The landscape of healthcare is continuously evolving, and with it, the ways in which individuals receive care. One such evolution within Medicaid is the rise of consumer directed care programs, also known as self-directed services. This model empowers Medicaid participants, or their designated representatives, to take greater control over their care and support services. Instead of relying solely on traditional agency-managed services, consumer direction offers a pathway to personalize care based on individual needs and preferences.
At its core, the Medicaid Consumer Directed Care Program is designed to provide an alternative to conventional service delivery models. It shifts decision-making authority to the participant, allowing them to actively manage their services with the assistance of a robust support system. This approach is rooted in person-centered planning, ensuring that the individual’s unique needs, goals, and choices are at the forefront of their care plan.
Self-direction in Medicaid promotes personal choice and control over various aspects of care delivery. This includes crucial decisions such as selecting who provides the services and how these services are delivered. A key component of this program is the concept of “employer authority,” as defined by the Centers for Medicare & Medicaid Services (CMS). This authority grants participants the power to recruit, hire, train, and supervise the individuals who provide their direct care. Furthermore, participants may also exercise “budget authority,” allowing them to have a say in how Medicaid funds allocated for their care are spent, within a defined budget and service plan.
Exploring Self-Direction Options within Medicaid
States have multiple avenues within their Medicaid programs to offer enrollees the option to self-direct their services. These options can be implemented under state plans and waivers, providing flexibility in how consumer directed care is structured and delivered. Understanding these options is the first step in accessing the benefits of a Medicaid consumer directed care program.
Key Guidelines of Self-Directed Medicaid Services
While specific guidelines may vary across different Medicaid funding authorities and state programs, there are common characteristics that underpin all Medicaid consumer directed care programs:
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Person-Centered Planning Process: CMS mandates a person-centered planning process as the foundation for self-directed care. This process is driven by the individual, with support from chosen representatives. It focuses on identifying the individual’s strengths, preferences, needs, and desired outcomes. The planning process can include individuals chosen by the participant who can contribute to the development of the care plan. Crucially, this process includes contingency planning, addressing scenarios where a service is unavailable, such as a worker being ill. This “back-up” plan is integrated into the individual’s person-centered plan. Risk assessment and mitigation strategies are also essential components of this planning phase.
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Service Plan: The service plan is a formal, written document outlining the specific services and supports tailored to meet the individual’s preferences, abilities, and needs. It serves as a roadmap for how the individual will direct their services and supports while remaining in their community. This plan is a direct output of the person-centered planning process and is crucial for accessing and managing Medicaid consumer directed care program benefits.
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Individualized Budget: An individualized budget is a defined amount of Medicaid funds that the participant can control and direct. This budget is developed through the person-centered planning process and is customized based on the individual’s needs and preferences as detailed in the service plan. States are required to have a clear methodology for calculating budget amounts based on reliable cost data and service utilization. They must also have procedures for adjusting budgets when service plans change and for evaluating participant expenditures to ensure appropriate use of funds within the consumer directed care program.
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Information and Assistance for Self-Direction: States are obligated to provide a comprehensive system of supports to assist individuals in navigating self-direction. This support system should be responsive to individual needs and provide guidance in developing service and budget plans, managing services and workers, and fulfilling employer responsibilities. Examples of these support services include: detailed information about how the Medicaid consumer directed care program works, clarification of individual rights and responsibilities, access to available resources, counseling services, training programs, support brokers or consultants, and financial management services (FMS). The level and frequency of support utilization are tailored to each individual’s unique circumstances and preferences within the consumer directed care program.
The Role of Support Guidelines in Consumer Directed Care
A vital component of Medicaid consumer directed care programs is the availability of a supports broker, consultant, or counselor. This professional acts as a guide and resource for individuals electing self-direction. The support broker assists the individual in directing their services, acts as a liaison between the participant and the program, and provides support in identifying personnel needs, accessing resources, and ensuring the individual can effectively manage their self-directed care. Critically, the support broker acts as an agent of the individual and takes direction from them, reinforcing the person-centered approach of the consumer directed care program.
Financial Management Services (FMS) and Budget Authority
Financial Management Services (FMS) are essential for individuals exercising budget authority within a Medicaid consumer directed care program. While participants can manage some or all FMS functions themselves, most prefer to utilize an FMS entity for assistance. FMS provides crucial support in several key areas:
- Understanding billing processes and documentation requirements for the consumer directed care program.
- Performing payroll and employer-related tasks, including tax withholding (federal, state, local, unemployment), workers’ compensation or insurance procurement, timesheet management, benefits administration, and payroll check issuance.
- Facilitating the purchase of approved goods and services within the individual’s budget.
- Tracking and monitoring budget expenditures to ensure fiscal responsibility within the consumer directed care program.
- Identifying budget overruns or underruns to facilitate budget adjustments and effective financial management.
Quality assurance and continuous improvement are integral to every state Medicaid agency (SMA) operating a consumer directed care program. SMAs are required to maintain a system of ongoing quality assurance that includes discovery, remediation, and quality improvement activities. This system ensures that the state identifies critical incidents or events affecting individuals, addresses shortcomings in service delivery, and seeks opportunities for system-wide improvements. The SMA is also responsible for monitoring system performance and individual outcome measures. It is important to note that specific quality requirements may vary depending on the funding authority and state regulations within the consumer directed care program.
A Brief History of Self-Direction in Medicaid
The movement towards self-direction in Medicaid began in the 1990s, with many states initiating “consumer-directed” personal care services under section 1905(a)(24) of the Social Security Act, which pertains to optional state plan personal care services. The Robert Wood Johnson Foundation played a significant role in fostering this movement by funding “Self-Determination” programs in 19 states during the mid-1990s. Self-direction of Medicaid services was a central tenet of these self-determination initiatives. These projects largely evolved into Medicaid-funded programs under section 1915(c) of the Act, the home and community-based services waiver program, a key pathway for consumer directed care.
In the late 1990s, the Robert Wood Johnson Foundation further supported the development of the “Cash and Counseling” (C&C) national demonstration and evaluation project in three states. These projects transitioned into demonstration programs under section 1115 authority of the Act. The Deficit Reduction Act (DRA) of 2005 expanded the avenues for states to offer self-direction, authorizing sections 1915(i) and 1915(j) of the Act. Most recently, in 2010, the Affordable Care Act, through section 1915(k) of the Act, provided further authorization for states to offer Medicaid consumer directed care services, solidifying its place as a significant option within Medicaid service delivery.
By understanding the principles, guidelines, and history of Medicaid consumer directed care programs, individuals can better navigate their options and advocate for a system that truly puts them at the center of their care.
