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On May 9, 2002, Secretary Thompson unveiled the Independence Plus initiative in response to Executive Order 13217, in which the Department of Health and Human Services (DHHS) promised to provide states with simplified model waiver and demonstration application templates that would promote person-centered planning and self-directed service options.

Independence Plus is based on the experiences and lessons learned from states that pioneered the philosophy of consumer self-direction. Specifically, two national pilot projects demonstrated the success of these approaches in the 1990s: (a) the Self-Determination project in nineteen (19) states, focused primarily in the Home and Community-Based Services § 1915(c) waivers, and (b) the "Cash and Counseling" project in three (3) states, focused on the § 1115 Demonstrations.  These programs afforded service recipients or their families the option to direct the design and delivery of services and supports, avoid unnecessary institutionalization, experience higher levels of satisfaction, and maximize the efficient use of community services and supports.


CMS defines a self-directed program as "a state Medicaid program that presents individuals with the option to control and direct Medicaid funds identified in an individual budget."  The CMS requirements for a comprehensive self-directed program, or Independence Plus,  include:

  • Person-centered planning - A process, directed by the participant, intended to identify the strengths, capacities, preferences, needs and desired outcomes of the participant.
  • Individual budgeting - The total dollar value of the services and supports, as specified in the plan of care, under the control and direction of the program participant.
  • Self-directed services and supports - A system of activities that assist the participant to develop, implement and manage the support services identified in his/her individual budget.
  • Quality assurance and quality improvement (QA/QI) - The QA/QI model will build on the existing foundation, formally introduced under the CMS Quality Framework, of discovery, remediation and continuous improvement.


CMS developed two optional electronic templates under Independence Plus. The templates provide guidance through elective design features for  self-directed programs, and use a streamlined application process intended to facilitate a faster federal approval of state proposals. 

  • Section 1115 Demonstration Template - Allows Medicaid beneficiaries to manage their cash allowance directly and to hire legally responsible relatives. 
  • Section 1915(c) Waiver Template - Allows Medicaid beneficiaries to self-direct a budget and a wide array of services necessary to keep a person from being institutionalized in a hospital, nursing facility or Intermediate Care Facility for the Mentally Retarded.

CMS is consolidating the existing Independence Plus template into a new web based Section 1915(c) application with instructions.  The consolidation enables: the expansion of a variety of self-directed options in existing waivers; consistent participant protections across all waiver programs; minimal administrative burden to states; an  easier Waiver amendment process; and improved communication of expectations for quality.


There are currently eleven (11) approved Independence Plus waivers in ten (10) states, and several states are working with CMS to submit proposals:

  • New Hampshire [§1915(c) new waiver, approved 12/16/02, effective 1/1/03];
  • South Carolina [§1915(c) new waiver, approved 3/11/03, effective 5/1/03];
  • Louisiana [§1915(c) new waiver, approved 4/24/03, effective 4/24/03];
  • North Carolina

          [§1915(c) new waiver, approved 12/23/03, effective 1/1/04];

-         [§1915(b)/(c) new waiver, approved 10/6/04, effective 4/1/05];

  • Florida [§1115 amendment to Cash and Counseling, approved 5/30/03, effective 5/30/03];
  • Maryland [§1915(c) new waiver, approved 10/21/04, effective 7/1/05];
  • California[§ 1115 new demonstration, approved 7/30/04, effective 8/1/05];
  • Delaware [(§1915(b)/(c) new waiver, approved 11/12/04, effective 12/1/04];
  • New Jersey [§1115 amendment to Cash and Counseling, approved 12/15/04, effective date pending receipt of Operational Protocol];
  • Connecticut [§1915(c) new waiver, approved 1/14/05, effective 2/1/05].

In addition, there are three (3) original Cash and Counseling §1115 demonstration programs (AR, NJ, and FL), two (2) other states with §1115 self-direction demonstrations similar to Cash and Counseling (OR and CO), and a multitude of states that offer self-directed program options in their §1915(c) home and community based waivers.  Twelve (12) states were awarded a 2003 Real Choice Systems Change Grant from CMS to develop Independence Plus proposals by 2006, and the Robert Wood Johnson Foundation, in partnership with the Office of the Assistant Secretary for Planning and Evaluation, and Administration on Aging, awarded Cash and Counseling grants on October 7, 2004 to another eleven (11) states to develop Independence Plus programs using either a §1915 (c) waiver or §1115 demonstration application.

CMS offers states ongoing technical assistance to design Independence Plus programs and self-directed options. 

For additional information on Independence Plus, click on the navigation links on the left side of this page.

Independence Plus Frequently Asked Questions (PDF 62KB)

Related Links Inside CMS

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Related Links Outside CMSExternal Linking Policy

Cash and Counseling Program
Center for Self-Determination
National Research and Training Center
National Empowerment Center
Substance Abuse and Mental Health Services Administration
Home and Community Based Services Resources

Page Last Modified: 12/14/2005 12:00:00 AM
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