Taking the Face Off the Clock
This is a behind-the-scenes look at consumer-directed waiver services in the Commonwealth of Virginia based on my personal understanding and lived experience—not legal or policy advice.
I want to be clear from the beginning that this isn’t a manual, textbook, or official policy guide. It’s simply my perspective as someone living inside the system.
I’ve realized a lot of people don’t truly understand how these services operate day to day. Truthfully, I didn’t understand all the moving parts either until we became part of them ourselves. Even now, new questions still come up. Like most things connected to government systems, there always seems to be some level of learning, relearning, clarifying, and figuring things out as you go.
Getting Started
You’ll likely be asked questions about daily care needs and why waiver services are being requested, so it helps to think ahead about the kinds of support that may be needed—things like personal care, supervision, respite, or help remaining safely in the home and community.
Important points here:
>You have the right to request a screening.
>You cannot legally be denied the opportunity to be screened. If someone refuses to screen you, ask for that denial in writing.
>You also do not have to already be on Medicaid—or even have submitted a Medicaid application yet—to request the screening itself.
Now, I’m going to be very candid here.
The screening process can feel deeply uncomfortable, because the questions are going to place a very bright spotlight on the individual’s needs and limitations. And if you’re a parent requesting a screening for your child, this is not the time to soften things, minimize things, or lead with the victories.
Most of us spend our lives doing exactly that. We focus on progress. Gains. The good moments. We adapt so completely to our loved one’s needs that many things simply become “normal” to us. But during a screening, the goal is to accurately reflect the level of support that is actually needed day to day.
So, if your 12-year-old wears pull-ups due to incontinence, but successfully used the toilet twice last month, this is not the time to share that victory. The determining factor is still the incontinence. That doesn’t erase the progress–it just means the need still exists. And that distinction matters.
Mommas, I know how difficult this is to focus on the “can’ts”, but this is one of those situations where it means approval or denial. And of course, be honest with your answers.
Once Approved…
Once an individual is approved for a waiver and chooses consumer-directed services, several things happen.
A service facilitator is chosen. Think of them as the person helping guide and monitor the process. They’re the liaison helping families navigate requirements, paperwork, updates, authorizations, and making sure services are operating as they should.
Then hours per week are assigned.
Those hours aren’t random. They’re determined based on the individual’s assessed needs. Some people receive fewer hours. Some receive significantly more. This is important–those approved hours are the maximum available. They cannot be exceeded.
The Employer of Record (EOR)
An Employer of Record (EOR) is appointed. This is the person responsible for overseeing individual(s) providing the caregiving. They review and approve timesheets, help manage providers, and ensure hours and tasks being submitted match the care being provided. Basically, the provider’s “supervisor” of sorts.
Sometimes the individual receiving services serves as the EOR (if they’re an adult), sometimes someone else does. It depends on the individual’s ability to manage those responsibilities.
Choosing Providers
The consumer or their representative then hires the providers they want. (Different terms for provider are “caregiver” or “attendant.”)
Those providers must pass background checks and complete enrollment requirements. This isn’t someone simply deciding to pay a family member under the table.
There are processes. Documentation. Requirements.
And whether someone has two providers or ten, the approved weekly hours are divided among them. That does not mean the hours must be equally divided. It simply means the total approved hours cannot be exceeded.
Respite Hours
There are also respite hours available—currently 480 hours per fiscal year. These are separate from regular provider care hours and are there to provide respite for the primary provider. (Live-in providers do not use respite hours.)
This part surprises people sometimes–respite can even apply overnight while the individual is asleep. Regular provider hours cannot be used during that time.
The Day-to-Day Reality
For non-live-in providers, care hours are documented through the EVV app—Electronic Visit Verification.
They clock in.
They clock out.
They document the care tasks performed.
If someone lives with the individual receiving care, their time can typically be submitted through the online portal instead of clocking in and out through the app.
At the end of each two-week pay period, submitted hours are reviewed by the EOR. The EOR checks those hours against the care that was actually provided. If accurate, EOR approves them. Some choose to approve them all at once at the end of the pay period, others may choose to approve them as they come in. Typically the following week, providers receive their pay.
That’s the basic rhythm of how the system functions.
The Service Facilitator’s Role
The service facilitator visits regularly—typically monthly. They’re looking at whether services are going smoothly, whether there have been issues with the app or portal, whether staffing is stable, whether there have been hospital stays, changes in health, or other concerns that affect services.
And I want to pause here for a second and say this clearly: These facilitators are often carrying enormous caseloads. A lot of what does work in this system works because there are people inside it trying very hard to hold it together.
The Hospital Rule
Here’s something many people don’t realize. If the individual receiving services is admitted to the hospital, waiver hours cannot be billed during that stay—even if the provider remains there around the clock continuing to provide care.
For example, if I were my daughter’s provider and she was admitted to the hospital, I could stay with her 24 hours a day for five straight days (and I have). During that time, I would still be providing care.
Toileting.
Bathing.
Feeding.
Supervision.
Personal grooming.
Comfort.
Advocacy.
The care doesn’t stop because the setting changes.
But those hours cannot be billed because it’s considered double-billing while the hospital is also being paid for care.
And before someone jumps to conclusions, yes—I understand the reasoning behind that policy. But I also think it’s important for people to understand the reality of what that can look like for families. The assumption is often that once someone enters a hospital, the provider gets to step away.
And many times, that’s just not true.
What I Hope People Understand
Consumer-directed services are often talked about very simplistically online—and sometimes suspiciously or condescendingly, as though families are simply getting paid to care for their loved one and little more.
But when you “remove the face from the clock” and actually look at the inner workings, you see something very different.
You see a layered system filled with responsibilities, oversight, moving parts, deadlines, approvals, documentation, and constant coordination.
It’s not simply “getting paid to care for your family member.”
It’s managing care inside a structured system while still living real life at the same time. Understanding that matters. The conversation changes when people actually see the inner workings instead of just reacting to the headline version of it.
Even after understanding the mechanics of how this system works, there’s still another layer underneath it all–the assumptions some people carry about the families using it.
That’s where I’m going in Part 7.
If this changed your perspective or helped you better understand what families inside this system are actually navigating, share it. Sometimes stigma starts to fade the moment people finally see the full picture.