Home and Community-Based (HCBS) Settings Rule: Modifications

What are HCBS Settings Rule Modifications?

Medicaid members have the same rights as all other people, including the right to make choices about their daily activities, schedule, and food choices. HCBS Settings Rule Modifications are restrictions or limitations to HBCS rights guaranteed to a Medicaid member under the HCBS Settings Rule. These modifications can apply to a specific rule requirement in certain circumstances when there is an assessed need for an individual resident.

What is the process to document an HCBS Settings Rule Modification?

These steps must be followed before implementing an HCBS Settings Rule Modification:

What are the assessment and documentation requirements for an HCBS Settings Rule Modification?

The following requirements must be assessed for and documented in the resident’s Medicaid person-centered plan:

• A specific and individualized need for the restriction or limitation
  • HCBS Settings Rule Modifications must be based on a specific assessed need to ensure the health, safety, and well-being of the resident or the community.
• The positive interventions and supports used prior to any modifications to the person-centered service plan
  • Positive interventions are evidence-based, intentional acts or series of actions meant to create a safe and worthwhile environment. They focus on identifying, teaching, and reinforcing positive behaviors as well as using strategies to address problem behavior.
  • Positive supports are the help or tools that individuals need to do something successfully. Supports can be people who are paid, people who are not paid, technology, medical equipment, mobility aids, home modifications, etc.
• Less intrusive methods of meeting the need that have been tried but did not work
  • Least intrusive methods are methods to achieve a desired outcome with the least amount of disruption to an individual’s independence, dignity, or daily life. They prioritize using the least restrictive means necessary to safeguard individual rights and wellbeing. Positive interventions, supports, and less intrusive methods should be utilized prior to an HCBS Settings Rule Modification.
  • An HCBS Settings Rule Modification should only be used if it is determined to be the least-intrusive method to achieve the desired outcome. If positive interventions, supports, and/or less intrusive methods have not been tried or the individual and residential provider determine new or different positive interventions, supports, and less intrusive methods need to be tried before an HCBS Settings Rule Modification is implemented, the resident, their care manager or consultant and residential provider should develop a plan for trying less intrusive methods and/or positive interventions and supports.
• Clear description of the condition(s) of the HCBS Settings Rule Modification that is based on the assessed need
• A plan for regular collection and review of data to measure the ongoing effectiveness of the modification
• The established time limits for periodic reviews to determine if the modification is still necessary or can be terminated
• The informed consent of the individual
• An assurance that interventions and supports will cause no harm to the individual

What are the responsibilities of the setting?

When the setting identifies an assessed need, they must collaborate with the resident (or legal decision maker if applicable) and the resident’s care manager or consultant. The setting is responsible to ensure that any HCBS Settings Rule Modifications are documented in the resident’s Medicaid person-centered service plan including receiving informed consent from the resident before the setting implements any modifications or restrictions.

The setting is responsible for ensuring that all direct care staff know:

• Residents' HCBS rights under the HCBS Settings Rule
• Which residents have approved HCBS Settings Rule Modifications
• How to implement individualized modifications, when applicable

Additional resources

• Client Rights: Your Rights When Receiving Treatment. Residents receiving services for mental health, substance use, or a developmental disability have additional client rights.
• HCBS Settings Rule Compliance for Residential Providers has more information on HCBS Settings Rule requirements.

Contact information

If you cannot find the answer to your question, email DHSHCBSSettings@dhs.wisconsin.gov or call 877-498-9525.