Maryland Department of Health and Mental Hygiene
CFC Training
CFC
Overview
Enrollment
Process
Services
Eligibility
2
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.
3
Former 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
4
Former Service Structure
MAPC
LAH
WOA
Personal Assistance Services
Case Management/Nurse Case Monitoring
Consumer Training
Personal Emergency Back-up Systems
Transition Services
Home Delivered Meals
Assistive Technology
Accessibility Adaptations
Environmental Assessments
Medical Day Care
Nutritionist/Dietician
Family Training
Behavioral Consultation
Assisted Living
Senior Center Plus
5
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
6
HCBO Waiver: Community Options
 Provides community services and supports that enable older
adults and individuals with physical disabilities to live in their
own homes
 Services provided under CFC are available to participants of
this waiver
 Extra services exclusively attached to this waiver are medical
day care, nutritionist/dietician, family training, behavioral
consultation, assisted living and senior center plus
7
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 available to all waiver participants
CFC
Waiver
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
9
Projected Enrollment in Each Program
Waiver
Participants
Receiving CFC
services 3,857
CFC-Only
Population
5,061
MAPC
Population 991
10
CFC Service Package




Personal Assistance
Nurse Monitoring
Supports Planning
Items or Services that Substitute for Human Assistance
 Environmental Assessments and /or Modifications
 Technology
 Home Delivered Meals
 Consumer Training
 Personal Emergency Response System
 Transition Services
11
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
12
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 after July 1st
 More people in the community will have access to waiver-like
services
13
Personal Assistance
 Assistance with Activities of Daily Living (ADLs),
Instrumental Activities of Daily Living, health related tasks
through hands on assistance, supervision, and/or cueing,
will be provided under the Personal Assistance Services .


Participants will be able to choose between receiving Personal
Assistance Services through an agency or an independent model.
Proposal to create a shared Personal Assistance Service for
participants that share a home.
14
Nurse Monitoring
•
•
Nurse Monitors provide quality oversight by
assessing the participant and monitoring the
provision of personal assistance services
The participant can determine the frequency of
nurse monitoring in a self directed model, but there
is a minimum of two times a year.
•
•
The Nurse Monitor recommends the frequency of
services, based on clinical judgment and whether there
are delegated nursing tasks.
Supports Planner adds Nurse Monitoring to the POS.
15
Nurse Monitoring
 Nurse Monitors are required to contact the
participant for the purpose of evaluating participant
status at a minimum of every 6 months, with at least
one in-person home or workplace visit every 12
months.
 More frequent nurse monitoring can be approved
if needed, as recommended by the nurse monitor.
 Nurse monitoring visits can be conducted on the
same day as the InterRAI.
16
Supports Planning
 Supports planning providers will engage participants in a
person-centered planning process that identifies the
goals, strengths, risks, and preferences of the participant.
 The Supports Planner will:
 Appropriately counsel an individual before enrollment; and
 Provide the necessary information, training, and assistance
to ensure that an individual has the required knowledge
and ability to manage their services and budgets.
17
Supports Planning Responsibilities
 Coordinate community services and supports from various
programs and payment sources to aid applicants and
participants in developing a comprehensive plan for
community living.
 Support applicants in locating and accessing housing options,
identifying housing barriers such as past credit, eviction, and
criminal histories, and in resolving the identified barriers.
 Assist the applicant in developing a comprehensive POS that
coordinates the transition from an institution, and maintains
community supports throughout the individual’s participation
in services.
18
Items that increase independence or
substitute for human assistance
 The following will be services permissible under CFC in the
category of items that substitute for human assistance:




Home delivered meals
Accessibility Adaptations
Environmental Assessments
Technology
 Each of these services are covered as items that substitute for human
assistance, but have their own enrolled provider pool
• “Other” items that substitute may also be covered to the
extent that they meet the service definition
• Only “Other” items that substitute for human assistance are paid
through the fiscal intermediary
19
Consumer Training
•
•
•
The topics covered by consumer training may include,
but are not limited to money management and
budgeting, independent living and meal planning.
These activities are to be targeted to the individualized
needs of the participant receiving the training; and
sensitive of the educational background, culture, and
general environment of the participant receiving the
training.
Consumer training will be provided by an approved
Medicaid provider.
20
Consumer vs. Self Direction Training
Consumer Training
Self Direction Training
Provided by MA Providers
Provided by MDOD
CFC Service (6% enhanced match)
CFC Administrative Activity (no
enhanced match)
Trains consumer on the acquisition,
Trains consumer on hiring, firing,
maintenance and enhancement of skills evaluating and managing Personal
necessary for individuals to perform
Assistance providers
ADLs, IADLs, and Health Related Tasks
21
Personal Emergency Response System
 A personal emergency response system (PERS) is an
electronic device, piece of equipment or system which,
upon activation, enables a participant to secure help in an
emergency, 24 hours per day, seven days per week.
 There are a variety of devices and systems available to
meet individual needs and preferences of CFC
participants choosing this service.
 This service may include any or all of the following components:
purchase/installation and monthly maintenance/monitoring of a
PERS device.
22
Transition Assistance
 Expenditures essential for transition and linked to an assessed
need for an individual to transition from an institution to a
community-based home setting.
 Such as security and utility deposits, bedding, basic kitchen
supplies, and other necessities.
 Items must be essential to a successful transition and may be
secured up to 60 days post-transition.
 Fiscal Intermediary only pays for items on an approved plan of
service.
 Excludes recreational and non-essential items such as home
décor, TVs, internet access, and gaming systems.
23
CFC and Waiver Eligibility
Community First Choice
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
25
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)
26
Community First Choice
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
27
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, Traumatic 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
28
Participation in Other Programs
 Waiver participants are eligible to receive CFC services,
supports will be coordinated between programs to ensure
adequate supports without duplication of services or allowing
contraindicated services
 Participants who receive bundled payments for some TBI,
DDA, assisted living or PACE services are not eligible to receive
CFC services on the same day
29
Other Eligibility Requirements
 To be eligible for CFC, the participant must reside in a community
residence. This 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, and
 privacy and locks
 The residence must be physically accessible to the participant.
 Any restrictions on the activities of the participant cannot be for the
convenience of the caregiver.
 The living arrangement must be subject to the normal landlord-tenant
or real property laws of the jurisdiction.
30
Waiver Eligibility
 Technical: Must be at least 18 years old
 Medical: Must meet a nursing facility level of care
 Financial: Eligibility is based on both income and
assets. The monthly income limit in based on 300% of
SSI. In 2014, the income standard is $2,163. Assets may
not exceed $2,000 or $2,500 depending on eligibility
category. The income standard changes annually in
January.
CFC and Waiver Enrollment
Applicants can enroll into
CFC from…
An institution
The community
33
Enrollment in CFC from Nursing Facility
Applicant in
Nursing
Facility
receives
options
counseling
Applicant has
community MA
Options Counselor refers to
LHD for assessment* and
provides Supports Planning
selection packet to
applicant**
No community
MA
Options Counselor helps
complete MA application.
Supports Planner
meets with participant
to create Plan of
Service***
Plan of
Service
approved by
DHMH
Supports
Planner
coordinates
transition
*LHD has 15 calendar days to complete assessment and Recommended Plan of Care
**Applicant has 21 calendar days to select a Supports Planner before auto assignment
***Supports Planner has 20 days to submit the POS
Contact is made
with Supports
Planning provider
Supports Planner
meets with participant
at least once every 90
days (can be waived by
participant)
34
Enrollment into Waiver from a Nursing
Facility
Applicant
in Nursing
Facility
receives
options
counseling
Has Long Term Care
MA
DEWS
Wavier
Application
Assistance
LHD for assessment
Provides Supports
Planning selection
packet to applicant
Has Community MA
Apply for CFC
Contact made
with Supports
Planning
Provider
Supports Planner
meets with
participant to
create Plan of
Service***
Plan of
Service
approved by
DHMH
Supports
Planner
coordinates
transition
*LHD has 15 calendar days to complete assessment and Recommended Plan of Care
**Applicant has 21 calendar days to select a Supports Planner before auto assignment
***Supports Planner has 20 days to submit the POS
Supports Planner
meets with participant
at least once every 90
days (can be waived
by participant)
35
Enrollment in CFC from the Community
Contact DHMH
Applicant in
Community
Applicant
contacts MAP
site, referred
to DHMH
Contact made with
Supports Planning
Provider
Community MA
status verified
by DHMH
Has
Community
MA
No Community
MA
Refer to Local
DSS
Supports Planner
meets with participant
to create Plan of
Service***
Plan of Service
approved by
DHMH
*LHD has 15 calendar days to complete assessment and Recommended Plan of Care
**Applicant has 21 calendar days to select a Supports Planner before auto assignment
***Supports Planner has 20 days to submit the POS
Add to LTSS
Referral to LHD
for assessment*
Mail out Supports
Planning selection
packet**
Supports Planner
meets with participant
at least once every 90
days (can be waived by
participant)
36
Assessment by the LHD
 After a person applies, they are referred to the local health
department for an assessment
 LTSS programs use the interRAI Home Care (HC) assessment,
the core standardized assessment adopted by the Department
 Informs and guides comprehensive care and service planning in
community-based settings
 Developed through years of research and is tested as reliable and
valid instrument to measure level of need
 Generates Clinical Assessment Protocols and Resource Utilization
Groups as indicators of need and areas of support
 Is used to determine Nursing Facility level of care
38
Supports Planner Provider Selection
 Applicants will be provided with information about all





Supports Planning agencies by the Options Counselor or via a
mailing form the Department
The applicant may contact the agency of choice
The Agency of Choice will enter the selection into LTSS
If no selection is made within 21 days, an agency will be autoassigned
A participant can choose to change their auto-assigned
supports planning provider agency at any time
Once the initial selection has been made by the applicant,
another agency may not be chosen for 45 days
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
43
Budgets by Group
Budget
$8,336
$8,336
$8,336
$8,336
$8,336
$8,336
$16,167
$16,167
Group 6
IA2
PB0
CB0
RA2
PC0
SSA
IB0
BB0
PD0
CC0
SE1
RB0
SSB
SE2
Grouper Description
Physical Function – Low ADL
Behavioral – Low ADL
Clin. Complex – Low ADL
Cognitive Impairment – Low ADL
Physical Function – Low ADL, Low to High IADL
Rehabilitation - Low ADL
Behavioral – Low ADL, High IADL
Clin. Complex – Low ADL, High IADL
Cognitive Impairment – Low ADL, Low to High
IADL
Physical Function – Low to Medium ADL
Clin. Complex – Low to Medium ADL
Rehabilitation Low – Low ADL, High IADL
Physical Function – Medium to High ADL
Special Care – Low to High ADL
Cognitive Impairment – Medium ADL
Behavioral – Medium ADL
Physical Function – High ADL
Clin. Complex – High ADL
Extensive Services 1 – Medium to High ADL
Rehabilitation High – High ADL
Special Care – Very High ADL
Extensive Services 2 – Medium to High ADL
Group 7
SE3
Extensive Services 3 – Medium to High ADL
$76,360
Group 1
Group 2
Group 3
Group 4
Group 5
RUG
PA1
BA1
CA1
IA1
PA2
RA1
BA2
CA2
$16,167
$16,167
$22,504
$22,504
$22,504
$22,504
$22,504
$22,504
$30,314
$30,314
$34,545
$34,545
$34,545
$43,558
44
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
45
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
46
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 documents to the
LTSSMaryland tracking system
47
Community First Choice
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
49
Plan of Service Development
 Supports planner will engage in a person-centered planning
process with the participant.
Review the interRAI assessment and Recommended POC .
Determine the desired level of self-direction.
Identify strengths, goals, and risks.
Develop a plan that includes Medicaid and non-Medicaid services
and supports.
 Identify back up providers for emergencies.




 The supports planner has 20 days to submit the POS.
 The requested POS will be reviewed by the Department to
assure health and safety standards are met.
50
Community First Choice
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
51
Ongoing Supports
 After enrollment, the participant receives services and
supports according to their plan of service
 Supports planners must contact the participant monthly
and conduct quarterly visits, unless waived by the
participant
 The nurse monitor will visits at a frequency they determine
based on their assessment of the clinical needs and
presence of any delegated nursing tasks
 Nurse monitoring may only be waived down to twice per year
 The supports planner is responsible for monitoring service
provision, health and welfare, and for initiating changes to
the level of support as needed
52
Contact Us
DHMH:
Jennifer Miles, MFP Housing Director
410.767.6832
Jennifer.Miles@maryland.gov
Michelle Haile, Health Policy Analyst
MFP Housing Specialist
410.767.4916
Michelle.Haile@maryland.gov
MDOD:
John Brennan, Chief of Staff
Maryland Department of Disabilities
410.767.3640
jbrennan@mdod.state.md.us
53