyone's needs. Nevertheless, the comparison illustrates the potential cost differences between community services and institutional care. Actual state costs also depend on Medicaid rates, federal matching funds, institutional needs, and the individual's service plan. (Virginia 2026–2028 budget materials; CareScout 2025 Cost of Care Survey.)
There are also longer-term consequences. Hospitalization interrupts education, employment, training, and ordinary community participation. Prolonged institutional placement can further restrict opportunities to develop functional skills, become more independent, and potentially reduce support needs. Where appropriate and desired, individuals may also earn income, pay taxes, or contribute toward healthcare costs through legally permitted arrangements.
These outcomes are possibilities, not guarantees. A person's dignity and right to appropriate services do not depend upon employment or economic productivity. However, the Commonwealth should account for these opportunities when evaluating the total long-term consequences of weakening community-based care.
Savings calculated from reduced authorizations alone cannot establish savings to Virginia if unmet needs are transferred to families, providers, MCOs, emergency departments, hospitals, or institutional services.
I respectfully request that DMAS withdraw all eight proposed amendments to the CL, FIS, and CCC+ waivers under General Notice 3470. I also request a distinct public-comment process concerning live-in caregiver EVV, examination of the existing regulatory exemption and implementation authority, at least six months for responsible implementation following meaningful public participation, and protection against caregiver-payment or consumer-service interruptions.
These requests for information, transparency, and safeguards do not constitute approval of the proposed amendments.
My complete public comment, including the detailed objections, legal and regulatory citations, financial analysis, and supporting sources, is available at:
https://merarose.live/advocacy/general-notice-3470.html
That page links directly to the complete public-comment PDF. I respectfully request that DMAS review the complete document and include it in the administrative record for General Notice 3470 along with this online submission.
An authorization on paper is not delivered care. Community integration and continuity of care must be measured by whether people with disabilities actually receive the assistance necessary to remain safe, supported, and meaningfully included in their homes and communities.