Home Care Plan of Care in New Hampshire: What It Includes and How to Change It

What the Care Plan Is

Once your parent is approved for the Choices for Independence (CFI) Medicaid waiver, a care coordinator from the assigned Case Management Agency (CMA) conducts an in-home visit to draft a Comprehensive Assessment and Care Plan. This document is the operational blueprint for everything that happens next — it specifies which services your parent will receive, how many hours per week, and which providers will deliver them.

The care plan is not a suggestion. It is the authorization document that tells providers what Medicaid will pay for. Services not listed in the care plan are not covered, and providers cannot deliver hours beyond what the plan authorizes without a formal amendment.

What the Care Plan Covers

A CFI waiver care plan can authorize a broad range of in-home services, tailored to the specific functional limitations identified during your parent's Medical Eligibility Assessment (MEA). Common service categories include:

• Personal care assistance — hands-on help with bathing, dressing, grooming, toileting, and transfers
• Homemaker services — light housekeeping, laundry, meal preparation, and grocery shopping
• Home health aide visits — for recipients who need both personal care and basic health monitoring
• Adult day health services — structured daytime programs that provide socialization, meals, and supervised activities
• Personal Emergency Response System (PERS) — a wearable alert device that connects to 24/7 monitoring
• Environmental accessibility adaptations — home modifications like grab bars, ramps, and bathroom retrofits required by the care plan
• Respite care — temporary relief for family caregivers, available in-home or at a licensed facility
• Non-medical transportation — rides to medical appointments, adult day programs, and essential errands
• Self-directed care — authorization for the recipient to hire and manage their own caregiver, including a family member, paid through a fiscal management agency

The care coordinator determines the type and quantity of each service based on the MEA findings, the recipient's stated preferences, and what is medically necessary to keep them safely at home. The plan must demonstrate that the total cost of community-based services does not exceed the cost of equivalent nursing facility care — this is the federal cost-neutrality requirement that applies to all 1915(c) waivers.

How the Plan Gets Written

The care coordinator visits your parent's home within 30 days of the Medicaid approval and conducts a comprehensive assessment that goes deeper than the clinical MEA. The coordinator evaluates:

• The physical layout of the home and any safety hazards
• Your parent's daily routine and which tasks require assistance
• The availability of informal supports (family, friends, neighbors)
• Your parent's preferences about who provides care and when
• Medical conditions that affect daily functioning

After the assessment, the coordinator drafts the care plan and reviews it with your parent (or their authorized representative). You should receive a copy of the plan. Read it carefully — it is your reference document for verifying that providers are delivering the authorized services.

How to Request Changes

Care needs change over time. A parent who was managing with 15 hours per week of personal care six months ago may now need 25 hours after a fall, a hospitalization, or progression of a cognitive condition. The care plan should reflect those changes, but it does not update automatically.

Contact the care coordinator directly when you notice a change in your parent's condition or care needs. Document what has changed — new falls, increased confusion, inability to manage a task that was previously independent — and provide dates and specifics. The coordinator can request a reassessment and amend the care plan to authorize additional hours or services.

If the care coordinator denies your request or you disagree with the plan, you have the right to appeal through the DHHS administrative hearing process. The key is documentation: the more detailed your record of your parent's daily functional limitations, the stronger your case for additional services.

Hospitalizations require particular attention. If your parent is admitted to a hospital or nursing facility for more than 30 days, their CFI waiver slot may be suspended. Work with the care coordinator and the facility discharge planner before your parent returns home to ensure the care plan is reinstated or updated to reflect any changes in condition.

Common Care Plan Problems

Authorized hours that go unfilled. The care plan authorizes services, but New Hampshire's home care staffing shortage means agencies sometimes cannot recruit workers to cover all authorized shifts. If this happens consistently, document every unfilled shift and discuss alternatives with your care coordinator — including switching providers or enrolling in self-directed care to hire your own caregiver.

Mismatch between authorization and need. The initial assessment may underestimate your parent's needs, especially if your parent minimized their difficulties during the coordinator's visit (the same masking behavior that complicates the MEA). If the care plan feels too thin, request a reassessment and bring your 14-day functional care log to the meeting.

Services not offered that should be. Some families don't realize that PERS devices, home modifications, and adult day services are covered under the CFI waiver. If the care coordinator did not mention these options, ask specifically. The coordinator is required to present all available services, not just personal care hours.

The Aging in Place in New Hampshire guide includes a CFI application tracker and a document preparation checklist that cover both the initial application process and ongoing care plan management — so you have a structured way to track authorizations, provider contacts, and reassessment deadlines in one place.

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