Long-Term Services Health Reform Provisions:Community First Choice Option
What it is
A new state plan option to provide home- and community-based services in Medicaid Section, 1915(k); available October 1, 2011. States that take up this option receive a 6 percentage point increase in federal matching payments (FMAP) for costs associated with the program.
States may provide services to Medicaid-eligible individuals whose income does not exceed 150% of poverty. States that have set a higher Medicaid income eligibility level for those who require institutional care can use that higher income level. There must be a state determination that, but for the provision of home- and community-based services, the individual would need nursing facility care.
Home and community attendant services provided in a community setting. Services for each participant must be based on an individual care plan developed through an assessment of the individual’s functional need. No restrictions on state program expenditures.
Required Services: States taking up this option must provide the following:
- Assistance with activities and instrumental activities of daily living (ADLs and IADLs) and health-related tasks, including hands-on assistance, cuing, and supervision.
- Acquisition, maintenance, and enhancement of skills to complete those tasks.
- Back-up systems, such as beepers, that will ensure continuity of care and support.
- Training on hiring and dismissing attendants, if desired by the individual.
Optional Services: States may also provide the following:
- Transition costs, such as the first month’s rent; rent or utility deposits; and kitchen supplies, bedding, and other necessities for an individual to move from a nursing facility to the community.
- Coverage for additional items noted in an individual’s care plan that will increase independence or substitute for personal assistance.
Excluded are: home modifications, room and board, medical supplies, and assistive technology (except items that would meet the definition of back-up systems to ensure care continuity).
Services can be provided under an agency or other model. Family members, as defined by DHHS, can provide services.
Providers are to be selected and services controlled by the individual or individual’s representative to the maximum extent possible. States must ensure that regardless of care model, services are provided in accordance with the Fair Labor Standards Act.
Requirements for states
Why this is important
Service availability: States must make services available statewide, with no caps or targeting by age, severity of disability, or any other criteria. Services must be provided in the most integrated setting appropriate, given an individual’s needs.
Maintenance of Effort: During the first year, a state must maintain or exceed its prior year Medicaid expenditure level for optional services provided to elderly individuals and people with disabilities.
Implementation Council: States must establish a Development and Implementation Council to collaborate on program design and implementation. The Council must have majority membership of the elderly, people with disabilities, or their representatives.
Quality Systems and Data: States must develop quality systems that incorporate consumer feedback and monitor health measures. The state must submit program reports to the Department of Health and Human Services.
States currently have an option to provide personal care services through their Medicaid plans, and 35 states currently do that. This option expands on those programs. It allows states to open eligibility to people at higher incomes and to offer additional services. The increased federal matching payment is a strong incentive for states to take up the option and expand home- and community-based care services in Medicaid. The option could pave the way for even broader expansions of home- and community-based services in Medicaid.