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120 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERplans). The importance of these HCFA guidelinesis that they clearly sanction the CD philosophythat has been in operation at the state level formany years—arrangements that also enable familymembers and other individuals to direct services(when the individual might not be able to do soby virtue of cognitive impairment, illness, oranother reason).While HCFA sanctions and supports CD models,Medicaid policy is still evolving to accommodatethe principles (and some of the operating features)of CD service models. CD models depart from traditionalMedicaid service delivery practices, featuringuse of alternative administrative mechanismsand altering program/provider/beneficiaryrelationships. The basic framework of existingMedicaid policy is the product of a much earlierera. As such, it did not anticipate service modelsin which the consumer exercises considerable control.HCFA is taking several steps to clarify andupdate its program guidelines to accommodateCD service models, and has been working withstates interested in offering CD services. FederalMedicaid policy poses certain issues with respectto the feasibility of operating some types of CDmodels (e.g., models based on “cashing out”Medicaid benefits). But it does not stand in oppositionto CD models.Several topics related to the interplay betweenMedicaid policy and CD services merit extendeddiscussion, because they are often a source ofuncertainty concerning the feasibility of furnishingMedicaid home and community services in afashion consistent and compatible with CD principles.These topics include (a) service planning andauthorization; (b) furnishing assistance to individualsin directing and managing their supports; (c)consumer choice and provider qualifications; and(d) performance of skilled nursing tasks. Each isdiscussed in turn.Service Planning and AuthorizationCD service models depart from professionallydirected service models by affirming that the individualplays a very active and decisive role inservice planning. Planning goals are identified incollaboration with the individual and specify indetail the services the person will receive. Whileperson-centered planning methods have beenassociated mainly with services for persons withdevelopmental disabilities, they are employed inhome and community services for individualswith other disabilities as well.With the exception of home health services,Medicaid policy does not dictate that home andcommunity service plans must be prepared bymedical, clinical, or case management professionals.Whether for HCB waiver services authorizedin a plan of care or personal care/personal assistanceservices under the optional state plan benefit,states have considerable latitude with regardto empowering the individual to manage anddirect authorized services. In personal assistanceservices, for example, many states already providethat individuals may directly schedule whenauthorized hours of services are to be furnishedand alter the schedule to meet their needs. In anHCBS waiver program, states also may permitthe individual to manage the schedule of serviceprovision or alter the mix of authorized servicesto meet their changing needs without having todevelop an entirely new plan of care. However,the statutory requirement that “services be providedpursuant to a written plan of care” mustcontinue to be met. Specific provisions includethe following:HCBS waiver program. Federal law requiresthat the services individualsreceive through an HCBS waiver programbe provided pursuant to a plan of care. 11Neither Federal law nor regulations specifythe process by which this plan of careis developed. The plan of care must meetthe requirements spelled out in the StateMedicaid Manual 12 and any other requirementsincluded in the state’s approvedHCBS waiver request. The plan of caremust also be consistent with the requirementthat the state assure the health andwelfare of the individual. 13 Personcenteredor other alternative planningprocesses that yield a plan of care thatmeets these fundamental requirementsare entirely acceptable with respect to theprovision of HCB waiver services.