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122 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERown supports. The Medicaid freedom of choiceprinciple extends only to “qualified” providers,however. And therein lies the source of limitationsand/or complications when seeking toimplement CD service programs. FederalMedicaid policy (whether under the Medicaidstate plan or through an HCBS waiver program)requires that a state spell out the qualificationsrequired of providers and agree to contract onlywith providers who meet such qualifications. 16These qualifications must be reasonable (i.e., mustrelate to provision of the service), and they alsomust comport with state law. Within these stipulations,states have considerable latitude in establishingthe qualifications required of providers ofhome and community services. The broader theserequirements, the more people will qualify to provideservices. Some states, however, limit provisionof personal care services to entities that arelicensed as “home care” or “home health agencies”or have been licensed to furnish communitydevelopmental disability services. This means, inturn, that individuals who provide home andcommunity services and supports must beemployees of such provider organizations. Whenprovider qualifications are expressed in this fashion,they can pose barriers to promoting CD services.Some of these barriers arise from provisionsof state Nurse Practice Acts, which frequently dictatethat even non-health care related personalassistance be provided under the supervision of anurse (and, not atypically, a nurse who him- orherself must be an employee of a licensed homecare or home health agency). 17 (This topic isaddressed in more detail below.)Thus, a central task for states interested in promotingCD services is a thorough assessment oftheir provider qualifications to determine whetherthey need to broaden the types of organizationsand individuals who may qualify as providers. Itis not necessary to limit providers to traditionalservice agencies. Provider qualifications may beexpressed solely with respect to the competenciesand skills individual workers must possess. Manytypes of Medicaid HCB services may be furnishedby friends, neighbors, and family members (otherthan spouses and parents of minor children). Invarious states (e.g., Kansas), families are encouragedto seek out individuals in their communitieswho can provide some types of HCB services forpeople with developmental disabilities.Consumer-directed models are choice-basedmodels. The problem often is that the choices aretoo few (there may be only one or two “qualifiedagencies” that serve the area where the individuallives). Revamping provider qualifications can bevital not only in promoting CD services but also inexpanding the potential sources of home andcommunity services for people with disabilitiesmore generally.Performance of Skilled Nursing TasksAlthough CD service models reject the medicalmodel, avoiding it can be complicated by statelaws and regulations concerning the performanceof “skilled nursing tasks.” Federal Medicaid policydoes not dictate who must perform skillednursing tasks, merely that such tasks be performedin compliance with applicable state laws.But state laws and regulations often dictate thatsuch tasks be performed by or closely supervisedby a licensed nurse—thereby creating obstacles toCD service models with a seeming bias in favor ofagency provision of services. Liability concernssometimes also stand in the way of promoting CDservice models.To avoid duplicating home health benefitsalready available through Medicare or under theMedicaid state plan, many HCBS waiver programsdo not offer skilled nursing or rehabilitativetherapies. However, “skilled” paraprofessionalservices still may be provided by personalcare attendants under HCBS waivers or under thepersonal care services optional state plan benefit—aslong as the services are provided in conformitywith the state’s Nurse Practice Act. A 1999HCFA State Medicaid Manual transmittal specificallystates:“Services such as those delegated by nursesor physicians to personal care attendantsmay be provided so long as the delegationis in keeping with state law or regulationand the services fit within the personalcare services benefit covered under astate’s plan. Services such as assistance