Maryland Department of Health and Mental Hygiene
Community First Choice
 CFC Overview
 Eligibility
 CFC
 Waiver
 Enrollment Process
 CFC
 Waiver
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
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
4
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
5
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
6
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
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
8
Projected Enrollment in Each Program
Waiver
Participants
Receiving CFC
services 3,857
CFC-Only
Population
5,061
MAPC
Population 991
9
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
10
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
11
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
12
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
14
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)
15
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
16
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
17
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
18
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.
19
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
22
CFC or Waiver?
 If a nursing facility resident has Long Term Care MA, they may not
qualify for Community MA because the income qualifications are
not the same
 The waiver has a higher income threshold
 Applicants may want to access the waiver even if they qualify for
CFC, as the wavier offers additional services
 Consumers qualify for CFC in the community, and can apply for it
from a NF regardless of their length of stay
 The waiver can be accessed only if the consumer has been in a
NF at least 30 days with LTC MA, or from the registry if in the
community
 Waiver participants have access to all services provided on the state
plan
23
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)
24
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)
25
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)
26
Enrollment into Waiver from the Community
 Only individuals who receive an invitation to apply from the waiver
registry can apply to the waiver from the community
 The waiver programs reached their budgetary caps in 2003
 A registry of people interested in applying was created
 As slots become available, invitations to apply are sent to the next
group of people on the registry
 There are currently nearly 20,000 people on the registry
 People who have community MA eligibility can apply for CFC
without waiting on the registry
 If a person needs the higher income threshold of the waiver
program, they must wait on the registry and are not eligible for
services
 CFC is not a waiver
27
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
29
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
34
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
35
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
36
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
37
Rates for Personal Assistance
 Participants choosing to self-direct, may elect to pay their
provider from the minimum current rate ($10.22) to the
maximum current rate ($14.27).
 For participants choosing not to self-direct, the number of
personal assistance hours will be calculated based on the
budget and the standard independent and/or agency rate
 The proposed standard independent and agency rate is the weighted
average of the current FY14 rates.
 Independent weighted average rate: $12.27
 Agency weighted average rate: $16.08
 This range would be adjusted each year in the event of rate
increases approved during the state budget process.
38
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 weighted weighted
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
39
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
40
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
42
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.
43
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
44
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
45
Christin Whitaker
Department of Health and Mental Hygiene
Community Options Administration Division
201 West Preston Street, Rm 136
Baltimore, MD 21201
christin.whitaker@maryland.gov
410-767-4449