Choices for Care Options

There are three different proposed options for Choices for Care: A, B, C. Please scroll down to view each of the options. You may comment on each of the options separately.

Choices for Care Option A

  • The State of Vermont would award up to two statewide contracts to deliver case management for the Choices for Care (CFC) program. Case management organization(s) would apply through a state-run competitive process.

    Home Health Agencies (HHAs) would no longer deliver CFC case management. HHAs continue to provide direct services.

    Local Area Agencies on Aging (AAAs) would no longer be designated as CFC case management providers for their regions. AAAs would have to compete for statewide contracts.

    • There will be changes to case management services, but very few changes to direct home and community-based services.
    • People living in Adult Family Care homes would receive case management from a statewide case management provider. (These people currently receive both direct HCBS and case management from the Adult Family Care provider agency).
    • Case management providers would not be the same organizations as the providers delivering direct services, so there would not be any conflict of interest.
    • An independent case management provider may complete clinical and functional assessments. (Currently, the State completes initial CFC clinical assessments. HCBS providers complete ongoing clinical and functional assessments, but that is a conflict. Feedback on who should perform which CFC assessments is welcome.)
    • People seeking services would have a simple system to choose a case management provider and to access HCBS.
    • One to two case management organizations for the whole state could help to make sure everyone gets the same high quality case management services.
    • Existing providers could think about ways to work together. They could develop new statewide organization(s) to apply for the contracts, as long as the new organizations are free of conflicts.*

    * Federal conflict of interest standards are available here.
    Conflict of interest requirements are described in plain language here when you click on “What does Conflict-Free Case Management require?”

  • ProsCons
    • There would be no conflict of interest. This option meets federal requirements.
    • An independent case manager would offer and support choices. They would help address problems/concerns with services and supports.
    • If two contracts are awarded, people will be able to choose from different case management organizations.
    • People would be able to easily understand the simple system for choosing a case management provider and getting services.
    • Having only one or two case management organizations would offer more consistency and equity for people across the state.
    • A process where case management organizations compete for the contracts may help the organizations be more creative, sharing new ideas and better ways to do things.
    • Competitive contracts can help the state to make sure the case management providers do a good job and offer quality services.
    • Independent statewide case management provider(s) may be able to help with other important system functions including training, data management and reporting, and information technology systems.
    • People will need to be supported to understand the changes in the system and the new roles and responsibilities of case managers and providers. They may need to develop new relationships with different providers.
    • Changes in the case management structure will be hard. It may disrupt things for some people and some providers.
    • There are not very many local Vermont organizations who may be ready and able to become a statewide case management provider.
    • Without being able to deliver CFC case management, HHAs may not want to deliver CFC HCBS. The state may need to develop additional HCBS providers.
    • A process where providers apply to the state and compete for the contracts (competitive procurement) takes time. There is a short timeline to meet the federal corrective action plan requirements. Pre-competition processes to learn about provider interest, understand stakeholder priorities, and to receive and accept feedback, will be limited.
    • The state role will change to manage competitive contract activities and oversight of case management. This may require some new staff or staff with some different skills.
  • This table helps explain who would do different activities under this option. The six functions listed across the top are key HCBS activities related to case management.

    Roles:Eligibility and EnrollmentNeeds AssessmentPerson-Centered PlanningReferral and LinkingService/ Resource ApprovalService Monitoring & Ongoing Coordination
    StateApprove financial and clinical eligibility/renewals


    (State approves people to get services)
    Maintain records

    Quality and compliance oversight

    (State keeps track of information about people’s needs. They make sure needs are getting assessed when they are supposed to)
    Quality and compliance oversight


    (State makes sure case managers are doing good person-centered planning)
    Quality and compliance oversight


    (State makes sure case managers are supporting access to services and choice)
    Approve CFC service plans


    Oversee utilization management


    (State approves service plans. State makes sure services are aligned with needs)
    Quality and compliance oversight


    (State makes sure case managers are doing a good job)
    Local AAARefer people to contracted case management entities


    (AAAs tell people how to find a case management provider)
    N/AN/AN/AN/AN/A
    Contracted case mgmt. entityCoordinate/complete eligibility assessments and intake paperwork for submission to AHS for approval


    (Case managers help people apply for services)
    Gather data and information, documents the person’s needs


    Conduct functional needs assessments (for example, Independent Living Assessment)


    (Case managers collect information about the person’s needs. They use standard tools to help understand needs, like the Independent Living Assessment)
    Facilitate discovery, identify what is important to and for the person


    Identify goals and strategies


    Develop service and support plan


    (Case managers help people make decisions about their goals and how to meet them. They help the person choose their services and supports and who will provide them. They develop the plan)
    Offer unbiased choices in services, supports and available resources


    Assist with access to services, enrolling with providers


    (Case managers help people understand choices about providers and supports. They help the person connect to providers and resources that are helpful to meet the person’s needs and goals)
    Submit service plans to state for approval


    (Case managers send plans to the State for approval)
    Ensure people are receiving services as needed and as planned


    Monitor progress


    Manage ongoing coordination


    (Case managers check in with the person regularly. They make sure things are going well and help solve problems when they are not. They bring teams together when needed to make things work better or make changes)
    Direct HCBS provider (includes HHAs)Refer people to contracted case management entity


    (Providers tell people where to go to apply for services)
    Contribute information and data, observed risks or needs


    (Providers share what they know about the person
    As preferred by the person, participate as a contributor to the development of ideas, strategies and approaches to inform the plan


    (If a person wants providers to be part of their person-centered planning, the provider can be included)
    N/AN/ASupport/track progress to goals

    Communicate with case management and support team about changes, problems, needs

    Manage day-to-day coordination tasks as part of HCBS delivery

    (Providers document how services are helping people. They work with case management to solve problems. They do some coordination as part of direct service)

    *Note: The bolded areas in each section are plain language explanations of the function.

Choices for Care Option B

  • Area Agencies on Aging (AAAs) would provide all Choices for Care (CFC) case management services.

    Home Health Agencies (HHAs) would not deliver CFC case management. HHAs continue to provide direct services.

    • People receiving CFC case management services from an HHA will have to change to a AAA for CFC case management.
    • There will be changes to case management services, but very few changes to direct home and community-based services.
    • People living in Adult Family Care homes would receive case management from a AAA. (These people currently receive both direct HCBS and case management from the Adult Family Care provider agency).
    • There is no conflict of interest because AAAs would provide case management, and HHAs and other providers provide direct HCBS.
    • People seeking services would have a simple system to choose a case management provider and to access HCBS.
  • ProsCons
    • There would be no conflict of interest. This option meets federal requirements.
    • AAA case manager would offer and support choices. They would help address problems/concerns with services and supports.
    • AAA case management provider may complete clinical and functional assessments.
    • This builds upon the existing conflict-free AAA case management system.
    • People would be able to easily understand the simple system for choosing a case management provider and getting services.
    • AAAs expand case management services, but do not have to change existing system.
    • HHAs keep their regions for home health and CFC HCBS. The only exception is CFC case management.
    • No changes in direct HCBS.
    • There would no longer be choices. There would be only one option for a case management organization.
    • Changes in the case management structure will be hard. It may disrupt things for some people and some providers.
    • Anyone who has a CFC case manager through an HHA now will have to switch to AAA case management.
    • Without being able to deliver CFC case management, HHAs may not want to deliver CFC HCBS. The state may need to develop additional HCBS providers.
    • AAAs would need to increase number of staff, and number of skilled staff, to meet the needs of all CFC participants.
  • This table helps explain who would do different activities under this option. The six functions listed across the top are key HCBS activities related to case management.

    Roles:Eligibility and EnrollmentNeeds AssessmentPerson-Centered PlanningReferral and LinkingService/ Resource ApprovalService Monitoring & Ongoing Coordination
    StateComplete eligibility assessments


    Approve financial and clinical eligibility/renewals


    (State approves people to get services)
    Maintain records

    Quality and compliance oversight

    (State keeps track of information about people’s needs. They make sure needs are getting assessed when they are supposed to)
    Quality and compliance oversight


    (State makes sure case managers are doing good person-centered planning)
    Quality and compliance oversight


    (State makes sure case managers are supporting access to services and choice)
    Approve CFC service plans


    Oversee utilization management


    (State approves service plans. State makes sure services are aligned with needs)
    Quality and compliance oversight


    (State makes sure case managers are doing a good job)
    AAACoordinate and support intake paperwork for submission to AHS for approval


    (AAA case managers help people apply for services)
    Gather data and information, document the person’s needs


    Conduct functional needs assessments (for example, Independent Living Assessment)


    (AAA case managers collect information about the person’s needs. They use standard tools to help understand needs, like the Independent Living Assessment)
    Facilitate discovery, identify what is important to and for the person

    Identify goals and strategies

    Develop service and support plan

    (AAA case managers help people make decisions about their goals and how to meet them. They help the person choose their services and supports and who will provide them. They develop the plan)
    Offer unbiased choices in services, supports and available resources

    Assist with access to services, enrolling with providers

    (AAA case managers help people understand choices about providers and supports. They help the person connect to providers and resources that are helpful to meet the person’s needs and goals)
    Submit service plans to state for approval


    (AAA case managers send plans to the State for approval)
    Ensure people are receiving services as needed and as planned


    Monitor progress


    Manage ongoing coordination


    (AAA case managers check in with the person regularly. They make sure things are going well and help solve problems when they are not. They bring teams together when needed to make things work better or make changes)
    Direct HCBS provider (includes HHAs)Refer people to contracted case management entity


    (Providers tell people where to go to apply for services)
    Contribute information and data, observed risks or needs


    (Providers share what they know about the person
    As preferred by the person, participate as a contributor to the development of ideas, strategies and approaches to inform the plan


    (If a person wants providers to be part of their person-centered planning, the provider can be included)
    N/AN/ASupport/track progress to goals

    Communicate with case management and support team about changes, problems, needs

    Manage day-to-day coordination tasks as part of HCBS delivery

    (Providers document how services are helping people. They work with case management to solve problems. They do some coordination as part of direct service)

    *Note: The bolded areas in each section are plain language explanations of the function.

Choices for Care Option C

  • Area Agencies on Aging (AAAs) and Home Health Agencies (HHAs) continue to deliver CFC case management.

    Home Health Agencies (HHAs) would no longer deliver direct home and community-based services (HCBS) to CFC participants receiving HHA case management, in order to eliminate conflict of interest.

    • This option may be complex or confusing for participants, families and providers.
    • Most participants would continue to have the choice between AAAs and HHAs for case management, unless they are receiving HCBS from the HHA.
    • For many participants, nothing would change. People receiving CFC case management and HCBS from an HHA would have to change providers for either case management or direct HCBS.
    • There may be a conflict of interest when an individual receives CFC case management from an HHA and requires skilled home health services that are not CFC services. There may also be a conflict when an individual receives CFC case management from an HHA and there are no other HCBS providers available. As a result, CMS may not approve this option.
    • People living in Adult Family Care homes would receive case management from the AAA or HHA. (These people currently receive both direct HCBS and case management from the Adult Family Care provider agency).
  • ProsCons
    • Keeps choice of case management provider for most participants.
    • Limited disruption to existing CFC case management delivery system.
    • AAA regional delivery of CFC case management does not change.
    • HHAs keep current regional structure and designation but have to make sure that no participant is receiving both HCBS and case management from them.
    • This option may be confusing for participants and families.
    • Participants who want to keep HHA case management may have a hard time finding a new direct HCBS provider.
    • The state would need to develop additional HCBS provider capacity.
    • HHAs and the State would have to pay close attention to who is getting HHA case management, and make sure those participants do not get other direct services from the HHA.
    • If a conflict comes up, individuals may need to change providers.
    • There may be a conflict of interest when an individual receives CFC case management from an HHA and requires skilled home health services that are not CFC services. There may also be a conflict when an individual receives CFC case management from an HHA and there are no other HCBS providers available. As a result, CMS may not approve this option.
  • This table helps explain who would do different activities under this option. The six functions listed across the top are key HCBS activities related to case management.

    Roles:Eligibility and EnrollmentNeeds AssessmentPerson-Centered PlanningReferral and LinkingService/ Resource ApprovalService Monitoring & Ongoing Coordination
    StateComplete eligibility assessments


    Approve financial and clinical eligibility/renewals


    Monitor HHA case management for individual conflicts


    (State approves people to get services. State watches for conflict in HHAs)
    Maintain records

    Quality and compliance oversight

    (State keeps track of information about people’s needs. They make sure needs are getting assessed when they are supposed to)
    Quality and compliance oversight


    (State makes sure case managers are doing good person-centered planning)
    Quality and compliance oversight


    (State makes sure case managers are supporting access to services and choice)
    Approve CFC service plans


    Oversee utilization management


    Monitor to ensure HHAs do not have COI for participants


    (State approves service plans. State makes sure services are aligned with needs. State watches for conflict in HHAs)
    Quality and compliance oversight


    (State makes sure case managers are doing a good job)
    AAA or HHA case mgmt.Coordinate and support intake paperwork for submission to AHS for approval


    (AAA or HHA case managers help people apply for services)
    Gather data and information, document the person’s needs


    Conduct functional needs assessments (for example, Independent Living Assessment)


    (AAA or HHA case managers collect information about the person’s needs. They use standard tools to help understand needs, like the Independent Living Assessment)
    Facilitate discovery, identify what is important to and for the person

    Identify goals and strategies

    Develop service and support plan

    (AAA or HHA case managers help people make decisions about their goals and how to meet them. They help the person choose their services and supports and who will provide them. They develop the plan)
    Offer unbiased choices in services, supports and available resources

    Assist with access to services, enrolling with providers

    (AAA or HHA case managers help people understand choices about providers and supports. They help the person connect to providers and resources that are helpful to meet the person’s needs and goals)
    Submit service plans to state for approval


    (AAA or HHA case managers send plans to the State for approval)
    Ensure people are receiving services as needed and as planned


    Monitor progress


    Manage ongoing coordination


    (AAA or HHA case managers check in with the person regularly. They make sure things are going well and help solve problems when they are not. They bring teams together when needed to make things work better or make changes)
    Direct HCBS provider (includes HHAs)Refer people to contracted case management entity


    (Providers tell people where to go to apply for services)
    Contribute information and data, observed risks or needs


    (Providers share what they know about the person
    As preferred by the person, participate as a contributor to the development of ideas, strategies and approaches to inform the plan


    (If a person wants providers to be part of their person-centered planning, the provider can be included)
    N/AN/ASupport/track progress to goals

    Communicate with case management and support team about changes, problems, needs

    Manage day-to-day coordination tasks as part of HCBS delivery

    (Providers document how services are helping people. They work with case management to solve problems. They do some coordination as part of direct service)

    *Note: The bolded areas in each section are plain language explanations of the function.

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