1915(c) and Independence Plus OverviewIn 1981, former President Ronald Reagan signed into law Public Law 97-35. Section 2176 of PL 97-35 established section 1915(c) of the Social Security Act (the Act), the Medicaid Home and Community-Based Services (HCBS) Waiver program. Prior to the passage of this legislation, Medicaid long-term care benefits were limited to home health and personal care services and to institutional facilities: hospitals, nursing facilities (NF), intermediate care facilities for persons with mental retardation (ICF/MR). The HCBS legislation provided a vehicle for states, for the first time, to offer additional services not otherwise available through their Medicaid programs to serve people in their own homes and communities. HCBS waivers afford States the flexibility to develop and implement creative alternatives to placing Medicaid-eligible individuals in hospitals, nursing facilities or intermediate care facilities for persons with mental retardation. The HCBS waiver program recognizes that many individuals at risk of being placed in these facilities can be cared for in their homes and communities, preserving their independence and ties to family and friends at a cost no higher than that of institutional care. Introduction to 1915(c) and Self Direction CMS recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services. Participant direction of waiver services means that the waiver participant has the authority to exercise decision making authority over some or all of her/his waiver services and accepts the responsibility for taking a direct role in managing them. Participant direction is an alternative to provider management of services wherein a service provider has the responsibility for managing all aspects of service delivery in accordance with the participant-centered service plan. Participant direction promotes personal choice and control over the delivery of waiver services, including who provides services and how they are delivered. For example, the participant may be afforded the opportunity and be supported to recruit, hire, and supervise individuals who furnish daily supports. When a waiver service is provider managed, a provider selected by the participant carries out these responsibilities. Incorporating participant direction into a waiver involves several interrelated dimensions. The following is an overview of the main dimensions of participant direction under a waiver: Participant Choice A waiver may be designed to exclusively serve individuals who want to direct some or all of their waiver services. Usually when this is the case, there is another waiver program that is available to individuals who do not wish to direct their services. Alternatively, a waiver may permit participants to direct some or all of their services or opt instead to receive provider-managed services exclusively. The Version 3.2 HCBS Waiver Application supports both basic waiver designs. When a waiver exclusively serves persons who want to direct some or all of their waiver services, this design is reflected in Appendix B-1 (Item B-1-b – additional targeting criteria) and in Appendix E-1. Also in Appendix E-1, the waiver may further specify that participant direction opportunities are limited to individuals who reside in designated types of living arrangements. Whenever the application refers to the election of participant direction or the exercise of decision making authority, references to the participant mean: (a) the participant acting independently on her/his own; (b) the parent(s) of a minor child who is a waiver participant acting on behalf of the child; (c) a legal representative when the representative has the authority to make pertinent decisions on behalf of the participant; and, (d) when permitted by the state, a non-legal representative who has been freely chosen by the participant to make decisions on the participant's behalf. Geographic Limitation As discussed in the instructions for Item 4-c in the Application module (statewideness), the waiver also may make participant direction opportunities available in some but not all the geographic regions where the waiver is in effect. Service Specifications In Appendix C-3, each service that is offered under the waiver may be specified as provider-managed, participant-directed, or both. The instructions for Appendix C-3 discuss the considerations associated with the specification of service delivery method. In general, the exercise of the participant direction opportunities (authorities) that are discussed below applies only to the waiver services that have been designated as participant-directed. Participant Direction Opportunities Appendix E-1 provides for the selection of two basic participant direction opportunities that may be made available through a waiver. These opportunities may be and often are used in combination and are not mutually exclusive. The opportunities are: - Participant Employer Authority. Under the Employer Authority, the participant is supported to recruit, hire, supervise and direct the workers who furnish supports. The participant functions as the common law employer or the co-employer of these workers. When the Employer Authority is utilized, the participant rather than a waiver provider agency carries out employer responsibilities for workers. The dimensions of participant decision making under the Employer Authority are specified in Appendix E-2-a of the application; and,
- Participant Budget Authority. Under the Budget Authority, the participant has the authority and accepts the responsibility to manage a participant-directed budget. Depending on the dimensions of the budget authority that are specified in Appendix E-2-b, this authority permits the participant to make decisions about the acquisition of waiver goods and services that are authorized in the waiver service plan and to manage the dollars included in a participant-directed budget.
As noted above, these two authorities are often used in combination to promote full-featured participant direction of waiver services. Supports for Participant Direction When a waiver offers participant direction opportunities, two types of supports must be made available to facilitate participant direction. These supports may be furnished as a waiver service (as specified in Appendix C-3) or under another Medicaid payment authority (principally as a Medicaid administrative activity). When one or both types of supports are furnished under another payment authority, they are described in detail in Appendix E-1. These supports are: - Information and Assistance in Support of Participant Direction. These supports are made available to participants to help them manage their waiver services. For example, assistance might be provided to help the participant locate workers who furnish direct supports or in crafting the service plan. The type and extent of the supports that must be available to participants depends on the nature of the participant direction opportunities provided under the waiver.
- Financial Management Services. These services are furnished for two purposes: (a) to address the legal and other requirements that arise when the participant functions as the employer of workers and (b) to make financial transactions on behalf of the participant when the participant has budget authority.
While their main purpose is to facilitate participant direction of services, these supports also provide important protections and safeguards for participants who direct their own waiver services. More detailed information about each of these main dimensions of participant direction is contained in the item-by-item instructions. To analyze Appendix E- of the new HCBS waiver application, scroll down this page to Inside of CMS section and click on the Quality ToolKit link.
Page Last Modified: 12/16/2005 9:55:00 AM
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