1915(k): Community First Choice State Plan Option to Provide Home and Community- Based 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 Final rule that includes HCB setting requirements for CFC issued January 16, 2014, Effective date is March 17,

State plan amendment 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 3

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 4

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. 5

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 6

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 7

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 8

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 9

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 10

Supports and Services under CFC: Overarching Requirements Services must be provided: o In the most integrated setting appropriate to the individual’s needs, and o 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 in order to lead an independent life 11

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 12

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 13

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 14

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 15

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 16

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 17

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 18

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 19

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 20

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: 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 21

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 22

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 23

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 24

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) 25

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 26

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 27

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 28

Allowable Services: MAY Cover Transition costs such as: o Rent and utility deposits o 1 st month’s rental and utilities o Bedding o Basic kitchen supplies, and o Other necessities linked to an assessed need for an individual to transition from an institution 29

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 30

Excluded Services Room and board (except as a part of transition services such as rent and utility deposits or 1 st 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

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*** 32

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 33

Self-directed Service Models 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 34

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 person- centered 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 35

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 36

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 37

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 38

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 39

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 40

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 41

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 42

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 43

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 44

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 45

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 46

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 47

Resources Technical assistance: o CMS website: o California, Maryland and Oregon’s approved CFC State plan amendments: o State-Plan-Amendments/Medicaid-State-Plan- Amendments.html State-Plan-Amendments/Medicaid-State-Plan- Amendments.html 48