Community First Choice CFC Overview Eligibility CFC Waiver Enrollment Process CFC Waiver 2 Community First Choice CFC Affordable Care Act ACA program expanding options for communitybased longterm services and supports ID: 700994
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Slide1
Community First Choice
Maryland Department of Health and Mental HygieneSlide2
Community First Choice
CFC Overview
Eligibility
CFCWaiverEnrollment ProcessCFCWaiver
2Slide3
Community 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 Plan
Emphasizes self directionIncreases the State’s enhanced match on all CFC services by 6 %Allows Medicaid to set consistent policy and rates across programs
Requires an institutional level of care
CFC will offer all mandatory and optional services allowable
Personal assistance servicesEmergency back-up systemsTransition services,Items that substitute for human assistanceTechnology, accessibility adaptations, home delivered meals, etc.
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Old Service Structure
4
Maryland 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 standard
Living at Home (LAH) Waiver
Target group ages 18-64 with disabilities
Nursing Facility Level of Care standardWaiver for Older Adults (WOA)Target group aged 50 and overNursing Facility Level of Care standardSlide5
New Service Structure
Services formerly offered through multiple programs are now consolidated under CFC
Maximizes 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
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Former Service Structure
MAPC
LAH
WOA
Personal
Assistance
Services
Case
Management/Nurse Case Monitoring
Consumer Training Personal Emergency Back-up Systems Transition Services Home Delivered Meals Assistive Technology Accessibility Adaptations Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus
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New Service Structure
MAPC
CFC
Waiver
Personal
Assistance
Services
Case Management/Supports Planning
Nurse Monitoring Personal Emergency Back-up Systems Transition Services Consumer TrainingHome Delivered Meals1 Assistive Technology1 Accessibility Adaptations1 Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living
Senior Center Plus
Items that sub *CFC Services will be available to all waiver participants Slide8
Levels of Care
The new merged waiver will continue to use the nursing facility level of care
The 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 clinicians
Levels of care will be reviewed annually
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9Slide10
CFC Service Package
Personal Assistance
Nurse Monitoring
Supports PlanningItems or Services that Substitute for Human AssistanceEnvironmental Assessments and /or ModificationsTechnology
Home Delivered Meals
Consumer Training
Personal Emergency Response SystemTransition Services 10Slide11
Service and System Enhancements
CFC adds emphasis on person-centered planning and self-direction
Maryland Department of Disabilities (MDOD) will be providing self-direction training on hiring, firing, and managing providers
CFC 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
11Slide12
Enhancements for Participants
All 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
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CFC and Waiver EligibilitySlide14
Community First Choice
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Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide15
Financial Eligibility
Participants 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)
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Community First Choice
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Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide17
Medical Eligibility
The 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 waivers
Community 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 Care17Slide18
Participation 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 services
Participants who receive bundled payments for some TBI, DDA, assisted living or PACE services are not eligible to receive CFC services on the same day
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Other Eligibility Requirements
To 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.
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Waiver Eligibility Technical: Must be at least 18 years old
Medical: Must meet a nursing facility level of care
Financial: 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. Slide21
CFC and Waiver EnrollmentSlide22
Applicants can enroll into CFC from…
An institution
The community
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CFC 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 same
The 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
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Enrollment in CFC from Nursing Facility
Applicant in Nursing Facility receives options counseling
Applicant has community MA
No community MA
Options 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 DHMH
Supports Planner coordinates transition
Supports 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 Slide25
Enrollment into Waiver from a Nursing Facility
25
Applicant in Nursing Facility receives options counseling
Has Long Term Care MA
Has Community MA
Wavier Application Assistance
Contact made with Supports Planning Provider
Supports Planner meets with participant to create Plan of Service***
Plan of Service approved by DHMH
Supports 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
DEWS
LHD for assessment
Provides Supports Planning selection packet to applicantSupports Planner coordinates transitionApply for CFCSlide26
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Enrollment in CFC from the Community
Contact DHMH
Applicant contacts MAP site, referred to DHMH
Community MA status verified by DHMH
No Community MA
Has Community MA
Contact made with Supports Planning Provider
Supports 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 Community
Refer to Local DSS
Plan of Service approved by DHMH
Add to LTSS
Referral 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 POSSlide27
Enrollment into Waiver from the Community
Only individuals who receive an invitation to apply from the waiver registry can apply to the waiver from the community
The waiver programs reached their budgetary caps in 2003
A 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
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Community First Choice
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Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide29
Assessment by the LHD
After a person applies, they are referred to the local health department for an assessment
LTSS 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
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Community First Choice
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Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide31
Supports Planner Provider Selection
Applicants will be provided with information about all Supports Planning agencies by the Options Counselor or via a mailing form the Department
The applicant may contact the agency of choice
The 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 daysSlide32
BudgetSlide33
Community First Choice
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Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide34
How budget is determined
The 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 needs
Participants 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
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Budgets by Group
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RUG
Grouper
Description
Budget
Group 1
PA1
Physical Function – Low ADL
$8,336
BA1
Behavioral – 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 6
SE2Extensive Services 2 – Medium to High ADL $43,558 Group 7
SE3
Extensive Services 3 – Medium to High ADL
$76,360
RUG
Grouper Description
Budget
Group 1
PA1
Physical Function – Low ADL
$8,336
BA1
Behavioral – Low ADL
$8,336
CA1
Clin. Complex – Low ADL
$8,336
IA1
Cognitive Impairment – Low ADL
$8,336
PA2
Physical Function – Low ADL, Low to High IADL
$8,336
RA1
Rehabilitation - Low ADL
$8,336
Group 2
BA2
Behavioral – Low ADL, High IADL
$16,167
CA2
Clin. Complex – Low ADL, High IADL
$16,167
IA2
Cognitive Impairment – Low ADL, Low to High IADL
$16,167
PB0
Physical Function – Low to Medium ADL
$16,167
Group 3
CB0
Clin. Complex – Low to Medium ADL
$22,504
RA2
Rehabilitation Low – Low ADL, High IADL
$22,504
PC0
Physical Function – Medium to High ADL
$22,504
SSA
Special Care – Low to High ADL
$22,504
IB0
Cognitive Impairment – Medium ADL
$22,504
BB0
Behavioral – Medium ADL
$22,504
Group 4
PD0
Physical Function – High ADL
$30,314
CC0
Clin. Complex – High ADL
$30,314
Group 5
SE1
Extensive Services 1 – Medium to High ADL
$34,545
RB0
Rehabilitation High – High ADL
$34,545
SSB
Special Care – Very High ADL
$34,545
Group 6
SE2
Extensive Services 2 – Medium to High ADL
$43,558
Group 7
SE3
Extensive Services 3 – Medium to High ADL
$76,360 Slide36
Services within the flexible budget
Personal Assistance
Home-Delivered Meals
“Other” Items that Substitute for Human AssistanceAll other services are included in the Plan of Service in addition to the flexible budget
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Services in the Plan
37
CFC Services Allowable Under Flexible Budget
Other CFC Services based on the Individual Participant’s Assessed Needs
Waiver
Services
Personal Assistance
Technology
Dietitian and Nutrition Services
Home-Delivered Meals
Environmental Accessibility Adaptations
Family Training
Other items that Substitute for Human Assistance
Environmental Assessments
Medical Day Care
Supports PlanningBehavioral Health Consultation Transition ServicesSenior Center Plus Consumer TrainingAssisted LivingPersonal Emergency Response Systems Nurse Monitoring Slide38
Rates for Personal Assistance
Participants 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 rate
The proposed standard independent and agency rate is the weighted average of the current FY14 rates. Independent weighted average rate: $12.27Agency weighted average rate: $16.08
This range would be adjusted each year in the event of rate increases approved during the state budget process.
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Example--Participants receiving personal assistance services 7 days a week
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Annual Budget
Daily Budget
Hours 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 Slide40
Exception Process
If 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 care
The 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 system40Slide41
Plan of ServiceSlide42
Community First Choice
42
Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide43
Supports 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.
43
Plan of Service Development Slide44
Community First Choice
44
Eligible for Medicaid (through a waiver or state plan)
Assessed by Local Health Department
Applicant selects Supports Planner
Develops Plan of Service
Department (DHMH) approves Plan of ServiceParticipant begins receiving services
Assigned a personal budgetSlide45
Ongoing Supports
After enrollment, the participant receives services and supports according to their plan of service
Supports planners must contact the participant monthly and conduct quarterly visits, unless waived by the participant
The 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 needed45Slide46
Christin Whitaker
Department of Health and Mental Hygiene
Community Options Administration Division
201 West Preston Street, Rm 136Baltimore, MD 21201christin.whitaker@maryland.gov410-767-4449