Home and Community Based Services Manual

Revised - July 2026

Introduction

The Independent Living Waiver (ILW) program offers a self-directed option that supports adults with disabilities to remain living independently in their homes. The waiver offers additional Personal Care services along with other supportive options for participants who have higher or specialized care needs.

Available ILW services include:

• CDS Personal Care hours
• Case Management (CM)
• Environmental Accessibility Adaptations (EAA)
• Specialized Medical Supplies (SMS)
• Financial Management Services (FMS)

Eligibility

The ILW aims to establish and maintain a community-based system of care for individuals 18 years of age and older with disabilities. These individuals live in and wish to continue living independently in their homes and/or communities and self-direct their services.

To qualify for the ILW, a participant must:

• Be 18-64 years old when they first enroll
  • Participants who turn sixty-five (65) while enrolled may stay in the program if they can still self-direct their care.
• Have a physical disability as defined in 19 CSR 15-8 that makes it necessary for someone else to help with daily tasks.
• When applicable, have a cognitive impairment with an onset on or after age twenty-two (22).
• Be able to self-direct their own CDS care.
• Meet Nursing Facility Level of Care (LOC).
• Have an appropriate Medicaid Eligibility (ME) code and be in an active Medicaid status.
  • Participants on Medicaid spenddown may receive ILW when their spenddown is met.
    • When the participant has not met their monthly spenddown liability, the participant and provider may arrange privately for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
    • Authorization of the ILW does not meet the eligibility requirements for Home and Community Based (HCB) Medicaid.
  • Participants in a ‘Transfer of Property’ penalty can receive the ILW.
  • Participants who receive Blind Pension (BP) are not eligible for the ILW.

Eligibility

To qualify for the ILW, a participant must:

• Be 18-64 years old when they first enroll
  • Participants who turn sixty-five (65) while enrolled may stay in the program if they can still self-direct their care.
• Have a physical disability as defined in 19 CSR 15-8 that makes it necessary for someone else to help with daily tasks.
• When applicable, have a cognitive impairment with an onset on or after age twenty-two (22).
• Be able to self-direct their own CDS care.
• Meet Nursing Facility Level of Care (LOC).
• Have an appropriate Medicaid Eligibility (ME) code and be in an active Medicaid status.
  • Participants on Medicaid spenddown may receive ILW when their spenddown is met.
    • When the participant has not met their monthly spenddown liability, the participant and provider may arrange privately for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
    • Authorization of the ILW does not meet the eligibility requirements for Home and Community Based (HCB) Medicaid.
  • Participants in a ‘Transfer of Property’ penalty can receive the ILW.
  • Participants who receive Blind Pension (BP) are not eligible for the ILW.

Restrictions

Participants in the ILW program are subject to the following restrictions and shall not:

• Be enrolled in any other waiver program, regardless of which state agency administers the waiver; 
• Live in any type of facility, group home, or boarding home;
• Be marked as 'CDS Restricted' in their case record.

Limitations 

The following are limitations to the ILW:

• Waiver Slots: Each waiver year (July 1 - June 30) has a limited number of participant slots. If a participant leaves the waiver during a waiver year, for any reason, the slot remains occupied for the duration of the waiver year. When slots are filled, eligible participants will be places on the waitlist.
  • The waitlist is prioritized based on participants’ level of care scores.
  • At the start of each waiver year, participants will be moved from the waitlist into the newly available slots. Bureau of Federal Programs (BFP) manages the waitlist and will redirect the allocation of slots as they become available. 
• Maximum Authorization: ILW Personal Care services are limited to a maximum of 49 hours per week.
  • ILW is authorized in units of fifteen (15) minutes. The monthly maximum is 868 units.

Process

When a potential need for an ILW service is identified, DSDS staff must first verify that the participant meets basic eligibility requirements, including age, appropriate ME code, and ability to self-direct.

Once basic eligibility is confirmed, DSDS will begin the planning process as follows:

• DSDS staff shall complete and upload a CDS worksheet, outlining all CDS and ILW services requested. 
  • If additional agency model services are or will be authorized, an In-Home Services (IHS) Worksheet outlining the specific services and tasks must also be completed. Both worksheets shall include clear explanations for each requested task, daily service frequency, and justification for the amount of time allocated.
• When all required documentation is completed, DSDS staff shall submit the ILW request to their supervisor for review.
• The supervisor shall confirm all steps have been completed correctly and that the participant’s unmet needs justify the request.
• If documentation supports the request, the supervisor will forward the request to Bureau of Federal Programs (BFP) for final review and approval before authorization. 
  • Pending approval from BFP, the participant may be authorized for services up to the state plan limits.

Service Description

CDS Personal Care

The ILW Personal Care services offer the same tasks as the CDS State Plan Personal Care. The waiver provides an opportunity for participants with identified needs to receive additional self-directed Personal Care services once State Plan Personal Care service limits have been reached. 

The ILW further provides an option for participants who have an impairment that does not interfere with their ability to self‑direct to delegate their self‑direction responsibilities to another person. Participants who choose to delegate self‑direction cannot receive authorization through State Plan CDS.

Financial Management Services (FMS)

FMS is provided to participants receiving Personal Care through the ILW to help them employ Personal Care attendants and access to other ILW services. FMS is authorized as one (1) unit per month.

FMS providers are responsible for the following:

• Assisting participants in verifying the attendant’s citizenship status.
• Collecting and processing Electronic Visit Verification (EVV) records.
• Processing payroll, including withholding, filing and payment of all applicable federal, state, and local employment-related taxes and insurance.
• Ensuring that all funds designated for attendants are used solely for wages and required employment taxes and insurance.
• Confirming that attendants are registered with the Family Care Safety Registry (FCSR).
• Providing information and assistance to the participant or their designee in arranging, directing, and managing services.
• Helping identify immediate and long-term needs, developing options to meet those needs, and accessing needed supports and services.
• Offering practical skills training to help participants or their designee independently direct and manage waiver services, including:
• Guidance on recruiting, hiring, and managing attendants.
  • Information on communication and problem-solving skills.
  • Support to ensure that participants understand their responsibilities in directing services.
  • Assistance with obtaining assistive technology services or devices.
    • Advocating for the participant by coordinating with individuals, businesses, or agencies to secure the best available service within existing resources.
  • Helping participants obtain three (3) cost statements when authorizing SME, SMS, and EAA services.
    • Ensuring the purchase price includes training on the operation and maintenance of equipment, along with ongoing upkeep.
    • Verifying that equipment and supply providers are enrolled as a State Plan Durable Medical Equipment (DME) provider or registered and in good standing with the Missouri Secretary of State’s Office.
    • Ensuring EAA providers meet all state and local licensing or certification requirements, including having any required business licenses and meeting all applicable building codes.

Case Management (CM)

CM helps participants access the waiver services, State Plan services, and other medical, social, educational, or community resources they need, regardless of the funding source.

All ILW participants must be authorized for CM. Case managers employed by the HCBS provider are required to deliver and document at least 12 hours of CM services per year, which must include monthly contact with the participant. CM is authorized as one (1) unit per month.

CM activities may include:

• Identifying potential abuse, neglect, or exploitation.
• Monitoring the delivery of services outlined in the participant’s care plan.
• Reviewing the care plan and evaluating the participant’s needs, including monthly contacts and face-to-face visits with the participant when appropriate.
• Supporting participants in accessing a full range of services and providers to meet their individual needs, regardless of funding source.

Environmental Accessibility Adaptations (EAA)

EAA are physical modifications to a participant’s home to protect their health and safety and/or help the participant live more independently in their home and community. EAA is limited to a maximum of $5,000 dollars within a five-year period. Units are based on the actual cost of the work performed (Services Units and Rates).

The following are examples of allowable EAA modifications:

• Installing ramps and grab-bars, widening doorways, and modifying bathroom facilities.
• Installing specialized electrical or plumbing systems required for the participant’s safety.
• Other home modifications that have a direct impact on the participant’s health and safety.

The following are examples of requests that are not allowed EAA: 

• General home improvements that do not provide a direct medical or remedial benefit, such as carpeting, roof repair, or central air conditioning.
• Participants living in rental property must first request that the landlord complete the needed modifications and/or give permission for the work to be done.

NOTE: EAA may only be authorized after the FMS provider verifies and documents that no other resources are available to meet the need.

Specialized Medical Equipment (SME)

SME includes devices, controls, or appliances that enable participants to increase their ability to perform activities of daily living. Authorization of SME is limited to $5,000 in a five-year period. A unit is based on the actual cost of the device (Service Rates and Units). Examples include:

• Lift chairs, commode chairs, patient lifts, trapeze equipment, oxygen, respiratory equipment, shower benches, augmentative communication devices, canes, walkers, or wheelchairs

Specialized Medical Supplies (SMS)

SME include items that will enable a participant to increase their ability to perform activities of daily living. A unit is based on the actual cost of supplies (Services Units and Rates). Examples include:

• Incontinence supplies, such as adult diapers and disposable bed pads
  • When a participant currently receives incontinence supplies through the Medicaid exception process, and the participant is being enrolled in the ILW, staff shall request authorization of SMS through the ILW.

NOTE: EAA, SME, and SMS shall only be authorized when it can be documented that such authorization will decrease the current authorization of or future need for personal care assistance services, either through the State Plan or the ILW.

SME and SMS shall be authorized only when it can be documented that these services cannot be covered by another source, such as Medicaid or Medicare covered Durable Medical Equipment.

Provider Choice

Providers must be enrolled as CDS providers with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance (MMAC) Unit. In addition, providers must have an ILW addendum on file with MMAC.

Payment is made directly to the HCBS provider, as Medicaid reimburses only contracted providers. However, the participant remains the employer of the attendant.

Provider Service Delivery

Providers should deliver all tasks authorized under both State Plan and ILW as State Plan services until the 60% cost maximum has been reached. After the 60% threshold is exhausted, providers must transition to delivering all tasks under ILW for the remainder of the month. This approach must be applied consistently in both the electronic visit verification and billing claims.

Authorization

The following will guide prior authorization in the electronic case management system for both State Plan CDS and ILW services upon approval from BFP.

CDS State Plan Personal Care

• On the Care Plan Builder Page, select ‘Add Service’
• From the ‘Service Type’ drop down select ‘Personal Care Assistance – CDS’
• Select ‘Add Task’
  • Add tasks up to the 60% cost maximum; tasks beyond the 60% cost maximum will be authorized under the ILW.
• Select the Provider
• Adjust the start date, as needed

ILW Personal Care

• On the Care Plan Builder Page, select ‘Add Service’
• From the ‘Service Type’ drop-down select ‘Personal Care Assistance – ILW’
• Select ‘Add Task’
  • Choose all tasks to be authorized as Personal Care – ILW.
  • Be careful not to duplicate tasks already authorized under Personal Care Assistance – CDS.
• Select the Provider
• Adjust the start date, as needed

Case Management

• CM will populate automatically when ‘Personal Care – Independent Living Waiver’ is selected on the Care Plan Builder.
• Case Management will auto-populate 1 unit per month with the same date range as Personal Care -Independent Living Waiver.
• If Personal Care Assistance – Independent Living Waiver is deleted, CM will be deleted.
• Select the Provider.
• Adjust the start date, as needed.
• In rare instances, a participant can be authorized for Case Management without the need for Personal Care above the 60% cost maximum. In these instances, CM can be added to the care plan manually
  • On the Care Plan Builder Page, select ‘Add Service’.
  • From the ‘Service Type’ drop-down, select ‘Case Management’.

Financial Management Services

• FMS will populate automatically when ‘Personal Care – Independent Living Waiver’ is selected on the Care Plan Builder.
• FMS will auto-populate 1 unit with the same date range as Personal Care -Independent Living Waiver.
• If Personal Care Assistance – Independent Living Waiver is deleted, FMS will be deleted.
• Select the Provider.
• Adjust the start date as needed.
• When CM is added to the care plan without the need for additional Personal Care, Financial Management will also be required.
  • On the Care Plan Builder Page, select ‘Add Service’.
  • From the ‘Service Type’ drop-down select ‘Financial Management’.