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HCBS Transition Plans: Update on Select Plans

August 30, 2016

During the months of July and August, the states of Missouri, Massachusetts, and Arkansas released revised versions of their home and community-based services (HCBS) Transition Plans and posted them for public comment. The state of Delaware was granted initial approval of its HCBS Transition Plan by CMS.

Massachusetts HCBS Transition Plan

Massachusetts’ HCBS Transition Plan was posted in July 2016 and its public comment period ended on August 10, 2016.

Massachusetts’ Transition Plan based its revisions to employment services on its “Blueprint for Success: Employing Individuals with Intellectual Disabilities in Massachusetts” program. Issued in November 2013, the blueprint proposes that the state close sheltered workshops by halting new referrals to them and transitioning the individuals in these settings into competitive integrated employment. The Transition Plan proposes significant revisions to Massachusetts’ community-based day services (CBDS). Most of these changes were focused on quality control and assurance, to ensure that CBDS providers create “meaningful daily activities” for their beneficiaries.

Massachusetts’ Department of Developmental Disabilities Services (DDS), in its self- assessment of CBDS services, conducted a survey to gather data on 98 CBDS providers. The results of this provider survey will be used to make significant changes with regards to the development of clear standards for CBDS programs, including the definition of “meaningful daily activities,” the development of training manuals and technical assistance, and the incorporation of qualitative and quantitative measures into DDS’ licensure and certification process for CBDS providers. Providers of day and employment services receiving HCBS funds under waivers from the Massachusetts Rehabilitation Commission (MRC) are now subject to stringent ongoing licensure and certification procedures to ensure that the services they provide truly adhere to the CMS Final Rules.

Missouri HCBS Transition Plan

The Missouri Transition Plan was posted on July 29, 2016 with a request for comments using the instructions on the Missouri notice.

The Missouri Transition Plan aligns its provider self-assessments with CMS guidance by categorizing settings that provide employment, health care, and residential services in the same location as presumptively isolating. These settings are rejected unless Missouri determines that they might overcome this presumption and unless CMS agrees with that determination through its heightened scrutiny review process. Missouri revised many of its employment-related service definitions for its Comprehensive and Community Support Waivers. For example, in Missouri’s Comprehensive Waiver, the service “Community Employment” was renamed “Supported Employment Services” to better align with the CMS definition. The language pertaining to Supported Employment was strengthened by aligning it with the CMS HCBS Settings Rule and by making it more individualized. Missouri defines both Group Supported Employment from Individual Supported Employment in its waivers, but treats them as sub-classifications of the same service, “Supported Employment.”

Arkansas HCBS Transition Plan

Arkansas’ Revised HCBS Transition Plan was posted on August 17, 2016. It is available for public comment through September 15, 2016.

The Arkansas HCBS Transition Plan includes a clear timeline for transitioning all HCBS, including state policies associated with home and community-based employment services, into full compliance with CMS Final Rules. The state intends to modify its provider certification standards and Waiver Manuals to maximize competitive integrated employment by rewriting these standards to incorporate the U.S. Department of Labor’s supported employment definition, as developed by the Employment First State Leadership Mentoring Program. The state generally found that its HCBS Waivers had policies, manuals, and statutory language that were partially, but not fully, compliant with CMS’ Final Rules regarding employment and community integration. The state plans to complete remediation for most waivers by 2017.

Delaware HCBS Transition Plan

On July 14, 2016, the state of Delaware was granted initial approval of its HCBS Transition Plan by CMS. CMS’ letter confirming initial approval states that Delaware completed its systemic assessment of all settings, identified remediation strategies to address the issues uncovered by its systemic assessment, and is working to implement these strategies. CMS reiterated the need for Delaware to address several concerns it had in order to receive final approval. First, CMS stated that Delaware must ensure that beneficiaries are provided with the ability to choose non-disability-specific settings as well as disability-specific settings for services across all home and community-based services the state provides. This includes non-residential employment settings. Second, CMS noted that all services that cluster participants for the purposes of receiving HCBS must be assessed by the state for compliance. CMS specifically mentions prevocational services, group supported employment services, and group day habilitation services as examples. Third, CMS clarified again that reverse integration practices are not enough by themselves for a setting to comply with CMS’ community integration requirements.

The state of Delaware administers two employment-related HCBS waiver programs designed to be compliant with CMS’ Final Rules: The Pathways program and the PROMISE program. Pathways is a waiver program for individuals with disabilities aged 14-25 who want to work that provides them with employment services that help them achieve their goals. PROMISE provides behavioral health services and other supports to individuals with substance abuse and mental health disorders who need these services to remain in the community. Delaware’s Transition Plan also lists specific home and community-based services (and the service definitions for each service) provided by its Department of Developmental Disability Services and Diamond State Health Plan that its compliance reviews and remediation will bring into full compliance with the Final Rules. This list specifically includes prevocational, day habilitation, and supported employment services.

For more information, read the Delaware HCBS Transition Plan.