1915(k): Community First Choice
State Plan Option to Provide Home and CommunityBased Attendant Services and Supports
Community First Choice (CFC)
•
Section 2401 of the Affordable Care Act added a new section 1915(k) to
the Social Security Act which establishes a new State plan option to
provide “person-centered” home and community-based attendant services
and supports
•
CFC provides for a perpetual 6 percentage point increase in Federal
medical assistance percentage (FMAP) for these services
•
Final rule (except CFC HCB setting requirements) issued May 7, 2012,
Effective date is October 1, 2011
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Final rule that includes HCB setting requirements for CFC issued January
16, 2014, Effective date is March 17, 2014
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State plan amendment
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CFC is a State plan option, NOT a waiver
•
California, Maryland, and Oregon have approved CFC State plan amendments
(SPAs), and at least four other states are in progress
•
Because CFC is a State plan option, it must be offered to all those eligible for
Medical assistance under the state plan, who meet the benefit specific eligibility
requirements
•
Services must be provided on a statewide basis
•
Cannot cap the number served, and cannot target
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Special CFC Requirement:
Development and Implementation Council
• The state must create a Development and Implementation
Council that includes a majority of members with
disabilities, elderly individuals, and their representatives
• State must consult and collaborate with the Council when
developing and implementing a State Plan amendment to
provide Community First Choice services and supports
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Special CFC Requirement:
Maintenance of Effort
• Maintenance of effort (MOE)
o For the first full 12 month period in which the State plan
amendment is implemented, the State must maintain or exceed
the level of State expenditures for home and community-based
attendant services and supports that the States has provided for
the previous 12 months under sections 1115, 1905(a), under
other subsections of 1915, or otherwise under the Act.
o The MOE for CFC services applies to expenditures comparable
to attendant services. Therefore, it applies to personal care,
attendant care, residential habilitation and any other
expenditure that is comparable to attendant services.
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Special CFC Requirement:
Self-direction
• CFC requires that states allow for the provision of
services to be self-directed under either :
o An agency- provider model,
o A self-directed model with service budget, or
o Other service delivery model defined by the State and
approved by the Secretary
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Eligibility Criteria: Level of Care
• CFC requires that any individual served under the option must
meet an institutional level of care (LOC)
• This means that the individual would otherwise require the level of
care furnished in a:
o Hospital
o Nursing facility
o Intermediate care facility for the intellectually disabled
o An institution providing psychiatric services for individuals
under age 21, or,
o Institution for mental diseases for individuals age 65 or over, if
the cost could be reimbursed under the State plan
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Allowable Medicaid Eligibility
Groups Under CFC
• Individuals eligible for Medicaid under the State plan up to
150% of Federal Poverty Level (FPL)
• Individuals with incomes above 150% of the FPL must be
part of an eligibility group that has access to the nursing
facility benefit
• At State discretion as to whether CFC will be provided to
individuals who meet Medicaid eligibility under the
medically needy provisions
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Medicaid Eligibility: Special Income Rules
• Individuals who are Medicaid eligible under the “special
income rules” are included in CFC
o These are individuals with income up to 300% of SSI
who obtain Medicaid eligibility by meeting the special
income rules for enrollment in a 1915(c) Home and
Community Based Services (HCBS) waiver
• For individuals who are Medicaid eligible only through
these special income rules, the person must be enrolled in
a 1915(c) HCBS waiver and receive at least one service
per month
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Other Eligibility Criteria
• Under CFC states cannot target the benefit
o CFC, unlike 1915(i) and 1915(c), does not allow a state to limit
the benefit to a particular group defined by age, diagnosis or
condition
• CFC must be available to all individuals who have an assessed
need for the services
• Individuals are NOT precluded from receiving other Medicaid
services including State plan, waiver, demonstration and grant
services
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Supports and Services under CFC:
Overarching Requirements
Services must be provided:
o In the most integrated setting appropriate to the
individual’s needs, and
oWithout 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 in order to lead an independent life
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HCB Setting Requirements
• The final rule defines, describes, and aligns setting
requirements for home and community-based services
provided under three Medicaid authorities
o 1915(c)-HCBS Waivers
o 1915(i)- State Plan HCBS
o 1915(k)-Community First Choice
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HCB Setting Requirements
• The home and community-based setting requirements
establish an outcome oriented definition that focuses on the
nature and quality of individuals’ experiences
• The requirements maximize opportunities for individuals
to have access to the benefits of community living and the
opportunity to receive services in the most integrated
setting
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HCB Setting Requirements
The final rule establishes:
• Mandatory requirements for the qualities of home and
community-based settings including discretion for the
Secretary to determine other appropriate qualities
• Settings that are not home and community-based
• Settings presumed not to be home and community-based
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HCB Setting Requirements
The Home and Community-Based setting:
• Is integrated in and supports access to the greater community
• Provides opportunities to seek employment and work in
competitive integrated settings, engage in community life, and
control personal resources
• Ensures the individual receives services in the community to the
same degree of access as individuals not receiving Medicaid
home and community-based services
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HCB Setting Requirements
• Is selected by the individual from among setting options,
including non-disability specific settings and an option for
a private unit in a residential setting
o Person-centered service plans document the options
based on the individual’s needs, preferences; and for
residential settings, the individual’s resources
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HCB Setting Requirements
• Ensures an individual’s rights of privacy, dignity,
respect, and freedom from coercion and restraint
• Optimizes individual initiative, autonomy, and
independence in making life choices
• Facilitates individual choice regarding services and
supports, and who provides them
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Home and Community-Based Setting Requirements for
Provider-Owned or Controlled Residential Settings
Additional requirements:
• Specific unit/dwelling is owned, rented, or occupied under
legally enforceable agreement
• Same responsibilities/protections from eviction as all tenants
under landlord tenant law of state, county, city or other
designated entity
• If tenant laws do not apply, state ensures lease, residency
agreement or other written agreement is in place providing
protections to address eviction processes and appeals
comparable to those provided under the jurisdiction’s landlord
tenant law
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Home and Community-Based Setting Requirements for
Provider-Owned or Controlled Residential Settings
• Each individual has privacy in their sleeping or living unit
• Units have lockable entrance doors, with the individual and
appropriate staff having keys to doors as needed
• Individuals sharing units have a choice of roommates
• Individuals have the freedom to furnish and decorate their
sleeping or living units within the lease or other agreement
• Individuals have freedom and support to control their
schedules and activities and have access to food any time
• Individuals may have visitors at any time
• Setting is physically accessible to the individual
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Home and Community-Based Setting Requirements for
Provider-Owned or Controlled Residential Settings
Modifications of the additional requirements must be:
• Supported by specific assessed need
• Justified in the person-centered service plan
• Documented in the person-centered service plan
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Home and Community-Based Setting Requirements for
Provider-Owned or Controlled Residential Settings
Documentation in the person-centered service plan of
modifications of the additional requirements includes:
•
•
•
•
•
•
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Specific individualized assessed need
Prior interventions and supports including less intrusive methods
Description of condition proportionate to assessed need
Ongoing data measuring effectiveness of modification
Established time limits for periodic review of modifications
Individual’s informed consent
Assurance that interventions and supports will not cause harm
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Settings that are NOT
Home and Community-Based
• Nursing facility
• Institution for mental diseases (IMD)
• Intermediate care facility for individuals with intellectual
disabilities (ICF/IID)
• Hospital providing long-term care services
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Settings PRESUMED NOT to Be Home
and Community-Based
• Settings in a publicly or privately-owned facility providing
inpatient treatment
• Settings on grounds of, or adjacent to, a public institution
• Settings with the effect of isolating individuals from the
broader community of individuals not receiving Medicaid
HCBS
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Settings PRESUMED NOT to Be Home and
Community-Based-Heightened Scrutiny
These settings (previous slide) may NOT be included in
states’ 1915(c), 1915(i) or 1915(k) HCBS programs unless:
•
A state submits evidence (including public input) demonstrating
that the setting does have the qualities of a
home and
community-based setting and NOT the qualities of an institution; AND
•
The Secretary finds, based on a heightened scrutiny review of the
evidence, that the setting meets the requirements for home and
community-based settings and does NOT have the qualities of an
institution
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Allowable Services:
MUST Cover
• Assistance w/ ADLs, IADLs, & health-related tasks
• Acquisition, maintenance and enhancement of skills necessary
for individual to accomplish ADLs, IADLs, and health-related
tasks
• Back-up systems or mechanisms to ensure continuity of services
and supports
• Voluntary training on how to select, manage and dismiss staff
(support for self-directed services)
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ADLs/IADLs
• Activities of Daily Living (ADLs) means:
o basic personal everyday activities including, but not limited to,
tasks such as eating, toileting, grooming, dressing, bathing,
and transferring
• Instrumental Activities of Daily Living (IADLs) means:
o activities related to living independently in the community,
including but not limited to, meal planning and preparation,
managing finances, shopping for food, clothing, and other
essential items, performing essential household chores,
communicating by phone or other media, and traveling around
and participating in the community
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Financial management entity (FME)
• States must make FME activities available to those with a
self-directed model with budget Financial management
entity may:
o Collect and process timesheets of the individual’s attendant care
providers
o Process payroll, withholding, filing, and payment of employment
related taxes and insurance
o Separately track budget funds and expenditures for each individual
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Financial management entity (FME)
• FME may:
o Track and report disbursements and balances of each individual’s
funds
o Process and pay invoices for services in the person-centered
service plan, and
o Provide individual periodic reports of expenditures and the status
of the approved service budget to the individual and to the State
• States may do these functions or engage vendors
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Allowable Services:
MAY Cover
• Transition costs such as:
o
o
o
o
o
Rent and utility deposits
1st month’s rental and utilities
Bedding
Basic kitchen supplies, and
Other necessities linked to an assessed need for an individual to
transition from an institution
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Allowable Services:
MAY Cover
• May cover supports on a 24/7 basis
• May occur in provider controlled settings
• Expenditures relating to a need identified in an individual’s
person-centered plan that increases his/her independence
or substitutes for human assistance to the extent the
expenditures would otherwise be made for the human
assistance
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Excluded Services
• Room and board (except as a part of transition services
such as rent and utility deposits or 1st month rent or
utilities)
• Special education and related services provided under the
Individuals with Disabilities Education Act that are related
to education only, and vocational rehabilitation services
provided under the Rehabilitation Act of 1973
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Excluded Services
• Assistive devices and assistive technology services
• Medical supplies and medical equipment, other than those
that meet the requirements, and,
• Home modifications
***UNLESS these services/items increase independence,
substitute for human assistance or are back-up systems to
ensure continuity of services***
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Possible ideas on goods and services
that increase independence
• “Smart” technology that allows the individual to control
the home (open doors, change temperature, turn lights off
and on)
• Environmental controls for the home or automobile
• Personal computers
• Mechanical aids that assist in transferring
• Sound response systems that substitute for awake,
overnight staff
• Ramp that allows the person to independently enter and
leave their home
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Self-directed Service Models
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•
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Agency-provider model
o Agency either provides or arranges for services
o Individual has a significant role in selection and dismissal of
employees, for the delivery of their care, and the services and supports
identified in the person-centered service plan
Self-directed model with service budget which affords the person the
authority to:
o Recruit and hire or select attendant care providers
o Dismiss providers
o Supervise providers including assigning duties, managing schedules,
training, evaluation, determining wages and authorizing payment
Other models at state request and CMS approval
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Self-directed model with service budget
• CFC details a number of criteria for
individual budgets including:
o Budgets must be developed and approved by the State
based on the assessment of functional need and personcentered service plan
o The process for developing budgets must be based on an
objective and reliable process
o Individuals have a variety of rights regarding changes to
budgets, sufficiency of budgets and how budgets are
calculated
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Self-directed Service Models
• May provide for direct cash payments to individuals
enrolled in CFC
• May use vouchers
• May provide financial management services-(but must
provide this if individuals cannot manage the cash option
without assistance)
• Must provide supports for self-direction
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Assessment: Conflict of Interest Standards
• Individuals doing assessments cannot be:
o Related by blood or marriage to the individual, or to any paid
caregiver of the individual
o Financially responsible for the individual or who could benefit
financially
o Empowered to make financial or health-related decisions on
behalf of the individual
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Assessment: Conflict of Interest Standards
•
Individuals doing assessments cannot be:
o Individuals who would benefit from the provision of assessed
needs and services
o Providers of State plan HCBS for the individual, or those who have an
interest in or are employed by a provider of services to the individual
o May be providers if they are the only willing and qualified
entity/entities in a geographic area
 State must devise additional safeguards including a clear and
accessible alternative dispute resolution process
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Support System
• States must assure that individuals have the information,
training, skills and supports they need to participate in CFC and
must provide for:
o Person-centered planning
o Information on the range of options and choices
o Information on grievance process and appeal rights
o Freedom of choice of providers and service models
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Quality Management
• States must have:
o A quality improvement strategy
o Methods to continuously monitor the health and welfare of
each individual including mandatory reporting,
investigation, and resolution of allegations of neglect, abuse,
or exploitation in connection with the provision of such
services and supports
o Measures of individual outcomes particularly health and
welfare
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Quality Management
• States must:
o Have standards for all service delivery models
o Assure that individuals have appeal rights for any
denials
o Establish reconsideration procedures for an individual’s
person-centered service plan, that is processes for a
person to request changes to their support plan
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Quality Management
• States must :
o Obtain and use feedback from individuals and their
representatives, disability organizations, providers,
families of disabled or elderly individuals, members of
the community and others to improve the quality of the
community-based attendant services and supports
benefit
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Quality Management
• States with regard to workers must comply with:
o All applicable provisions of the Fair Labor Standards Act
o Withholding and payment of Federal and State income
and payroll taxes
o The provision of unemployment and workers
compensation insurance
o Maintenance of general liability insurance
o Occupational health and safety
o Any other employment or tax related requirements
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Data and Reporting
• For each federal fiscal year the state operates CFC, the
state must report:
o The number of individuals who are estimated to receive
CFC
o The number of individuals who received the services and
supports during the preceding Federal fiscal year
o The number of individuals served broken down by type of
disability, age, gender, education level, and employment
status, including supported employment
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Data and Reporting
o The specific number of individuals who have been
previously served under sections 1115, 1915(c) and(i)
of the Act, or the personal care State plan option.
o Data regarding how the State provides CFC and other
home and community-based services
o The cost of providing CFC and other home and
community-based services and supports
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Data and Reporting
o Data regarding how the State provides individuals with
disabilities who otherwise qualify for institutional care under
the State plan or under a waiver the choice to receive home
and community-based services in lieu of institutional care
o Data regarding the impact of CFC services and supports on
the physical and emotional health of individuals
CMS is developing additional guidance on these data requirements
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CMS Requirements
• CMS is required by 12/31/15 to conduct an evaluation in order
to determine:
o the effectiveness of this provision in allowing individuals to
lead an independent life to the maximum extent possible
o the impact on physical and emotional health of individuals
receiving these services
o a comparative analysis of the costs of services provided
under Community First Choice and those provided in an
institution.
• An interim report of this evaluation was due to Congress by
12/31/13
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Resources
• Technical assistance:
o www.hcbs-ta.org
• CMS website:
o http://www.medicaid.gov/HCBS
• California, Maryland and Oregon’s approved CFC State plan
amendments:
o http://www.medicaid.gov/State-Resource-Center/MedicaidState-Plan-Amendments/Medicaid-State-PlanAmendments.html
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