Project Overview

Background

Many Vermonters seek long-term services and supports in their homes and communities. They prefer this to living in an institutional setting like nursing homes or other medical facilities. People with disabilities, older adults, and others with support needs can get home and community-based services (HCBS) through state programs. In Vermont, this includes people with intellectual or developmental disabilities, physical disabilities, brain injuries, mental health conditions, and/or aging needs.

Case management is an important part of HCBS. Case managers help people:

  • figure out what they may need,
  • set goals,
  • find resources to help people live good lives,
  • help people access services and supports, and
  • make sure that services are working well for each person.

Vermont is changing case management to meet federal HCBS rules, address conflict of interest, and to make the system work better. Conflict of interest occurs when the interests of an organization or an individual could compromise the judgment, decisions, or actions taken on behalf of people served. The federal HCBS conflict of interest rules require that the organizations that provide assessments (the way programs determine what someone needs) and case management cannot also deliver other HCBS.

The HCBS-COI Project

The Vermont Agency of Human Services is working to redesign parts of the Home and Community-Based Services (HCBS) system to avoid conflict of interest issues. Team members from across the Vermont Agency of Human Services (AHS), including staff from the central office and the Department of Disabilities, Aging and Independent Living (DAIL),  are working together on this important change. Additionally, AHS has hired a contractor, Health Management Associates (HMA). HMA is helping the state with technical assistance and supporting stakeholder involvement in the process.

DAIL has developed two charts representing the current timelines for changes to case management for the Choices for Care, Brain Injury, and Developmental Services Programs. The timelines are based on the State decisions made through the Options and Recommendations process, aligned with the requirements of Vermont Medicaid’s HCBS-COI Corrective Action Plan as negotiated with CMS.

*Please note that project timelines are subject to change; these documents will be updated as needed.

Principles for the Vermont HCBS-COI Redesign*

Vermonters who need home and community-based services (HCBS) will have equal opportunity to:

  • Learn about service and support options from a neutral, trusted source.
  • Access publicly-funded services through an easy-to-use, unbiased and equitable process.
  • Be empowered and supported to make informed choices about a range of available services and supports and who delivers them, such as opportunities to live at home or in the community.
  • Participate in person-centered planning and services that respect and encourage self-determination, independence, growth, dignity, individual preferences and goals.
  • Feel confident about the quality of services and supports, including the focus on individual health and welfare, integration and coordination of care, and participants’ rights.

Goals for the Vermont
HCBS-COI Redesign*

  • Case management functions are provided separately from the delivery of direct services to ensure federal compliance, improve access for all Vermonters, and protect participants’ rights.
  • Participants are empowered to make informed decisions about their lives and their services, including who supports them and how they are supported, for both case management and HCBS.
  • Person-centered thinking and coordination of care are central to all activities related to service delivery, including case management.
  • Case management roles and responsibilities are clearly defined and described, as are those of HCBS providers, including the intersections for collaboration and cooperation.
  • To the greatest extent possible, stability is maintained for provider agencies and within the workforce.

*Please note that throughout the above principles and goals, references to “participants” and “individuals” are inclusive of families when applicable.

This website, the HCBS-COI Advisory Committee, and the HCBS-COI email distribution list are all intended to offer information and opportunities for stakeholder engagement for this important project.

Vermont sunset over the mountains

Key Activities and Milestones for the HCBS-COI Project

History

On January 16, 2014, the Centers for Medicare & Medicaid Services (CMS) issued final rules on home and community-based services (HCBS) requirements. The rule supports improved quality in HCBS programs, outlines person-centered planning requirements, and expects that people receiving services and supports funded by Medicaid can fully participate in the broader community. This includes receiving services in the most integrated setting of their choice, from the provider of their choice. A key part of these HCBS rules requires that case management (service coordination) is provided in a conflict-free manner.

As addressed in the October 22, 2021 Global Commitment Register Clarification on Home and Community-Based Services (HCBS) Conflict of Interest, Vermont Medicaid submitted its HCBS conflict of interest plan to the Centers for Medicare and Medicaid Services (CMS). The corrective action plan was approved by CMS on March 7th, 2023. The policy documents are available here:

The applicable federal rules [42 CFR § 441.730(b)] require that Vermont have Conflict of Interest standards in the Medicaid HCBS program:

“Conflict of interest standards. The State must define conflict of interest standards that ensure the independence of individual and agency agents who conduct (whether as a service or an administrative activity) the independent evaluation of eligibility for State plan HCBS, who are responsible for the independent assessment of need for HCBS, or who are responsible for the development of the service plan. The conflict of interest standards apply to all individuals and entities, public or private. At a minimum, these agents must not be any of the following:

  1. Related by blood or marriage to the individual, or to any paid caregiver of the individual.
  2. Financially responsible for the individual.
  3. Empowered to make financial or health-related decisions on behalf of the individual.
  4. Holding financial interest, as defined in § 411.354 of this chapter, in any entity that is paid to provide care for the individual.
  5. Providers of State plan HCBS for the individual, or those who have an interest in or are employed by a provider of State plan HCBS for the individual, except when the State demonstrates that the only willing and qualified agent to perform independent assessments and develop person-centered service plans in a geographic area also provides HCBS, and the State devises conflict of interest protections including separation of agent and provider functions within provider entities, which are described in the State plan for medical assistance and approved by the Secretary, and individuals are provided with a clear and accessible alternative dispute resolution process”
Health Management Associates logo
State of Vermont logo

© 2024 Health Management Associates
Any views or opinions expressed through this site belong solely to the author and may not reflect the views of the State of Vermont or its agencies.

Back to top