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Medicaid (Title XIX of the Social Security Act)
Consumer Directed Services

c.) Consumer Directed Services

i.) Personal Assistance Services

States may provide coverage of self-directed personal assistance services for individuals who, without such services, would receive personal care services under the state plan or home and community-based services pursuant to a waiver.92  The state must assess the needs, strengths and preferences of the participant93 and, on the basis of this assessment, establish a plan for such personal assistance services.94 Based on this assessment and the plan, the state must establish a budget that is open for public inspection.95  Utilizing a quality assurance and risk management strategy, the state must establish and implement the plan and budget and assure that each is consistent with the participant’s resources and capabilities.96

The state must annually report the number of individuals receiving self-directed personal assistance and every three years, the state must include an evaluation of the overall impact on the health and welfare of participating individuals as compared to non-participants.97

ii.) Home and Community-Based Attendant Services

States may amend their plans to include coverage of home and community-based attendant services and supports for individuals who would otherwise be eligible for nursing facility services, without which they would require care in a hospital, nursing facility, ICF-MR, or institution for mental disease.98  The state must create a plan of services and supports based on an assessment of each individual’s functional needs, agreed upon by each participant (or his representative) in writing.99  The state must establish and maintain a comprehensive quality assurance system that satisfies the following requirements: 100

  • Incorporates feedback from consumers and their representatives;
  • Monitors the health and well-being of each participant; and
  • Has a process for reporting, investigating and resolving allegations of neglect, abuse or exploitation.

States must annually report:

  • The number of individuals estimated to receive home and community-based attendant services; and101
  • The specific number who received attendant services the preceding fiscal year, organized into groups by disability, age, gender, education level and employment status and the number of individuals within each group previously served under other home and community-based services provided by the state (or via waiver).102

The Secretary will evaluate the provision of home and community-based attendant services and supports to determine whether such services allow the participants to lead an independent life and what impact the services have on the physical and emotional health of participants. 103


  • 92. Social Security Act § 1915(j)(1), 42 U.S.C. 1396n(j)(1).
  • 93. Social Security Act § 1915(j)(5)(B), 42 U.S.C. 1396n(j)(5)(B).
  • 94. Social Security Act § 1915(j)(5)(C), 42 U.S.C. 1396n(j)(5)(C).
  • 95. Social Security Act § 1915(j)(5)(D), 42 U.S.C. 1396n(j)(5)(D).
  • 96. Social Security Act § 1915(j)(5)(E), 42 U.S.C. 1396n(j)(5)(E).
  • 97. Social Security Act § 1915(j)(2)(E), 42 U.S.C. 1396n(j)(2)(E).
  • 98. Social Security Act § 1915(k)(1), 42 U.S.C. 1396n(k)(1).
  • 99. Social Security Act § 1915(k)(1)(A)(i), 42 U.S.C. 1396n(k)(1)(A)(i).
  • 100. Social Security Act § 1915(k)(3)(D), 42 U.S.C. 1396n(k)(3)(D).
  • 101. Social Security Act § 1915(k)(5)(B)(i), 42 U.S.C. 1396n(k)(5)(B)(i).
  • 102. Social Security Act § 1915(k)(5)(B), 42 U.S.C. 1396n(k)(5)(B).
  • 103. Social Security Act § 1915(k)(5)(A), 42 U.S.C. 1396n(k)(5)(A).