June 6, 2014

TO: Heads of Operating Divisions 

Heads of Staff Divisions

SUBJECT: Section 2402(a) of the Affordable Care Act – Guidance for Implementing 

Standards for Person-Centered Planning and Self-Direction in Home and 

Community-Based Services Programs

Section 2402(a) of the Affordable Care Act requires the Secretary to ensure all states receiving 

federal funds develop service systems that are responsive to the needs and choices of 

beneficiaries receiving home and community-based long-term services (HCBS), maximize 

independence and self-direction, provide support coordination to assist with a communitysupported life, and achieve a more consistent and coordinated approach to the administration of 

policies and procedures across public programs providing HCBS. 

The attached guidance contains standards on person-centered planning and self-direction of 

HCBS that should be embedded in all HHS funded HCBS programs as appropriate. The 

guidance is consistent with the final rule from the Centers for Medicare & Medicaid Services on 

Medicaid HCBS and meets the requirement in section 2402(a) for a more consistent 

administration of policies and procedures across programs. This guidance is the Department’s 

first step in implementing section 2402(a). 

HHS agencies that administer HCBS programs are to apply these standards on person-centered 

planning and self-direction as you develop or revise regulations, policies and guidance, provide 

technical assistance, offer funding opportunities, or take other relevant actions. The agencies 

most directly affected by this guidance include: 

• Administration for Community Living 

• Centers for Medicare & Medicaid Services 

• Health Resources and Services Administration

• Indian Health Service

• Substance Abuse and Mental Health Services Administration

• Administration for Children and Families

If your agency is not listed above, you are encouraged to review this guidance and consider how 

the programs you administer, including your research and demonstration programs, could be 

used to promote the use and further enhancement of person-centered planning and self-direction. 

All HHS agencies are encouraged to share this guidance with relevant stakeholders, including 

funded agencies, contractors, advocacy groups, advisory councils, associations, and others who 

may have a role in the home and community-based system. 
The Secretary

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This guidance is not intended to supersede or otherwise conflict with existing regulations or 

guidance, nor does it provide a basis for enforceability on non-Departmental entities. 

Section 2402(a) does not prescribe a specific timeframe for achieving full implementation. 

However, it is expected the affected agencies will take active steps to implement this guidance. 

The Administration for Community Living will coordinate section 2402(a) activities within the 

Department as part of the work of the Community Living Council Strategic Plan. Sharon Lewis,

my Senior Advisor for Disability Policy and Principal Deputy Administrator for Community 

Living, will chair an interagency team to oversee the implementation of this guidance and future 

section 2402(a) activities. I am asking the Heads of the agencies listed above and other 

interested Operating Divisions and Staff Divisions to let Sharon know who you want to represent 

you on this group. This interagency team will develop annual work plans (including a roll-out 

plan of this guidance to stakeholders), share lessons learned and best practices, and report to the 

Secretary on an annual basis on the progress being made in implementing section 2402(a). For 

your reference, a list of the members of the June 2010 workgroup that contributed to the 

development of this guidance is enclosed.

For questions regarding this guidance, please contact Shawn Terrell, Administration for 

Community Living at (202) 357-3517 or shawn.terrell@acl.hhs.gov . 

Thank you for your support in implementing section 2402(a). 

Kathleen Sebelius

Enclosures:

• HCBS Section 2402(a) Guidance

• Roster of June 2010 Section 2402(a) Workgroup 
Guidance to HHS Agencies for Implementing 

Principles of Section 2402(a) of the Affordable 

Care Act:

Standards for Person-Centered Planning and 

Self-Direction in Home and Community-Based Services

Programs

Introduction

The Patient Protection and Affordable Care Act (Pub. L. 111–148, enacted on March 23, 2010), 

amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111–152, 

enacted on March 30, 2010), collectively referred to as the Affordable Care Act (ACA), includes 

section 2402(a), entitled “Oversight and Assessment of the Administration of Home and 

Community-Based Services.” This section requires promulgation of regulations by the Secretary 

of Health and Human Services (HHS) to ensure states develop community-based long-term 

services and supports (LTSS) systems designed to allocate resources and provide the necessary 

supports and coordination to be responsive to the person-centered needs and choices of older 

adults and people with disabilities in ways that maximize their independence and ability to 

engage in self-direction of their services, and achieve a more consistent and coordinated 

approach to the administration of policies and procedures across public programs. 

LTSS are assistance with activities of daily living and instrumental activities of daily living 

provided to older people and adults with disabilities that cannot perform these activities on 

their own due to a physical, cognitive, or chronic health condition. LTSS may provide care, case 

management, and service coordination to people who live in their own home, a residential 

setting, a nursing facility, or other institutional setting. LTSS also include supports provided to 

family members and other unpaid caregivers. LTSS may be provided in institutional and 

community settings. 

For purposes of this guidance, home and community-based services (HCBS) are services and 

supports that assist older adults and people with disabilities (including mental health and 

substance use disorders) to live with dignity and independence in community settings. HCBS 

complement medical and other traditional health services, and help people to maintain and 

improve health and quality of life in their chosen community setting. HCBS play an important 

role in healthcare integration efforts, including the evolution of health and medical homes, and 

care transitions. 

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This guidance is not intended to supersede or otherwise conflict with existing regulations or 

policies, or other guidance issued by HHS. Affected HHS operating and staff divisions are 

expected to take active steps to implement the guidance. HHS agencies should use it to 

develop or revise requirements and options, as appropriate, within programs that offer or 

impact policies related to HCBS. Specifically, the standards in this guidance should be used in 

future program regulations, program policies, funding opportunities, technical assistance 

contracts, grant opportunities, and other programs funding HCBS. The statute applies to all 

federal and state programs, including those “other than the state Medicaid program,” as cited 

in section 2402(a) of the ACA. HHS staff performing duties such as contract monitoring and 

grant administration must have the knowledge and capacity to report on the implementation of 

this guidance to the Secretary upon request. 

This initial guidance serves as an important first step in implementing section 2402(a) of the 

ACA. It outlines the standards for person-centered planning (PCP) and self-direction (SD) that 

should be reflected in all HHS programs that fund or provide HCBS.

Background

Over the past forty years federal, state, local, and tribal governments have developed and 

financed HCBS for older adults and people with disabilities across the lifespan to promote 

community living, and to avert or minimize institutionalization. 

The scope of HCBS offered under various federal and state programs is significant. For example, 

HCBS provided under Medicaid waiver and state plan authorities include programs authorized 

under section 1915(c) of the Social Security Act (the Act); newer programs under sections

1915(i), 1915(j) and the 1915(k) of the Act; and other HCBS that may be covered under the

Medicaid State Plan such as home health and personal care. HCBS may also be offered in a 

managed care environment through for example, concurrent section 1915(b) and (c) Medicaid 

waivers or section 1115 demonstration projects. HCBS are often included in initiatives and 

demonstrations to improve care for Medicare-Medicaid dually eligible beneficiaries. In 2014 the 

Centers for Medicare & Medicaid Services (CMS) issued a related final regulation on HCBS and 

related guidance that outlines requirements for PCP and SD. Medicaid State plan home health, 

personal care, case management, and many rehabilitative services benefits are HCBS.

HCBS are also offered through block grant programs administered by the Substance Abuse and 

Mental Health Services Administration and grants from other HHS operating divisions including 

the Administration for Community Living (ACL), the Health Resources and Services 

Administration, and the Indian Health Service. The ACL and CMS are presently working with the 

U.S. Department of Veterans Affairs to expand the availability of HCBS for veterans. There are 

also many programs offered by states, territories, and the District of Columbia that provide 

HCBS using non-federal payment sources, or combined resources. 

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The number of HCBS programs and wide variation in services, eligibility rules, delivery systems, 

payers, and associated regulatory authorities create significant challenges for states and 

programs that have day-to-day responsibility for implementation. This can result in 

administrative duplication; inconsistent policies; gaps in service adequacy; inconsistencies in 

plans of care; poor service quality; fraud, abuse, and mistakes; and other issues. 

The impact of these differences among HCBS policies and practices on the people who need 

HCBS is significant. Individuals, families, and caregivers are often faced with navigating a 

confusing maze of policies and bureaucracies, which can impede access. System framework

issues also contribute to fragmented services, duplicative efforts, people not receiving the 

services they need for which they are eligible, or individuals not having access to preferred

services such as self-directed HCBS that maximize choice, control, and satisfaction. 

This guidance will improve the efficient administration and consumer experience of programs 

at the state, federal, and community levels by aligning HCBS to standards for PCP and SD, and 

by enhancing the ability of HHS’s oversight of PCP and SD. 

Approach to Implementation and the Development of Standards 

In response to a 2010 request from the Secretary of HHS, the Office on Disability, now under 

the umbrella of the ACL, convened a workgroup on section 2402(a) implementation that 

included staff from the following agencies: 

• Administration on Aging (now an ACL component)

• Administration on Intellectual and Developmental Disabilities (now an ACL component )

• Assistant Secretary for Planning and Evaluation

• Centers for Medicare & Medicaid Services

• Health Resources and Services Administration

• Indian Health Service

• Office for Civil Rights

• Substance Abuse and Mental Health Services Administration

The workgroup met regularly over the course of two years as members considered a range of 

options and strategies for implementing section 2402(a) of the ACA. In addition to 

implementation strategies the workgroup discussed key focus areas including PCP, SD, 

workforce competency and adequacy, quality of life, and a definition for HCBS. The workgroup 

developed concept papers, conducted interviews with subject matter experts, and engaged in 

outreach to key stakeholders including advocacy groups, state associations, people with 

disabilities and older adults, providers, and other federal departments and agencies.

A consensus emerged among members of the workgroup that the initial focus of internal HHS 

guidance should be on two areas, PCP and SD, as a first step toward implementing important 

provisions of section 2402(a) of the ACA in a manner that supports consistent application and 

availability across state and federal programs. 

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Standards for Person-Centered Planning

Overview of Person-Centered Planning

Underpinning successful HCBS is the importance of a complete and inclusive PCP process that

addresses the person’s array of HCBS needs in the context of personal goals, preferences, 

community and family supports, financial resources, and other areas important to the person. 

The process should result in the provision of appropriate services consistent with the efficient 

use of available resources. 

To support the PCP process, some states are utilizing or developing a standardized

comprehensive functional assessment process to determine eligibility for various programs 

through a “no wrong door” approach. Functional assessments are related to the PCP process, 

and must be undertaken using a person-centered approach. The functional assessment and the 

PCP should be used as a basis for service authorization, utilization review, budgeting, measuring 

goals and improving outcomes, and other purposes. However, the PCP process often results in 

quality-of-life goals that exceed the ability of any set of program-specific services and supports 

to fully meet them. Therefore, the PCP process must not be limited by program specific 

functional assessments. One of the functions of the PCP process is to help the person and the 

support team to develop innovative and non-traditional ways to meet the goals in the plan. The 

goals must not be restricted due to a lack of easily identified services or supports. Several

initiatives in HHS support a standardized functional assessment process including the Balancing 

Incentive Program, (http://www.balancingincentiveprogram.org/), and the Aging and Disability 

Resource Centers (http://acl.gov/Programs/Integrated_Programs/ADRCs/Index.aspx). 

Definition of Person-Centered Planning

Person-centered planning is a process directed by the person with LTSS needs. It may include a 

representative who the person has freely chosen, and/or who is authorized to make personal or 

health decisions for the person. PCP should also include family members, legal guardians, 

friends, caregivers, and others the person or his/her representative wishes to include. PCP 

should involve the individuals receiving services and supports to the maximum extent possible,

even if the person has a legal representative. The PCP approach identifies the person’s 

strengths, goals, preferences, needs (medical and HCBS), and desired outcomes. The role of 

agency workers (e.g., options counselors, support brokers, social workers and others) in the 

PCP process is to enable and assist people to identify and access a unique mix of paid and 

unpaid services to meet their needs, and provide support during planning. The person’s goals

and preferences in areas such as recreation, transportation, friendships, therapies, home, 

employment, family relationships, and treatments are part of a written plan that is consistent 

with the person’s needs and desires. 

Preferences may include, for example, the following concepts related to the person’s 

experience and necessary supports:

• Family and friends

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• Housing

• Employment

• Community integration

• Behavioral health

• Culture

• Social activities

• Recreation

• Vocational training

• Relationships

• Language and health literacy

• Other community living choices

PCP assists the person to construct and articulate a vision for the future, consider various paths, 

engage in decision-making and problem solving, monitor progress, and make needed 

adjustments to goals and HCBS in a timely manner. It highlights individual responsibility 

including taking appropriate risks (e.g. back-up staff, emergency planning). It also helps the 

team working with the individual to know the person better. 

Person-Centered Planning Process

PCP must be implemented in a manner that supports the person, makes him or her central to

the process, and recognizes the person as the expert on goals and needs. In order for this to 

occur there are certain process elements, consistent with statutory or regulatory provisions. 

These include: 

1. The person or representative must have control over who is included in the planning 

process, as well as the authority to request meetings and revise the plan (and any 

related budget) whenever necessary. 

2. The process is timely and occurs at times and locations of convenience to the 

person, his/her representative, family members, and others. 

3. Necessary information and support is provided to ensure the person and/or

representative is central to the process, and understands the information. This

includes the provision of auxiliary aids and services when needed for effective 

communication. 

4. A strengths-based approach to identifying the positive attributes of the person must 

be used, including an assessment of the person’s strengths and needs. The person 

should be able to choose the specific PCP format or tool used for the PCP. 

5. Personal preferences must be used to develop goals, and to meet the person’s HCBS 

needs. 

6. The person’s cultural preferences must be acknowledged in the PCP process, and

policies/practices should be consistent with the HHS Office on Minority Health 

Standards National Standards on Culturally and Linguistically Appropriate Services 

(CLAS) http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.

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7. The PCP process must provide meaningful access to participants and/or their 

representatives with limited English proficiency (LEP), including low literacy 

materials and interpreters.

8. People under guardianship or other legal assignment of individual rights, or who are 

being considered as candidates for these arrangements, should have the 

opportunity in the PCP process to address any concerns. 

9. There must be mechanisms for solving conflict or disagreement within the process, 

including clear conflict of interest guidelines. 

10. People must be offered information on the full range of HCBS available to support 

achievement of personally identified goals.

11. The person or representative must be central in determining what available HCBS 

are appropriate and will be used.

12. The person must be able to choose between providers or provider entities -

including the option of SD services - when choice is available.

13. The PCP must be reviewed at least every twelve months or sooner, when the 

person’s functional needs change, circumstances change, quality of life goals 

change, or at the person’s request. There must be a clear process for individuals to

request updates. The accountable entity must respond to such requests in a timely 

manner that does not jeopardize the person’s health and safety.

14. PCP should not be constrained by any pre-conceived limits on the person’s ability to 

make choices.

15. Employment and housing in integrated settings must be explored, and planning 

should be consistent with the individual’s goals and preferences, including where

the individual resides, and who they live with. 

Elements of the Person-Centered Plan

The person-centered service plan must identify the services and supports that are necessary to 

meet the person’s identified needs, preferences, and quality of life goals. To the extent that 

PCPs are consistent with statutory and regulatory provisions, the PCP must have the following 

attributes: 

1. Reflect that the setting where the person resides is chosen by the individual. The 

chosen setting must be integrated in and support full access to the greater 

community, including opportunities to seek employment and work in competitive 

integrated settings, engage in community life, control personal resources, and 

receive services in the community to the same degree of access as individuals not 

receiving HCBS.

2. The plan must be prepared in person-first singular language and be understandable

by the person and/or representative. 

3. In order to be strengths-based, the positive attributes of the person must be 

considered and documented at the beginning of the plan. 

4. The plan must identify risks, while considering the person’s right to assume some 

degree of personal risk, and include measures available to reduce risks or identify 

alternate ways to achieve personal goals.

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5. Goals must be documented in the person’s and/or representative’s own words, with 

clarity regarding the amount, duration, and scope of HCBS that will be provided to 

assist the person. Goals will consider the quality of life concepts important to the 

person.

6. The plan must describe the services and supports that will be necessary and specify 

what HCBS are to be provided through various resources including natural supports,

to meet the goals in the PCP. 

7. The specific person or persons, and/or provider agency or other entity providing 

services and supports must be documented. 

8. The plan must assure the health and safety of the person.

9. Non-paid supports and items needed to achieve the goals must be documented. 

10. The plan must include the signatures of everyone with responsibility for its 

implementation including the person and/or representative, his or her case 

manager, the support broker/agent (where applicable), and a timeline for review. 

The plan should be discussed with family/friends/caregivers designated by the 

individual so that they fully understand it and their role(s).

11. Any effort to restrict the right of a person to realize preferences or goals must be 

justified by a specific and individualized assessed safety need and documented in the 

PCP. The following requirements must be documented in the PCP when a safety

need warrants such a restriction:

a. The specific and individualized assessed safety need.

b. The positive interventions and supports used prior to any modifications or 

additions to the PCP regarding safety needs.

c. Documentation of less intrusive methods of meeting the safety needs that 

have been tried, but were not successful.

d. A clear description of the condition that is directly proportionate to the 

specific assessed safety need.

e. A regular collection and review of data to measure the ongoing effectiveness 

of the safety modification.

f. Established time limits for periodic reviews to determine if the safety 

modification is still necessary or can be terminated.

g. Informed consent of the person to the proposed safety modification; and

h. An assurance that the modification itself will not cause harm to the person.

12. The plan must identify the person(s) and/or entity responsible for monitoring its 

implementation.

13. The plan must identify needed services, and prevent unnecessary or inappropriate

services and supports.

14. An emergency back-up plan must be documented that encompasses a range of 

circumstances (e.g. weather, housing, staff).

15. The plan must address elements of SD (e.g. fiscal intermediary, support 

broker/agent, alternative services) whenever a self-directed service delivery system 

is chosen.

16. All persons directly involved in the planning process must receive a copy of the plan

or portion of the plan, as determined by the participant or representative. 

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Person-Centered Planning Implementation

Implementing the person-centered plan requires monitoring progress to achieve identified 

goals, so that appropriate action is taken when necessary. This includes mechanisms to ensure

all HCBS - paid and unpaid - are delivered, that the plan is reviewed according to the 

established timeline; there is a feedback mechanism for the person or representative to report 

on progress, issues and problems; and that changes can be made in an expedient manner. 

People receiving HCBS must be fully involved in the process to update their service plans based 

on their needs and preferences on an ongoing and regular basis, no less often than annually,

based on the time the plan was created or last revisited.

Successful implementation for systems or accountable entities (e.g. state or local programs)

requires policy, mission/vision statements, and operations documents at the federal, state, 

local, and person-level (for self-direction) aligned to incorporate PCP standards, and that staff 

involved in the PCP process have a consistent understanding of the process and 

implementation. In order for PCP principles to be fully realized leadership, administrative, and 

other staff are strongly encouraged to receive competency-based training in PCP. A process for 

monitoring PCP should be implemented at the federal, state, and local levels and incorporated 

as an integral component of quality improvement activities across HCBS programs. 

For people using HCBS, this includes active engagement in the planning and service delivery 

process involving a number of support professionals. The person’s input informs the quality of 

services and supports when he/she takes an active role in the PCP process by:

• Providing accurate information for eligibility and service planning.

• Actively identifying and engaging providers, case managers, family members, friends, 

direct support workers, support brokers, medical professionals, and others.

• Approving and signing only a plan that is developed and accepted by everyone involved.

• Participating fully after the approved plan is implemented (e.g., appearing timely for 

meetings and appointments, reviewing the plan regularly).

• Providing regular feedback on the HCBS provided. 

Standards for Self-Direction

Overview of Self-Direction

Section 2402(a) of the ACA emphasizes the importance of allocating resources to enable people 

to maximize their independence including by employing LTSS providers directly, designing an 

individualized, self-directed, community supported life, and using an accurate, fair, and flexible

system for individual budget determinations. This service delivery model is referred to as selfdirection, participant-direction, consumer-direction, and cash and counseling. Although PCP 

must be at the center of planning for all individuals receiving HCBS, SD may not be desired, or 

may not be available, to those who seek or are receiving HCBS. Longstanding evidence from 

demonstrations and programs such as “Cash and Counseling” and CMS’s “Independence Plus”

program indicate better outcomes and cost savings result through the use of SD. The concept of 

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SD may also be integrated into the traditional service delivery system through a focus on 

gradual transfer of control and the provision of regular opportunities to make choices in many 

contexts and settings, permitting the person to experience self-directed opportunities absent 

an established self-directed service delivery system. These types of precursor activities may be 

useful for people who are not, for whatever reason, able to experience the full benefits of a 

self-directed service delivery model. 

Self-direction is a service delivery model where HCBS are planned, budgeted, and directly 

controlled by the person receiving services. Self-direction should involve the individuals 

receiving HCBS to the maximum extent possible and include family members, guardians, or 

other legal representatives as applicable. Through SD, the person can maximize independence

and control over needed HCBS, including for example, choosing and discharging personal care 

staff. Often SD services are provided in the person’s own home. SD typically involves a fiscal 

intermediary or financial management service, that performs tasks such as payroll processing 

and tax withholding. Many people who choose to self-direct also use the services of a support 

broker or agent, to assist them in managing the self-directed HCBS and associated tasks. Often 

family members and the HCBS consumer are trained as support brokers/agents, although they 

may not perform the associated tasks. People who self-direct their HCBS may have varying 

levels of control over a flexible budget, which is required to be sufficient to meet their needs 

appropriately in the community, and maintain health and safety.

The principles and processes described below are used to ensure consistent standards for SD

across public programs. Program features that create the ideal environment for successful SD

include: 

• A common understanding of SD among case managers, direct service workers, support 

broker/agents, individuals and their families, any agency-based staff, and others.

• Consistent and effective implementation of the SD model structure and related 

functions such as support broker/agent, and financial management service/fiscal 

intermediary.

• The option to use a SD model is made available to all individuals who receive HCBS. 

• Clear rules and procedures are established for people to manage their direct service 

workers (e.g., hiring and firing, staff responsibilities, conflict resolution, salary, 

supervision, scheduling, etc.).

• A budget process is in place that assures appropriate and timely HCBS are provided 

based on the person’s needs as specified in the PCP. The team-based budget

formulation and approval process is used to address the person’s assessed individual 

needs (e.g. not associated with any particular residential setting, “one size fits all” 

rubric, or other arbitrary methodology disassociated from the individual); is flexible;

permits for timely, straightforward modifications and adjustments; and maintains the 

person’s health and safety in the community. 

Definition of Self-Direction

SD means a consumer-controlled method of selecting and using services and supports that 

allow the person maximum control over his or her HCBS including the amount, duration, and 

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scope of services and supports as well as choice of provider(s). Often, in addition to the typical 

range of HCBS, self-directed delivery systems permit the person to purchase alternative goods 

and supports (where authorized by statute or regulation) that may not be available in 

traditional HCBS service delivery systems. Alternatively, some services available in traditional 

services delivery (e.g. respite care, day programs, criminal background checks, drug and alcohol 

screens, training) may not be available in a self-directed service delivery model. There are also 

various administrative arrangements that apply specifically to SD. For example, the person may 

act as the “employer of record” with the necessary supports to perform that function, and/or

have a significant and meaningful role in the supervision of direct service worker(s). Some 

people may use a representative to direct their HCBS, and family members or legal guardians 

may have a role to assist people under guardianship, or un-emancipated minors. People who 

are self-directing their services should be given as much responsibility as they desire to hire, 

train, supervise, schedule, determine duties, and dismiss the providers or direct service workers

whom they employ directly, or for whom they may share employment responsibilities with an 

agency. Many people use the services of a support broker or agent to assist them in these and 

other duties, with the support broker/agent included as distinct service in the person’s PCP. 

Payment of SD HCBS could be through the provision of vouchers, direct cash payments, or use 

of a fiscal agent or fiscal intermediary to assist in paying for services and making certain all 

necessary payroll functions, including the payment of taxes, are performed. Fiscal 

agents/intermediaries may also provide regular service and payment summaries to the person 

receiving HCBS, and issue payment to providers, direct service workers, and support 

brokers/agents through electronic or paper methods. In some self-directed models, fiscal 

agency fees are based on a monthly or utilization basis, and are included in the person’s HCBS 

budget. Self-directed models exist in both traditional fee for service and managed care delivery 

systems. 

Required Elements of Self-Direction

HCBS programs that provide SD must incorporate the following elements, to the extent they 

are consistent with statutory and regulatory provisions: 

1. SD service delivery models must meet the PCP standards described in this document.

2. SD, when offered within programs, should be available to all individuals regardless of 

age, disability, diagnosis, functional limitations, cognitive status, sex, sexual orientation, 

race, ethnicity, physical characteristics, national origin, religion, and other such factors.

3. When representatives are required, they must be freely chosen when circumstances 

permit. 

4. HCBS consumers must have access to information and counseling and information on 

self-direction through a variety of sources as needed or desired, so they can make an 

informed decision when choosing a SD service delivery model.

5. Case managers and administrative staff should have training in SD. This includes 

training, for example, on recruitment and education of direct service workers, budget 

processing, how the PCP relates to the SD budget, needed alternative supports, housing 

search, etc. 

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6. When a person chooses SD, an assessment of the supports needed to be successful 

should be conducted. People who choose SD must have access, for example, to

culturally-linguistically sensitive information, training in issues specific to self-direction, 

financial/fiscal management services, and support brokers/agents, to assist them in the 

successful management of their HCBS. 

7. In addition, the following information and support should be provided:

a. PCP and how it is applied through SD.

b. Use of and access to the grievance process.

c. Individual rights, including appeal rights.

d. Reassessment and review schedules for PCP, budgeting, etc. 

8. The SD PCP must specify the following:

a. The HCBS the individual will be responsible for self-directing.

b. The methods by which the person will plan, direct or control services, including 

whether authority will be exercised over the employment of service providers 

and/or authority over expenditures from the individualized budget.

c. Appropriate risk management techniques that explicitly recognize the roles and 

sharing of responsibilities in SD, and assure the continued appropriateness of the 

PCP and budget based upon the resources and support needs of the person.

d. The process for facilitating voluntary (and involuntary) transition from selfdirection to a traditional service delivery model or other arrangement (e.g. 

institutional setting). There must be procedures to ensure the continuity of 

services during the transition from self-direction to other service delivery 

methods or provider types.

e. Financial/fiscal management supports to be provided.

f. Support broker/agent services, irrespective of payment method (fee for service, 

managed care). If there is no support broker/agent required or chosen, the 

person must have training in acting as his/her own support broker.

9. If the PCP includes the employer authority to select, manage, or dismiss providers, it 

must specify the authority to be exercised by the person, any limits to the authority, and 

the parties responsible for functions outside the authority of the person.

10. If the PCP includes budget authority (which identifies the dollar value of the HCBS under 

the control and direction of the person), the SD PCP must meet the following 

requirements:

a. Outline the method(s) for calculating the dollar values and/or categories in the 

budget, based on reliable costs and service utilization.

b. Define a flexible and easily accessible process for making timely adjustments in 

dollar values to reflect changes in the person’s SD PCP, particularly to support 

health and safety.

c. Provide for a regular procedure to evaluate expenditures under the budget, 

including those outlined in the SD PCP.

11. The SD planning process must be conducted in a manner and language understandable 

to the person and his/her representative(s). Individuals and/or their representatives 

must be provided with auxiliary aids and services if necessary for effective 

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communication. The SD process must provide meaningful access to people and/or their 

representatives who have limited English proficiency.

12. SD program entities must explicitly outline and make transparent to all stakeholders 

enrollment requirements such as limitations based on geography, demographic factors, 

residential arrangements, etc. 

13. People must have the flexibility to choose the needed services and supports that best 

meet their needs and preferences within the context of a PCP process that includes the 

development of an agreed upon, multi-lateral, and approved funding allocation/budget 

amount for the projected SD HCBS.

14. People must have the flexibility to choose how funds will be used based on the HCBS

identified in the PCP, consistent with the requirements of the funding authority, in a 

transparent manner, including (where appropriate), the ability to move funds 

categorically as needed. 

15. People must have the flexibility to expeditiously and seamlessly change their service 

plans and budget allocations, based on different needs and preferences, with an 

assurance of health and safety.

16. People must be able to choose their paid and unpaid direct care workers and/or medical 

support staff, may include family and friends based on administrative policies, so long as 

they meet agreed upon guidelines and qualifications for the position, and are willing to 

perform the duties. 

17. People must be allowed to direct the training of their workers in a manner consistent 

with applicable program requirements, and receive financial support to accomplish 

critical training needs as appropriate and available. 

18. People must be provided with opportunities to participate in defining quality, such as 

the determination of worker qualifications and training, personal goal setting, and 

performance measures.

19. People must be supported in taking risks associated with pursuing their goals. There

must be a back-up plan for assumed risks, and for a variety of emergency situations.

20. People must have the opportunity, as identified in the PCP and budget, to allocate or set 

aside funds for emergency needs (e.g., more costly emergency back-up workers, 

alternative emergency housing) to the extent authorized by applicable law and 

regulations.

21. People must have the opportunity, as identified in their PCP and budget, to allocate or 

set aside funds for, and where authorized, specialized purchases made timely such as

necessary home or vehicle modifications to support independence and avoid 

unnecessary institutionalization. 

22. People who need assistance with decision-making and do not have an authorized 

representative must have the option to choose an informal representative to assist 

them in selecting or managing services and supports, and/or have a person authorized 

to make personal or health decisions for them. People must also have access to one-onone assistance as needed or requested with selecting or changing their informal

representative. 

23. The finalized SD PCP must be signed by the person or his/her legal representative, and a 

written copy of the plan and budget should be provided to all relevant parties. 

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