HCBS Plan of Care: How to Create a Well-Crafted Plan

11 Jan 2022
Discover the impact of a well-crafted HCBS plan of care and unlock the power of coordinated healthcare.

Understanding HCBS Programs

The Home- and Community-Based Services (HCBS) programs play an invaluable role in providing person-centered care for individuals requiring assistance with daily activities due to functional limitations. These programs aim to foster independence by offering care within the comfort of the patient's home and community.

Overview of HCBS

HCBS encompasses a wide range of services designed to meet the unique needs of individuals with functional limitations. These services address both health and human services, meeting medical needs while also supporting daily living [1]. The primary goal of HCBS is to empower individuals to maintain their independence by receiving care at home, rather than being relocated to care facilities.

According to Medicaid.gov, in 2014, 53% of all Medicaid long-term care spending was allocated to home and community-based services, totaling $80.6 billion. This demonstrates the significant commitment to providing care in the setting most comfortable for the patient.

Categories of HCBS

HCBS programs can be categorized into two main areas: health services and human services. Health services are designed to meet the medical needs of individuals, such as medical equipment, health monitoring, and medication management. On the other hand, human services support daily living activities, such as meal preparation, housekeeping, and personal care [1].

By offering a wide range of services, HCBS programs ensure that each individual's hcbs plan of care is tailored to their specific needs, promoting a higher quality of life and fostering independence within their own homes and communities.

Coordination of HCBS Care

The coordination of Home and Community-based Services (HCBS) care is a crucial component of the HCBS plan of care. This section will discuss the role of lead agencies in coordinating HCBS care, as well as the role of tribes in the provision of these services.

Lead Agencies in HCBS

Lead agencies within states are typically responsible for the coordination of HCBS care and services, often serving as primary care coordinators. These entities could include a county's department of human and social services. Service providers contract with these lead agencies to deliver HCBS care, ensuring that individuals have access to the necessary services within their homes and communities.

The role of these agencies is paramount in ensuring that the care delivered is not only adequate but also tailored to the specific needs of individuals. Through effective coordination, these agencies can enhance the quality of life for individuals in need of HCBS, promoting independence and community living.

Role of Tribes in HCBS

Beyond the coordination of care by lead agencies, tribes can also play a significant role in the provision of HCBS care. Tribes can apply with their state to become lead agencies, subject to state eligibility requirements. Tribes without lead agency status can contract with appropriate entities for service provision and care coordination.

For instance, the Oneida Nation became a lead agency for a state waiver to enhance access to Medicaid and state HCBS. This exemplifies how tribes can take a proactive role in the provision of care within their communities, ensuring that their members have access to the necessary services [1].

The involvement of tribes in the coordination and provision of HCBS care not only ensures that their members have access to necessary services but also promotes cultural competence in the delivery of care. This is an essential aspect of a well-crafted HCBS plan of care, as it ensures that the services provided are not only efficient but also culturally sensitive.

Funding for HCBS

Understanding the financial support available for Home and Community-Based Services (HCBS) is critical to implementing an effective HCBS plan of care. The funding for HCBS largely comes from state waivers and other sources, such as tribes and private long-term care insurance held by patients.

State Waivers for HCBS

HCBS programs are often funded by state waivers, which are part of a state's Medicaid program serving a specific group of individuals. This funding method enables states to design innovative and fiscally responsible long-term service programs. Medicaid now pays for a comprehensive range of home and community services that provide alternatives to unnecessary institutional care [2].

Medicaid coverage of home and community services has expanded significantly over time. In 1988, only 10% of Medicaid long-term care spending went towards home and community services. But, as of 1999, this figure had risen to 28%, underscoring the growing recognition of the value and benefits of HCBS [2].

Other Funding Sources for HCBS

Beyond state waivers, other funding sources for HCBS may include tribes or private long-term care insurance held by patients. The role of tribes in HCBS funding underscores the importance of intergovernmental cooperation in supporting home and community-based care. Meanwhile, private long-term care insurance serves as a crucial financial safety net for many individuals, enabling them to access necessary services while managing out-of-pocket costs.

While Medicaid and state waivers are significant sources of HCBS funding, these other sources play a critical role in ensuring that all individuals can access the care they need in their homes and communities. It's essential to explore all potential funding sources when creating a HCBS plan of care.

HCBS Services

Home and Community-Based Services (HCBS) offer a variety of care types to meet the diverse needs of individuals requiring long-term services and supports (LTSS). This section will focus on transitional care within HCBS and special HCBS programs.

Transitional Care in HCBS

Transitional care is a significant component of a well-rounded HCBS plan of care. It aims to maintain care quality during transitions between hospital or nursing home facilities and home or residential settings. The primary goal of transitional care is to ensure successful transfers and prevent gaps in care. This process includes a thorough review of the individual's health status, medication management, and follow-up care arrangements CMS.gov.

Transitional care is particularly beneficial to individuals who have recently been discharged from hospital or nursing home care and need assistance adapting to a home or community-based setting. By providing this crucial support, HCBS helps to improve health outcomes, reduce hospital readmissions, and enhance the individual's overall quality of life.

Special HCBS Programs

The HCBS model encompasses various programs designed to support specific types of care. These programs provide a valuable starting point for tribes beginning to provide LTSS in their communities or those lacking resources for facility-based care CMS.gov.

Among these special HCBS programs are the Program of All-Inclusive Care for the Elderly (PACE) and the Money Follows the Person (MFP) Rebalancing Demonstration Grant. PACE is a comprehensive service delivery system and integrated Medicare and Medicaid financing model that allows individuals aged 55 and over who are otherwise eligible for nursing home care to receive a comprehensive array of health and LTSS in a variety of settings. On the other hand, the MFP program assists states in rebalancing their LTSS systems to increase the use of HCBS while reducing the use of institutionally-based services.

These special programs provide a framework for the provision of HCBS and offer guidance and support to those implementing and managing HCBS in their communities. They play a vital role in ensuring that individuals receive the services and supports they need to live independently and enjoy a high quality of life.

Expansion of HCBS Coverage

To ensure the well-being of individuals who need long-term care, the coverage of Home and Community-Based Services (HCBS) has been significantly expanded over time. This expansion has been largely supported by Medicaid and the 1915(c) waiver program.

Medicaid Coverage of HCBS

Medicaid now pays for a comprehensive range of home and community services that provide alternatives to unnecessary institutional care. Many states have led the way in using Medicaid to design innovative and fiscally responsible long-term service programs. This has made it possible to create an effective HCBS plan of care for many individuals who require these services [2].

According to ASPE, Medicaid coverage of home and community services has expanded significantly over time. In 1988, only 10% of Medicaid long-term care spending went towards home and community services. However, by 1999, that number had risen to 28%. This increase in funding has made home and community services more accessible to those who need them.

1915(c) Waiver Program

The 1915(c) waiver program has also played a crucial role in expanding the coverage of HCBS. This program allows states to provide home and community services that are not typically covered by Medicaid, as long as they are required to prevent institutionalization. Services covered under the waiver program include case management, homemaker services, personal care, adult day health, habilitation, respite care, and more [2].

This waiver program has broadened the scope of services that can be included in an HCBS plan of care. It has also made it possible for more individuals to access these services, further reducing the need for institutional care.

The expansion of HCBS coverage through Medicaid and the 1915(c) waiver program has helped to ensure that individuals can access the care they need in their own homes and communities. These programs have made it possible for more individuals to benefit from a well-crafted HCBS plan of care, enhancing their quality of life and promoting their independence.

Personal Care Services in HCBS

Home and Community-Based Services (HCBS) encompass a variety of care options, including personal care services. These services are integral to helping individuals maintain their independence, dignity, and quality of life. In this section, we will delve into Medicaid coverage of personal care and the Katie Beckett provision.

Medicaid Coverage of Personal Care

Medicaid has covered personal care services since the mid-1970s, and states have the option to offer these services under their Medicaid state plans. The services provided can include assistance with activities of daily living (ADLs), such as bathing, dressing, eating, and mobility, as well as instrumental activities of daily living (IADLs), like housekeeping, meal preparation, and medication management [2].

A well-structured HCBS plan of care ensures the provision of these services in a manner that aligns with the individual's needs, preferences, and goals. It's also important to note that the eligibility for these services, as well as the extent and type of services provided, varies by state.

Katie Beckett Provision

The Katie Beckett provision, named after a child whose parents petitioned for her to receive Medicaid services at home, has been a groundbreaking development in HCBS. This provision allows states to cover noninstitutionalized children with disabilities.

Before this provision, the income and resources of parents were automatically counted as available for medical expenses if the child lived at home. However, if the child was institutionalized, only the child's own income and resources were counted. This often resulted in families having to make the difficult decision of institutionalizing their child to qualify for Medicaid coverage.

With the implementation of the Katie Beckett provision, children with disabilities can now receive the care they need in the comfort and familiarity of their own homes. This has contributed significantly to the expansion and accessibility of HCBS, providing families with more choices and control over their child's care [2].

In conclusion, personal care services, supported by Medicaid and provisions like the Katie Beckett rule, play a crucial role in making HCBS a reality for many individuals. By understanding these elements, one can better navigate the HCBS landscape and make informed decisions about their care or the care of their loved ones.


[1]: https://www.cms.gov/training-education/partner-outreach-resources/american-indian-alaska-native/ltss-ta-center/information/ltss-models/home-and-community-based-services

[2]: https://aspe.hhs.gov/reports/understanding-medicaid-home-community-services-primer-0

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