Moms In Motion Public Comment
Moms In Motion has several concerns we believe need to be addressed in the proposed applications, but two in particular that have immediate impact:
The 56-hour soft cap for DD Waivers:
We are opposed to this soft cap in general. While it reduces costs to the state, it also puts all of those that need more hours at risk and places even more hardship on their caregivers. Unless and until the state is prepared to raise the Attendant pay significantly so that families are able to get help without relying on loved ones to be paid attendants, this change should not happen. With the current pay rates, it is near impossible to find someone outside of the home to do the work that is required. Therefore, family caregivers have become the 24/7 caregivers, both paid and natural support. If the pay rates were significantly increased, families would more easily be able to hire outside attendants for the paid hours to get some relief and then continue to provide unpaid natural supports the rest of the time. Capping these hours without making those significant increases in pay rates simply cuts costs for the state. It does nothing to improve the quality of life of the members, and instead it places added burden on the families already providing 24/7 care now.
In many cases, the needs of those on DD Waivers is different from those on the CCC+ Waiver. As such, the exception criteria that will be applied cannot be equal to CCC+. DMAS says that the exception criteria that will be used will match those of the exception criteria for the CCC+ Waiver, which currently has the same “soft” cap. Those criteria include:
12VAC30-120-927. Exception criteria for personal care services.
1. [Summary] Level of Care B, which includes a medical nursing need, or Level of Care C, which includes a skilled nursing need.
2. In addition, the individual shall have at least one of the following:
a. Documentation of dependencies in all of the following activities of daily living: bathing, dressing, transferring, toileting, and eating or feeding, as defined by the current LTSS screening criteria (12VAC30-60-303) submitted to the service authorization contractor via DMAS-99;
b. Documentation of dependencies in both behavior and orientation as defined by the current LTSS screening criteria (12VAC30-60-303) submitted to the service authorization contractor via DMAS-99; or
c. Documentation from the local department of social services that the individual has an open case (as described in subdivisions 2 c (1) and 2 c (2) of this section) with either adult protective services (APS) or child protective services (CPS) and is therefore in need of additional services beyond the maximum allowed 56 hours per week. Documentation can be in the form of a phone log contact or any other documentation supplied (submitted to the service authorization contractor via attestation).
(1) For APS, an open case is defined as a substantiated APS case with a disposition of needs protective services and the adult accepts the needed services.
(2) For CPS, an open case is defined as being open to CPS investigation if it is both founded by the investigation and the completed family assessment documents the case with moderate or high risk.
Moms In Motion would argue that the criteria for qualification to receive services through CCC+ are fundamentally different from those for the DD Waivers. That said, the exception criteria for Personal Care hours should be fundamentally different from one another. DD Waiver exception criteria should align with the needs of those receiving services.
2. The transition from Services Facilitation as a standalone service to Support Brokerage.
Enacted Language:
PP. Effective July 1, 2026, the Department of Medical Assistance Services shall incorporate service facilitation into the statewide service broker model via the Fiscal Employer contract and eliminate service facilitation as a standalone service. The Department of Medical Assistance Services shall seek federal authority through the necessary waiver(s) and/or state plan amendments under Titles XIX and XXI of the Social Security Act to effect these changes. The department shall promulgate emergency regulations to implement these changes within 280 days or less from the enactment of this act. The department shall implement this change upon federal approval and prior to the completion of any regulatory process undertaken in order to effect such change.
DMAS has not given families or providers clear direction on what entity/entities will have responsibility for Support Brokerage. The enacted language and the language in their waiver applications seem to indicate that it is the Fiscal Employer Agents. However, in a recent DMAS Town Hall, October 7, 2026, providers were told that is the responsibility of the MCOs, and we assume DMAS for FFS and DBHDS for DD Waivers, to decide how Support Brokerage will look and whether or not to subcontract that service to existing providers. Here is a quote from slide 7 of that presentation, “MCOs are currently defining what that looks like. Option 1: MCO Contracted Support Brokers, Option 2: MCO will contract with the F/EA”. This language goes directly against the language in both the enacted language from the General Assembly and of DMAS’s own waiver applications.
Our questions are these:
If the enacted language and the applications put the responsibility on the Fiscal Employer contract, why then are the MCO’s involved in this decision at all?
MCOs do not oversee FFS or DD Waivers. Who then is responsible for the Support Brokerage for these individuals?
Moms In Motion is not arguing against moving to this model. There is documented proof in other states that this model can work. However, HOW this model is implemented, the transition itself, matters the most, especially to the people receiving services.
Mistakes made by other states in rolling out similar programs:
Florida - inadequate training and delayed access to assistance
U.S. Department of Health and Human Services / Mathematica, 2004-2005
The fiscal agent’s performance on roll out was hampered by slow cash flow, higher-than-expected costs, and inadequate reimbursement from the program.
Only 39% of consultants [brokers] reported that they were adequately trained for their responsibilities
The fiscal agent experienced staffing and payment-processing problems, including delays in workers [attendants] receiving paychecks.
Oregon - reduced self-direction options and fragmented support
Oregon Department of Human Services, 2022 report
Identified gaps include: limited customer service [for brokerage] because financial-management contractors focus primarily on payroll, no definition for who is responsible for training, staffing [brokers] is inadequate to meet the needs of those receiving services.
A more recent report from the Medicaid and CHIP Payment and Access Commission (MACPAC), published in June 2025, found that Case Management organizations (in Virginia’s case this would be DBHDS Support Coordinators and MCO Care Coordinators) and beneficiary advocacy organizations (think the Arc, Autism Society, and private advocates) often ended up providing brokerage-like assistance, and those organizations reported challenges providing that assistance alongside their other responsibilities. https://www.macpac.gov/publication/june-2025-report-to-congress-on-medicaid-and-chip/
This is important for Virginia because the challenge is not simply whether fiscal-employer agents or MCOs can hire support brokers, but it is also whether the state clearly defines their responsibilities, equips them to perform those responsibilities, and ensures that members actually receive the assistance they need. Will the proposed structure preserve the independence, individualized assistance, and practical support that make consumer direction possible?
According to DMAS’s own Waiver Service Utilization and Expenditures website, which was last refreshed on 10/4/26, there are currently 26,483 (FY27) people in Virginia using Consumer-Directed Personal Care, Respite, and Companion Services. Of those, 18,395 (FY27) are currently using Services Facilitation. https://www.dmas.virginia.gov/data-reporting/programs-services/waiver-services/
DMAS’s proposed roll out for Support Brokerage states that all 26,000 people receiving these services will be rolled into the new model between March 1, 2027 and May 31, 2027. https://www.dmas.virginia.gov/for-members/benefits-and-services/waivers/
What does this mean for the people receiving these services? The following steps must occur without any hiccups in order for attendants to continue to get paid without interruption:
All current authorizations that are in place for every one of the 26,000 people on these services will end the night before the regional rollout date where they live.
The new Support Broker entity, whether that is the MCO or the Fiscal Agent has not yet been defined by DMAS, will then issue a Continuity of Care authorization for 90 days. If this is the Fiscal Agent’s responsibility as the broker entity, do they issue that auth to themselves? If it’s the MCO’s responsibility, is this something their electronic systems will automatically do? Or does there need to be human intervention to make it happen? What happens if there is a mistake and no Continuity of Care (CoC) auth is issued? Whose responsibility is that to correct?
Once CoC auths are in place, then the new Support Brokers will have to physically go to the homes, do their assessments of needs, write new plans of care, and then submit NEW authorization requests all within 90 days of the regional roll out date.
March 1, roll out #1 - 90 day count begins
April 1, roll out #2 - 90 day count begins. 60 days left on roll out #1.
May 1, roll out #3 - 90 day count begins. 30 days left on roll out #1, 60 days left on roll out #2.
June 1, final roll out - 90 day count begins. All roll out #1 folks must have new authorizations in place or attendants stop getting paid. 30 days left on roll out #2, 60 days left on roll out #3.
July 1 - roll out #2 folks must have new authorization in place or attendants stop getting paid. 30 days left on roll out #3.
August 1 - roll out #3 folks must have new authorization in place.
All of this work is being done by the same set of Support Brokers over 5 months for 26,000 people, and there cannot be mistakes or missed dates or attendants stop getting paid.
Things the state needs to consider:
Continuity of Care
Member Choice
Cost Effectiveness
The reality of what it will take for this kind of roll out: Fair and transparent implementation
Continuity of Care:
We find it highly unlikely that either the Fiscal Agents or the MCOs (and still not sure where the FFS and DD Waivers would fall) will be staffed with enough Support Brokers to make this implementation happen smoothly starting March 1, 2027.
Existing/Established Service Facilitation companies all across the state already have established relationships with all 26,000 people, their families, their Employers of Record, and their attendants.
Existing/Established Service Facilitation companies already have the practical knowledge of individual circumstances, documentation requirements, waiver processes, and common problems and how to prevent them.
Retaining experienced staff through subcontracting could reduce disruptions to these families’ services, reduce retraining efforts, reduce the possibility of duplicate assessments, and avoid administrative errors.
A transition subcontract could help the new model become operational within the state’s proposed timeline.
DMAS’ own public record in this Town Hall site includes literally hundreds of public comments from families describing the value of long-standing relationships with individual Services Facilitators. They demonstrate the importance families place on continuity.
The request: Clearly define what entities are responsible for Support Brokerage. Then, require each entity to offer qualified existing/established Services Facilitator providers a defined pathway to subcontract for Support Brokerage services in order to prevent any gaps in services for those affected by this change.
Member Choice:
Virginia's current regulatory framework recognizes consumer-directed services and establishes responsibilities for the individual, the Employer of Record, and the Services Facilitator. On the DMAS Town Hall call on October 7, 2026, Nichole Martin told attendees that Services Facilitation is currently a service that allows for choice. She said that Support Brokerage is more of a contractual arrangement and so ‘choice’ is not a consideration.
According to US Government’s own Medicaid website:
https://www.medicaid.gov/medicaid/long-term-services-supports/self-directed-services:
“Self-direction promotes personal choice and control over the delivery of waiver and state plan services, including who provides the services and how services are provided.”
‘Choice’ is a fundamental proponent of self-direction. DMAS should not treat the transition as merely an internal staffing decision by the fiscal-employer agents or MCOs. These families CHOSE their existing providers. DMAS should strive to preserve meaningful choice wherever legally and operationally possible. DMAS needs to explain to these families why excluding qualified existing providers that were chosen by the people receiving services would benefit them.
A subcontracting framework could preserve choice by allowing:
Existing/Established providers to continue providing support through an approved contractual arrangement.
Families should be allowed to select providers from a list of qualified, subcontracted provider companies OR support broker employees of the Support Brokerage entity itself.
Members should be allowed to request a change in assigned broker when their current broker isn’t meeting their needs
The Fiscal Agent or MCO would still retain accountability for the contract compliance while drawing on experienced community providers at the same time.
Cost Effectiveness
Virginia's budget materials identify streamlining Services Facilitation as an operational-efficiency initiative. The state's budget decision package projected reductions in Medicaid program expenditures associated with the change. https://reports.dpb.virginia.gov/p3_opview?Biennium=2026-2028&BudgetRound=Initial&WorkItemStepId=C8F7FAC5-7B7A-48A6-ADEB-333C6D8C8208
Subcontracting is a potential means of achieving the state’s financial objectives without sacrificing service quality. Using existing providers may reduce:
Recruiting and onboarding costs
Training and supervision expenses
Duplicative administrative infrastructure
Disruptions that lead to missed visits, delayed authorizations, or avoidable corrective work
The costs of rebuilding relationships with families who already have established facilitators.
It may be helpful for DMAS and the Fiscal Agent or MCOs, whoever will be responsible for Support Brokerage, to compare the full cost of these alternatives:
Building a new Support Broker workforce internally
Hiring individual former Services Facilitators directly
Subcontracting with established providers to deliver services through existing infrastructure
Your analysis should include total cost per participant, staffing, travel, training, supervision, quality assurance, technology, employee benefits costs, payroll taxes, and transition expenses. It also needs to include the hours between visits that support the families, troubleshoot payroll and auth issues, and provide additional resources and information. We believe you will find that the most cost effective path is to require the Fiscal Agent or MCOs, whoever is responsible, to subcontract with existing/established Services Facilitation companies.
The Reality of the Roll Out
The question ahead is not whether or not DMAS/Virginia will move forward with the new Support Brokerage model, since Matthew Jones said at the Oct. 7th Town Hall call that “it’s practically a done deal”. The question is HOW the state will roll it out. Things for DMAS to consider throughout this transition are:
Geographic coverage: Existing/established Services Facilitation companies have experienced service facilitators across the entire state, including communities where recruiting and retaining qualified personnel may be difficult for a new Support Broker organization.
Existing workforce: Experienced Services Facilitators could transition into the new model rather than leave the system entirely. Why not leverage the people who already know how to do this work?
Operational readiness: Existing/established Services Facilitators already understand the state’s waiver requirements, documentation, family communications, and fiscal-agent workflows. There would be no learning curve.
Transition capacity: Existing/established Services Facilitators can help train our teams, transfer knowledge, coordinate communications, and identify potential service gaps. This takes the burden off of the Support Brokerage organization.
Scalability: An established organization can offer an immediate delivery structure rather than requiring the fiscal-agent or MCO to build every operational capability from scratch.
The request: Give existing Services Facilitation companies the opportunity to submit a formal statewide subcontract proposal, with defined deliverables, performance standards, and pricing. The subcontract opportunity brings with it the ability for the Fiscal Agent and/or MCO to request transparent criteria like qualifications, geographic coverage, experience, quality standards and quality assurance processes. It also offers the opportunity for providers to compete, which could bring additional cost savings to both the Support Broker and the state.
In Conclusion:
As Virginia makes this transition, DMAS should first make it clear which entity/entities are responsible for Support Brokerage, the Fiscal-Employer Agent(s) or the MCOs, or both. Then DMAS should require the designated Fiscal-Employer Agents and/or MCOs, whoever is in charge of Support Brokerage, to establish a formal subcontracting pathway for qualified existing Services Facilitation providers.
These organizations bring extensive statewide operational experience, established relationships with all 26,000 Medicaid waiver participants and their families, an experienced workforce, and existing infrastructure dedicated to consumer-directed services.
Excluding established providers from the transition would risk unnecessary disruption, loss of institutional knowledge, workforce displacement, and avoidable costs associated with rebuilding existing capabilities.
A subcontracting framework would allow the Commonwealth to pursue its operational objectives while preserving experienced personnel, supporting continuity of care, and maintaining access to qualified providers across Virginia who offer provider choice.
We therefore request that DMAS require the FE/As and/or the MCOs to offer transparent subcontracting opportunities to qualified existing providers prior to CMS approval of these changes, but contingent on CMS approval of them. We also request that they evaluate proposals using consistent performance and cost-effectiveness criteria, and establish measurable standards for continuity, service quality, participant satisfaction, and geographic access.
We urge DMAS to consider that existing/established Services Facilitation organizations want to be a part of the solution to make this transition as smooth as possible for the families we serve. Without a meaningful and well-defined pathway to subcontracting, however, these Services Facilitation companies will need to evaluate whether they have a future serving these famillies and whether their businesses will be financially sustainable through this transition and beyond. If these businesses cannot see a meaningful and sustainable path forward, what is DMAS’s plan for these 26,000 families if the companies decide to close their doors prior to the roll out of Support Brokerage? The responsibility of ensuring continuity of care would be in the hands of DMAS themselves and we believe the families being served deserve to know DMAS’s plan for this possibility.
The transition should be designed around the needs of members receiving services—not simply around the organizational structure of the entities administering the new model.