Our family has 10 years of firsthand experience with Virginia’s Consumer Directed Services program, and my son will depend on it for the rest of his life.

I support Virginia’s transition from Services Facilitation to a support broker model, provided that the Virginia Department of Medical Assistance Services (DMAS) uses this transition to establish stronger accountability, transparency, and protection of individual choice.

According to DMAS’s fiscal year 2023 report, Virginia has approximately 49,000 CCC+ Waiver members and 16,000 DD Waiver members. Among them, the people who choose Consumer Directed Services depend on the program for the authority to recruit, hire, train, supervise, and dismiss the attendants providing their personal care. These attendants may feed them, medicate them, bathe and toilet them, and see them naked every day. That is what individual choice means in this program. This is real life, and it is the standard by which this transition should be judged.

At the recent town hall, DMAS officials acknowledged serious problems in the existing Services Facilitation model. Required visits have not consistently occurred, the Commonwealth has lacked reliable ways to distinguish effective performance from poor performance, and deficiencies identified through federal review have had substantial financial consequences.

The General Assembly’s decision to replace Services Facilitation gives DMAS both an opportunity and a responsibility to correct these problems by establishing enforceable requirements through its contractual relationships with managed care organizations (MCOs) and Fiscal/Employer Agents (F/EAs).

The community’s concern is valid: transferring these responsibilities to MCOs and F/EAs does not automatically solve the accountability problem. It may also introduce different risks. DMAS can address the known vulnerabilities and detect and mitigate emerging risks by incorporating three safeguards into its contracts with MCOs and F/EAs:

1. Establish Measurable Accountability. Define what effective support brokerage must accomplish, including timely contact, understandable communication with individuals and their representatives, accurate documentation of support needed and received, continuity during transitions, and action when unmet needs are identified. DMAS should monitor results, require corrective action, and impose meaningful consequences when an MCO or F/EA fails to meet its contractual standards. F/EA accountability must include broker performance.
2. Require Transparent Information. Require a reliable record that connects what the individual needs, what the care plan specifies, what has been authorized, and what was actually delivered and paid. Individuals and authorized representatives should be able to review and correct information about their services. DMAS retains ultimate responsibility for identifying discrepancies, comparing MCO and F/EA performance, and monitoring continuity. That oversight cannot depend exclusively on reports prepared by the organizations being evaluated.
3. Obtain Direct Individual Feedback. Give individuals an accessible pathway to provide feedback and file grievances directly with DMAS or through an independent process. Their feedback should not have to pass through the broker, F/EA, or MCO whose performance may be at issue. DMAS should track patterns, publish aggregate findings, and demonstrate what corrective action was taken.

The town hall also exposed an immediate transition risk: a large Services Facilitation provider could leave the program on short notice. DMAS has said that existing prior authorizations will be extended for 90 days to help protect continuity. That is important, but it protects authorization rather than continuity itself. It does not transfer the information needed to understand the individual, establish contact with a new broker, or identify and address gaps during the transition. Continuity will require a standardized transition record for every participant, firm transfer deadlines, confirmation that the receiving broker has the necessary information, and a process for the individual or authorized representative to correct anything that is missing or inaccurate.

Continuity with trusted professionals matters, but no system can guarantee that the same service facilitator, support coordinator, care coordinator, or other professional will remain assigned to an individual. I also understand that service facilitators and other professionals may face painful changes to their jobs, careers, and businesses. Their concerns are real, but the risks are not equal. Professionals can change employers, business models, or careers. Our individuals cannot change their disabilities or choose different support needs.

What Virginia must preserve is more fundamental: Consumer Directed Services and the individual’s choice of personal attendant.

Virginia is not required to offer this self-directed waiver option. It exists because the Centers for Medicare & Medicaid Services (CMS) approved it, and it can continue only if Virginia demonstrates adequate oversight, quality, financial integrity, protection of health and welfare, and compliance with federal requirements, including Virginia’s Permanent Injunction with the Department of Justice (DOJ).

CMS places ultimate responsibility on DMAS for quality assurance, performance monitoring, remediation, and improvement. Virginia should use this transition to show CMS that it has learned from the weaknesses of Services Facilitation and has designed stronger protections into the new model. The difficulty of this transition is justified only if it creates stronger accountability, greater transparency, and direct channels for individual feedback, all of which are necessary to preserve the opportunity for Virginians with disabilities to choose and direct the people who provide their intimate daily support.