The CFSS service delivery plan is the document that turns a lead agency assessment into a set of services a worker can deliver and an agency can bill. Minn. Stat. § 256B.85, subd. 2 defines it as "a written document detailing the services and supports chosen by the participant to meet assessed needs that are within the approved CFSS service authorization." The participant, or the participant's representative, develops it through a person-centered process, it must contain the 15 elements in subd. 6(c), the participant agrees to it in writing, the providers responsible for carrying it out sign it, and the lead agency or case manager approves it before services start.
For a Community First Services and Supports (CFSS) agency-provider, the plan is the document the support worker's daily tasks must match and one of the records the Minnesota Department of Human Services (DHS) asks for when a T1019 claim is reviewed.
This guide follows the plan from assessment to claim, as of September 2026. For the program itself, start with what CFSS is.
Where the plan fits: assessment, plan, authorization
The plan sits between two lead agency actions. First, a certified assessor at the lead agency (the county, Tribal nation, or managed care organization) completes a MnCHOICES assessment under § 256B.0911. Subd. 5 requires it to be face-to-face, initially and at least annually, or when there is a significant change in the participant's condition or need, with the results communicated in writing within ten business days.
Second, the lead agency authorizes the service. Subd. 8(a) states that all CFSS "must be authorized by the commissioner or the commissioner's designee before services begin," and that the authorization must be completed "no later than 40 calendar days from the date of the assessment." In the agency model that is a number of 15-minute units; in the budget model it is a dollar budget.
Between those steps the participant writes the plan, with up to six consultation sessions per authorization (billed as T1023) if they want help, and the service agreement that follows cannot exceed 12 months (subd. 11(c)). Subd. 9 closes the loop by listing as noncovered any service "not authorized by the certified assessor or included in the CFSS service delivery plan" and any service "provided prior to the authorization of services and the approval of the CFSS service delivery plan."
Who develops the CFSS service delivery plan
Subd. 6(a) is specific: the plan "must be developed and evaluated through a person-centered planning process by the participant, or the participant's representative or legal representative who may be assisted by a consultation services provider."
The agency-provider does not write the plan; it reviews it, since the same paragraph requires review "by the participant, the consultation services provider, and the agency-provider or FMS provider prior to starting services." DHS sets the format under subd. 6(b) and publishes the template in its DHS-6893 form series.
The 15 required contents of the plan
Subd. 6(c) says the plan must be person-centered and must do each of the following. The table is the checklist a reviewer uses.
| # | The plan must |
|---|---|
| 1 | Specify the consultation services provider, agency-provider, or FMS provider selected by the participant |
| 2 | Reflect the setting in which the participant resides that is chosen by the participant |
| 3 | Reflect the participant's strengths and preferences |
| 4 | Include the methods and supports used to address the needs identified through the assessment of functional needs |
| 5 | Include the participant's identified goals and desired outcomes |
| 6 | Reflect the services and supports, paid and unpaid, that will help achieve the goals, including their costs and providers, including natural supports |
| 7 | Identify the amount and frequency of face-to-face supports and of remote supports and technology |
| 8 | Identify risk factors and measures in place to minimize them, including individualized backup plans |
| 9 | Be understandable to the participant and the individuals providing support |
| 10 | Identify the individual or entity responsible for monitoring the plan |
| 11 | Be finalized and agreed to in writing by the participant and signed by the individuals and providers responsible for its implementation |
| 12 | Be distributed to the participant and other people involved in the plan |
| 13 | Prevent the provision of unnecessary or inappropriate care |
| 14 | Include a detailed budget for expenditures for budget model participants, or agency-model participants purchasing goods |
| 15 | Include a plan for worker training and development under subd. 18a: what components, when, how, and how they relate to the participant's needs |
Subd. 6(d) adds a sixteenth point. The plan must describe the units or dollar amount available as both an annual total and a monthly average covering the months of the service agreement. The amount used each month may vary, but funds above the annual authorization cannot be added unless the certified assessor assesses and authorizes a change in condition and documents it in the support plan and the service delivery plan.
What changes in the agency model
Under subd. 11(b), the agency must allow the participant "a significant role in the selection and dismissal of the support workers for the delivery of the services and supports specified in the participant's CFSS service delivery plan." Under subd. 11(g), goods bought by an agency-model participant must be specified in the plan and a detailed budget, and paid through an FMS provider.
Element 15, the worker training and development plan, is the agency's operating document. Subd. 18a says those services must be "described in the participant's CFSS service delivery plan and documented in the participant's file," and that direct observation, monitoring, and coaching of a new worker must be provided at the start of services and specified in the plan. The CFSS support worker requirements guide covers the 30-day competency observation that goes with it, and the agency model vs budget model comparison shows how the plan differs when the participant is the employer.
Who signs and who approves
Three groups touch the plan before services start:
- The participant. Subd. 6(c)(11) requires the plan to be "finalized and agreed to in writing by the participant." When a representative is appointed, subd. 14a(f) requires the representative to be identified at the time of assessment and listed on the service agreement and the service delivery plan.
- The implementers. The same clause requires signatures from "individuals and providers responsible for its implementation." In the agency model that is the agency-provider.
- The approver. Subd. 6(f) states that the plan "must be approved by the lead agency for participants without a case manager or care coordinator," and that "a case manager or care coordinator must approve the plan for a waiver or alternative care program participant." The approval arrives as a service delivery plan addendum, which the agency files with the plan.
The consultation services provider is not a required signer, but under subd. 6(e) it consults with the participant, the agency-provider, and the case manager or care coordinator whenever the plan is developed or modified.
Compliance note: an unsigned plan is not a plan. If the participant's signature, the agency's signature, or the lead agency approval is missing, every claim dated before the missing item was obtained is at risk under subd. 9. Date every signature, and file the addendum next to the plan so the approval date can be shown.
When the plan must be reviewed or updated
The statute sets two clocks, one for the participant and one for the agency.
| Trigger | Who acts | Requirement | Source |
|---|---|---|---|
| Before services start | Participant, consultation services provider, agency-provider or FMS | Review the plan | Subd. 6(a) |
| Annual reassessment | Same | Review the plan at least annually | Subd. 6(a) |
| Significant change in condition, or change in need | Same | Review and revise; the lead agency may reassess and reauthorize | Subd. 5 and 6(a) |
| 90 days after service initiation, then at least quarterly | Agency-provider with the participant | Evaluate whether the plan identifies current needs, goals are being met, workers are competent, and revisions are needed | Subd. 11a(a) and (b) |
| Discovery of a change in condition | Agency-provider | In-person evaluation within 30 calendar days | Subd. 11a(a) |
| Evaluation shows changes are needed | Agency-provider | Revised plan to the participant within 30 calendar days of the evaluation | Subd. 11a(b) |
| 60 days before the current authorization ends | Agency-provider or FMS provider | Request the reassessment on DHS forms | Subd. 10(b)(10) |
Subd. 11a also requires quarterly evaluations during the first year to be in person, and at least one in-person quarterly evaluation each year after that. The 60-day rule is the agency's duty, not the participant's, and it is what keeps the next plan and authorization from lapsing.
How the plan supports the T1019 claim
The CFSS billing guide lists the records an agency must have before it submits any claim, and the service delivery plan and the lead agency addendum are on that list next to the assessment copy and the service authorization. Three statutory links connect the plan to the claim. Subd. 12(a)(8) requires an enrolling agency-provider to hold a copy of its time sheet and a copy of the participant's service delivery plan. Subd. 9 makes services outside the plan, or before its approval, noncovered. Subd. 15(b) requires the support worker's time sheet to "correspond to the participant's assessed needs within the scope of CFSS covered services," which is the plan's element 4; the PCA and CFSS time sheet guide lists every field the time sheet must carry.
A T1019 line is defensible when the date of service is inside the authorization, the tasks on the time sheet for that date are tasks in the plan, and the plan was approved before that date. Under DHS pre-payment review, those facts may be checked before payment.
Contents checklist for the agency file
Before the first claim, confirm the participant file holds: the dated assessment copy; the plan with all 15 elements and the subd. 6(d) amounts; dated participant and agency signatures; the dated lead agency, case manager, or care coordinator approval; the service authorization letter with its period and unit total; each worker's training and development plan; the written participant agreement and any representative agreement; and a review log showing the pre-service review, each 90-day and quarterly evaluation (in person or not), and each revision date.
How Trustora helps
Trustora's CFSS participant record stores the service delivery plan as a structured document with the 15 subd. 6(c) elements as required fields, the annual and monthly amounts from subd. 6(d), the participant and agency signature dates, and the lead agency addendum with its approval date. The 90-day and quarterly evaluation due dates are calculated from the service start date, and the compliance engine alerts before an evaluation or an annual review lapses.
Because the plan's tasks feed the caregiver app, a support worker records visit activities against the plan rather than from memory, and the pre-claim gate checks that each T1019 line falls inside the authorization period and after the plan approval date before it is released. The one-click DHS audit binder assembles the assessment, plan, addendum, authorization, and evaluation log for any participant and date range. See the platform overview for the full CFSS workflow.