Provisional Service Plans Can Be Used to Begin Medicaid HCBS Protection Instantly
Entry to Medicaid house and community-based providers (HCBS) is often restricted by federal Medicaid coverage that requires {that a} service plan be accomplished earlier than HCBS protection begins. Assume, for instance, that an individual breaks a hip and, after a brief hospitalization, wants day by day long-term providers (resembling help with dressing, bathing, and getting ready meals). They would like to obtain wanted providers at house, however an HCBS service plan can’t be finalized for a number of weeks or months, whereas Medicaid nursing facility protection can begin instantly. This coverage discrepancy tends to drive individuals into nursing services unnecessarily, towards particular person preferences and with greater prices.
An underutilized resolution for this difficulty is a provisional service plan, as initially described within the federal authorities’s Olmstead Letter No. 3, Attachment 3-a (2000). A provisional service plan units forth the essential HCBS required by the particular person, permitting Medicaid HCBS protection to start instantly. The provisional plan stays in impact for 60 days or till finalization of a complete person-centered service plan, whichever happens first.
A March 2025 report from the Medicaid and CHIP Fee and Entry Fee (MACPAC) (see ch. 2) discovered that 24 states use provisional plans of care, throughout 59 separate HCBS waiver applications. To extend use of provisional plans of care, MACPAC recommends that the federal authorities difficulty steering to states on related coverage and operational concerns.
States and state advocates, after all, do not need to attend for federal steering. See under for a template memorandum, an inventory of sources, and a question-and-answer doc. The template memorandum could be tailored to be used in your state to assist advocacy for provisional service plans. The useful resource data, together with the Q & As, could be included with the memorandum or not, at your discretion.
Be at liberty to make use of any a part of these supplies and to delete, add and edit as you select in an effort to meet your wants. It’s possible you’ll particularly need to add state-specific data to extra exactly handle your state’s system of long-term providers and helps.
We encourage you to contact Justice in Getting older to tell us of any advocacy in your state on these points. Working collectively we will improve HCBS entry and remove the institutional bias that too often incentivizes nursing facility care over HCBS.
Questions and Solutions
Is the issue restricted to people wanting to stay residing at house?
No. The issue can also happen in residential services which may settle for HCBS funding (resembling, in most states, assisted residing services). In these services, a protection delay may end up in the resident being unable to pay the power for the weeks or months between the HCBS software date (when the resident has spent right down to Medicaid eligibility ranges) and the date on which HCBS protection begins.
This downside is discovered nationwide in virtually all HCBS applications, regardless that CMS has solely cited the HCBS waiver legislation (i.e., legislation governing Part 1915(c) waivers) for a statutory requirement that service plan approval precede the efficient day of HCBS protection.
For example, think about Medicaid demonstration waivers (i.e., Part 1115 waivers). Nothing within the demonstration waiver statute units any particular necessities concerning service plans however, as a sensible matter, demonstration waivers usually are designed and carried out to make protection efficient solely after a complete service plan is in place.
A state may handle this downside by modifying the demonstration waiver coverage to permit for HCBS protection to be initiated ASAP by a fundamental service plan (whether or not referred to as “provisional” or one thing else), with continued protection being contingent upon a complete service plan being accomplished subsequently inside a specified time frame.
At root, it often doesn’t matter why a state is requiring complete service plans previous to the HCBS efficient date. Regardless of the motive, the state doubtless can clear up the issue by authorizing all HCBS protection to develop into efficient upon improvement of a fundamental service plan, with the great plan being developed subsequently.
Is a provisional service plan the identical factor as presumptive eligibility?
No, though each could be helpful in enhancing entry to HCBS, as mentioned within the March 2025 MACPAC report.
Some states use presumptive eligibility to deal with the delay in figuring out monetary eligibility for HCBS. As mentioned above, figuring out monetary eligibility routinely requires weeks and even months. Consequently, a supplier runs a threat by offering providers whereas Medicaid eligibility is pending.
If monetary eligibility finally is granted for non-HCBS providers, all is effectively — the Medicaid program will pay retroactively. But when eligibility is denied, the supplier receives no Medicaid fee for providers already offered.
Presumptive eligibility can remove the monetary threat to the supplier. Underneath presumptive eligibility, the Medicaid program grants eligibility instantly and reimburses suppliers whereas the applying is pending. If Medicaid finally denies the applying, that denial will likely be prospective-only, and won’t have an effect on funds for the providers lined underneath presumptive eligibility.
Presumptive eligibility can be utilized along with provisional service plans to expedite HCBS protection. The HCBS protection may start virtually instantly, regardless that the Medicaid eligibility willpower and complete service plan wouldn’t be finalized till weeks or months later.
Additional details about presumptive eligibility for HCBS is on the market within the 2025 MACPAC report (ch. 2) and a 2021 AARP difficulty temporary.
Are all HCBS software delays attributable to service plan necessities?
Is the “no HCBS fee with out in-place service plan” downside associated to HCBS waitlists?
HCBS wait lists are a separate downside. Some states have restricted HCBS slots for his or her 1915(c) waivers. In these states, HCBS candidates could have to attend months or years for his or her identify to rise to the highest of the waitlist. Arguing towards enrollee caps and waitlists is a crucial side of HCBS advocacy, along with urging use of provisional service plans and presumptive eligibility.
Assets
Observe that these sources use totally different phrases to confer with what this toolkit refers to as a “provisional service plan.”
- Olmstead Letter No. 3, Attachment 3-a (federal steering authorizing use of provisional service plans to provoke immediate protection of HCBS; makes use of the time period “provisional written plan of care”)
- Medicaid and CHIP Fee and Entry Fee (MACPAC), March 2025 Report back to Congress on Medicaid and CHIP, ch. 2 (March 2025)
- Technical Information for HCBS waivers (complete federal information on administrating HCBS waivers; see pages 194-95 for dialogue of “short-term interim service plan”)
- Individual-Centered Service Planning in HCBS: Necessities and Greatest Practices (CMS 2024 webinar slides, together with dialogue of “provisional written plan of care” on slide #18)
- Part 1396n(c) of Title 42 of the USA Code, also called Part 1915(c) of the Social Safety Act (authorizing statute for HCBS waivers; in line with CMS, requires that service plan be in place previous to first day of HCBS protection)
- Value v. Medicaid Director, 838 F. 3d 739 (6th Circuit 2016) (federal appellate case rejecting problem to CMS’s interpretation that HCBS fee can not start till service plan is in place)
- Part 441.301(c)(1), (2) of Title 42 of the Code of Federal Laws (federal necessities for complete service planning in HCBS waivers)
Template Letter
Directions: Obtain and customise this letter to reply to your state’s scenario and your group’s advocacy priorities. Edit the highlighted and bracketed textual content and embrace further examples of conditions and limitations your shoppers face to point out why it’s important your state use provisional service plans to deal with the present downside, in order that individuals needing private care help on quick discover could make a good selection between nursing facility care and HCBS.
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The Drawback: State Medicaid Coverage Is Forcing Older Adults to Obtain Wanted Care in Nursing Services Moderately than at Dwelling
It’s a typical scenario. Somebody suffers a medical setback (a damaged hip or stroke, for instance) and now wants persevering with help with day by day actions resembling dressing, bathing or consuming. Or, alternatively, they need assistance because of a persistent situation resembling dementia. In all these conditions, sadly, [your state]’s Medicaid program usually forces them to obtain the mandatory help in a nursing facility as a substitute of at house.
A important difficulty is the distinction within the Medicaid efficient date between house and community-based providers (HCBS) and nursing facility providers. For HCBS, Medicaid fee can not develop into efficient till a service plan is authorised, which can take weeks or months. Then again, Medicaid fee to a nursing facility could be efficient beginning on the particular person’s first day within the facility, even when Medicaid protection isn’t authorised till weeks and even months later. In different phrases, Medicaid nursing facility fee could be retroactive again to the primary day of providers. The identical is just not true for HCBS.
What does this imply as a sensible matter? A nursing facility will likely be keen to confess the particular person instantly, figuring out that the power ultimately will obtain fee for care offered, ranging from the particular person’s first day within the facility. An HCBS supplier, nevertheless, will NOT be keen to offer providers instantly, as a result of they by no means will likely be paid for the preliminary days or even weeks of service. So, on account of this coverage discrepancy, the particular person is compelled to maneuver to the nursing facility in an effort to obtain obligatory care.
The present scenario is a lose-lose. The particular person needing care is compelled right into a nursing facility, reasonably than having the ability to obtain obligatory help at house. And the state unnecessarily pays the considerably greater value of a nursing facility.
A Coverage Answer: State Medicaid Program Makes use of Provisional Service Plans
Growing a full HCBS service plan takes time. Underneath HCBS rules, the plan have to be person-centered, and the planning course of should embrace numerous steps to facilitate that person-centeredness.
However the federal Facilities for Medicare & Medicaid Providers (CMS) permits states to make use of provisional service plans to begin fee expeditiously. CMS steering states that these provisional plans “identif[y] the important Medicaid providers that will likely be offered within the particular person’s first 60 days of waiver eligibility, whereas a fuller plan of care is being developed and carried out.” (Olmstead Letter No. 3, Attachment 3-a) A March 2025 report from the the Medicaid and CHIP Fee and Entry Fee (MACPAC) exhibits that 24 states use provisional service plans, throughout 59 separate HCBS waiver applications. MACPAC recommends higher use of provisional service plans in an effort to scale back limitations to make use of of HCBS. (See chapter 2 of the report.)
[YOUR STATE] can use provisional service plans to deal with the present downside, in order that individuals needing private care help on quick discover could make a good selection between nursing facility care and HCBS. If an individual prefers HCBS, they may be capable of use a provisional service plan to provoke immediate care at house (or one other HCBS setting), reasonably than be compelled into undesirable and unduly costly nursing facility care.
