Virginia HCBS Public Comment

Opening position

I am the parent of waiver service recipients, a caregiver, and a longtime disability advocate. My concerns are informed by firsthand experience navigating Medicaid waiver services, consumer-directed care, and the practical challenges of maintaining necessary support at home. I am not an attorney. The legal and regulatory references in this comment reflect my good-faith understanding as a layperson, with sources provided so readers can review them directly.

I strongly oppose all eight proposed amendments to Virginia’s Community Living (CL), Family and Individual Supports (FIS), and Commonwealth Coordinated Care Plus (CCC+) Medicaid waivers in General Notice 3470, and I request that DMAS withdraw all eight. These objections concern the actual care, rights, autonomy, and community lives of Virginians with disabilities and the effects on their caregivers, families, providers, managed care organizations, hospitals, and the Commonwealth.

I am not asking only for better explanations, revised guidance, or assurances that exceptions may be available. Where I discuss safeguards or request documentation, those requests do not waive my objection to the underlying changes. The same person may experience several proposals simultaneously, together with the separate live-in EVV policy. The cumulative risk of destabilizing essential support deserves at least as much scrutiny as each amendment considered alone.

1. Proposed 56-hour weekly threshold for personal assistance (CL and FIS)

A weekly numerical threshold is not an assessment of what an individual needs. A person who requires assistance with bathing, eating, dressing, transfers, toileting, communication, health and safety at irregular times does not suddenly need fewer hours because the default authorization is set at 56. Calling it a “soft cap” does not resolve the problem: exceptions can require more documentation, additional decisions, and delays even where the need has already been established.

Family caregivers cannot simply be assigned the unpaid hours that disappear from an authorization. The federal HCBS person-centered planning rule treats natural supports as voluntary, and CMS explained that the planning process must not compel unpaid services. Where a relative is also a lawful paid attendant, existing employment relationships and applicable wage-and-hour obligations must be distinguished from ordinary voluntary family assistance. Not every act of family support constitutes compensable employment, but removing authorization hours does not create free workers. (Sources: 42 C.F.R. § 441.301(c)(2)(v); CMS final rule, 79 Fed. Reg. 2948; U.S. Department of Labor home-care guidance.)

An underfunded care plan can force relatives out of employment, fragment attendant schedules, increase appeals, and leave MCOs, hospitals or institutional providers addressing preventable crises. Community integration suffers when someone cannot attend school, work, appointments or ordinary activities because assistance is missing. Continuity of care means assistance actually delivered, not eligibility or an authorization remaining on paper. I oppose the threshold itself, not merely defects in the exception process.

References: Federal HCBS person-centered planning · DOL home care guidance

2. Elimination of standalone Services Facilitation (CL, FIS and CCC+)

Services Facilitation is not just administrative paperwork. An established facilitator can know an individual’s communication needs, medical and functional history, attendant arrangements, local providers, unresolved authorizations and safety concerns. Moving those functions into a statewide Support Broker arrangement through the Fiscal/Employer Agent (F/EA) contract can disrupt that knowledge and reduce genuine consumer choice.

This creates structural ethical concerns as well. When planning-related assistance, enrollment, fiscal administration and dispute resolution are concentrated within connected systems, who independently supports someone challenging a failure within those systems? The HCBS rule includes conflict-of-interest protections for person-centered planning. Internal separation of departments is not necessarily independent advocacy. Existing services should not be eliminated simply because a new contractor is designated. (Source: 42 C.F.R. § 441.301(c)(1)(vi).)

Families should not be expected to replace lost facilitation with unpaid administrative work. Transitions create risks for support coordinators, DBHDS-connected services, providers and MCOs, including lost records and authorization delays. Community integration depends on accessible, individualized support; continuity depends on retaining that support and its institutional knowledge. I oppose eliminating standalone Services Facilitation.

References: 42 C.F.R. § 441.301

3. Employer of Record designation and delegation (CL, FIS and CCC+)

Making the service recipient the Employer of Record (EOR), with delegated functions when necessary, does not automatically make complex employment duties accessible. Disability-related cognitive, communication, mobility or sensory limitations can affect payroll approval, hiring, discipline, tax forms, electronic records and rapid decisions during emergencies.

Delegation may help some participants, but it also raises responsibility and ethics questions when the participant, representative, attendant, broker and fiscal entity have overlapping interests. Incorrect forms or unclear authority can cause delayed wages, caregiver departures, appeals and disrupted services. The proposed structure should not transfer administrative risk to the person receiving care or an unpaid relative. Consumer direction must enhance autonomy and community integration; continuity requires preserving existing attendant relationships and pay during any change. I oppose this restructuring as proposed.

4. Removal of the specified working-disabled eligibility group (CL and FIS)

DMAS describes the TWWIIA Basic Coverage Group language as included in error or never operationalized. I acknowledge that description and do not suggest the proposal abolishes Medicaid Works generally. I nevertheless oppose removing an eligibility provision without demonstrated analysis of whether current or future applicants could lose a meaningful route to assistance.

People with disabilities, employers, benefit counselors and families need confidence that increased earnings or work will not unexpectedly jeopardize necessary supports. Eligibility confusion can generate interruptions, appeals and preventable health costs. Community integration includes opportunities for integrated employment, while continuity requires uninterrupted qualifying coverage and care. A characterization as a technical correction does not, by itself, resolve the concern.

5. Removal of legally responsible persons as transportation providers (CL and FIS)

DMAS describes removing legally responsible persons from a specified Employment and Community Transportation provider category and has indicated that the category was not operationalized. That limits claims about existing paid trips but does not answer whether the change removes a potentially important option for individuals with disability-specific transportation needs.

Transportation must be available in practice: accessible to a wheelchair or necessary equipment; appropriate to communication, behavioral, medical and safety needs; reliable in rural areas; and available at the right time. A directory listing cannot carry a person to employment, care or a community event. Families, providers, CSBs, MCOs, clinics and employers absorb the consequences when transport fails. Because transportation supports community integration and access to ongoing care, I oppose deleting the provider option without evidence that doing so cannot narrow real access.

6. Paid legally responsible caregiver enrollment corrections (CL and FIS)

DMAS characterizes this change as correcting a form reference because the enhanced enrollment agreement is now in the F/EA’s standard packet. It should not be represented as a general prohibition on paid family caregiving. Still, I oppose any change that could destabilize lawful caregiving or subject families to consequences for following the forms and directions they were originally given.

Caregiver enrollment and payroll errors can mean interrupted wages, staffing loss and avoidable agency or MCO disputes. The person receiving services still needs care during a paperwork correction. Community integration often depends on a stable paid caregiver; continuity requires protecting properly authorized delivered care and the existing working relationship. An administrative correction should not become an avenue for lost services or retroactive penalties.

7. Removal of higher-level DMAS review after an adverse level-of-care finding (CCC+)

A level-of-care finding can decide whether a person remains eligible for the support that makes living at home possible. Removing a higher-level DMAS review eliminates an opportunity to catch missing clinical evidence, a misunderstanding of complex disabilities or assessment errors before a person experiences the consequences.

Stability while receiving services does not prove those services are no longer needed. Families, clinicians and providers need a meaningful review process before care ends, not only the prospect of disputing the termination afterward. Errors can increase pressure on hospitals, discharge teams, MCOs and institutions. Applicable Medicaid notice and hearing protections remain important. Community integration and continuity of care both weigh against removing a preventive checkpoint. I oppose this change. (Source: 42 C.F.R. Part 431, Subpart E.)

References: Medicaid fair-hearing rules

8. Removal of MCO service-plan quality reviews and related LOCERI oversight (CCC+)

I strongly oppose both parts of this oversight change. Item 8 removes MCOs as reviewers of specified service-plan quality measures in Appendix D. DMAS’s summary also identifies removal of references to higher-level LOCERI reviews. The CCC+ application separately describes revising LOC4 and deleting LOC5, which tracks higher-level reviews after adverse level-of-care findings. The application assigns service-plan measure reviews to the State; I am not claiming all monitoring ends. I oppose removing these existing protections, not merely a lack of explanation. (Sources: General Notice 3470, Item 8; DMAS amendment summary, Items 7–8; CCC+ application, p. 3 and Appendices B and D.)

Sources: Virginia Town Hall, General Notice 3470, Item 8 · DMAS, summary of proposed amendments, Items 7 and 8 · CCC+ amendment application, p. 3 and Appendices B and D

Individualized care and accountability

A plan may omit assessed needs, rely on unavailable providers, or remain inaccurate after a person’s circumstances change. Federal HCBS rules require an identified monitor and periodic or needs-based plan review. People with disabilities, families and caregivers should not become the only system for detecting missed care. (Source: 42 C.F.R. § 441.301(c)(2)(viii) and (c)(3).)

Sources: 42 C.F.R. § 441.301(c)(2)(viii) and (c)(3), plan monitoring and review

Administrative and financial consequences

DMAS, MCOs, clinicians, providers and hospitals still have to resolve gaps. Removing an early review can shift work into appeals, emergency care, delayed discharge and more costly institutional services. Managed-care quality obligations continue, but that does not establish that the specific protection being removed is unnecessary. (Sources: 42 C.F.R. §§ 438.330 and 438.340.)

Sources: 42 C.F.R. § 438.330(b), quality assessment and performance improvement · 42 C.F.R. § 438.340, state managed-care quality strategy

Community integration

Review must examine whether support enables education, employment, healthcare, relationships and ordinary community participation, not just whether forms are complete. (Source: 42 C.F.R. § 441.301(c)(4)(i).)

Sources: 42 C.F.R. § 441.301(c)(4)(i), community access

Continuity of care

Sixty authorized hours are not sixty delivered hours when only thirty-five can be staffed. Review must detect unfilled care and verify that corrective action restores services before health, safety or a community placement is destabilized.

Connection to Item 7 and requested action

Removing the higher-level review and its related monitoring measure affects both error correction and accountability for that protection. I request withdrawal of Item 8 as well as Item 7. Reassigning oversight or explaining what remains does not resolve my objection to removing established safeguards.

Sources: DMAS, summary of proposed amendments, Items 7 and 8 · CCC+ amendment application, p. 3 and Appendices B and D

Separate issue: live-in caregiver EVV and necessary public scrutiny

DMAS explicitly excludes live-in EVV from the eight waiver amendments. Federal EVV legislation, 42 U.S.C. § 1396b(l), together with CMS’s live-in guidance, does not make EVV mandatory as a federal minimum for qualifying live-in caregivers. Virginia’s published 12VAC30-60-65(C)(4) separately lists live-in caregivers as exempt. Yet DMAS announced an October 1, 2026 implementation under the 2026 Appropriation Act. I am concerned about this unresolved relationship among the governing authorities and implementation directions. These sources do not necessarily prove the state has no power to change the exemption; they do require a clear account of the legal basis and regulatory process.

Live-in care is often intermittent and urgent. Clock-in systems, inaccurate plans, app or telephone failures, GPS errors, missed clock events during emergencies, and correction or payroll delays can threaten the only caregiver available. An authorization without someone able to deliver the care is not continuity. I request a separate, meaningful public-comment proceeding capable of influencing the policy, a review of the current regulatory conflict, and no less than six months after that proceeding for analysis, accessibility accommodation, system testing, training, correction procedures and careful implementation. The Commonwealth should prevent payment and service interruptions and protect consumer choice and community integration during the review. (Sources: 42 U.S.C. § 1396b(l); Virginia 12VAC30-60-65; September 9 DMAS EVV bulletin.)

References: Virginia live-in EVV exemption, 12VAC30-60-65 · Federal EVV statute · DMAS September 9 EVV bulletin

Why fiscal analysis and long-term community opportunity matter

Virginia’s 2026–2028 budget projected approximately $44.85 million in biennial General Fund reductions for standardizing personal-assistance hours. Averaged across 21,079 authorized CL/FIS waiver slots, that is about $2,128 per slot over two years. But a statewide average is not what any individual loses, and projected General Fund reductions are not proven net Commonwealth savings.

Virginia’s surveyed 2025 annual median prices were $80,080 for 44 weekly hours of nonmedical home care versus $123,005 for a semi-private nursing-home room, a $42,925 annual difference. These are market prices, not actual Medicaid reimbursement, and 44 hours will not meet every individual’s needs. The comparison nevertheless illustrates how expensive losing community support can be. The actual state fiscal result depends on Medicaid rates, federal matching funds, service mix and institutional costs. (Sources: Virginia 2026–2028 budget materials; CareScout 2025 cost-of-care survey.)

The expense of institutional placement is not only the bed or medical bill. Hospitalization interrupts education, employment, training and ordinary community life; long-term institutionalization may further restrict opportunities to develop practical skills, gain independence and, where possible and desired, earn income and contribute through taxes or lawful insurance cost-sharing. These benefits are not guaranteed and a person’s dignity does not depend on employment or income. A complete fiscal analysis should include foreseeable losses of community opportunity, caregiver employment, preventable emergency care and longer-term public costs.

References: Virginia budget Item 291 · CMS HCBS financing trends · CareScout Virginia cost-of-care survey

Requested action

I respectfully request withdrawal of all eight proposed CL, FIS and CCC+ waiver amendments. Questions, suggested safeguards and requests for records do not constitute consent to implement the policies. I also request a distinct public-comment process for live-in EVV, resolution of the conflict between the existing exemption and the announced implementation, at least six months for responsible implementation after meaningful comment, and explicit protection of delivered care and lawful caregiver payment throughout the transition.

Please consider the complete, detailed public comment, including linked legislation, regulations, cases, fiscal calculations and source documents, at Read the full public comment (PDF) . I request that this full statement be reviewed and included in the administrative record along with this online summary. An authorization on paper is not delivered care; community integration and continuity must be measured by whether actual support continues.