Thank you for the opportunity to provide comments on strengthening Virginia’s Medicaid Home and Community-Based Services for individuals with intellectual and developmental disabilities . As Virginia continues implementing the federal DOJ Settlement Agreement, I urge the Commonwealth to take a systemwide approach to rate adjustments. To maintain capacity, quality, and person-centered choice, rate increases must apply equitably across all Medicaid waiver services, not only those under the DOJ Permanent Injunction. The System is Interconnected Virginia’s HCBS waiver services—function as a single continuum. Selective rate increases destabilize this system. The same workforce supports individuals across service types; underfunding one weakens all. When non-residential services remain stagnant: • Providers cannot offer competitive wages, leading to >50% DSP turnover statewide. • Individuals lose meaningful daytime activities and employment supports. • Families face increased crises and institutional placements. Community integration—the foundation of the DOJ Agreement and HCBS Settings Rule—depends on a stable, coordinated continuum of supports. The Workforce Crisis is Systemwide Low wages, high stress, and limited benefits affect all waiver services. Targeted increases for certain services risk pulling staff from other programs, worsening inequities and limiting choice. Rate parity is essential to stabilize the workforce across all settings. Equity, Choice, and Fiscal Responsibility Virginia’s Olmstead commitment guarantees individuals the right to live, work, and participate in community life. That right is hollow without properly funded supports enabling access to employment, education, and recreation. Underfunding programs leads to isolation, family strain, and higher-cost residential or crisis placements. Comprehensive rate adjustments reduce long-term state expenditures by preventing regression and promoting community inclusion. Regulatory and Quality Demands Require Fiscal Stability Providers must meet DBHDS, DMAS, and CARF standards—training, supervision, data tracking, transportation, and compliance—without adequate reimbursement. Inconsistent rates undermine quality and safety expectations. Equitable increases are essential for providers to maintain compliance and accountability. Aligning Rates with Real Costs Rate methodology should reflect real workforce and operational costs, including regional wage differentials, transportation, insurance, and supervision. A uniform, data-driven model across all services ensures transparency and fairness, allowing providers to plan sustainably and expand innovative, inclusive programs. Ethical Imperative and Recommendations Equity in rates affirms the equal dignity and worth of every individual. Unequal funding signals that some lives and goals are valued more than others and contradicts Virginia’s Employment First vision. Recommendations: 1. Apply rate adjustments across all Medicaid waiver services. 2. Update methodologies using current cost and workforce data. 3. Establish a multi-year rate review cycle (every 2–3 years). 4. Include provider representation in rate study workgroups. 5. Fund DSP wage parity, credentialing, and career ladders across all services. 6. Link funding to measurable quality and inclusion outcomes. 7. Ensure transparent communication about rate decisions and impacts.

Disability Commission Members, As a professional who's worked with and on behalf of persons with IDD I am writing in reference to IDD waiver rates. While we acknowledge the efforts by DMAS to recommend rate increases for the 11 services identified in the DOJ Permanent Injunction the service system will not survive this sort of splitting of services and rates. Not including rate increases which translate to wage increases for DSP's (direct support professionals) working in other services; supporting the majority of people with IDD who have waivers; will basically break the system. What DSPs can earn is based on the DMAS rate reimbursements for services. Many DSP's are earning wages which qualify them for SNAP and Medicaid. That is a result of low reimbursement rates which are not regularly adjusted nor are COLA's regularly instituted. In order to meet the growing needs of the persons in and waiting for services, and o comply with the DOJ permanent injunction we must stabilize the system with unilateral rate increases which translate to increases in DSP wages. thank you Joanne Orchant Aceto

Virginia’s disability services system is underfunded to the point of failure. This is not a workforce shortage; it is a structural funding problem that threatens federal compliance, erodes provider capacity, and drives up public assistance costs. Families like mine depend on Direct Support Professionals (DSPs) to keep loved ones with disabilities living safely in the community. Yet state-set rates don’t cover the real cost of delivering regulated services. Providers cannot sustain operations, DSPs cannot maintain stable employment, and the Commonwealth faces growing fiscal and legal risk. By U.S. Census analysis, 100% of Virginia DSP households are SNAP-eligible and 12% are Medicaid-eligible. DSPs are the working poor trapped in “SNAP churn”—unstable hours, unpaid leave, and lack of family coverage cause constant eligibility changes. When systems can’t keep up, over- and under-payments inflate Virginia’s SNAP error rate (11.5%). If not reduced to 6% by 2027, the USDA may penalize Virginia up to $270 million. Chronic underfunding of the DSP workforce drives the instability that causes these errors. At the same time, 50,000 Virginians with disabilities are protected by a U.S. DOJ permanent injunction requiring expanded home- and community-based services. The main barrier to compliance is inadequate rates that prevent DSP employers from stabilizing their workforce. This is a rate-setting failure, not a recruitment issue. Thirteen years under DOJ oversight, Virginia has yet to rebuild the three essential elements of a compliant rate structure: 1. Regional DSP wage targets: Every DSP household remains SNAP-eligible. Exiting the “SNAP gap” requires $22.20/hr statewide, $25.93 in NoVA, and $19/hr ROS. 2. Defined build-up factor: CMS guidance supports about 1.8× the wage to fund taxes, benefits, overtime differentials, training, supervision, non-billable time, and required capacity. The latest state study failed to publish a clear factor or transparent methodology. 3. Realistic staffing assumptions: Current rates assume one DSP for seven individuals in group programs, yet oversight and accreditation show an average of 3.5 DSPs per seven are needed to meet standards and protect individual rights. Providers cannot raise prices or cut quality. Their revenue is fixed by policy while state rules dictate service and staffing standards. DMAS data show providers already redirect scarce funds into wages just to compete with entry-level jobs. Each DOJ review cites the same deficits. State agencies add oversight instead of fixing the root cause—rates that fail to fund training, supervision, and stable staffing. The cycle repeats: more paperwork, fewer services, and families in crisis. Action Needed • This year: Raise reimbursement and authorize deemed status to cut redundant oversight and keep providers open. • Next year: Direct DMAS to complete a full CMS-aligned rate study of all services, including regional wage targets, a published ~1.8× build-up factor, and local cost studies to match reimbursement with regulated delivery. A multi-year stabilization plan for the disability workforce will reduce SNAP error penalties, lower Medicaid churn, ensure DOJ compliance, and rebuild community capacity for 50,000 Virginians. This is not about “raises.” It is about fiscal responsibility, legal compliance, and protecting the rights of Virginians with disabilities.