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.
State-wideness
Comparability
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
One-time approval. Changes must be submitted to CMS and approved.
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.
Administered by the Single State Medicaid Agency (SSMA).
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.
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.
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.
42 CFR §447.205 for payment methodology.
Standard state plan public notice requirements apply.
Must either operate a HCBS waiver covering PAS or have an approved state plan amendment for “traditional” PAS as a companion to 1915(j).
Allowed
May determine process for setting individual budgets for participant-directed services.
- 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).
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.
Required. Reimbursable only as an administrative activity. Service reimbursement is not available.
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.
Permitted as a permissible purchase as described at 42 CFR 441.482.
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.
Rate methodology must be approved as a part of the state plan.
N/A. State must submit CMS 179 including estimated FY impact on federal budget.
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.
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).
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.
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.