CMS Regulations

The Centers for Medicare and Medicaid Services (CMS) published Home and Community Based Services (HCBS) Regulations on January 16, 2014. These regulations became effective on March 17, 2014 and impact all 1915c HCBS Waivers. In Illinois, this includes all three of the Developmental Disability HCBS Medicaid Waivers: Children's In Home Support Waiver, Children's Residential Waiver, and the Adult Waiver. The Regulations address three broad areas: Conflict of Interest Free Case Management, Person Centered Planning and Settings. These regulations apply to people who are in any of the Medicaid Waiver programs listed above.

Conflict of Interest Free Case Management specifies that States are required to separate case management functions (including the person centered plan development) from service delivery functions. Case management includes: determination of eligibility, provider identification, service plan development, and monitoring of Plan. "Conflict free" means that Case Management must be performed by someone other than a relative of the person served, someone other than a direct provider of service, someone who does not have a financial interest in a provider, or someone who is not employed by a provider.

In Illinois, the Independent Service Coordination agencies will serve as the Conflict of Interest Free Case Management entity. Effective July 1, 2017, the ISC agencies will be responsible for ensuring the implementation of the Person Centered Planning process. They will also continue to serve as the local source for information, help families "navigate" the system, and serve as the front person for addressing problems related to outcomes and quality.

The Person Centered Planning can be described as the balance between what is important to a person and what is important for a person. It is a way to identify strengths, preferences, needs (both clinical and support needs) and desired outcomes of a person. Person Centered Planning:

  • Must be driven by the person
  • Ensure services are delivered in a manner that reflects personal preferences and choices
  • Must include evidence that setting is chosen by the individual
  • Assist to achieve personally defined outcomes in the most integrated setting
  • Contributes to the assurance of health and welfare of the person receiving services
  • Must include opportunities to seek employment and work in competitive integrated settings
  • Must include opportunities to engage in community life, control personal resources, and receive services in the community to same degree of access as those not receiving Medicaid Home and Community Based Services.
  • Includes risk factors and measures to minimize risk
  • Should be written in plain language that can be understood by the person who receives services and their guardian
  • Reflects cultural considerations
  • Include strategies for solving disagreements

Person Centered Planning includes 3 main components:

  1. Discovery Tool
  2. Personal Plan
  3. Implementation Strategies

Discovery is one component of Person Centered Planning. The Discovery process is designed to gather information in order to capture what is important to the person and what is important for the person. The Independent Service Coordination (ISC) agencies will be responsible for facilitating the Discovery process and documenting what they gather in the Discovery Tool. The Discovery process is not a one-time event, but a series of information gathering. The ISC will gather information through discussions (face to face, phone, and electronic), observations, and record reviews (evaluations, assessments, case notes). This process should begin with the individual and then include the guardian, advocate or family, and others chosen by the individual. It should also include current providers and other caregivers. The information captured during this process is used to develop the Personal Plan which summarizes key and critical areas of the person's life.

The Personal Plan is the single, integrated personal vision for a person's life. It focuses on the individual's strengths, preferences, needs and desires. The Independent Service Coordination (ISC) agencies will be responsible for developing the Personal Plan in conjunction with the individual, guardian, family, and providers. The Personal Plan will not only contain the outcomes that the person requires in their life, but also document choices of qualified providers, reflect what is important to the person regarding delivery of services in a manner which ensures both personal preferences and health and welfare, include risk factors and plans to minimize them.

The Implementation Strategies are developed by provider agencies. Provider agencies are accountable for providing services and supports that will assist the person to pursue the outcomes identified in the Personal Plan. The Implementation Strategy describes how the provider agencies will support the person to achieve his/her desires and needs. The Strategies will be evaluated to assure consistency between the stated desires and provider-directed activities/support.