Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. 3. State Plan Coverage of HCBS


Section 6086 of the DRA-2005 added §1915(i) to the Social Security Act, effective January 2007.43 This provision permits a state to offer HCBS under its Medicaid State Plan without having to secure Federal approval of a waiver. Section 1915(i) was subsequently amended by the Patient Protection and Affordable Care Act of 2010 (hereafter called the Affordable Care Act). The amendments only affect one of the DRA-2005 provisions related to participant direction: states may now offer “other” services (as they can in §1915(c) waivers), which means that participants will have the flexibility to purchase a wide range of “goods and services” to reduce their dependence, as long as they are included in the service plan. CMS has not yet published a final rule for the §1915(i) authority.

Participant Direction of State Plan HCBS

The §1915(i) authority specifically allows states to incorporate a participant direction option for the delivery of State Plan HCBS.44 Under the statute, participant-directed services are defined as HCBS“which are planned and purchased under the direction and control of such individual or the individual’s authorized representative.”

States that elect to incorporate a participant direction option in the provision of State Plan HCBS must address the following:

  • Assessment. The state must provide for a process to assess the “needs, capabilities, and preferences” of the individual.

  • Service Plan. The state must have a person-centered service plan development process that is directed by the individual or the individual’s authorized representative. The process must (1) build upon the individual’s capacity to engage in activities that promote community life; (2) respect the individual’s preferences, choices, and abilities; and (3) involve families, friends, and professionals as desired or required by the individual or his/her authorized representative. The service plan must also include appropriate risk management techniques that recognize the roles and sharing of responsibilities in obtaining services in a participant-directed manner and ensure the appropriateness of the service plan based on the resources and capabilities of the individual or the individual’s authorized representative.

  • Limitation of Services That May Be Participant Directed. A state must specify which of the services it offers under its §1915(i) benefit may be directed by participants. The service plan must specify the services that participants or their representatives will self-direct, the methods by which they will self-direct, and the supports that are available to the participant.

  • Methods of Participant Direction. A statemust also specify the methods by which participants may direct their services. States may elect to offer participants the employer and/or budget authority along similar lines as allowed under the HCBS waiver authority.

  • Participant-Directed Budget. States may offer participants a participant-directed budget that identifies the dollar value of the services and supports under the control and direction of the individual or the individual’s authorized representative. When a state offers a participant-directed budget, it must specify the methods by which the budget is calculated and provide for a process to adjust the budget based on changes in an individual’s assessment and service plan.45

  • Financial Management Services. A state may provide financial management services as an administrative activity to support participants who elect to direct their services or contract with an outside entity to provide these services.

In most respects, the elements of a participant direction option under §1915(i) closely parallel those in HCBS waivers.

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