The Life Plan
The life plan represents a comprehensive living document created as the result of a person-centered planning process directed by the member, with assistance, as needed by a representative(s) identified by the member and in collaboration with the Care Management team. The life plan is an understandable and personal plan for implementing decisions made during planning and includes all service and habilitation plan components.
The Care Manager utilizes a variety of comprehensive assessment tools as part of person-centered planning to assist in gathering information about the member. With the information gathered through the comprehensive assessment and person-centered planning process with the input of the member and the interdisciplinary team the Care Manager will develop the person-centered plan called the life plan.
6 Sections in the Life Plan
Section 1 includes an IDT summary and information the member wants to share about relationships, home, and their health and medical services.
Section 2 describes the members’ Outcomes and Support Strategies.
Section 3 lists the Individual Safeguards/IPOP that accurately reflects all safety concerns of the member.
Section 4 lists the HCBS Waiver Services and Medicaid State Plan Authorized Services approved for the member.
Section 5 lists the member’s contacts (natural supports and other community resource contacts).
Section 6 documents the Acknowledgements and Agreements.
Once an individual’s life plan has been developed and finalized, the life plan becomes the active plan of care document. A life plan is finalized when it is signed by the Care Manager and the individual receiving services or their representative. The life plan document does not expire, as it remains in effect until the next Life Plan is finalized.
Per ADM 2018-ADM-06R2 issued August 2022, providers responsible for delivering services documented in Sections 2 and/or 3 of the life plan must sign the life plan to acknowledge and agree to provide the provider-assigned goals, supports, and safeguards associated with those services, per the finalized plan.
The service provider’s signature indicating acknowledgement and agreement may be done via the following methods:
- Provider signature
- A signed letter or other attestation from the provider that indicates their written informed consent.
- As a last resort, a Staff Action Plan signed by the service provider that aligns with the provider assigned goals, supports, and safeguards in Sections 2 and/or 3 of the Life Plan can suffice to indicate service provider signature of the life plan.
The service provider’s signature on the life plan and/or Staff Action Plan indicating acknowledgement and agreement to provide the goals, supports and safeguards associated with their services should be done after the life plan is finalized.
When discrepancies are identified, Care Managers and Providers work together to come to a resolution. When issues are unable to be resolved, ACA/NY has a practice in place to address formal disputes.