The Life Plan Process

Life Plan Process Key Points

In keeping with 2018-ADM-0R62 and feedback from Providers, we updated our Life Plan Standard Operating Procedure (SOP) with added focus on ensuring:

  • All HCBS Waiver Providers are invited to the Life Plan meeting with advanced notice.
  • The meeting is person-centered and meaningful to the person supported.
  • The finalized Life Plan is distributed timely.

Scheduling and Invitations

The Life Plan meeting is scheduled well in advance with the time and place based on the Member’s preference. Life Plan meeting invitations are sent to the Member, their Circle of Support, including all HCBS Waiver Providers, at least 30 days prior to the meeting.

When the PATHS assessment meeting occurs for Members enrolled in Comprehensive Home Health Care Management, the Life Plan meeting is scheduled for the month following the PATHS assessment.


The Life Plan draft is distributed to the Member and/or their representative and their Circle of Support before the meeting. Pre-planning with information sharing to ensure technical billing information is accurate is encouraged. You may email the care manager prior to the meeting with pre-planning changes.

Life Plan Meeting

The annual Life Plan meeting must be in person, with the Member and Care Manager present. The semi-annual Life Plan meeting may be conducted in person or via telehealth as determined by the Member and/or their representative. (For Willowbrook Class Members and Members in Basic Home and Community-Based Waiver (HCBS) plan support, the annual and semi-annual Life Plan meeting must be held in person.) The meeting is meaningful to the Member; they are the focus, and their choices, wants, and wishes are reinforced.

Section 1

The assessment narrative summary is reviewed.  This section includes relevant personal history and appropriate contextual information, skills, abilities, aspirations, needs, interests, reasonable accommodations, cultural considerations, meaningful activities, challenges, etc.

Section 2

Outcomes and support strategies are reviewed. A minimum of two POMs and three goals are required. Identified POMS and goals are generated and autopopulated through the PATHS assessment. A generated POM or goal can be deleted if a Member does not wish to work on it. POMs and goals not generated can be added.

Section 3

Individual Safeguards/Individual Plan of Protection (IPOP) are reviewed. Identified Individual Safeguards/Individual Plan of Protection are generated through the PATHS assessment and auto-populated. Goals/action steps that are not generated can be added.

Section 4

HCBS Waiver services that are auto-generated from the Member’s authorized services in the CHOICES system are reviewed. Care Managers cannot change the effective date generated from Choices. At the Provider’s request, Care Managers can add the original start date (obtained from the CR4) that the Member was originally authorized for the service under “Special Considerations” in Section 4.

At the close of the Life Plan meeting, everyone involved should have a collective understanding of the changes discussed and agreed upon.

Following the Life Plan Meeting

The Care Manager completes the Life Plan and submits the Life Plan draft for supervisor approval. Upon the supervisor’s approval, the Life Plan is sent to the Member and/or representative for their written informed consent (approval). Verbal approval is no longer accepted following the end of the PHE.

The Life Plan becomes finalized within 45 days of the Life Plan meeting upon receipt of the Member and/or representative’s written informed consent. The finalized Life Plan is distributed to the Member and/or representative and Waiver Providers.

Waiver Providers are requested to acknowledge and agree to the goals and safeguards in sections II and III of the Life Plan. Upon receipt of Provider acknowledgment, the Life Plan is acknowledged and agreed upon.

If a Member and/or representative or Waiver Provider would like a copy of the acknowledged and agreed Life Plan with the Provider’s signature, they may receive one upon request from the Care Manager.