Implementing the Community
First Choice Option in New York
Lana Mutters, MPH
Norain Siddiqui, MPH
Policy Analyst
New York Association on Independent Living
Policy Analyst
Center for Disability Rights
History
• Grassroots – ADAPT
• Community Choice Act (CCA)
• Affordable Care Act includes Community First Choice Option
(March 2010)
• New York State – Selection of Option (March 2011)
• DOH CFC Workgroup (June 2012)
What is CFC?
 Community-based Medicaid state plan service
(1915[k] State Plan Amendment)
 Includes hands-on assistance, safety monitoring,
cueing, ADL, IADL
 First program to provide services based on functional
need, not diagnosis or age
Eligibility
• Must be Medicaid eligible
• Must require an institutional level of care
(hospital, nursing facility, ICF-MR, or IMD)
Background and Basics
 Affordable Care Act establishes Community First
Choice (CFC) under § 1915(k) of Social Security Act
under Medicaid
 CFC supports independence, integration, personcentered, consumer-directed in accordance with the
Olmstead decision of 1999
 As state plan amendment, entitlement
Services must be provided in
community-based setting
CANNOT include:
• Nursing facilities
• Institutions for Mental Diseases (IMD)
• Intermediate Care Facilities for Mentally Retarded (ICF-MR)
• Any public/private facility that provides inpatient institutional
treatment
• Any building on grounds of disability-specific housing complex
Required Services
• Attendant services and supports for
– activities of daily living (ADL)
– instrumental activities of daily living (IADL)
– health-related tasks
• Attendant services and supports include
– hands-on assistance
– safety monitoring
– cueing
• Assistance with the learning skills necessary to accomplish ADL, IADL,
and health-related tasks
• Purchase of back-up systems (beepers) to ensure continuity of services
and supports
• NYS must develop/offer a voluntary training on how to select, manage,
dismiss attendants
Permissible Services & Supports
• Transition costs
– i.e. security deposits for rent/utilities
– purchasing basic kitchen supplies, etc.
• Services that increase independence or
substitute for human assistance
– i.e. learning how to use public transportation
Excluded Services
• Room and board
• Special education and related services provided
under IDEA and vocational rehab
• Assistive technologies (other than those used as
back-up systems)
• Medical supplies and equipment
• Home modifications
Models for Service Delivery
• “Agency Provider Model” *
–
–
–
–
•
range of approaches
individual has ability to select, train, dismiss attendant
Traditional agency managed services
Agency-with-Choice model where the agency operates solely as a
fiscal intermediary
“Self-Directed Model with service budget”
– Vouchers
– Direct Cash Payments (similar to Cash & Counseling)
– Fiscal Agent
* Chosen by New York in State Plan Amendment
How does CFC benefit New York?
• Supports Governor’s commitment to Olmstead
• Enhanced 6% FMAP with no sunset
• Addresses gaps in long term care system
• Streamlines system to reduce administrative
redundancies
How is CFC different?
• Cross-disability
• Home and/or community settings
• Includes transition costs from an institution to a home
• Maximizes consumer control and allows for a proxy chosen by individual
to direct care
• Supplemented with backup and emergency attendant services
• Voluntary training on how to self direct
• Availability of equipment or e-mods that substitute for human
assistance
CFC will work for you
• Applicable in multiple settings
• Flexible scheduling
• Person-centered
• Eliminates silos
• Self-direction
• Budgeting
New York’s State Plan Amendment
• Submitted in December 2013, still awaiting CMS
approval
• “Agency with Choice” model
• NYAIL & CDR would like to see clarifications on:
1. IADL “Care of others”
2. Stakeholder feedback
Notable Issues
• Definition of “community” and “setting”
– Dept. of Health and Human Services finalized definition in January 2014
– Rules now in line with Olmstead
…settings do not include a nursing
facility, institution for mental diseases, or
an intermediate care facility for individuals
with intellectual disabilities…we have
established that home and communitybased settings must exhibit specific
qualities to be eligible sites for delivery of
home and community-based services.
Notable issues cont.
• Nurse Practice Act
– NPA only allows licensed nurses to perform health-related tasks (i.e.
catheter, vent care, etc.)
– Must be amended to allow “advanced aide” to do these tasks, as
overseen by nurse
• Cost effective
• Aides already perform tasks in CDPAP
• Nurse shortage
– Contentious debate between NYS, NYSNA, disability rights groups
over patient safety, professional scope, civil rights
Nurse Practice Act cont.
• If State fails to enact NPA exemption, entire SPA could be
dismissed by CMS
• CFC requires services to be delivered “without regard to the
individual’s age, type or nature of disability, severity of
disability, or the form of home and community-based
attendant services and supports that the individual requires
to lead an independent life.”
Where are we now?
•
•
•
•
Waiting for CMS to approve SPA
CFC in the budget process
Presented draft CFC language to Assembly
Pending CFC legislation
CFC in other states
Currently Participating
• California
• Oregon
• Maryland
State Plan Amendment Withdrawn
• Arizona
• Louisiana
Plan to Participate 2014 Fiscal Year
• Montana
• Texas
• Arkansas
• Wisconsin
• Minnesota
Additional resources
DOH CFC workgroup
http://www.health.ny.gov/facilities/long_term_care/
Final regulations
https://www.federalregister.gov/articles/2012/05/07/2012-10294/medicaid-programcommunity-first-choice-option
CMS final rules on HCBS
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-TermServices-and-Supports/Home-and-Community-Based-Services/Home-and-CommunityBased-Services.html
Questions?
Lana Mutters
New York Association on Independent Living
(518) 465-4650
LMutters@ilny.org
Norain Siddiqui
Center For Disability Rights
(518) 320-7100
nsiddiqui@cdrnys.org