What problem did MACPAC find in self-directed HCBS supports?

In a Sept. 25, 2026, presentation based on three-state case studies, MACPAC staff said Information and Assistance roles are often unclear, with overlapping duties that blur who reports incidents, follows up, and stays accountable. Poor I&A quality was linked to service delays, paperwork errors, delayed provider payment, and safety concerns.

What policy option did MACPAC staff propose for self-direction?

Staff proposed that Congress and CMS clarify and streamline all self-direction supports under a single entity and reimburse those supports through an administrative contract, aiming for clearer accountability and less data fragmentation. Commissioners were asked for feedback before any formal recommendation language.

MACPAC: put self-direction supports under one entity

MACPAC’s Sept. 25, 2026, briefing found unclear Information and Assistance roles disrupt self-directed HCBS. Staff floated a policy option: Congress and CMS should streamline supports under one administratively contracted entity.

practice · self-direction · macpac · hcbs · fms

Chona Kasinger for Disabled And Here, CC BY 4.0

Direct Support News desk · September 25, 2026 · Updated October 2, 2026 · 1 min read

MACPAC staff told commissioners on Sept. 25, 2026, that Information and Assistance (I&A) in self-direction is often unclear—and that the confusion can delay services, muddle incident follow-up, and slow pay to HCBS workers. The findings come from a federal policy scan plus case studies in three states with different Medicaid authorities and delivery systems, detailed in MACPAC’s publication and meeting slides.

Self-direction lets people choose providers and shape the amount, duration, and scope of services in a person-centered plan. Federal rules also call for quality systems, I&A supports, financial management services (FMS), and an individualized budget. Staff said overlapping I&A duties leave ambiguity about who reports, follows up, and stays accountable when something goes wrong.

Policy option on the table

MACPAC’s policy option asks Congress and CMS to clarify and streamline all self-direction supports under a single entity, reimbursed through an administrative contract. Staff argued that would sharpen health-and-welfare accountability, cut the number of offices beneficiaries juggle, and reduce fragmented data across health plans, FMS systems, and supports brokers. They noted only 10 states use Section 1915(j) authority—where statute defines a support system—while 46 states offered self-direction under 1915(c) in 2023 without parallel I&A rules.

Commissioners were asked whether the evidence supports moving to draft recommendation language at a future meeting. No final recommendation was adopted in the slides.

Why this matters for providers and DSPs

When I&A breaks down, DSPs and family employers wait on budgets, timesheets, and authorizations while people go without hours. A single contracted support entity—if Congress and CMS pursue it—could change who answers incident questions and who supports coordinators call when pay stalls. Until then, agencies and FMS vendors should map who owns reporting and resource navigation in each self-directed program they touch.

Common questions

What problem did MACPAC find in self-directed HCBS supports?: In a Sept. 25, 2026, presentation based on three-state case studies, MACPAC staff said Information and Assistance roles are often unclear, with overlapping duties that blur who reports incidents, follows up, and stays accountable. Poor I&A quality was linked to service delays, paperwork errors, delayed provider payment, and safety concerns.
What policy option did MACPAC staff propose for self-direction?: Staff proposed that Congress and CMS clarify and streamline all self-direction supports under a single entity and reimburse those supports through an administrative contract, aiming for clearer accountability and less data fragmentation. Commissioners were asked for feedback before any formal recommendation language.