I am submitting this comment in opposition to Virginia’s proposed changes to consumer-directed Home and Community-Based Services (HCBS), including the proposed 56-hour weekly soft cap on personal assistance, the elimination of independent Services Facilitation, and the removal of the Electronic Visit Verification (EVV) exemption for live-in caregivers effective October 1, 2026.
These proposals raise serious concerns about the long-term sustainability of community-based care, the ability of people with disabilities to remain in their homes, and the increasing burden being placed on families who provide essential support. Virginia should carefully consider the real-world consequences of these changes before moving forward.
The purpose of Home and Community-Based Services is to enable people with disabilities to live safely in their homes and participate in their communities. When adequate care hours and resources are unavailable, that goal becomes increasingly difficult to achieve.
Without sufficient personal assistance, some individuals may ultimately require crisis services, hospitalization, or placement in state-funded institutions. This is not in the best interest of the individuals involved, their families, or the state.
Institutional placement removes people from their homes and communities, disrupts family relationships, and can significantly diminish personal autonomy. It also creates substantial public expenses. Virginia should not pursue policies that make community-based care harder to access without considering whether the resulting institutional care could cost the state considerably more.
Keeping people safely in their homes should be a priority, both for their well-being and for responsible stewardship of taxpayer dollars. Policies that undermine the availability of community-based care risk producing precisely the outcomes the HCBS system was designed to prevent.
Virginia must recognize the reality of the direct-care workforce. Recruiting and retaining qualified individuals to provide personal assistance is already incredibly difficult, particularly at a wage of $13.88 per hour.
When compensation is insufficient to attract and retain reliable workers, families are often the ones left standing to provide the care. This is not necessarily because family members are best positioned to meet every need, but because there may be no one else available.
Family caregivers are already struggling to balance employment, financial responsibilities, household obligations, and the extensive demands of caring for a family member with significant disabilities. Many cannot simply leave their jobs or devote unlimited hours to caregiving without jeopardizing their own financial stability.
When paid assistance is unavailable, insufficient, or difficult to secure, the burden does not disappear. It shifts to families, often without additional resources or support. This can lead to caregiver exhaustion, lost income, reduced workforce participation, and eventually an inability to sustain care at home.
Virginia should be strengthening the supports that make community living possible, not implementing policies that add administrative obstacles while families are already stretched to their limits.
A person’s disability and functional needs cannot be reduced to a standard weekly number of hours.
Personal-assistance services should be based on individualized assessments and documented need. Some individuals may require more than 56 hours of assistance each week to remain safe and maintain an appropriate quality of life. The existence of a proposed 56-hour soft cap should not create an additional presumption against authorizing the care they need.
Even a soft cap can introduce additional reviews, delays, and administrative hurdles for those whose needs exceed the threshold. It places another burden on individuals and families who must justify why their circumstances warrant more assistance.
The appropriate standard is the individual’s documented functional need, not an arbitrary benchmark chosen for administrative convenience.
Virginia should ensure that authorization decisions reflect actual needs and that individuals are not placed at greater risk because their required hours exceed a preferred threshold.
Independent Services Facilitators provide valuable support beyond routine paperwork. They develop familiarity with individuals’ circumstances, functional needs, living arrangements, and support systems. This continuity can be particularly important during reassessments, service authorizations, and disputes over approved hours.
Virginia’s proposal to eliminate independent Services Facilitation and transfer assessment and Plan of Care responsibilities to Support Brokers provided through Fiscal/Employer Agents raises concerns about consolidation of responsibilities and the loss of independent support.
Before eliminating an established provider network, Virginia should demonstrate what specific problems this change will solve, what evidence supports the proposed model, and how consumer choice, continuity, and independent accountability will be maintained.
Administrative efficiency should not be pursued at the expense of the quality of support available to people with disabilities. Existing services should be improved where necessary rather than dismantled without clear evidence that the replacement will produce better outcomes.
Virginia’s decision to eliminate the EVV exemption for live-in caregivers effective October 1, 2026, adds another compliance requirement for families already navigating a complex system.
Requiring a caregiver who resides in the same home as the individual receiving services to electronically verify arrival at that home raises practical questions. Unlike an attendant arriving for a scheduled visit, a live-in caregiver already lives there. Requiring clock-in and clock-out procedures through an EVV-compliant system, including location services when using a mobile application, adds administrative and privacy burdens without changing that underlying reality.
Program integrity and fraud prevention are important. However, oversight should be proportionate to the risk being addressed. Virginia should demonstrate why eliminating the exemption is necessary and why less intrusive verification methods would be inadequate.
The provision of Medicaid-funded care should not automatically subject a family's home to continual electronic verification when the caregiver and individual reside together.
Virginia should reconsider this change and restore an appropriate exemption for live-in caregivers.
These proposals cannot be evaluated solely as individual administrative changes. Their combined effect could be substantial: more restrictive authorization processes, the loss of independent professional support, changes to Employer of Record structures, mandatory electronic verification for live-in caregivers, and continued difficulty recruiting and retaining paid attendants.
For families already struggling to maintain care, the cumulative burden could make consumer-directed services increasingly difficult to manage. For individuals with significant disabilities, the consequences could include unmet needs, reduced safety, and eventual institutional placement.
Virginia should conduct and publicly release an analysis of the combined effects of these changes on waiver participants, family caregivers, direct-care workforce retention, continuity of care, administrative burden, institutionalization risk, and state Medicaid expenditures.
Waiver participants, family caregivers, attendants, Services Facilitators, and disability advocates should have a meaningful role in evaluating these proposals before structural changes are implemented.
I urge DMAS and Virginia policymakers to:
Reassess and withdraw the proposed 56-hour weekly soft cap, ensuring that personal-assistance hours continue to be determined by individualized, documented functional need.
Preserve independent Services Facilitation, maintaining consumer choice and independent professional support rather than transferring this function exclusively to Support Brokers through Fiscal/Employer Agents.
Restore an appropriate EVV exemption for live-in caregivers, reconsidering the elimination of the existing exemption.
Evaluate the direct-care workforce crisis, including the difficulty of recruiting and retaining qualified attendants at $13.88 per hour and the resulting burden on unpaid family caregivers.
Conduct and publicly release a comprehensive analysis of the cumulative effects of these proposals on care continuity, caregiver retention, institutionalization risk, and state Medicaid expenditures.
Meaningfully involve affected individuals and their support networks before implementing structural changes to consumer-directed services.
Virginia must recognize that accountability, fiscal responsibility, and consumer autonomy are compatible goals. A system that makes it harder to obtain necessary care, drives families toward exhaustion, and increases the likelihood of institutional placement is not a sustainable solution.
When qualified paid caregivers cannot be found, families become the safety net. When families can no longer sustain that responsibility, the state may be left to provide far more intensive and expensive care.
Turning people with disabilities over to institutions because adequate community-based support is unavailable is not in their best interest, is not in the best interest of their families, and is unlikely to save Virginia money. The state should invest in a system that supports people in their homes, sustains the caregivers who make that possible, and allocates services according to actual need.
I urge DMAS and CMS to reject these amendments as currently proposed and urge Virginia policymakers to reconsider the elimination of the live-in caregiver EVV exemption. Virginia should strengthen community-based care, not create additional barriers that threaten its availability.