Authority Comparison Chart

Waiver Information found at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c/index.html

State plan option Information found at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915i/index.html

State plan option Information found at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/self-directed-personal-assistant-services-1915-j/index.html

State plan option Information found at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/community-first-choice-cfc-1915-k/index.html

Demonstration Waiver

Information found at: https://www.medicaid.gov/medicaid/section-1115-demonstrations/index.html

Enacted into statute: 1981

This rule was revised and added to the existing 1915 (c) regulations

Issued: January 16, 2014 (effective March 17, 2014)

Settings that were in the state’s HCBS delivery system prior to the effective date of the rule (3/17/14) must comport with the settings requirements in the final rule by 3/17/2023. Settings that are new to the state’s HCBS delivery system after March 17, 2014 must comport with the final rule settings requirements prior to HCBS being delivered in those settings.  All other requirements in this final rule, including conflict of interest mitigation and person-centered planning requirements, became effective on March 17, 2014.

Link to 1915(c) Regulations

Enacted into statute January 1, 2007

Revised in statute: October 1, 2010

Final Rule Issued: January 16, 2014 (effective March 17, 2014)

Settings provisions effective for preexisting programs 3/23/2023)

Link to 1915(i) Regulations

Enacted into statute: January 1, 2007

Final Rule: October 3, 2008

Link to 1915(j) Regulations

Enacted into statute: October 1, 2011

Final Rule: May 7, 2012

Settings provisions applicable to 1915(k) published January 16, 2014.

Link to 1915(k) Regulations

Enacted into statute: 1990

Final Rule: February 27, 2012

Link to 1115 Regulations

The 1915(c) waiver authority permits a state to offer home and community-based services to individuals who: (a) are found to require a level of institutional care; (b) are members of a target group that is included in the waiver; (c) meet applicable Medicaid financial eligibility criteria; (d) require one or more waiver services in order to function in the community.

1915(i) permits states to offer HCBS to Medicaid-eligible individuals who meet state-defined minimum needs-based criteria that are less stringent than institutional criteria, and state-optional target group criteria. May also provide services to individuals whose needs exceed the state’s minimum needs-based criteria including those who meet an institutional level of care.

Section 1915(j) of the Act allows States to amend their Medicaid State plans to provide individuals with the option to self-direct their personal assistance services. 1915(j) may provide this option to individuals for whom there has been a determination that, but for the provision of such services, the individuals would require and receive State Plan personal care services, or section 1915(c) home and community-based waiver services.

1915(k) permits states to provide individuals meeting an institutional level of care the opportunity to receive necessary personal attendant services (PAS) and supports in a home and community-based setting. The CFC option expands Medicaid opportunities for the provision of home and community-based long-term services and supports (LTSS) and is an additional tool that states can use to facilitate community integration while receiving enhanced Federal match of six (6) additional percentage points for CFC services and supports.

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program (CHIP) programs. Under this authority, the Secretary may waive certain provisions of the Medicaid law to give states additional flexibility to design and improve their programs.

• State-wideness
• Comparability

Community income rules for medically needy population

• Comparability

Community income rules for medically needy population

State-wideness

Comparability

Community income rules for medically needy population.

Secretary may waive multiple requirements under §1902 of the Social Security Act if waivers promote the objectives of the Medicaid law and intent of the program.

Information on waiver processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html

Application submitted electronically via §1915(c) HCBS waiver application.

Application and instructions available at: https://wms-mmdl.cms.gov/WMS/faces/portal.jsp

Information on SPA processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html

State plan amendment submitted on pre-print.

Preprint available at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915i/index.html

Information on SPA processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html

State plan amendment submitted on pre-print.

Preprint available at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/self-directed-personal-assistant-services-1915-j/index.html

Information on SPA processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html

State plan amendment submitted on pre-print.

Preprint and Technical Guide available at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/community-first-choice-cfc-1915-k/index.htm

Standardized application requirements found at: 431.412(a)(1): https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html

Depending on the nature and scope of the 1115 application, different processes may apply.

It is advisable for states to contact CMS to discuss application intentions prior to submission.

Initial application: 3 years (5 year-approvals available if the program serves individuals eligible for both Medicare & Medicaid)

Renewal:5 years

States may make amendment to the approved waiver at any time during the approved waiver period.

Waiver amendments with substantive changes may only take effect on or after the date when the amendment is approved by CMS.

Substantive changes also must be accompanied by information on how the state has assured smooth transitions and minimal adverse impact on individuals impacted by the change.

One-time approval. Changes must be submitted to CMS and approved.

If using targeting option, renewal every 5 years.

States may amend their state plan at any time post-approval.

Amendments with substantive changes may only take effect on or after the date when the amendment is approved by CMS.

Substantive changes also must be accompanied by information on how the state has assured smooth transitions and minimal adverse impact on individuals impacted by the change.

One-time approval. Changes must be submitted to CMS and approved.

One-time approval. Changes must be submitted to CMS and approved.

Initial application: 5 years

Renewal: 5 years

Annual reports. (CMS 372 reports on statistical data and quality).

Evidence Based Review process prior to renewal.

Link to process: https://www.medicaid.gov/sites/default/files/2019-12/3-cmcs-quality-memo-narrative_0.pdf

Evidence Based Review process that begins 39 months after SPA effective date.

Annual Report. The State must provide to CMS an annual report on the number of individuals served and the total expenditures on their behalf in the aggregate.

Three-year evaluation. The State must provide to CMS an evaluation of the overall impact of the self-directed PAS option on the health and welfare of participating individuals compared to non-participants every 3 years.

Annual reports on numbers of individuals served, expenditures and utilization and certain quality measures and additional information (42 CFR 441.580).

Monthly progress calls, quarterly and annual progress reports and other reports as required in the approved STCs.

Administered by the Single State Medicaid Agency (SSMA).

May be operated by another state agency under an interagency agreement or memorandum of understanding.

Administered by the Single State Medicaid Agency (SSMA).

May be operated by another state agency under an interagency agreement or memorandum of understanding.

Administered by the Single State Medicaid Agency (SSMA).

Administered by the Single State Medicaid Agency (SSMA) though may involve another state agency in operations and administration.

Administered by the Single State Medicaid Agency (SSMA).

Certain provisions may be operated by other entities as approved by CMS.

Required between providers and the SSMA.

Delegation allowed to a provider agency under the Organized Health Care Delivery System or Provider of Financial Management Services. Requires written specification of delegated activity and a voluntary reassignment of payment by the provider of services.

Required between providers and the SSMA.

Delegation allowed to a provider agency under the Organized Health Care Delivery System or Provider of Financial Management Services.

Requires written specification of delegated activity and a voluntary reassignment of payment by the provider of services.

Required between providers and the SSMA.

Delegation allowed to a provider agency under the Organized Health Care Delivery System or Provider of Financial Management Services. Requires written specification of delegated activity and a voluntary reassignment of payment by the provider of services.

Required between providers and the SSMA.

Required unless otherwise stipulated in the approved standard terms and conditions and approved waiver authorities.

A state may specify the Medicaid eligibility groups that are served in the waiver. In order for an eligibility group to be included in the waiver, it must already have been included in the state plan.

States are permitted to use institutional income and resource rules for the medically needy (institutional deeming).

May include the special income level group of individuals and may permit income up to 300% of SSI.

Individuals eligible for Medicaid under the State plan up to 150% of Federal Poverty Level.

States may also include special income group of individuals with income up to 300% SSI/FBR, who are eligible for HCBS under a §1915(c), (d), or (e) waiver or §1115 demonstration waiver.

Individuals must be Medicaid eligible for and receiving services under either state plan requirements or eligible for and receiving services under a §1915(c) HCBS waiver.

State must cover all categorical eligibility groups and may elect to cover medically needy.

Individuals eligible for the CFC benefit are either:

1. in an eligibility group entitled to nursing facility services under the State plan; or
2. are not in an eligibility group entitled to nursing facility services but whose income is at or below 150 percent of the Federal poverty level.

State defines eligibility categories and may expand or propose modified eligibility within the 1115 demonstration.

Individuals must meet institutional level of care.

Waivers are limited to one or more of the following target groups or any subgroup thereof:

• Aged or disabled, or both;
• Individuals with Intellectual Disabilities or a developmental disability, or both;
• Persons with mental illnesses.

States may also specify age ranges within the target groups and/or subgroups served.

Additional targeting criteria may include but are not limited to:

• Nature or type of disability;
• Specific diseases or conditions;
• Functional limitations (e.g., extent of assistance required in activities of daily (ADLs) and/or instrumental activities of daily living (IADLs).

Additional criteria also may be specified in order to align the waiver to service population eligibility criteria that are specified in state law.

A state may elect not to apply comparability requirements set forth in the statute. This provision enables states, at their election, to target the HCBS State Plan option.  These target groups must be defined on the basis of any combination of the

following:

1. Age.
2. Diagnosis.
3. Disability.
4. Medicaid Eligibility Group

And may not have the impact of limiting individuals choice of provider and/or living setting.

NOTE: See approval section above for 1915(i) benefits that include targeting.

Regardless of whether a state elects to target the 1915(i), each 1915(i) must include need based criteria which are factors used to determine an individual’s requirements for support, and may include risk factors. The criteria are not characteristics that describe the individual or the individual’s condition. A diagnosis is not a sufficient factor on which to base a determination of need.

Needs based criteria must be less stringent than institutional level of care criteria.

In addition to needs based criteria for eligibility for HCBS as a state plan option, the state may establish needs based criteria for each service.

Section 1915(j)(1) requires that the self-directed PAS State plan opportunity be available to individuals for whom there has been a determination that, but for the provision of such services, would require and receive State plan personal care services or section 1915(c) waiver services.

The state may elect to target this benefit to particular populations.

States may NOT target 1915(k) benefit. Services must be provided on a statewide basis, in a manner that provides such services and supports in the most integrated setting appropriate to the individual’s needs, and without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community- based attendant services and supports that the individual requires in order to lead an independent life.

Individuals must meet institutional level of care.

Individuals eligible for Medicaid under 42 CFR 435.217, must continue to meet the eligibility requirements for the 1915(c) waiver in order to maintain eligibility for Medicaid and CFC.

The approved Special Terms and Conditions as approved by the Secretary set forth the eligibility requirements for benefit packages and/or services.

42 CFR 447.205. for payment methodology

The state is required to establish a public input process specifically for HCBS waiver changes that are substantive in nature.

Consistent with 42 CFR 441.304(f) stipulates that a state must share with the public the entire waiver. In addition, the state’s public input process must have included at least two (2) statements of public notice and public input procedures, with at least one being web-based AND at least one being non-electronic to ensure that individuals without computer access have the opportunity to provide input. This state must provide at least a 30-day public notice and comment period, and be completed prior to submission of the proposed change to CMS.

42 CFR §447.205 for payment methodology.

Section 441.715(c)(1) requires states to provide at least 60 days - notice of a proposed modification of the needs-based criteria to the Secretary, the public, and each individual enrolled in the State plan HCBS benefit. In addition § 441.715(c)(5) requires any changes in service due to the modification of needs-based criteria under the adjustment authority to be treated as these actions are subject to the fair hearing requirements of part 431 subpart E of this chapter. States are also required under § 431.12 to provide for a medical care advisory committee to advise the Medicaid agency director about health and medical care services, and the committee must have the opportunity for participation in policy development and program administration.

42 CFR §447.205 for payment methodology.

Standard state plan public notice requirements apply.

42 CFR §447.205 for payment methodology.

Must create a Development and Implementation Council that includes a majority of members with disabilities, elderly individuals, and their representatives. State must consult and collaborate with the Council when developing and implementing a State Plan amendment to provide HCBS attendant services.

States must provide at least a 30-day public notice and comment period for applications for new demonstrations and extensions of existing demonstrations. This process is followed by a federal public comment period.

Information about the process can be found at https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-transparency-requirements/index.html.

States may operate multiple 1915(c) HCBS waivers

Cannot cover:

Room & board costs.

Habilitation does not include special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.

Multiple State plan amendments covering different target groups permitted.

Cannot cover:

Room & board costs.

Habilitation does not include special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.

Must either operate a HCBS waiver covering PAS or have an approved state plan amendment for “traditional” PAS as a companion to 1915(j).

MOE requirement for 1st fiscal year for services provided under §1115,

§1905(a), and §1915, of the Act.

Must establish & consult with a Development & Implementation Council with majority representation from consumers.

Cannot cover:

Certain assistive devices & assistive technology services; medical supplies & equipment, home modifications.

Room & board costs.

Special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.

Increased FMAP

§1915(k)(2) of the Act provides that States offering this option to eligible individuals during a fiscal year quarter occurring on or after October 1, 2011 will be eligible for a 6 percentage point increase in the Federal medical assistance percentage (FMAP).

State must operate in accordance with the approved Special Terms and Conditions.

Cannot cover: Room & Board costs.

Allowed.

Not allowed.

Allowed

Not allowed.

State estimates numbers served.

Operates as an entitlement to all who are eligible.

Allowed.

May determine process for setting individual budgets for participant-directed services.

May determine process for setting individual budgets for participant-directed services.

May determine process for setting individual budgets for participant-directed services.

Budget neutrality must be maintained. Caps or benefit limits may apply pursuant to approved STPs.

Statutory Services:

• Case management services
• Homemaker/home aide services & personal care services
• Adult day health services
• Habilitation services
• Respite care
• Other services requested by State as Secretary may approve”
• Day treatment or other partial hospitalization services*
• Psychosocial rehabilitation services*
• Clinic services*

*For individuals with chronic mental illness

Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final rule.

Same as §1915(c) services.

Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final.

• Personal care or related services.
• Home and community-based services otherwise available to the participant under the state plan or an approved §1915(c) waiver.
• At state’s discretion, items that increase an individual’s independence or substitute for human assistance.

Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final rule (subject to transition period for existing programs/services).

MUST COVER:

• Assistance w/ ADLs, IADLs, & health related tasks.
• Acquisition, maintenance & enhancement of skills necessary for individual to accomplish ADLs, IADLs, & health-related tasks.
• Back-up systems or mechanisms to ensure continuity of services & supports.
• Voluntary training on how to select, manage and dismiss staff.

MAY COVER

Permissible services and supports may include, but are not limited to, the following: (1) Expenditures for transition costs such as rent and utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies, and other necessities linked to an assessed need for an individual to transition from an institution to a home and community-based setting where the individual resides; (2) Expenditures relating to a need identified in an individual’s person-centered service plan that increases an individual’s independence or substitutes for human assistance, to the extent that expenditures would otherwise be made for the human assistance.

Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final rule.

State decides what services are covered, subject to CMS approval.

Reasonable standards identified by the state, subject to CMS approval.

Reasonable standards identified by the state, subject to CMS approval.

Expectations set forth at:

States have the option to permit participants, or their representatives, if applicable, to hire any individual capable of providing the assigned tasks, including legally liable relatives, as paid providers of the PAS identified in the service plan and budget. Participants, or their representatives, if applicable, retain the right to train their workers in the specific areas of personal assistance needed by the participant and to perform the needed assistance in a manner that comports with the participant’s personal, cultural, and/or religious preferences. Participants, or their representatives, if applicable, also have the right to access other training provided by or through the State so that their PAS providers can meet any additional qualifications required or desired by participants, or participants’ representatives, if applicable. Participants, or their representatives, if applicable, retain the right to establish additional staff qualifications based on participants’ needs and preferences.

Provider qualification expectations for 1915(k) are set forth in 42 CFR 441.565. The State determines the provider qualifications for providers to provide CFC services under the agency provider model. Individuals receiving services under the agency provider model retain the right to establish additional staff qualifications based on the individual’s needs and preferences.

For the self-directed model with service budget, an individual has the option to permit family members, or any other individuals, to provide Community First Choice services and supports identified in the person centered service plan, provided they meet the qualifications to provide the services and supports established by the individual, including additional training.

In all instances, the individual may identify additional expectations for providers to ensure they meet the specific needs of the individual.

Determined by state, subject to CMS approval.

Required if participant direction is offered. May be covered as a waiver service or a Medicaid administrative activity.

Required if participant direction is offered. May be covered as a service or as a Medicaid administrative activity.

Required. Reimbursable only as an administrative activity. Service reimbursement is not available.

The state must make available financial management services to all individuals with a service budget. May be included as a service or an administrative activity.

Subject to specific requirements set forth in the approved STPs.

States may identify what options are available for employer authority in a participant directed model of service:

Co-Employment. Under this approach, the participant is supported by an agency that functions as the common law employer of workers recruited by the participant. Also known as “agency with choice.”

Common Law Employer. Under this approach, the participant is considered the legally responsible employer (common law employer) of workers whom he or she (or his or her representative) hires, supervises and discharges directly. The participant or his or her representative is liable for the performance of necessary employment-related tasks and uses a Government or Vendor Fiscal/Employer Agent.

States may identify what options are available for employer authority in a participant directed model of service:

Co-Employment. Under this approach, the participant is supported by an agency that functions as the common law employer of workers recruited by the participant. Also known as “agency with choice”

Common Law Employer. Under this approach, the participant is considered the legally responsible employer (common law employer) of workers whom he or she (or his or her representative) hires, supervises and discharges directly. The participant or his or her representative is liable for the performance of necessary employment-related tasks and uses a Government or Vendor Fiscal/Employer Agent.

Participant may be the employer of record under a Fiscal/Employer Agent model or the provider entity may be the employer of record under an Agency with Choice model.

Agency Provider Model: Services & supports provided by entities under contract or provider agreement. Participant has a significant role in the selection and dismissal of providers. Entity may provide services directly through their employees or arrange for the provision of services under the direction of the individual receiving services.

Self-Directed Model with Service Budget: Service plan and budget directed by the individual and based on functional needs assessment. FMS must be available. Direct cash or vouchers may also be used.

Other Service Delivery Model: States may propose other models.

Subject to specific requirements set forth in the approved STPs.

Permitted as a waiver service.

Permitted as a covered service.

Permitted as a permissible purchase as described at 42 CFR 441.482.

Permitted as a covered service at the state’s election for expenditures relating to a need identified in an individual’s person-centered service plan that increases an individual’s independence or substitutes for human assistance, to the extent that expenditures would otherwise be made for the human assistance.

Permitted subject to the approved STCs.

Required (state may offer options that can be utilized voluntarily by providers to meet this requirement).

Can be coupled with a managed care authority for different payment arrangements.

Required (state may offer options that can be utilized voluntarily by providers to meet this requirement).

Can be coupled with a managed care authority for different payment arrangements.

Required (state may offer options that can be utilized voluntarily by providers to meet this requirement).

Can be coupled with a managed care authority for different payment arrangements.

Required (state may offer options that can be utilized voluntarily by providers to meet this requirement).

Can be coupled with a managed care authority for different payment arrangements.

Required (state may offer options that can be utilized voluntarily by providers to meet this requirement) unless otherwise stipulated in approved STCs.

State must describe the methods that are employed to establish provider payment rates for waiver services and the entity or entities that are responsible for rate determination.

Rate methodology must be approved as a part of the state plan.

Rate methodology must be approved as a part of the state plan.

Rate methodology must be approved as a part of the state plan.

Payment rates and methodologies subject to the provisions approved within the STCs.

Cost-neutrality.

Average annual Medicaid costs per waiver participant cannot exceed average institutional cost per person for each level of care.

N/A. State must submit CMS 179 including estimated FY impact on federal budget.

N/A. State must submit CMS 179 including estimated FY impact on federal budget.

N/A. State must submit CMS 179 including estimated FY impact on federal budget.

For the first full fiscal year in which the State Plan amendment is implemented, a State must maintain, or exceed, the level of expenditures for services provided under

§1115, §1905(a), and

§1915, of the Act, or otherwise to individuals with disabilities or elderly individuals attributable to the preceding fiscal year.

Budget neutrality. Federal spending under the waiver cannot exceed what it would have been spent in absence of the waiver. 

Extensive quality management and quality improvement activities required per the HCBS Waiver Application, including how state will comply with all waiver assurances and how state will conduct quality oversight, monitoring and discovery, remediation and improvement of issues relating to quality.

Extensive quality management and quality improvement activities required, including how state will comply with multiple requirements and how state will conduct quality oversight, monitoring and discovery, remediation and improvement of issues relating to quality.

Requires a quality assurance and improvement plan including how state conducts discovery, remediation and quality improvement.

State must provide system performance measures, outcome measures, and satisfaction measures that will be monitored and evaluated.

States must establish and maintain a comprehensive, continuous quality assurance system, described in the State plan amendment, which includes:

• A quality improvement strategy
• Methods to monitor health and welfare
• Individual outcomes measures
• Standards for service models, training, appeals and reconsiderations, etc.

Other items as required by the secretary

Extensive data collection and evaluation plans to assess the effectiveness of the project or demonstration as established within the state’s approved STCs.

HCBS requirements apply if the 1115 contains HCBS.

Participants have access to and must utilize state plan services provided under 1905(a) (including all EPSDT benefits) before using identical extended state plan services under the waiver.

Waiver services may not duplicate state plan services.

Individuals may be eligible for and receive services from multiple HCBS authorities simultaneously, so long as the person centered service plan ensures no duplication of services.

HCBS waivers may be operated concurrently with other authorities, for example 1915(a) or 1915(b).

Participants have access to and must utilize state plan services provided under 1905(a) (including EPSDT) before using identical services covered through 1915(i).

1915(i) services must not duplicate services available under the state plan.

Individuals may be eligible for and receive services from multiple HCBS authorities simultaneously, so long as the person centered service plan ensures no duplication of services.

HCBS as a state plan option may be operated concurrently with other authorities, for example 1915(a) or 1915(b).

State must either operate a HCBS waiver covering PAS or have an approved state plan amendment for “traditional” PAS.

Individuals voluntarily or involuntarily dis-enrolled from §1915(j) must have access to other PAS services under the state plan or §1915(c).

Individuals may be eligible for and receive services from multiple HCBS authorities simultaneously, so long as the person centered service plan (PCSP) ensures no duplication of services.

1915(j) may be operated concurrently with other authorities, for example 1915(a) or 1915(b).

Individuals may be eligible for and receive services from multiple HCBS authorities simultaneously, so long as the person centered service plan ensures no duplication of services.

1915(k) may be operated concurrently with other authorities, for example 1915(a) or 1915(b).

State defines relationship to state plan, waivers, and amendments, subject to CMS approval.

Requirements at 42 CFR 431.301(c)(1)(vi).

Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person centered service plans in a geographic area also provides HCBS. In these cases, the State must devise conflict of interest protections including separation of entity and provider functions within provider entities, which must be approved by CMS. Individuals must be provided with a clear and accessible alternative dispute resolution process

Under no circumstances can a direct service provider determine eligibility – this applies to financial and functional eligibility. The requirements listed are the minimum; states may impose additional criteria.

Requirements at 42 CFR 441.730(b). Individuals or entities providing case management functions (developing person-centered service plan) cannot be:

• Related by blood or marriage to the individual or a paid caregiver
• Financially responsible for the individual
• Empowered to make health-related decisions
• Individuals who would benefit financially from service provision
• Providers of State Plan HCBS

Providers of State Plan HCBS can provide case management functions only when:

• The state demonstrates that they are the only willing and qualified entity/entities in a geographic area;
• The state devises conflict of interest protections, including separation of assessment/planning and HCBS provider functions within entities; and;
• Individuals are provided with a clear and accessible alternative dispute resolution process.

Under no circumstances can a direct service provider determine eligibility – this applies to financial and functional eligibility.

The requirements listed are the minimum; states may impose additional criteria.

Requirements at 42 CFR 441.468.

When an entity that is permitted to provide other State plan services is responsible for service plan development, the State must describe the safeguards that are in place to ensure that the service provider’s role in the planning process is fully disclosed to the participant, or participant’s representative, if applicable, and controls are in place to avoid any possible conflict of interest.

Requirements at 42 CFR 441.550(c).

Individuals or entities providing case management (developing person-centered service plan) cannot be:

• Related by blood or marriage to the individual or a paid caregiver
• Financially responsible for the individual
• Empowered to make health-related decisions
• Individuals who would benefit financially from service provision
• Providers of State Plan HCBS

Providers of State Plan HCBS can provide case management only when:

• The state demonstrates that they are the only willing and qualified entity/entities in a geographic area;
• The state devises conflict of interest protections, including separation of assessment/planning and HCBS provider functions within entities; and;

Individuals are provided with a clear and accessible alternative dispute resolution process.

If HCBS are included in 1115, COI provisions will apply subject to approved STCs.

Must meet the requirements regarding the person centered plan and process at 42 CFR 441.301(c)(1), (2) and (3).

The person centered plan must be based on an independent assessment.

In addition to specific requirements regarding the process used to develop the plan, the regulations establish that the person-centered service plan must reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.

Must meet the requirements regarding the person centered plan and process at 42 CFR 441.725.

The person centered plan must be based on an independent assessment.

In addition to specific requirements regarding the process used to develop the plan, reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.

Must meet the requirements regarding the person centered plan and process at 42 CFR 441.468.

In addition to other requirements set forth, a State must develop a service plan for each program participant using a person-centered and directed planning process to ensure the following: (1) The identification of each program participant’s preferences, choices, and abilities, and strategies to address those preferences, choices, and abilities. (2) The option for the program participant, or participant’s representative, if applicable, to exercise choice and control over services and supports discussed in the plan. (3) Assessment of, and planning for avoiding, risks that may pose harm to a participant.

Must meet the requirements regarding the person centered plan and process at 42 CFR 441.540.

In addition to specific requirements regarding the process used to develop the plan, the regulations establish that the person-centered service plan must reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.

If HCBS are included in 1115, provisions will apply subject to approved STCs.