This is one of the most important questions that DMAS should answer before implementing this change.

If an individual has documented needs requiring 24-hour support, and their family cannot safely provide the hours that Medicaid no longer authorizes, what is the state's plan?

Families should not be expected to fill an unlimited gap in care with unpaid labor.

Many family caregivers already provide extensive care around the clock. They may have had to reduce their employment, leave the workforce entirely, sacrifice retirement savings, or give up other responsibilities because their loved one requires substantial assistance.

Reducing authorized hours without adequately accounting for the family's ability to provide the remaining care could put both the individual and the caregiver at risk.

It could also create exactly the outcome that Virginia's HCBS system is intended to prevent: unnecessary placement in a residential or institutional setting.

If an individual can safely remain at home with adequate supports, the state should not adopt policies that inadvertently make remaining at home impossible.

The state should also examine the financial consequences of this policy. Reducing home-based services does not necessarily eliminate the need for care. It may simply shift the cost to another part of the Medicaid system. If an individual can no longer remain at home because sufficient supports are unavailable, the state may ultimately incur significant costs for residential services, crisis intervention, hospitalization, emergency services, or other supports.