Twenty-four hour back-up can refer to having an informal back-up plan in the event that a direct care worker does not show, as well as to the existence of a formal systems-level back-up when the informal back-up plan fails. This may include on-call care coordinators and/or providers.
Historically states resisted a formal 24-hour back-up provision in participant-directed services when it was first proposed for the Independence Plus designation for 1915(c) waiver programs (subsequently rescinded). And more recently, some states have been challenged to fully comply with the systems-level 24-hour back-up requirement in the MFP demonstrations. The argument against requiring 24-hour back-up in the FFS environment has been the cost associated with on-call personnel. Yet, in most MLTSS programs we investigated, 24-hour back-up is a routine feature of the care delivery system with MCO (or provider) round-the-clock hotlines or after-hours call-in systems in place to respond to members in need of assistance.