I am writing as the sister of an individual with profound physical and cognitive disabilities to express my concerns regarding the proposed amendments to Virginia's Medicaid waiver programs, particularly the 56-hour soft cap on personal assistance, the elimination of independent Service Facilitators, and the removal of certain eligibility review safeguards.

My sister is completely dependent on others for every aspect of her daily life. She cannot speak, walk, eat independently, or even sit upright without assistance. She cannot communicate when something is wrong, explain what she needs, or advocate for herself. Her well-being and safety depend entirely on the people entrusted with her care.

For individuals like my sister, caregiving is not confined to a standard workday or a predetermined number of hours. Their needs are constant, often complex, and cannot simply be reduced to fit an administrative threshold. While the proposed 56-hour cap includes an exception process, I am concerned about the practical realities of obtaining those exceptions. An exception process is only meaningful if it is accessible, timely, and reliable. Families should not have to fight through administrative red tape to secure care for needs that are permanent, extensively documented, and unlikely to change.

These concerns are compounded in rural Virginia, where qualified caregivers and specialized services can already be difficult to find. Families in rural communities may have few alternatives when a provider becomes unavailable or services are interrupted. The proposed transition from independent Service Facilitators to a statewide Support Broker model raises legitimate questions about whether families will retain access to knowledgeable professionals who understand their circumstances and local resources. A statewide system may be administratively uniform, but that does not necessarily mean it will be equally accessible or effective in every community.

I am also concerned about the proposal to eliminate the requirement for higher-level DMAS review when an individual is determined to no longer meet the level-of-care criteria under the CCC+ waiver. For individuals who cannot communicate or advocate for themselves, independent oversight and additional review safeguards are particularly important. Removing such protections without clearly identifying equivalent safeguards deserves careful scrutiny.

I recognize the Commonwealth's responsibility to administer Medicaid efficiently and responsibly. However, the success of these changes should not be measured solely by administrative efficiencies or projected savings. It must also be measured by whether individuals continue receiving the care they need, whether families can navigate the system without unreasonable burdens, and whether vulnerable Virginians remain protected from interruptions in essential services.

I urge DMAS to establish clear and expedited exception procedures, protect existing services while requests or appeals are pending, demonstrate that the Support Broker model can adequately serve rural communities, and preserve meaningful independent review protections.

Above all, I ask decision-makers to consider those who cannot participate in this public comment process themselves. My sister cannot write a letter, attend a hearing, or explain the consequences of losing access to care. Neither can many of the individuals who will be directly affected by these changes.

These individuals deserve a system that prioritizes their safety, dignity, and continuity of care, rather than one that places additional administrative obstacles between them and the assistance they depend upon.