Table Sample

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)
Service/ Resource Approval 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)
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 BIP providerRefer people to AAAs and/or DAIL for application


(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)
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