Community First Choice

Community First Choice

Community First ChoiceMaryland Department of Health and Mental Hygiene1CFC Training 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.

3Former 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 standard4Former 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 Plus5New 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 waiver Reduces duplicate applicationsOffers a full menu of services to waiver participants Simplifies administration

6HCBO Waiver: Community OptionsProvides community services and supports that enable older adults and individuals with physical disabilities to live in their own homesServices provided under CFC are available to participants of this waiver Extra services exclusively attached to this waiver are medical day care, nutritionist/dietician, family training, behavioral consultation, assisted living and senior center plus7New 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 available to all waiver participants 8Levels 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

910CFC Service Package Personal AssistanceNurse MonitoringSupports PlanningItems or Services that Substitute for Human AssistanceEnvironmental Assessments and /or ModificationsTechnologyHome Delivered MealsConsumer TrainingPersonal Emergency Response SystemTransition Services

11Service 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

12Enhancements 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

13Personal AssistanceAssistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living, health related tasks through hands on assistance, supervision, and/or cueing, will be provided under the Personal Assistance Services. Participants will be able to choose between receiving Personal Assistance Services through an agency or an independent model.Proposal to create a shared Personal Assistance Service for participants that share a home.

14Nurse MonitoringNurse Monitors provide quality oversight by assessing the participant and monitoring the provision of personal assistance servicesThe participant can determine the frequency of nurse monitoring in a self directed model, but there is a minimum of two times a year. The Nurse Monitor recommends the frequency of services, based on clinical judgment and whether there are delegated nursing tasks.Supports Planner adds Nurse Monitoring to the POS.

15Nurse MonitoringNurse Monitors are required to contact the participant for the purpose of evaluating participant status at a minimum of every 6 months, with at least one in-person home or workplace visit every 12 months.More frequent nurse monitoring can be approved if needed, as recommended by the nurse monitor. Nurse monitoring visits can be conducted on the same day as the InterRAI.

16Supports Planning Supports planning providers will engage participants in a person-centered planning process that identifies the goals, strengths, risks, and preferences of the participant. The Supports Planner will:Appropriately counsel an individual before enrollment; and Provide the necessary information, training, and assistance to ensure that an individual has the required knowledge and ability to manage their services and budgets.

17Supports Planning Responsibilities Coordinate community services and supports from various programs and payment sources to aid applicants and participants in developing a comprehensive plan for community living. Support applicants in locating and accessing housing options, identifying housing barriers such as past credit, eviction, and criminal histories, and in resolving the identified barriers. Assist the applicant in developing a comprehensive POS that coordinates the transition from an institution, and maintains community supports throughout the individuals participation in services.

18Items that increase independence or substitute for human assistance The following will be services permissible under CFC in the category of items that substitute for human assistance:Home delivered mealsAccessibility AdaptationsEnvironmental AssessmentsTechnologyEach of these services are covered as items that substitute for human assistance, but have their own enrolled provider poolOther items that substitute may also be covered to the extent that they meet the service definitionOnly Other items that substitute for human assistance are paid through the fiscal intermediary

19Consumer TrainingThe topics covered by consumer training may include, but are not limited to money management and budgeting, independent living and meal planning. These activities are to be targeted to the individualized needs of the participant receiving the training; and sensitive of the educational background, culture, and general environment of the participant receiving the training. Consumer training will be provided by an approved Medicaid provider.

20Consumer vs. Self Direction TrainingConsumer TrainingSelf Direction TrainingProvided by MA Providers

Provided by MDOD

CFC Service (6% enhanced match)CFC Administrative Activity (no enhanced match)Trains consumer on the acquisition, maintenance and enhancement of skills necessary for individuals to perform ADLs, IADLs, and Health Related TasksTrains consumer on hiring, firing, evaluating and managing Personal Assistance providers21Personal Emergency Response SystemA personal emergency response system (PERS) is an electronic device, piece of equipment or system which, upon activation, enables a participant to secure help in an emergency, 24 hours per day, seven days per week. There are a variety of devices and systems available to meet individual needs and preferences of CFC participants choosing this service. This service may include any or all of the following components: purchase/installation and monthly maintenance/monitoring of a PERS device.

22Transition Assistance Expenditures essential for transition and linked to an assessed need for an individual to transition from an institution to a community-based home setting. Such as security and utility deposits, bedding, basic kitchen supplies, and other necessities. Items must be essential to a successful transition and may be secured up to 60 days post-transition.Fiscal Intermediary only pays for items on an approved plan of service. Excludes recreational and non-essential items such as home dcor, TVs, internet access, and gaming systems.23CFC and Waiver EligibilityCommunity First Choice25Eligible 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)

26Community First Choice27Eligible 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

28Participation 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 day29Other 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 locksThe 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.

30Citation: 73 Fed. reg. 18,676, 18,685-86 (2008)30Waiver 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

3334Enrollment 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 35Applicant 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 planning36Enrollment 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 POSCommunity First Choice37Eligible 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

38Community First Choice39Eligible 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 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 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

43Budgets by Group44RUGGrouper 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 budget45Services in the Plan 46CFC 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 MonitoringException 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 system47Plan of ServiceCommunity First Choice49Eligible 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.

50Plan of Service Development Community First Choice51Eligible 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 needed52Contact Us53DHMH:Jennifer Miles, MFP Housing [email protected]

Michelle Haile, Health Policy Analyst MFP Housing Specialist [email protected]

MDOD:John Brennan, Chief of StaffMaryland Department of [email protected]