Community First Choice

Community First ChoiceMaryland Department of Health and Mental Hygiene1Community First Choice CFC OverviewEligibilityCFCWaiverEnrollment ProcessCFCWaiver

2Community 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 PlanEmphasizes self directionIncreases the States enhanced match on all CFC services by 6 %Allows Medicaid to set consistent policy and rates across programsRequires an institutional level of careCFC will offer all mandatory and optional services allowablePersonal assistance servicesEmergency back-up systemsTransition services,Items that substitute for human assistanceTechnology, accessibility adaptations, home delivered meals, etc.

3Old Service Structure4Maryland 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 standardLiving at Home (LAH) WaiverTarget group ages 18-64 with disabilitiesNursing Facility Level of Care standardWaiver for Older Adults (WOA)Target group aged 50 and overNursing Facility Level of Care standard4New Service Structure Services formerly offered through multiple programs are now consolidated under CFCMaximizes the enhanced Federal match Resolves inconsistent rates and policies across programsThese two 1915(c) waiver programs merged into a single waiverReduces duplicate applicationsOffers a full menu of services to waiver participants Simplifies administration

5Former Service StructureMAPCLAHWOAPersonal Assistance ServicesCase Management/Nurse Case MonitoringConsumer TrainingPersonal Emergency Back-up SystemsTransition ServicesHome Delivered MealsAssistive TechnologyAccessibility AdaptationsEnvironmental AssessmentsMedical Day CareNutritionist/DieticianFamily TrainingBehavioral ConsultationAssisted LivingSenior Center Plus6New Service StructureMAPCCFCWaiverPersonal Assistance ServicesCase Management/Supports PlanningNurse MonitoringPersonal Emergency Back-up SystemsTransition ServicesConsumer TrainingHome Delivered Meals1Assistive Technology1Accessibility Adaptations1Environmental AssessmentsMedical Day CareNutritionist/DieticianFamily TrainingBehavioral ConsultationAssisted LivingSenior Center PlusItems that sub *CFC Services will be available to all waiver participants 7Levels of CareThe new merged waiver will continue to use the nursing facility level of careThe CFC program will be available to individuals who meet any institutional level of care.Includes nursing facility, chronic hospitals, ICF/IID, and psychiatric hospitalsMAPC 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 servicesMAPC and NF Levels of Care will be determined with a core standardized assessment instrument, the interRAI-Home Care, completed by local health department cliniciansLevels of care will be reviewed annually

89CFC Service Package Personal AssistanceNurse MonitoringSupports PlanningItems or Services that Substitute for Human AssistanceEnvironmental Assessments and /or ModificationsTechnologyHome Delivered MealsConsumer TrainingPersonal Emergency Response SystemTransition Services

10Service and System EnhancementsCFC adds emphasis on person-centered planning and self-directionMaryland Department of Disabilities (MDOD) will be providing self-direction training on hiring, firing, and managing providersCFC offers the participant some flexibility in choosing provider rates for personal assistance servicesBudgets will be set based on the assessment of need and approved by the DepartmentParticipants will be able to act as their own supports planner and request changes to their plans and rates via the LTSSMaryland tracking system portal

11Enhancements for ParticipantsAll participants have access to:increased self-direction opportunities, a larger provider pool, and choice of supports planning providersWaiver participants now have choice in case management (supports planning) providers and access to a larger provider poolMAPC 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

12CFC and Waiver EligibilityCommunity First Choice14Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetFinancial EligibilityParticipants 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 ANDParticipants mustBe in an eligibility group under the State plan that includes nursing facility services; orIf 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)

15Community First Choice16Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetMedical EligibilityThe 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 waiversCommunity Options, New Directions, Community Pathways, Autism, Traumatic Brain Injury, Medical Day Care, ModelMedical needs will be assessed by the Local Health Department using the interRAIUCA (currently Delmarva) will verify Nursing Facility and MAPC levels of Care

17Participation 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 servicesParticipants who receive bundled payments for some TBI, DDA, assisted living or PACE services are not eligible to receive CFC services on the same day18Other Eligibility RequirementsTo 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, andprivacy 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.

19Citation: 73 Fed. reg. 18,676, 18,685-86 (2008)19Waiver EligibilityTechnical: Must be at least 18 years oldMedical: Must meet a nursing facility level of careFinancial: 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 EnrollmentApplicants can enroll into CFC fromAn institution The community

22CFC 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 sameThe waiver has a higher income threshold Applicants may want to access the waiver even if they qualify for CFC, as the wavier offers additional servicesConsumers qualify for CFC in the community, and can apply for it from a NF regardless of their length of stayThe 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 communityWaiver participants have access to all services provided on the state plan

232324Enrollment in CFC from Nursing Facility

Applicant in Nursing Facility receives options counselingApplicant has community MANo community MAOptions Counselor refers to LHD for assessment* and provides Supports Planning selection packet to applicant**Options Counselor helps complete MA application. Contact is made with Supports Planning provider Supports Planner meets with participant to create Plan of Service***Plan of Service approved by DHMHSupports Planner coordinates transitionSupports Planner meets with participant at least once every 90 days (can be waived by participant)*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

Enrollment into Waiver from a Nursing Facility 25Applicant in Nursing Facility receives options counselingHas Long Term Care MAHas Community MAWavier Application AssistanceContact made with Supports Planning ProviderSupports Planner meets with participant to create Plan of Service***Plan of Service approved by DHMHSupports Planner meets with participant at least once every 90 days (can be waived by participant)*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 POSDEWSLHD for assessmentProvides Supports Planning selection packet to applicantSupports Planner coordinates transitionApply for CFCInsert block for transition planning26Enrollment in CFC from the Community Contact DHMHApplicant contacts MAP site, referred to DHMHCommunity MA status verified by DHMHNo Community MAHas Community MAContact made with Supports Planning ProviderSupports Planner meets with participant to create Plan of Service***Supports Planner meets with participant at least once every 90 days (can be waived by participant)Applicant in CommunityRefer to Local DSSPlan of Service approved by DHMHAdd to LTSSReferral to LHD for assessment*Mail out Supports Planning selection packet***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 POSEnrollment into Waiver from the CommunityOnly individuals who receive an invitation to apply from the waiver registry can apply to the waiver from the communityThe waiver programs reached their budgetary caps in 2003A registry of people interested in applying was createdAs slots become available, invitations to apply are sent to the next group of people on the registryThere are currently nearly 20,000 people on the registryPeople who have community MA eligibility can apply for CFC without waiting on the registryIf a person needs the higher income threshold of the waiver program, they must wait on the registry and are not eligible for servicesCFC is not a waiver

27Community First Choice28Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetAssessment by the LHDAfter a person applies, they are referred to the local health department for an assessmentLTSS programs use the interRAI Home Care (HC) assessment, the core standardized assessment adopted by the DepartmentInforms and guides comprehensive care and service planning in community-based settingsDeveloped through years of research and is tested as reliable and valid instrument to measure level of needGenerates Clinical Assessment Protocols and Resource Utilization Groups as indicators of need and areas of supportIs used to determine Nursing Facility level of care

29Community First Choice30Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetSupports Planner Provider SelectionApplicants will be provided with information about all Supports Planning agencies by the Options Counselor or via a mailing form the DepartmentThe applicant may contact the agency of choiceThe Agency of Choice will enter the selection into LTSS If no selection is made within 21 days, an agency will be auto-assignedA participant can choose to change their auto-assigned supports planning provider agency at any timeOnce the initial selection has been made by the applicant, another agency may not be chosen for 45 days

BudgetCommunity First Choice33Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetHow budget is determinedThe 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 needsParticipants will use this budget for certain services and are then empowered to determine their personal assistance hours and schedules within their budgetOther services will be provided as needed and accounted for outside of the flexible budget

34Budgets by Group35RUGGrouper DescriptionBudgetGroup 1PA1Physical Function Low ADL$8,336 BA1Behavioral Low ADL$8,336 CA1Clin. Complex Low ADL$8,336 IA1Cognitive Impairment Low ADL$8,336 PA2Physical Function Low ADL, Low to High IADL $8,336 RA1Rehabilitation - Low ADL$8,336 Group 2BA2Behavioral Low ADL, High IADL$16,167 CA2Clin. Complex Low ADL, High IADL $16,167 IA2Cognitive Impairment Low ADL, Low to High IADL$16,167 PB0Physical Function Low to Medium ADL $16,167 Group 3CB0Clin. Complex Low to Medium ADL $22,504 RA2Rehabilitation Low Low ADL, High IADL$22,504 PC0Physical Function Medium to High ADL $22,504 SSASpecial Care Low to High ADL $22,504 IB0Cognitive Impairment Medium ADL $22,504 BB0Behavioral Medium ADL $22,504 Group 4PD0Physical Function High ADL $30,314 CC0Clin. Complex High ADL $30,314 Group 5SE1Extensive Services 1 Medium to High ADL $34,545 RB0Rehabilitation High High ADL $34,545 SSBSpecial Care Very High ADL $34,545 Group 6SE2Extensive Services 2 Medium to High ADL $43,558 Group 7SE3Extensive Services 3 Medium to High ADL $76,360 RUGGrouper DescriptionBudgetGroup 1PA1Physical Function Low ADL$8,336 BA1Behavioral Low ADL$8,336 CA1Clin. Complex Low ADL$8,336 IA1Cognitive Impairment Low ADL$8,336 PA2Physical Function Low ADL, Low to High IADL $8,336 RA1Rehabilitation - Low ADL$8,336 Group 2BA2Behavioral Low ADL, High IADL$16,167 CA2Clin. Complex Low ADL, High IADL $16,167 IA2Cognitive Impairment Low ADL, Low to High IADL$16,167 PB0Physical Function Low to Medium ADL $16,167 Group 3CB0Clin. Complex Low to Medium ADL $22,504 RA2Rehabilitation Low Low ADL, High IADL$22,504 PC0Physical Function Medium to High ADL $22,504 SSASpecial Care Low to High ADL $22,504 IB0Cognitive Impairment Medium ADL $22,504 BB0Behavioral Medium ADL $22,504 Group 4PD0Physical Function High ADL $30,314 CC0Clin. Complex High ADL $30,314 Group 5SE1Extensive Services 1 Medium to High ADL $34,545 RB0Rehabilitation High High ADL $34,545 SSBSpecial Care Very High ADL $34,545 Group 6SE2Extensive Services 2 Medium to High ADL $43,558 Group 7SE3Extensive Services 3 Medium to High ADL $76,360 Services within the flexible budgetPersonal AssistanceHome-Delivered MealsOther Items that Substitute for Human Assistance

All other services are included in the Plan of Service in addition to the flexible budget36Services in the Plan 37CFC Services Allowable Under Flexible BudgetOther CFC Services based on the Individual Participants Assessed NeedsWaiver ServicesPersonal AssistanceTechnologyDietitian and Nutrition ServicesHome-Delivered MealsEnvironmental Accessibility AdaptationsFamily TrainingOther items that Substitute for Human AssistanceEnvironmental AssessmentsMedical Day CareSupports PlanningBehavioral Health ConsultationTransition ServicesSenior Center PlusConsumer TrainingAssisted LivingPersonal Emergency Response SystemsNurse MonitoringRates for Personal AssistanceParticipants 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 rateThe proposed standard independent and agency rate is the weighted average of the current FY14 rates. Independent weighted average rate: $12.27Agency weighted average rate: $16.08This range would be adjusted each year in the event of rate increases approved during the state budget process.

38Example--Participants receiving personal assistance services 7 days a week 39Annual BudgetDaily BudgetHours at Min independent rate ($10.22)Hours at Max independent rate ($14.27)Hours at weighted rate ($12.27)Hours at weighted agency rate ($16.08)Group 1 $ 8,336 $22.84 2.2 1.6 1.9 1.4 Group 2 $ 16,167 $44.29 4.3 3.1 3.6 2.8 Group 3 $ 22,504 $61.65 6.0 4.3 5.0 3.8 Group 4 $ 30,314 $83.05 8.1 5.8 6.8 5.2 Group 5 $ 34,545 $94.64 9.3 6.6 7.7 5.9 Group 6 $ 43,558 $119.34 11.7 8.4 9.7 7.4 Group 7 $ 76,360 $209.21 20.5 14.7 17.1 13.0 Exception ProcessIf 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 careThe 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 system40Plan of ServiceCommunity First Choice42Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetSupports 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.

43Plan of Service Development Community First Choice44Eligible for Medicaid (through a waiver or state plan)Assessed by Local Health DepartmentApplicant selects Supports Planner Develops Plan of ServiceDepartment (DHMH) approves Plan of ServiceParticipant begins receiving servicesAssigned a personal budgetOngoing SupportsAfter enrollment, the participant receives services and supports according to their plan of serviceSupports planners must contact the participant monthly and conduct quarterly visits, unless waived by the participantThe nurse monitor will visits at a frequency they determine based on their assessment of the clinical needs and presence of any delegated nursing tasksNurse monitoring may only be waived down to twice per yearThe supports planner is responsible for monitoring service provision, health and welfare, and for initiating changes to the level of support as needed45

Christin WhitakerDepartment of Health and Mental HygieneCommunity Options Administration Division201 West Preston Street, Rm 136Baltimore, MD 21201christin.whitaker@maryland.gov410-767-4449