Federal Home and Community Based
Service Settings Rules
An Overview
Medicaid Final Rules
The Centers for Medicaid and Medicare Services
(CMS) made the new rule
CMS is the Federal agency that runs Medicaid in all
states
Published in Federal Register on January 16, 2014
and became effective on March 17, 2014
Main Points of Rules
Defines and describes home and community based
settings under section 1915 (c) waivers and section
1915 (i) state plans
Sets forth requirements for person-centered
planning process and person-centered service plan
Lays out transition timeframe and requirements
Medicaid Final Rules
In Idaho we use Medicaid for Home and Community
Based Services provided through State Plans (Section
1915(i)), or HCBS waivers (Section 1915(c))
Goal of the rule: Truly community based services
Action to Support Goal: Medicaid will only pay for
services and supports when they are provided in an
integrated manner
Qualities of a HCBS Setting
◦ Is integrated and supports access to the greater
community
◦ Provides opportunities to seek employment and work
in competitive integrated settings, engage in
community life, and control personal resources
◦ Ensures the individual receives services in the
community to the same degree of access as
individuals not receiving Medicaid home and
community-based services
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Qualities of a HCBS Setting
◦ Setting is selected by the individual from among options,
including non-disability specific settings
◦ Ensures an individual’s rights of privacy, dignity, respect,
and freedom from coercion and restraint
◦ Provides for individual initiative, autonomy, and
independence in making life choices
◦ Allows individual choice about services and supports, and
who provides them
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Additional Requirements for Provider-Owned
Residential Settings
◦ Specific unit/dwelling is owned, rented, or occupied under a
legally enforceable agreement such as a lease or other legally
enforceable agreement
◦ Same responsibilities/protections from eviction as all tenants
under landlord tenant law of state, county, or city or other
designated entity
◦ Each individual has privacy in their sleeping or living unit
◦ Units have lockable entrance doors, with appropriate staff
having keys to doors as needed
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Additional Requirements for Provider-Owned
Residential Settings
◦ Choice of roommate
◦ Freedom to furnish or decorate the space according to the
lease agreement
◦ Individuals have freedom and support to control their
schedules and activities including access to food at any time
◦ Individuals may have visitors at any time
◦ Setting is physically accessible to the individual
Settings Excluded from the Rule
◦ Nursing facilities
◦ Institutions for mental diseases, intermediate
care facilities for individuals with intellectual
disabilities (ICF/IID)
◦ Hospitals providing long-term care services
Settings that May Isolate
Some settings are presumed to have institutional
qualities and will not meet the rule’s requirements
for home and community-based settings
Settings that May Isolate
Settings that have the following qualities might be
isolating:
◦ Designed specifically for people with disabilities, often
for people with a certain type of disability
◦ Individuals in the setting are primarily or exclusively
people with disabilities, and are served mostly by on-site
staff
Settings that May Isolate
Other things to consider:
◦ If the setting is designed to provide multiple types of
services and activities on-site
◦ If people have limited interaction with the broader
community
◦ If interventions and restrictions are used that are typical
in institutional
Settings that May Isolate
Examples of settings that may isolate:
◦ Farmstead or disability-specific farm community
◦ Gated/secured community for people with disabilities
◦ Residential Schools
◦ Multiple settings co-located and operationally related
◦ CMS will be providing further guidance with examples of nonresidential settings that isolate
Person Centered Planning
Person centered planning has been part of the delivery of
services to children and adults with disabilities for many years
For the first time, the HCBS rule puts the requirements for
person-centered planning into regulation – known in the HCBS
rule as “person centered service planning.”
Person Centered Service Planning
◦ The individual may invite anyone they want. Interpreters or
communication device should be provided if needed
◦ Meeting must be held in a manner that respects the individual’s
culture and is conducted in a language the individual understands
◦ It should be clear how conflicts or differences among team
members will be resolved
Person Centered Service Planning
◦ The process should offer the individual choices about the types of
services they want, where they want them provided, information on
residential options, where they spend their day, and why those
choices were made
◦ All those providing services to the individual must sign off on the
individual’s plan that they have reviewed the individual’s plan
◦ The plan must be changed or updated at the individual’s request,
but must be renewed at least annually
Person Centered Service Planning
The written plan should include:
◦ Options presented to the individual about where to live, what was
chosen, and why
◦ Where the individual chose to receive other services, like
supported employment
◦ The individual’s strengths, preferences, and needs
◦ The supports needed, both paid and unpaid
◦ Things the individual wants to accomplish (their goals) and how
they will know they have achieved them (outcomes)
Person Centered Service Planning
The plan must also:
◦ Be written in plain language that the individual understands
◦ Note any risks the individual might have and plans for dealing
with them
◦ Include the name of the person responsible for making sure
the plan is followed
◦ Include the signatures of everyone who participated, and
everyone should get a copy
Changing the Setting or Service
Sometimes, in order for a person with a disability to be wellsupported and safe in the community, plan changes must be
made. For example, some people cannot have unlimited
access to food because of risk to their health. If an individual
needs supports or changes made, these need to be written
into the person-centered plan.
Transition Plan
◦ States must submit transition plans to the Centers for Medicaid
and Medicare (CMS) that outline the changes to the HCBS
program to gain compliance with the new regulations
◦ A State must provide at least a 30-day public notice and
comment period and two statements of public notice and
input procedures on this plan
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Transition Plan
◦ The State must consider and modify the plan to account for public
comment
◦ If a state substantively amends the plan, the new plan must be put
out for public comment
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Public Comment
The draft Idaho State Transition Plan for Home and
Community Based Services and Settings closed public
comment on November 2, 2014.
But….
After the November 2, 2014 public comment deadline the
transition plan will be modified based on public comment
and posted again for public comment in January 2015
Things to Think About
◦ What are necessary supports and settings for community integration?
◦ What does “having a meaningful day” really mean? How can an HCBS
program support how an individual defines a meaningful day?
◦ How does a program maintain the idea that community integration may
look different for everyone?
◦ How can an HCBS program support community integration, foster
friendships and connections, ensure self-determination, and encourage
independence?
Things to Think About
◦ If a person with a disability values the interactions they have with other
people with disabilities, how can those relationships be fostered in such a
way that it does not promote segregation?
◦ In fostering independence and integration, how does an HCBS program
maintain the flexibility to meet the desires of an individual?
◦ For example, if a person does not enjoy being social every day and would not
like to have supported volunteer activities out in the community, but would
prefer to quietly feed the ducks with other people in the park, how can a
program support that version of community integration?
Things to Think About
Where are HCBS provided now?
◦ Are Medicaid-funded HCBS services currently provided in excluded
institutional settings? Are they provided in settings presumed to be
institutional under the new regulations?
◦ For example, are there group homes owned by a provider that also has ICFI/IDs? Nursing homes? Are these group homes on the same property as the
institutional setting?
◦ Are there group homes owned/operated by the State on or adjacent to
institutions?
◦ Is HCBS provided in settings that have the effect of isolating individuals?
◦ Is the setting designed specifically for people with disabilities, and often even
for people with a certain type of disability?
Things to Think About
◦ Is the setting primarily or exclusively people with disabilities and onsite staff provides many services to them?
◦ Are multiple types of services and activities on-site, including
housing, day services, medical, behavioral and therapeutic services,
and/or social and recreational activities?
◦ Do people in the setting have limited, if any interaction with the
broader community?
◦ Do the settings use/authorize interventions/restrictions that are
used in institutional settings or are deemed unacceptable in
Medicaid institutional settings (e.g., seclusion)
Things to Think About
◦ What needs to change in the current person-centered planning
process to be compliant with the regulations and to foster
community integration, self-determination, and
independence? This would include changes to the role of the
individual representative.
The above questions are a starting point for the broader discussion. Once there is an
understanding about what an HCBS program should look like, with some understanding of
what is possible, the next step is identifying which aspects of the current program need to
change.
NHeLP | National Health Law Program | August 28, 2014
Intention of the Rule
◦ Support people with disabilities to have lives like people
without disabilities
◦ Provide opportunities for true integration, independence,
choice and self-determination in all aspects of life – where
people live, how they spend their days, and real community
membership
◦ Ensure quality services that meet people’s needs and help
them achieve goals they have identified through real personcentered planning
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Additional Resources
CMS Home and Community Based Services Rule and
Fact Sheets
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-TermServices-and-Supports/Home-and-Community-Based-Services/Home-and-CommunityBased-Services.html
For More Information:
Christine Pisani
Executive Director
Idaho Council on Developmental Disabilities
E-mail: Christine.Pisani@icdd.Idaho.gov
Phone: 208-334-2178
Toll Free: 1-800-544-2433
Website: icdd.idaho.gov