Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Service Planning and Authorization

10/29/2010

Participant direction service models use the needs assessment and service planning processes as fundamental activities to safeguard participants’ health and welfare, and to ensure that the services and supports provided enable participants to meet their individual community living goals. The participant direction model differs from professional-directed service models by affirming that the participant is the center of--and leads--the service planning process. Person-centered planning (PCP) is a critical component of participant-directed service planning, which enables and helps the individual to identify and access a personalized mix of paid and non-paid services and supports. While PCP methods used to be associated only with service planning for persons with developmental disabilities, these methods are now employed for individuals with any type of disability, and CMS encourages and supports the use of person/family-centered planning methods in service plan development.

With the exception of home health services, Medicaid policy does not dictate that service plans must be prepared by medical, clinical, or case management professionals. Whether for waiver services authorized in a plan of care or personal care services under the optional State Plan benefit, states have considerable latitude with regard to empowering the individual to manage authorized services. Under the Personal Care option, for example, many states already allow participants to determine when authorized service hours are to be furnished and to alter the schedule to meet their needs.

In an HCBS waiver program, states may also permit participants to manage the service schedule or alter the mix of authorized services to meet their changing needs without having to develop an entirely new service plan. However, the statutory requirement that “services be provided pursuant to a written plan of care” must continue to be met.

Federal law requires that the services individuals receive through an HCBS waiver program be provided pursuant to a plan of care.54 Neither Federal law nor regulations specify the process by which this plan of care is to be developed. The plan of care must meet the requirements spelled out in the State Medicaid Manual and the Technical Guide for HCBS waivers, as well as requirements included in the state’s approved HCBS waiver request. Effective service plan development processes are essential to ensure that waiver participants will receive the services and supports they need and want in order to successfully live and thrive in the community. States must specify in their waiver application how the participant-centered plan will be developed as well as how the state will monitor the service planning process to ensure that it is person centered.

At one time, Federal regulations dictated that the §1905(a) optional State Plan Personal Care benefit be authorized by a physician and supervised by nursing personnel. In the Omnibus Reconciliation Act of 1993, states were specifically authorized to use alternative service authorization methods, including those that do not require the involvement of medical personnel. This policy change enables states to adopt alternative approaches to personal care service planning. A common approach is to delegate this task to case managers who are responsible for assessing eligibility and authorizing services.55

Section 1915(i) highlights service planning as a fundamental component of participant direction, intended to both safeguard health and welfare, as well as ensure meaningful involvement of participants in identifying and selecting the services and supports they need. Section 1915(j)(5)(B) emphasizes the assessment and service planning process by requiring an assessment of the participant’s “needs, strengths, and preferences” for personal assistance services.

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