Background
A March 2025 report from the Medicaid and CHIP Cost and Entry Fee (MACPAC) highlights methods to facilitate immediate entry to dwelling and community-based companies (HCBS). In chapter 2, the MACPAC report contains discussions of presumptive eligibility, expedited eligibility, and provisional service plans. Every of those methods can be utilized productively — oftentimes in conjunction. This useful resource focuses on the usage of provisional service plans.
Entry to Medicaid dwelling and community-based companies (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 companies (comparable to help with dressing, bathing, and making ready meals). They would like to obtain wanted companies at dwelling, 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 amenities unnecessarily, in opposition to particular person preferences and with larger 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 fundamental HCBS required by the individual, 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.
MACPAC 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.
See under for a template memorandum, a listing of sources, and a question-and-answer doc. The template memorandum may be tailored to be used in your state to assist advocacy for provisional service plans. The useful resource info, together with the Q & As, may 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 as a way to meet your wants. It’s possible you’ll particularly wish to add state-specific info to extra exactly tackle your state’s system of long-term companies and helps.
We encourage you to contact Justice in Growing old 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 dwelling?
No. The issue might also happen in residential amenities which may settle for HCBS funding (comparable to, in most states, assisted residing amenities). In these amenities, 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 all the way down to Medicaid eligibility ranges) and the date on which HCBS protection begins.
This downside is discovered nationwide in virtually all HCBS applications, despite the fact that CMS has solely cited the HCBS waiver regulation (i.e., regulation governing 1915(c) waivers) for a statutory requirement that service plan approval precede the efficient day of HCBS protection.
For example, take into account 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 typically are designed and carried out to make protection efficient solely after a complete service plan is in place.
A state might tackle 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 possible can remedy 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 may 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. Because of this, a supplier runs a danger by offering companies whereas Medicaid eligibility is pending.
If monetary eligibility in the end is granted for non-HCBS companies, all is effectively — the Medicaid program will pay retroactively. But when eligibility is denied, the supplier receives no Medicaid fee for companies already supplied.
Presumptive eligibility can remove the monetary danger to the supplier. Underneath presumptive eligibility, the Medicaid program grants eligibility instantly and reimburses suppliers whereas the applying is pending. If Medicaid in the end denies the applying, that denial might be prospective-only, and won’t have an effect on funds for the companies lined beneath presumptive eligibility.
Presumptive eligibility can be utilized along with provisional service plans to expedite HCBS protection. The HCBS protection might start virtually instantly, despite the fact 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 accessible 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 in opposition to enrollee caps and waitlists is a vital aspect of HCBS advocacy, along with urging use of provisional service plans and presumptive eligibility.
Assets
Notice that these sources use completely different phrases to confer with what the memorandum 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 Cost 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 “non permanent interim service plan”)
- Particular person-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 america Code, also referred to as 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 answer your state’s state of affairs and your group’s advocacy priorities. Edit the highlighted and bracketed textual content and embrace further examples of conditions and boundaries your purchasers face to indicate 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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Obtain as Phrase (.docx)
The Downside: State Medicaid Coverage Is Forcing Older Adults to Obtain Wanted Care in Nursing Amenities Fairly than at Dwelling
It’s a typical state of affairs. Somebody suffers a medical setback (a damaged hip or stroke, for instance) and now wants persevering with help with day by day actions comparable to dressing, bathing or consuming. Or, alternatively, they need assistance because of a persistent situation comparable to dementia. In all these conditions, sadly, [your state]’s Medicaid program usually forces them to obtain the required help in a nursing facility as an alternative of at dwelling.
A important difficulty is the distinction within the Medicaid efficient date between dwelling and community-based companies (HCBS) and nursing facility companies. For HCBS, Medicaid fee can not develop into efficient till a service plan is permitted, which can take weeks or months. Alternatively, Medicaid fee to a nursing facility may be efficient beginning on the individual’s first day within the facility, even when Medicaid protection isn’t permitted till weeks and even months later. In different phrases, Medicaid nursing facility fee may be retroactive again to the primary day of companies. The identical will not be true for HCBS.
What does this imply as a sensible matter? A nursing facility might be keen to confess the individual instantly, realizing that the power finally will obtain fee for care supplied, ranging from the individual’s first day within the facility. An HCBS supplier, nevertheless, will NOT be keen to supply companies instantly, as a result of they by no means might be paid for the preliminary days or perhaps weeks of service. So, because of this coverage discrepancy, the individual is pressured to maneuver to the nursing facility as a way to obtain essential care.
The present state of affairs is a lose-lose. The individual needing care is pressured right into a nursing facility, somewhat than having the ability to obtain essential help at dwelling. And the state unnecessarily pays the considerably larger value of a nursing facility.
A Coverage Resolution: State Medicaid Program Makes use of Provisional Service Plans
Creating a full HCBS service plan takes time. Underneath HCBS laws, the plan have to be person-centered, and the planning course of should embrace varied steps to facilitate that person-centeredness.
However the federal Facilities for Medicare & Medicaid Companies (CMS) permits states to make use of provisional service plans to start out fee expeditiously. CMS steering states that these provisional plans “identif[y] the important Medicaid companies that might be supplied within the individual’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 Cost and Entry Fee (MACPAC) reveals that 24 states use provisional service plans, throughout 59 separate HCBS waiver applications. MACPAC recommends higher use of provisional service plans as a way to cut back boundaries 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’ll be capable of use a provisional service plan to provoke immediate care at dwelling (or one other HCBS setting), somewhat than be pressured into undesirable and unduly costly nursing facility care.
