I am submitting these comments as the parent of a child with significant disabilities who receives services through Virginia's Commonwealth Coordinated Care Plus (CCC Plus) Waiver. Our family utilizes consumer-directed attendant care, and I serve as the Employer of Record (EOR).

First, I appreciate DMAS's efforts to evaluate and modernize the administration of consumer-directed services. Families depend on these services every day, and improvements that reduce administrative complexity, increase consistency, and strengthen accountability should be welcomed.

Transition from Service Facilitators to Support Brokers

I am not inherently opposed to eliminating the existing independent service facilitation model in favor of support brokers employed through the Fiscal-Employer Agent (FEA). In fact, our family's experience with service facilitation has been mixed.

We have experienced frequent changes in service facilitators, inconsistent interpretations of program requirements, and difficulties obtaining clear guidance regarding authorized attendant-care hours and supervision-related needs. At times, these issues have created significant administrative burdens for our family and required substantial effort to resolve.

If the proposed support broker model provides more consistent training, standardized assessments, clearer guidance, and greater accountability, it could represent a meaningful improvement.

However, changing the organizational structure alone will not solve these problems. I encourage DMAS to address the following questions as part of implementation:

1. Assessment consistency: What standardized assessment criteria and training will ensure that support brokers apply Medicaid requirements consistently across families and regions?

2. Accountability and escalation: What independent mechanism will be available when a family disputes a support broker's assessment, interpretation of policy, or recommendation affecting authorized services?

3. Continuity of services: How will DMAS ensure that existing service authorizations, attendant employment arrangements, and care plans remain uninterrupted during the transition?

4. Transparency: Will families receive written explanations of assessment findings, proposed changes, applicable policies, and available appeal rights?

Employer of Record Responsibilities

I also encourage DMAS to provide clear, written guidance regarding proposed changes to the EOR structure, particularly for recipients who cannot independently manage employment responsibilities due to intellectual or developmental disabilities.

Families need to understand whether existing responsibilities involving hiring, employment eligibility verification, timesheet approval, tax documentation, and employment-related liability will change.

Any transition should minimize additional administrative burdens on families already managing complex medical, educational, and caregiving needs.

Eligibility Reviews and Procedural Safeguards

I am particularly interested in the proposal to eliminate the additional DMAS nurse review associated with certain level-of-care determinations.

While I recognize the importance of administrative efficiency, additional review processes can serve as important safeguards against incorrect decisions that could jeopardize essential services.

I encourage DMAS to explain what protections will remain in place, how families will be notified of adverse determinations, and whether an independent review opportunity will be available before services are disrupted.

Closing Comments

Our family has experienced both the tremendous value of Virginia's Medicaid waiver services and the considerable challenges associated with navigating their administration. We have also experienced situations in which resolving service-related concerns required escalation well beyond the individuals and organizations initially responsible for addressing them.

Those experiences have reinforced my belief that accountability must be built into the system rather than depend on a family's ability to identify the right person, understand complex regulations, or persist through multiple levels of escalation.

I support efforts to make consumer-directed services more efficient and consistent. I do not believe preserving the current service facilitation structure should be an objective in itself if a different model can better serve recipients and families.

Ultimately, the measure of success should not be whether the administrative transition is completed on schedule or produces cost savings. It should be whether individuals with disabilities receive appropriate, uninterrupted services and whether their families have clear, accessible, and effective mechanisms for resolving problems.

Thank you for considering these comments and for the opportunity to provide input.