Implementing the Community First Choice Option in New York Lana Mutters, MPH Policy Analyst New York Association on Independent Living Norain Siddiqui,

Implementing the Community First Choice Option in New York

Lana Mutters, MPHPolicy Analyst

New York Association on Independent Living

Norain Siddiqui, MPHPolicy Analyst

Center for Disability Rights

History• Grassroots – ADAPT

• Community Choice Act (CCA)

• Affordable Care Act includes Community First Choice Option (March 2010)

• New York State – Selection of Option (March 2011)

• DOH CFC Workgroup (June 2012)

What is CFC?

Community-based Medicaid state plan service (1915[k] State Plan Amendment)

Includes hands-on assistance, safety monitoring, cueing, ADL, IADL

First program to provide services based on functional need, not diagnosis or age

Eligibility

• Must be Medicaid eligible• Must require an institutional level of care

(hospital, nursing facility, ICF-MR, or IMD)

Background and BasicsAffordable Care Act establishes Community First

Choice (CFC) under § 1915(k) of Social Security Act under Medicaid

CFC supports independence, integration, person-centered, consumer-directed in accordance with the Olmstead decision of 1999

As state plan amendment, entitlement

CANNOT include:• Nursing facilities

• Institutions for Mental Diseases (IMD)

• Intermediate Care Facilities for Mentally Retarded (ICF-MR)

• Any public/private facility that provides inpatient institutional treatment

• Any building on grounds of disability-specific housing complex

Services must be provided in community-based setting

Required Services• Attendant services and supports for

– activities of daily living (ADL) – instrumental activities of daily living (IADL)– health-related tasks

• Attendant services and supports include– hands-on assistance– safety monitoring– cueing

• Assistance with the learning skills necessary to accomplish ADL, IADL, and health-related tasks

• Purchase of back-up systems (beepers) to ensure continuity of services and supports

• NYS must develop/offer a voluntary training on how to select, manage, dismiss attendants

Permissible Services & Supports

• Transition costs – i.e. security deposits for rent/utilities– purchasing basic kitchen supplies, etc.

• Services that increase independence or substitute for human assistance– i.e. learning how to use public transportation

Excluded Services• Room and board

• Special education and related services provided

under IDEA and vocational rehab

• Assistive technologies (other than those used as

back-up systems)

• Medical supplies and equipment

• Home modifications

Models for Service Delivery• “Agency Provider Model” *

– range of approaches– individual has ability to select, train, dismiss attendant– Traditional agency managed services– Agency-with-Choice model where the agency operates solely as a

fiscal intermediary

• “Self-Directed Model with service budget”– Vouchers– Direct Cash Payments (similar to Cash & Counseling)– Fiscal Agent

* Chosen by New York in State Plan Amendment

How does CFC benefit New York?

• Supports Governor’s commitment to Olmstead

• Enhanced 6% FMAP with no sunset

• Addresses gaps in long term care system

• Streamlines system to reduce administrative redundancies

How is CFC different?• Cross-disability

• Home and/or community settings

• Includes transition costs from an institution to a home

• Maximizes consumer control and allows for a proxy chosen by individual

to direct care

• Supplemented with backup and emergency attendant services

• Voluntary training on how to self direct

• Availability of equipment or e-mods that substitute for human assistance

CFC will work for you• Applicable in multiple settings

• Flexible scheduling

• Person-centered

• Eliminates silos

• Self-direction

• Budgeting

New York’s State Plan Amendment • Submitted in December 2013, still awaiting CMS

approval

• “Agency with Choice” model

• NYAIL & CDR would like to see clarifications on:1. IADL “Care of others”2. Stakeholder feedback

Notable Issues• Definition of “community” and “setting”

– Dept. of Health and Human Services finalized definition in January 2014– Rules now in line with Olmstead

…settings do not include a nursingfacility, institution for mental diseases, or an intermediate care facility for individuals with intellectual disabilities…we have established that home and community-based settings must exhibit specific qualities to be eligible sites for delivery of home and community-based services.

Notable issues cont. • Nurse Practice Act

– NPA only allows licensed nurses to perform health-related tasks (i.e.

catheter, vent care, etc.)

– Must be amended to allow “advanced aide” to do these tasks, as

overseen by nurse

• Cost effective

• Aides already perform tasks in CDPAP

• Nurse shortage

– Contentious debate between NYS, NYSNA, disability rights groups

over patient safety, professional scope, civil rights

Nurse Practice Act cont. • If State fails to enact NPA exemption, entire SPA could be

dismissed by CMS

• CFC requires services to be delivered “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 to lead an independent life.”

Where are we now?

• Waiting for CMS to approve SPA • CFC in the budget process • Presented draft CFC language to Assembly • Pending CFC legislation

CFC in other statesCurrently Participating • California • Oregon • Maryland State Plan Amendment Withdrawn • Arizona • LouisianaPlan to Participate 2014 Fiscal Year • Montana • Texas• Arkansas• Wisconsin• Minnesota

Additional resourcesDOH CFC workgrouphttp://www.health.ny.gov/facilities/long_term_care/

Final regulationshttps://www.federalregister.gov/articles/2012/05/07/2012-10294/medicaid-program-community-first-choice-option

CMS final rules on HCBS http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html

Questions?Lana MuttersNew York Association on Independent Living(518) 465-4650 [email protected]

Norain Siddiqui Center For Disability Rights (518) [email protected]