V. Self-Directed Services and Individual Budgeting

Note: This section applies only to the Adult Waiver and Children's Support Waiver.

Self-Directed Services

Self-direction is available to all Children's Support Waiver participants, and to Adult Waiver participants who choose the Home-Based Support Services (HBS) option. Within established overall cost limits, these options are designed to give participants the opportunity to direct some or all of their services. Participants also have the option of receiving agency-directed services if they desire.

No more than three unrelated individuals with developmental disabilities may live in a single home. Homes will be located to promote inclusion of individuals in their neighborhoods and communities and to avoid concentrating individuals with disabilities in a single neighborhood or community.

The Adult Home-Based Support Services (HBS) option provides participant direction opportunities for participants who live in their families' homes or in homes the participants own or lease. The Children's Support Waiver supports participants in their families' homes.

All participants receive assistance in directing service delivery options from independent Individual Service and Support Advocates (ISSAs). Participants also receive assistance in paying domestic employees from a Fiscal Employer Agent.

Upon initiation of self-directed services, the Service Facilitator provides to the participant or guardian a manual that includes guidelines for selecting personal support workers, financial management services information, rights and responsibilities, and other Waiver requirements. The Service Facilitator and the ISSA assist the participant and guardian to understand the service options available under the Waiver, and review the information with participants at least annually as part of the service planning process. 

The Service Facilitator documents the participant's choice of the type of supports and providers as part of the individual service plan. See Section IV, Individual Service Plan, for additional information about service plans. The Service Facilitator assists the individual to complete Service Agreements with each provider selected to work with the individual and completes a Service Authorizations for domestic employees paid by a fiscal employer agent.

If at any time the participant or family voluntarily decides they no longer want to receive self-directed services, they can request agency-based services and supports. Typically, the individual must give 30-day advance written notice to the domestic employee; however, this is not mandatory. The participant then selects a community agency to provide and direct Waiver services. Such changes are discussed among those responsible for service planning and the Service Facilitator documents agreed upon changes in the service plan and Service Agreements and Service Authorizations. The Service Facilitator gives copies of the revised Service Authorizations to the Fiscal Employer Agent.

If an investigation determines that the participant, participant's guardian, or participant's family committed fraud regarding self-directed program funds, the participant or family may be involuntarily restricted from self-directed services by the Division. This determination by the Division is subject to appeal to the Medicaid Agency. The outcome of the appeal process is final. In this event, agency-based services are made available and documented in the service plan.

Please refer to Section III, Self-Directed Service Options, for additional information on Home-Based Support Services.

Individual Budgeting 

Upon being authorized for self-directed services, the participant, and family or guardian are informed in writing by the Division and in person by the ISSA about the overall cost limit, self-directed opportunities, including budget amount authority and employer authority. Once services have begun, the Division, the Service Facilitator and the ISSA keep the participant and guardian informed of any adjustments to the overall amount.

  • The monthly maximum budget for the Children's Support Waiver and Home-Based Support Services (HBS) option in the Adult Waiver is based on the service plan, but may not exceed the overall Waiver monthly and annual cost limit.
    • For the Children's Support Waiver and for adults in HBS who are still in school, the monthly maximum is two times the Supplemental Security Income (SSI) amount.
    • For participants in HBS who are no longer in school, the monthly maximum is three times the Supplemental Security Income (SSI) amount.
  • Excluded from the annual and monthly cost maximum calculations are Individual Service and Support Advocacy (ISSA) services, and tangible items such as accessibility modifications and adaptive equipment/assistive technology. These services and tangible items are subject to separate limits.
  • Participants, guardians, Service Facilitators, fiscal employer agent and ISSA staff receive a rate chart that contains information on the statewide rates and any utilization limits by service type. The State updates the rate chart periodically when rate adjustments are implemented, based on State appropriations.

The service plan specifies the types of and amounts of covered services needed by the participant within the overall cost limits. Statewide rates apply for some services. For other services, the participant is given the authority, with help from the local Service Facilitator, to negotiate individual rates.

Limits in spending are in place based on the monthly budget, and participants are encouraged by members of the service planning team to allocate authorized services throughout the year to avoid premature depletion of program funds.

A written Service Agreement is executed between the participant, the local Service Facilitator and each service provider. For domestic employees, a Service Authorization is also completed and sent to the fiscal employer agent.

The Service Authorization is signed by the employer of record (the participant, guardian, or employer representative) and the Service Facilitator. The Service Agreement/Authorization defines the terms of the services to be provided including the effective date, the rate of payment, the maximum units of service to be provided each month and the maximum monthly charge.

All services provided must be for the direct benefit of the individual.

Service Facilitators assist participants and guardians to ensure that all services and service changes are within the monthly budget. Any adjustments must be within the participant's overall monthly and annual service cost limit, and are allowed without prior approval by the State. Service Facilitators must share changes in Service Agreements/Service Authorizations with the Fiscal Employer Agent and ISSA for monitoring purposes.