I am submitting this comment in strong opposition to Virginia's proposed changes to consumer-directed Home and Community-Based Services, including the 56-hour weekly soft cap on personal assistance and the elimination of independent Services Facilitation in favor of Support Brokers provided through the Fiscal/Employer Agent.
I also strongly oppose Virginia's separate decision to eliminate the Electronic Visit Verification exemption for live-in caregivers effective October 1, 2026.
I am not asking DMAS merely to improve the implementation of these policies. I am asking Virginia to reconsider the direction it is taking.
I am the caregiver of an adult with significant developmental disabilities who depends upon Virginia's DD Waiver system to live safely in the community. I have also worked professionally as a Medicaid waiver Services Facilitator. I have therefore experienced consumer direction from both sides of the system.
Taken together, these changes move Virginia away from meaningful consumer direction and toward greater centralization, administrative control and surveillance of people with disabilities and the families who support them.
I oppose the 56-hour soft cap.
A person's disability does not operate on a 56-hour schedule.
Personal-assistance hours should be determined by an individualized assessment of documented functional need. If an assessment establishes that a person requires 70, 80, 90 or more hours of assistance each week to remain safely in the community, the existence of an arbitrary 56-hour threshold should not change that determination.
Calling the policy a "soft cap" does not eliminate my concern. A cap creates a presumption. It creates an additional administrative hurdle for people whose needs exceed it and places the burden on disabled people and their families to repeatedly demonstrate why their disability requires more assistance than the state would prefer to authorize.
Virginia should not establish 56 hours as the benchmark and then require people with greater needs to prove why they deserve an exception.
The benchmark should be the individual's documented need.
Virginia should withdraw the proposed 56-hour cap.
I oppose eliminating independent Services Facilitation.
Services Facilitators are not interchangeable paperwork processors.
An effective Service Facilitator learns the individual, the family, the attendants, the home environment and the person's functional needs. That knowledge develops over time and becomes especially important during reassessments, service authorizations and disputes concerning hours.
Virginia proposes eliminating this independent provider structure and moving assessment and Plan-of-Care responsibilities to Support Brokers provided through Fiscal/Employer Agents.
That concentrates additional responsibility within organizations already responsible for important fiscal and administrative functions in consumer direction.
I do not believe Virginia has demonstrated that eliminating independent Services Facilitation will produce better outcomes for people with disabilities.
Before dismantling an existing statewide profession and provider network, Virginia should be able to demonstrate what problem elimination of Services Facilitation solves, what evidence supports the Support Broker model, how outcomes will improve, and how consumer choice and independent accountability will be preserved.
Families should not lose established relationships with qualified professionals simply because administrative consolidation is more convenient.
Virginia should retain independent Services Facilitation and improve the existing system where improvement is necessary.
I oppose mandatory EVV for live-in caregivers.
Requiring a caregiver who lives in the same home as the person receiving services to electronically verify that they have arrived at that home makes little practical sense.
The caregiver did not "arrive" for a visit. They live there.
Virginia now requires live-in consumer-directed attendants to clock in and out using an EVV-compliant system. When the mobile application is used, location services must be enabled.
For families already living with the extraordinary administrative demands of Medicaid, disability services, medical care and consumer direction, this adds another compliance requirement without changing the reality that the caregiver and disabled individual share a home.
Program integrity is important. Fraud should be investigated and prevented.
But oversight should be proportionate to the actual risk being addressed. Virginia should explain what evidence demonstrates that eliminating the live-in exemption is necessary and why less intrusive methods of verifying services would be inadequate.
Living with a disabled family member should not transform the family home into a location that must continually be electronically verified simply because Medicaid pays for some of the care occurring there.
I ask Virginia to restore the live-in caregiver EVV exemption.
I am especially concerned about the cumulative effect of these policies.
Each policy may be described administratively as a separate change.
Families will not experience them separately.
A family could simultaneously face a new 56-hour authorization threshold, lose an established independent Service Facilitator, transition to a Support Broker connected to a Fiscal/Employer Agent, adjust to new Employer-of-Record structures, and comply with mandatory EVV even when the paid caregiver lives in the home.
That is not administrative simplification from the family's perspective.
It is additional administrative control imposed upon people who are already managing extraordinarily complex care.
Consumer direction should mean more than allowing a Medicaid member to select an attendant.
It should reflect a fundamental principle: people with disabilities should have meaningful control over the supports that allow them to live in their own homes and participate in their communities.
Virginia should evaluate these policies against the alternative.
For many people with significant disabilities, HCBS is what makes community living possible.
When adequate personal assistance becomes harder to obtain, when administrative burdens drive caregivers from the workforce, or when families can no longer navigate the system, the alternative may eventually become hospitalization, crisis services, congregate care or institutional placement.
That outcome is neither person-centered nor necessarily fiscally responsible.
I therefore ask DMAS to:
Families like mine are not asking Virginia to operate a system without accountability.
We are asking Virginia to recognize that accountability and consumer autonomy are not opposing principles.
The purpose of Home and Community-Based Services is to make life in the community possible.
Virginia should strengthen that system—not make the people who depend upon it overcome additional barriers to remain in their own homes.
I strongly urge DMAS and CMS not to approve these amendments as currently proposed, and I urge Virginia policymakers to reconsider the elimination of the live-in EVV exemption.
Amanda C Sandos