Maryland Department of Health and Mental Hygiene
Community First Choice (CFC)
 Affordable Care Act (ACA) program expanding options for
community-based long-term services and supports.
 Allows waiver-like services to be provided in the State Plan
 Emphasizes self direction
 Increases the State’s enhanced match on all CFC services by 6 %
 Allows Medicaid to set consistent policy and rates across programs
 Requires an institutional level of care
 CFC will offer all mandatory and optional services allowable
 Personal assistance services
 Emergency back-up systems
 Transition services,
 Items that substitute for human assistance

Technology, accessibility adaptations, home delivered meals, etc.
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Old Service Structure
 Maryland operated 3 Medicaid programs that offered
personal assistance services:
 Medical Assistance Personal Care (MAPC)
 State plan program that offers personal care and nurse case
monitoring
 Uses the 302 assessment and has a 1 ADL medical necessity
standard
 Living at Home (LAH) Waiver
 Target group ages 18-64 with disabilities
 Nursing Facility Level of Care standard
 Waiver for Older Adults (WOA)
 Target group aged 50 and over
 Nursing Facility Level of Care standard
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New Service Structure
 Services formerly offered through multiple programs are now
consolidated under CFC
 Maximizes the enhanced Federal match
 Resolves inconsistent rates and policies across programs
 These two 1915(c) waiver programs merged into a single
waiver
 Reduces duplicate applications
 Offers a full menu of services to waiver participants
 Simplifies administration
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Service and System Enhancements
 CFC adds emphasis on person-centered planning and self-
direction
 Maryland Department of Disabilities (MDOD) will be providing
self-direction training on hiring, firing, and managing providers
 CFC offers the participant some flexibility in choosing provider
rates for personal assistance services
 Budgets will be set based on the assessment of need and
approved by the Department
 Participants will be able to act as their own supports planner
and request changes to their plans and rates via the
LTSSMaryland tracking system portal
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Enhancements for Participants
• All participants have access to:



increased self-direction opportunities,
a larger provider pool, and
choice of supports planning providers
 Waiver participants now have choice in case management
(supports planning) providers and access to a larger provider
pool
 MAPC will move to an improved rate structure and increased
self direction options
 More people in the community will have access to waiver-like
services
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Levels of Care
 The new merged waiver will continue to use the nursing
facility level of care
 The CFC program will be available to individuals who meet any
institutional level of care.
 Includes nursing facility, chronic hospitals, ICF/IID, and psychiatric
hospitals
 MAPC uses a standard that is lower than NF LOC; one ADL
 We estimate that approximately 80% of the MAPC participants meet
nursing facility LOC and will be eligible to receive CFC services
 MAPC and NF Levels of Care will be determined with a core
standardized assessment instrument, the interRAI-Home Care,
completed by local health department clinicians
 Levels of care will be reviewed annually
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New Service Structure
MAPC
Personal Assistance Services
Case Management/Supports Planning
Nurse Monitoring
Personal Emergency Back-up Systems
Transition Services
Consumer Training
Home Delivered Meals1
Assistive Technology1
Accessibility Adaptations1
Environmental Assessments
Medical Day Care
Nutritionist/Dietician
Family Training
Behavioral Consultation
Assisted Living
Senior Center Plus
1. Items that sub
*CFC Services will be available to all waiver participants
CFC
CO Waiver
Financial Eligibility
 Participants must already be in a waiver and meet the financial
qualifications of that waiver, OR
 Participants must be eligible for Medicaid under the State Plan
AND
 Participants must
 Be in an eligibility group under the State plan that includes
nursing facility services; or
 If in an eligibility group under the State plan that does not
include such nursing facility services, have an income that is
at or below 150 percent of the Federal poverty level (FPL)
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Medical Eligibility
 The individual must meet the institutional level of care
 Individuals participating in any of the waiver programs meet
an institutional level of care, as this is a requirement for all
waivers
 Community Options, New Directions, Community Pathways,
Autism, Brain Injury, Medical Day Care, Model
 Medical needs will be assessed by the Local Health
Department using the interRAI
 UCA (currently Delmarva) will verify Nursing Facility and
MAPC levels of Care
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Participation in Other Programs
 Waiver participants are eligible to receive CFC services, but
supports should be coordinated between programs to ensure
adequate supports without duplication of services or allowing
contraindicated services
 Participants who receive bundled payments for some DDA,
assisted living, or PACE services are not eligible to receive CFC
services on the same day
 Supports planners must obtain copies of supports plans from
other programs, upload them into the LTSS, and account for
them in the LTSS POS
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Community Definition
 To be eligible for CFC, the participant must reside in a
community residence as defined by the new Federal
regulation
 CMS Toolkit on the community definition released on March
2014
 Important eligibility requirement that means that the
participant has:






access to the community and community services,
control over choice of roommates,
choice of if and when to receive visitors,
access to food at any time,
landlord-tenant or real property laws of the jurisdiction, and
privacy and locks.
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Community Definition
 People in assisted living, group homes, and alternative living
units are not currently eligible for CFC
 Definition will apply to most HCBS settings in the future
 Unknown impact on day settings
 Rebecca VanAmburg is the State lead on implementation
 Have until March 2015 to develop a transition plan for all
programs to meet the definition
 Up to 5 years to implement the plan, if approved by CMS
 Will be hosting stakeholder groups and gathering public input on
a transition plan
CFC Budget Process
Community First Choice Process
Eligible for Medicaid
(through a waiver or
state plan)
Assigned a
personal
budget
Develops
Plan of
Service
Assessed by
Local Health
Department
Department
(DHMH) approves
Plan of Service
Applicant
selects
Supports
Planner
Participant
begins receiving
services
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How budget is determined
 The interRAI assessment has existing algorithms statistically
validated in this instrument to assign one of 23 Resource
Utilization Groups (RUGs) to participants
 Using RUGs-based acuity, the Department assigns participants
to groups with a given budget for each group based on a scale
of needs
 Participants will use this budget for certain services and are
then empowered to determine their personal assistance hours
and schedules within their budget
 Other services will be provided as needed and accounted for
outside of the flexible budget
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Budgets by Group
Grouper Description
Group 1 Physical Function – Low ADL
Budget
$8,336
Group 2 Behavioral – Low ADL, High IADL
$16,167
Group 3 Clin. Complex – Low to Medium ADL
$22,504
Group 4 Physical Function – High ADL
$30,314
Group 5 Extensive Services 1 – Medium to High ADL
$34,545
Group 6 Extensive Services 2 – Medium to High ADL
$43,558
Group 7 Extensive Services 3 – Medium to High ADL
$76,360
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Services within the flexible budget
1.
2.
3.
Personal Assistance
Home-Delivered Meals
“Other” Items that Substitute for Human Assistance
 All other services are included in the Plan of Service in
addition to the flexible budget
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Services in the Plan
CFC Services Allowable
Under Flexible Budget
Other CFC Services based on
the Individual Participant’s
Assessed Needs
Personal Assistance
Technology
Dietitian and Nutrition
Services
Home-Delivered Meals
Environmental Accessibility
Adaptations
Family Training
Other items that Substitute for
Human Assistance
Environmental Assessments
Medical Day Care
Supports Planning
Behavioral Health
Consultation
Transition Services
Senior Center Plus
Consumer Training
Personal Emergency Response
Systems
Waiver Services
Assisted Living
Nurse Monitoring
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Example--Participants receiving personal
assistance services 7 days a week
Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
Group 7
Annual
Budget
$ 8,336
$ 16,167
$ 22,504
$ 30,314
$ 34,545
$ 43,558
$ 76,360
Hours at Min Hours at Max Hours at Hours at
independent independent standard standard
rate
rate
rate
agency rate
Daily Budget ($10.22)
($14.27)
($12.27) ($16.08)
1.6
2.2
1.9
1.4
$22.84
3.1
4.3
3.6
2.8
$44.29
4.3
6.0
5.0
3.8
$61.65
5.8
8.1
6.8
5.2
$83.05
6.6
9.3
7.7
5.9
$94.64
8.4
11.7
9.7
7.4
$119.34
14.7
20.5
17.1
13.0
$209.21
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Exception Process
 If a person cannot be supported in the community within the
recommended flexible budget, an exceptions process exists to
request additional funds, beyond those assigned through the
interRAI and the RUGs referenced.
 The exceptions process is also used to request items of services
not recommended by the clinician in the recommended plan of
care
 The supports planner is responsible for explaining this process
to the participant, completing the exceptions form, acquiring
any additional documentation needed to support the
exception request, and uploading all supporting documents to
the LTSSMaryland tracking system
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Concerns about implementation
 Adequate, accurate information about denials and appeal
rights
 Process of negotiating exceptions requests before approval
 Requests for additional information about process and
outcomes
How many people negotiated hours to avoid denials?
How many people have had their hours cut?
Has anyone gone back to a facility because of a reduction?
How is DHMH processing exceptions? What are the criteria for
approval?
 What are the qualifications of the supports planners and review team
at DHMH?

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
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DHMH is committed to addressing all
concerns and offering transparency
 94% of plans with exceptions are approved
 1% denial rate overall for the nearly 3,000 plans approved to
date
 Public meeting, led by advocates, to be held June 16th so all
concerns and issues can be heard by DHMH
 Data requests in progress
 Number of people reinstitutionalized
 Number of people who have experienced a reduction in
hours
 Spending on personal assistance services pre-and post
implementation
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Other Upcoming
Change
Fair Labor Standards Act
Domestic Service Final Rule
 FLSA Domestic Service Final Rule 29 CFR 552
 Published October 1, 2013, with an effective date of
January 1, 2015.
 Regulations concern domestic workers under the FLSA,
bringing minimum wage and overtime protection to
workers who enable individuals with disabilities and the
elderly to continue to live in their homes and participate
in their communities.
Co-employers
 DOL definition: An employer of a personal assistance
provider other than the individual receiving services or
their representative
 Maryland is likely to be considered the co-employer
 Based on DOL’s example of Oregon’s program
 Co-employers cannot claim exemptions of minimum
wage and overtime
Overtime
 When the State is the co-employer, overtime applies
across participants
 Current 40 hour per week limit is per participant
 If a provider works for John and Jane, they can work 40
hours for John and 40 hours for Jane (total of 80 hours)
 New limit is for the provider
 Expands to include all participants the provider serves
 The provider can only work 40 hours total for both John and
Jane
Travel time
 Existing regulations state that employees who travel to
more than one worksite for an employer during the
workday must be paid for travel time between each
worksite
 Once the state I the co-employer, the provider will get
paid for travel time between participant
 Time between shifts for John and Jane
Next Steps
 Further Research
 How are other States implementing the rule?
 How many of our providers serve more than 1 person per
day?
 How many providers work more than 40 hours because
they work for more than 1 participant?
 What is the budget impact?
 How do you calculate travel time?
 What budget pays for the travel time?
 Future Stakeholder Meetings and Discussion
Questions?
Lorraine Nawara
Lorraine.nawara@maryland.gov
Referrals/General Questions
DHMH.CFC@maryland.gov
410-767-1739
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