10 October 2026

Live-In Caregiver EVV Exemption: Public Participation, Fiscal Accountability, and Protection of Home-Based Care

To the Virginia Department of Medical Assistance Services (DMAS):

Thank you for the opportunity to comment on policies affecting individuals with disabilities and their families.

I am submitting this comment as a Virginia resident and family member whose household relies on long-term services and supports provided through Virginia Medicaid.

Although the elimination of the Electronic Visit Verification (EVV) exemption for live-in caregivers, effective October 1, 2026, is not itself part of the proposed waiver amendments under Notice No. 3470, its implementation affects many of the same families. I respectfully ask DMAS to consider the cumulative effects of these overlapping policies.

The purpose of this comment is not to oppose accountability or appropriate verification. It is to ask whether the anticipated benefits have been adequately evaluated alongside the administrative, financial, and human consequences for families already providing extensive care.

1. Caregiver Availability, Labor Market Competition, and Family-Based Care

Many families rely on live-in family caregivers because finding and retaining qualified outside caregivers can be particularly difficult for individuals with severe developmental disabilities.

Caregiving is not always a predictable shift. Assistance may be needed unexpectedly, and caregivers must understand an individual’s communication methods, behaviors, routines, and safety needs.

Families using consumer-directed services compete with restaurants, retail businesses, and private care agencies for available workers. Some employers may offer comparable or higher compensation for positions without the same personal care and safety responsibilities.

Caregiving may involve bathing, feeding, toileting, behavioral support, assistance with daily activities, and immediate responses to safety risks. These responsibilities can be substantial.

Even when an outside worker is available, that worker may not be able to immediately replace an experienced family caregiver who has spent years learning the individual’s needs.

I respectfully ask whether DMAS evaluated:

• The availability of qualified replacement caregivers.
• Competition from other industries and private care agencies.
• The difficulty of recruiting and retaining caregivers at Medicaid-funded compensation levels.
• The additional unpaid support that family members provide beyond authorized service hours.
• The potential consequences if family caregivers can no longer sustain these arrangements.

2. Federal EVV Requirements, State Discretion, and Other States’ Approaches

Federal law establishes EVV requirements for certain Medicaid-funded services. However, federal EVV requirements and the treatment of qualifying live-in caregivers are not identical questions.

Virginia previously permitted a live-in caregiver exemption and subsequently eliminated it effective October 1, 2026.

Our preliminary review identified 13 states with documented live-in caregiver EVV exemptions or comparable exceptions at the time of review. This is not presented as a complete or independently verified national count, and state rules may differ in scope and implementation.

Nevertheless, these differing approaches raise questions about the alternatives available to Virginia.

I respectfully ask DMAS:

• Which elements of the October 2026 change were required by federal law, and which resulted from Virginia policy or budget decisions?
• Did DMAS examine states that continue to recognize live-in caregiver exemptions or alternative verification arrangements?
• What evidence supported the decision to discontinue Virginia’s previous approach?
• Were less burdensome alternatives evaluated?
• What legal or administrative steps would be necessary to reconsider or restore the exemption?

I also request clarification as to whether any pending Attorney General regulatory review concerning EVV has a legal relationship to the October 1 policy change.

3. Projected Savings and the Full Fiscal Impact

Virginia budget materials identify approximately $2.25 million in projected annual savings associated with strengthened personal-care oversight.

I respectfully request clarification of the amount specifically attributable to eliminating the live-in caregiver EVV exemption and the methodology used to calculate it.

In particular, were the following potential costs considered?

• Additional administrative work performed by fiscal/payroll agents and Consumer Direct staff.
• Increased telephone support and technical assistance.
• Time spent correcting EVV errors and resolving payroll discrepancies.
• Uncompensated administrative work performed by family caregivers.
• Training, translation, and qualified interpretation services across multiple languages.
• Potential delays or interruptions in authorized home-based services.
• Caregiver recruitment and retention difficulties.
• The possibility that some families may become unable to sustain home-based caregiving arrangements.
• Potential increases in expenditures for alternative residential or institutional services.

I also ask DMAS to distinguish savings resulting from prevention of documented improper payments from savings resulting from missed entries, delayed reimbursement, reduced utilization, or other administrative effects.

Preventing improper payments and failing to reimburse legitimate authorized care are not equivalent outcomes.

Were all these potential expenses included in the projected savings, or might some costs be transferred to families, administrative contractors, or other Medicaid programs rather than eliminated?

4. Language Access, Technology, and Effective Training

Meaningful access to EVV support should not depend on a caregiver’s English proficiency, computer skills, smartphone ownership, or ability to navigate an automated telephone system.

Virginia families speak many languages. Language assistance must address the languages actually needed by affected families, not merely English and Spanish.

Some live-in caregivers are elderly, have limited technological experience, or cannot independently complete online training.

Providing a website link does not necessarily establish that a caregiver can understand the instructions or successfully operate the system.

In some households, another family member must assume these administrative responsibilities without compensation.

I respectfully ask DMAS:

• Is individualized training available, including practical assistance at home when necessary?
• Are qualified interpreters and translated materials available in the languages caregivers need?
• How does DMAS determine whether training has actually enabled a caregiver to use EVV?
• What alternatives exist for caregivers who cannot successfully use the system despite training?
• What support is available to households without smartphones, computers, or reliable internet access?
• Were recurring interpretation, training, and support costs included in the fiscal analysis?

5. Practical Caregiving, GPS Verification, and Employer of Record Responsibilities

The responsibilities of live-in caregivers differ from those of employees who arrive at a separate workplace and begin a scheduled shift.

A child with significant disabilities may require immediate assistance upon waking. A caregiver may need to respond to an urgent safety situation before completing an electronic time entry.

The priority in such circumstances must be the safety and well-being of the person receiving services.

I respectfully ask how DMAS distinguishes a delayed EVV entry caused by legitimate caregiving responsibilities from inaccurate reporting, and what protections allow authorized services to be documented and paid appropriately.

I also request clarification of the additional verification value provided by GPS-based EVV.

GPS information associated with a caregiver’s device may establish the device’s location at a particular time, but it does not independently establish that the Medicaid recipient was present or that a particular service was performed.

This distinction is especially relevant when a caregiver accompanies a recipient outside the home.

Furthermore, Consumer-Directed services already include Employer of Record responsibilities relating to oversight and approval of hours.

I respectfully ask:

• What specific oversight gaps does mandatory EVV address beyond existing Employer of Record responsibilities?
• What evidence demonstrates that EVV provides additional protection against improper payments among live-in caregivers?
• Has DMAS examined the frequency and financial significance of documented improper payments specifically involving live-in family caregivers?
• Could Employer of Record approval, existing documentation, and targeted verification provide comparable accountability with fewer administrative burdens?
• Are location data collected only when EVV entries occur, or at other times as well?

6. Limited Access to Assistance Outside Business Hours

On Saturday, October 10, 2026, after regular business hours, I called two Consumer Direct telephone support numbers listed for Virginia.

Both calls reached recorded messages indicating that the offices were closed. Live assistance was not available through either number at that time.

This experience raises an important practical concern.

When a caregiver encounters an EVV problem outside business hours, the obligation to document the shift remains, even though immediate assistance may not be available.

An unresolved issue may carry over into the next business day.

Instead of focusing on caregiving responsibilities, the caregiver or another family member may need to spend time contacting Consumer Direct, waiting for assistance, explaining the issue, and correcting entries.

This creates additional administrative work for families and payroll support personnel.

I respectfully ask DMAS:

• What immediate assistance is available during evenings, weekends, and holidays?
• What procedures permit legitimate time-entry errors to be corrected without jeopardizing timely payment?
• How are system outages, missed entries, and delayed entries handled?
• Are caregivers protected when authorized services were provided but an EVV error could not be corrected immediately?
• Has DMAS calculated the cumulative costs of additional staff time, caregiver time, repeated support requests, and interpretation services?

7. Public Notice and Meaningful Participation

I respectfully request that DMAS disclose:

• The total number of Medicaid recipients receiving services from live-in caregivers before October 1, 2026.
• The number of live-in caregivers affected.
• The number of affected households.
• The number of households directly notified before implementation.
• The dates, methods, languages, and accessible formats used for notification.
• The opportunities provided for affected families to comment before implementation.
• The number of affected households experiencing service interruptions or changes following implementation, as data become available.

If no separate public comment period was provided specifically for eliminating the exemption, what other consultation procedures were used?

Who participated, how many affected families did they represent, and what concerns influenced the decision?

Publishing information on a government website does not necessarily establish that affected families received, understood, or had a meaningful opportunity to respond.

The absence of public objections should not be interpreted as agreement when the number of affected families who actually received and understood the information is unknown.

8. Family Stability, Nonverbal Individuals, and Institutional Placement Risks

Home- and community-based services support individuals with disabilities in remaining in their homes and communities whenever appropriate.

For individuals with severe developmental disabilities, familiar caregivers and stable routines may be essential to emotional security, behavior, and daily functioning.

The inability to communicate verbally should never be mistaken for an inability to understand, experience emotions, or form meaningful attachments.

Nonverbal children and adults may understand far more than they can express through speech.

They may recognize familiar caregivers, depend on established routines, and experience security within their families.

If an established home-based caregiving arrangement becomes unsustainable, separation from familiar caregivers and surroundings may cause emotional distress, increased anxiety, behavioral difficulties, or challenges adapting to an unfamiliar environment.

The absence of spoken language does not diminish a child’s need for love, familiarity, stability, and emotional safety.

Virginia’s Developmental Disability Waivers are intended to provide community-based alternatives for eligible individuals who meet an institutional level-of-care standard.

That eligibility framework makes the potential consequences of disrupted home-based care particularly important to evaluate.

I respectfully ask whether DMAS has assessed the risk that additional administrative burdens, reduced caregiver availability, or interruptions in authorized services could increase the likelihood of residential or institutional placement for some recipients.

9. Cumulative Policy Effects and Long-Term Medicaid Costs

I respectfully ask DMAS whether it has evaluated the combined effects of:

• Additional EVV requirements for live-in caregivers.
• Proposed or potential limitations on authorized service hours.
• Administrative barriers to obtaining, documenting, or correcting authorized hours.
• Difficulties recruiting and retaining qualified caregivers.
• Proposed changes to service coordination and support structures.
• Increased responsibilities placed on family caregivers.

Each policy may be evaluated separately, but families experience their combined effects.

A family that can manage one additional requirement may not be able to sustain several new obligations simultaneously.

Some parents may need to reduce outside employment or leave their jobs to maintain necessary care. Others may eventually find that their existing home-based arrangements are no longer sustainable.

If that occurs, some families may need to consider alternative residential or institutional services.

Such transitions can have substantial personal consequences and may also create additional Medicaid expenditures.

I respectfully ask whether DMAS has conducted a comprehensive fiscal impact analysis comparing projected administrative savings with the potential costs of disrupted home care, reduced caregiver availability, additional administrative services, and alternative residential or institutional placements.

Any comparison of home-based and institutional costs should use comparable service categories and data from the same fiscal period.

If such an analysis exists, I request that DMAS make its methodology, assumptions, and findings publicly available.

If no comprehensive analysis has been conducted, I respectfully request an explanation.

I also ask what mechanisms exist to identify and assist families whose caregiving arrangements are becoming unsustainable before a crisis occurs.

Preventing avoidable disruption may protect both Medicaid recipients and public resources.

10. Monitoring, Reconsideration, and Public Accountability

To evaluate the consequences of eliminating the live-in caregiver EVV exemption, I respectfully request that DMAS identify measurable indicators and compare outcomes before and after October 1, 2026.

Relevant indicators could include:

• EVV error and correction rates.
• Administrative support requests and response times.
• Delayed or disputed caregiver payments.
• Caregiver recruitment and turnover.
• Interruptions in authorized services.
• Changes in residential or institutional placement.
• Administrative expenditures and costs transferred to families.

I also ask how these outcomes will be monitored, whether the findings will be publicly reported, and what procedures exist to reconsider the policy if significant unintended consequences emerge.

Would DMAS consider recommending restoration of the live-in caregiver exemption or equivalent protections if the additional verification benefits do not justify the burdens?

I would also welcome an opportunity to discuss these practical concerns directly with DMAS representatives.

11. Final Request for Public Explanation

Finally, I respectfully ask DMAS to publicly explain the specific documented problems that motivated the decision to eliminate the EVV live-in caregiver exemption.

What evidence demonstrated that the previous exemption was creating problems requiring its elimination?

What measurable improvements does DMAS expect the new requirements to produce for Medicaid recipients?

How will those improvements be evaluated?

Were less burdensome alternatives considered, and if so, why were they rejected?

Most importantly, what evidence supports the conclusion that the anticipated benefits of eliminating the exemption outweigh the additional administrative, financial, and personal burdens placed on affected families?

I respectfully request a clear public explanation accessible to all affected families, including those who may not have been aware of the policy change or its implications before implementation.

The purpose of this comment is to identify potential unintended consequences before they become difficult or impossible to reverse.

The ultimate objective should be to strengthen accountability while preserving safe, stable, and sustainable home- and community-based care.

Thank you for considering these concerns and for the opportunity to participate in this public comment process.

Sincerely,

Larisa Turkatte
Virginia Resident and Single Mother to a child with disabilities.