I am submitting this comment anonymously as a Virginia Services Facilitator with six years of experience in consumer-directed services, including three years working exclusively with individuals receiving Developmental Disabilities (DD) Waiver services. My experience includes managing a caseload of approximately 80 individuals, working with Services Facilitators across multiple agencies, and providing consultation and training when policies and procedures change.
I support Virginia's proposed transition from Services Facilitation to a Support Broker model, but my support is conditional. I believe meaningful reform is necessary within Virginia's consumer-directed services system. However, replacing Services Facilitators with Support Brokers will not, by itself, correct the problems that already exist. For this transition to represent genuine improvement, the Department of Medical Assistance Services (DMAS) must establish enforceable performance standards, transparent reporting systems, clearly defined responsibilities, and meaningful accountability for every entity involved in administering and delivering consumer-directed services.
Virginia has divided responsibility for consumer-directed services among Fiscal/Employer Agents (FEAs), managed care organizations (MCOs), Services Facilitators, and other entities without a sufficiently coordinated system of performance standards, shared information, and enforceable accountability. When an authorization is delayed, an attendant enrollment is not completed, payroll fails, Electronic Visit Verification (EVV) data are rejected, or required records are not transferred, DMAS may lack consistent information to determine what happened, which entity was responsible, whether requirements were met, or whether corrective action occurred.
These are not new concerns. The Virginia Board for People with Disabilities' 2023 assessment of Medicaid consumer-directed services, informed by DMAS data, stakeholder research, and survey responses, identified problems involving FEA communication, inconsistent guidance, customer service, unclear responsibilities, and difficulties resolving problems. Its recommendations called for improvements in administrative processes, communication, and accountability. These findings demonstrate that operational weaknesses existed well before the proposed Support Broker transition.
Without standardized reporting, reliable administrative records, and consistent performance measures, how can DMAS determine whether a service failure resulted from attendant noncompliance, an authorization problem, an FEA processing error, an MCO failure, or another contractor's inaction? How can DMAS identify recurring patterns, distinguish administrative errors from intentional misconduct, enforce corrective action, or demonstrate that public funds are being administered appropriately?
My concerns are based on firsthand professional experience. Throughout my career, I have encountered serious agency noncompliance and suspected fraud, abuse, and neglect. I have reported suspected misconduct involving Services Facilitators, provider agencies, attendants, and Employers of Record (EORs). Some reports resulted in investigations in which I participated, including interviews with representatives of the Virginia Attorney General's Office concerning suspected Medicaid fraud.
What troubles me is that despite reporting serious concerns and participating in investigations, I did not consistently observe meaningful changes or corrective actions addressing the problems identified. I recognize that investigations and enforcement activities may occur without the reporting individual being informed. Nevertheless, from my position in the field, I often could not determine whether concerns had been resolved, whether corrective measures were implemented, or whether the individuals receiving services were adequately protected.
Services Facilitators have traditionally served an important monitoring role within consumer-directed services. Through assessments, home visits, documentation, and reporting, we are positioned to identify changes in participants' needs, problems with service delivery, and potential noncompliance. We are effectively the eyes and ears of DMAS in the field. However, that responsibility has limited effectiveness when there is no reliable process for determining whether reported concerns resulted in appropriate investigation, corrective action, or improved outcomes.
I am not suggesting that fraud is widespread among Services Facilitators or that every administrative failure involves misconduct. Many Services Facilitators work diligently to protect the individuals they serve. My concern is that accountability must extend across the entire system. Reporting a problem should not be the end of the process. DMAS needs the rules, tools, and enforcement mechanisms to determine responsibility, identify patterns of noncompliance, and verify that appropriate action occurred.
I also believe participants, Employers of Record, and attendants are underutilized resources for strengthening program integrity. Consumer-directed services are unique because participants and their designated EORs are directly involved in managing Medicaid-funded services. EORs hire and supervise attendants, monitor services, and approve timesheets used in the Medicaid payment process. Attendants provide the actual services, while participants experience firsthand whether their needs are being met. Each has information that can contribute to an accurate understanding of service delivery.
Yet, in my professional experience, participants and EORs often have limited visibility into monitoring reports, assessments, and documented changes in participant needs that are submitted through the Medicaid system. Information maintained by Services Facilitators, Support Coordinators, MCOs, FEAs, and other entities is frequently separated across different administrative systems. This limits opportunities to identify inaccuracies, report changes, or ensure that decisions about services are based on complete and relevant information.
An EOR may be responsible for approving attendant hours and overseeing service quality without knowing what has been documented about the participant's needs or changes in condition. Likewise, DMAS may receive professional monitoring reports without routinely providing participants and EORs an opportunity to review relevant information, identify discrepancies, or contribute their own observations. Attendants may also possess important information about changes in a participant's condition or the services actually provided, but need appropriate ways to report that information and review records directly related to their responsibilities.
The Support Broker transition presents an opportunity to address this disconnect through a centralized, participant-accessible information and reporting system. Such a system should allow participants to review relevant service records, document changes in their needs, report satisfaction with attendants, raise concerns about service quality or potential abuse, and submit their own observations for consideration alongside professional assessments. EORs should have appropriate access to information necessary to fulfill their responsibilities and opportunities to submit independently attributed reports. Attendants should have access to relevant service instructions and records concerning their work, along with a means of reporting concerns or correcting inaccurate information.
Participants should also have a meaningful role in determining how their information is shared with Support Brokers, Support Coordinators, care coordinators, and other authorized entities, consistent with Medicaid requirements and privacy protections. Confidential reporting options must be available when concerns involve an EOR, attendant, or household member so that transparency does not create additional risks for the participant.
This proposal does not necessarily require DMAS to purchase or develop an entirely new platform. DMAS could establish minimum standards requiring existing systems to exchange information securely while providing appropriate access to participants and other authorized individuals. The objective should be a reliable, accessible record that allows information to follow the participant, supports accurate assessments, identifies discrepancies, documents reported concerns, and tracks responsibility for corrective action.
Importantly, participant and EOR self-reports should be separately attributed and retained alongside professional documentation without replacing independent assessments or verification. This would allow DMAS to consider information from multiple perspectives rather than relying exclusively on reports submitted by contracted entities. It would also create a mechanism for participants and EORs to identify information they believe is inaccurate or incomplete before it influences service decisions.
Transparency is not simply about giving people access to records. It is about ensuring that the information used to authorize, administer, monitor, and evaluate Medicaid-funded services is accurate, relevant, and subject to appropriate review.
Accountability must also include clear reporting and enforcement procedures. Participants, EORs, and attendants need accessible ways to communicate concerns directly to the appropriate responsible entity, including DMAS when necessary. The fraud, waste, and abuse hotline should not be the only practical avenue for reporting unresolved program-integrity concerns. There should be a process for acknowledging reports, assigning responsibility, documenting findings and corrective actions, and communicating appropriate outcomes while protecting confidential investigative information.
These expectations should apply to every entity involved in consumer-directed services, whether contracted, paid, or unpaid, with responsibilities appropriate to each role. MCOs, FEAs, and Support Brokers should be subject to measurable performance standards, routine audits, documented corrective-action requirements, and enforceable consequences for repeated or serious noncompliance. EORs, attendants, and participants must also understand their applicable responsibilities and have access to the information and tools necessary to fulfill them.
The proposed Support Broker model should not simply transfer existing monitoring responsibilities from one group of professionals to another. It should establish how information will be collected, shared, reviewed, and used to improve services and identify noncompliance. DMAS must be able to independently evaluate performance across contracted entities rather than relying exclusively on information those entities report about themselves.
My conditional support for the transition does not eliminate my concerns about its implementation. Based on conversations with Services Facilitators across agencies, there is significant uncertainty throughout the existing workforce. Following the October 7, 2026, Services Facilitator town hall, I have checked regularly for updated guidance from DMAS, MCOs, and FEAs. As of this comment, I have been unable to locate sufficient written implementation guidance or an accessible transcript of that meeting.
Services Facilitators are attempting to interpret the transition independently, resulting in inconsistent information being shared with participants and families. People are concerned about losing authorized hours, losing their choice of attendants, and experiencing interruptions in services. Although DMAS has discussed temporary protections for existing authorizations, participants need clear written explanations of those protections and how they will be implemented.
DMAS has asked Services Facilitators to cooperate with the transition. Cooperation requires communication. We cannot responsibly help participants navigate a significant administrative change when we are left to develop our own interpretations of requirements that have not been clearly communicated. DMAS should establish a centralized source of official guidance, implementation timelines, town hall materials, updated questions and answers, and procedures for resolving conflicting information.
The participant must remain central to this transition. Agencies, contractors, and administrative responsibilities may change, but the participant remains the one constant. Individuals should not have to repeatedly explain their needs or reconstruct their service history because essential records were not transferred. The transition should include accessible information, verified transfer of service records, opportunities for participant self-reporting, and clear responsibility for resolving missing documentation or interrupted services.
I recognize that many Services Facilitators and participants oppose this transition. Their concerns deserve consideration, and my support should not be interpreted as dismissing the relationships, professional knowledge, and protections that existing Services Facilitators provide. My position comes from years of direct experience observing both the strengths and weaknesses of Virginia's consumer-directed services system.
I support meaningful reform, but transferring responsibilities to Support Brokers, MCOs, and FEAs is not the same as correcting the underlying problems. If DMAS does not establish the information-sharing requirements, oversight tools, performance standards, and enforcement mechanisms necessary to identify failures and hold responsible parties accountable, those problems may simply continue under a different administrative structure.
My support for this transition depends on whether Virginia is prepared to make these substantive changes. Success should not be measured by the elimination of Services Facilitation as a standalone service or by how quickly participants are transferred to Support Brokers. It should be measured by whether participants are better protected, EORs are better supported, information is more accurate and accessible, services are more reliable, public funds are properly administered, and every responsible entity can be held accountable.
Virginia has an opportunity to do more than change who delivers a service. It has an opportunity to establish a consumer-directed services system in which accountability, transparency, participant involvement, and enforcement are measurable requirements rather than expectations.
I respectfully urge DMAS to make these requirements central to the proposed transition.