Per the federal 1915(c) Home and Community-Based Services (HCBS) Waivers Final Rule, published January 2014, service planning for participants in Medicaid HCBS programs under section 1915(c) and 1915(i) of the Act must be developed through a person-centered planning process that addresses health and long-term services and support needs in a manner that reflects individual preferences and goals.  The rule is available at www.federalregister.gov/articles/2014/01/16/2014-00487/medicaid-program-state-plan-home-and-community-based-services-5-year-period-for-waivers-provider.

 

The rules require that the person-centered planning process is directed by the individual with long-term support needs, and may include a representative that the individual has freely chosen and others chosen by the individual to contribute to the process. The rule describes the minimum requirements for person-centered plans developed through this process, including that the process results in a person-centered plan with individually identified goals and preferences, including those related community participation, employment, income and savings, health care and wellness, education and others. 

 

This planning process, and the resulting person-centered service plan, will assist the individual in achieving personally defined outcomes in the most integrated community setting, ensure delivery of services in a manner that reflects personal preferences and choices, and contribute to the assurance of health and welfare. 

 

The template below is intended as a support in the development of an individual's Person-Centered Individual Service Plan (PCP) in order to establish an array of home and community-based services that promote community living for the individual, thereby avoiding institutionalization. The individual and his/ her PCP Team (as chosen by the individual) work together to document his/her strengths, goals, preferences, preferred outcomes, and desired supports/services (both Medicaid and non- Medicaid).

 

The PCP serves as a roadmap towards achieving the individual's goals, and should be reviewed and updated at least every twelve months or when the person's functional needs change, circumstances change, quality of life goals change, or at the person's request. It might make sense to complete the various PCP sections in a different order than what is presented, depending on the preferences and needs of the individual.