CMS-10398 #50 Community First Choice (CFC) State Plan pre-print
Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)
50 - Template Community First Choice 04-25-17
GenIC #50 (Extension w/o change): Community First Choice State Plan
OMB: 0938-1148
OMB No.: 0938-1148
CMS
Form: CMS-10398 #50
Attachment 3.1 – K
Community First Choice (CFC) State Plan Option
STATE/TERRITORY:
1915(k)
42 CFR 441 Subpart K
Benefit Summary:
Please provide a brief general overview of the state's proposed CFC benefit, including but not limited to an overview of services, delivery method, impact on other LTSS programs, and how services will be coordinated between the CFC program and other state services provided:
Community First Choice Development and Implementation Council
Name
of State Development and Implementation Council:
<mm/dd/yyyy>
Date of 1st Council meeting:
The state has consulted with its Development and Implementation Council before submitting its Community First Choice State Plan amendment.
The state has consulted with its Development and Implementation Council on its assessment of compliance with home and community-based settings requirements, including on the settings the state believes overcome the presumption of having institutional qualities.
y/n
The state has sought public input on home and community-based settings compliance beyond the Development and Implementation Council. If yes, please describe.
Community First Choice Program Eligibility
Individuals are eligible for medical assistance under an eligibility group identified in the state plan.
Categorically Needy Individuals
Medically Needy Individuals
Medically Needy individuals receive the same services that are provided to Categorically Needy individuals
Different services than those provided to Categorically Needy individuals are provided to Medically Needy individuals. (If this box is checked, a separate template must be submitted to describe the CFC benefits provided to Medically Needy individuals)
The state assures the following:
Individuals are in eligibility groups in which they are entitled to nursing facility services, or
If in an eligibility group under the state plan that does not include such nursing facility services, and to which the state has elected to make CFC services available (if not otherwise required), have an income that is at or below 150 percent of the Federal poverty level (FPL)
Level of Care
The state assures that absent the provision of home and community based attendant services and supports provided under CFC, individuals would require the level of care furnished in a long-term care hospital, a nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution providing inpatient psychiatric services for individuals under age 21, or an institution for mental diseases for individuals age 65 or over.
y/n
The state has chosen to permanently waive the annual recertification of level of care requirement for individuals in accordance with 441.510(c)(1) & (2).
Please indicate the levels of care that are being waived:
Long-term care hospital
Nursing facility
Intermediate care facility for individuals with intellectual disabilities
Institution providing psychiatric services for individuals under age 21
Institution for mental diseases for individuals age 65 or over
Describe the state process for determining an individual's level of care:
Informing Individuals Potentially Eligible for the Community First Choice Option
Indicate
how the state ensures that individuals potentially eligible for
Community First Choice services and supports are informed of the
program's availability and services:
Letter
Other – Describe:
Please describe the process used for informing beneficiaries:
Assurances (All assurances must be checked).
Services
are provided on a statewide basis.
Individuals
make an affirmative choice to receive services through the Community
First Choice benefit.
Services are provided 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 needs to lead an independent life.
Individuals receiving services through Community First Choice will not be precluded from receiving other home and community-based long-term care services and supports through other Medicaid state plan, waiver, grant or demonstration authorities.
During the five-year period that begins January 1, 2014, spousal impoverishment rules are used to determine the eligibility of individuals with a community spouse who seek eligibility for home and community-based services provided under 1915(k).
CFC Service Models
Indicate
which service models are used in the state's Community First Choice
program to provide consumer-directed home and community-based
attendant services and supports (Select all that apply):
Agency-Provider Model
Self-Directed Model with Service Budget
Other Service Model. Describe:
Please complete the following section if the state is using the Self-Directed Model with Service Budget or the Other Service Model if it includes a Service Budget
Financial Management Services
The state must make available financial management services to all individuals with a service budget.
The
state will claim costs associated financial management services as:
A Medicaid Service
An Administrative Activity
The state assures that FMS activities will be provided in accordance with 42 CFR 441.545(B)(1). (Must check)
If applicable, please describe the types of activities that the FMS entity will be providing, in addition to the regulatory requirements at 42 CFR 441.545(B)(1).
Specify the type of entity that provides financial management services:
State Medicaid Agency
Another State Agency
Developmental Disabilities Agency
Aging Agency
Mental Health Agency
Substance Use Agency
Other Type of Agency
Describe:
Vender Organization
Describe:
Other Payment Methods
The state also provides for the payment of Community First Choice services through the following methods:
y/n
Use of Direct Cash Payments - The state elects to disburse cash prospectively to CFCO participants. The state assures that all Internal Revenue Service (IRS) requirements regarding payroll/tax filing functions will be followed, including when participants perform the payroll/tax filing functions themselves.
Describe the Methods Used:
y/n
Describe the Methods Used:
Service Budget Methodology
Describe the budget methodology the state uses to determine the individual's service budget amount. Also describe how the state assures that the individual's budget allocation is objective and evidence-based utilizing valid, reliable cost data and can be applied consistently to individuals:
Describe how the state informs the individual of the specific dollar amount they may use for Community First Choice services and supports before the person-centered service plan is finalized:
Describe how the individual may adjust the budget, including how he or she may freely change the budget and the circumstances, if any, which may require prior approval of the budget change from the state:
Describe the circumstances that may require a change in the person-centered service plan:
Describe how the individual requests a fair hearing if his or her request for a budget adjustment is denied or the amount of the budget is reduced:
Describe the procedures used to safeguard individuals when the budgeted service amount is insufficient to meet the individual's needs:
Describe how the state notifies individuals of the amount of any limit to the individual's Community First Choice services and supports:
Describe the process for making adjustments to the individual's budget when a reassessment indicates there has been a change in his or her medical condition, functional status, or living situation:
Mandatory Services and Supports
Assistance with ADLs, IADLs, and health-related tasks through hand-on assistance, supervision, and/or cueing.
Identify the activities to be provided by applicable provider type and any describe any service limitations related to such activities.
Personal Attendant Services. Describe:
y/n
Provider Type:
License Required
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type. Describe:
Companion Services. Describe:
y/n
License Required. Describe:
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type. Describe:
Homemaker/Chore
Services. Describe:
Provider Type:
y/n
License Required. Describe:
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type. Describe:
Other Services. Describe:
y/n
Provider Type:
License Required
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type. Describe:
The acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks.
Identify the activities to be provided by applicable provider type and any describe any service limitations related to such activities Name of Service. Describe:
y/n
License Required. Describe:
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type. Describe:
Individual back-up systems or mechanisms to ensure continuity of services and supports.
Identify the systems or mechanisms to be provided and limitations for:
Personal Emergency Response Systems
Pagers
Other Mobile Electronic Devices
Other. Describe:
Describe any limitations for the systems or mechanisms provided:
y/n
Provider Type:
License Required
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type. Describe:
Voluntary training on how to select, manage and dismiss attendants.
The state will claim costs associated with voluntary training as (check one):
A Medicaid Service
An Administrative Activity
Describe the voluntary training program the state will provide to individuals on selecting, managing and dismissing attendants:
y/n
Provider Type:
License Required
y/n
Certification Required. Describe:
y/n
Education-Based Standard. Describe:
y/n
Other Qualifications Required for this Provider Type:
Optional Services and Supports:
Indicate which of the following optional services and supports the state provides and provide a detailed description of these benefits and any limitations applicable to them.
y/n
Transition Costs (Provided to individuals transitioning from a nursing facility, Institution for Mental Disease, Intermediate care facility for Individuals with Intellectual Disabilities to a community based home setting) – Check all of the following costs that apply:
Rental and Security Deposits
Description and Limitations:
Utility Security Deposits
Description and Limitations:
First Month’s Rent
Description and Limitations:
First Month’s Utilities
Description and Limitations:
Basic Kitchen Supplies
Description and Limitations:
Bedding and Furniture
Description and Limitations:
Other Household Items
Description and Limitations:
Other Services or Supports Necessary for Transition from Institution to Community
Description and Limitations:
y/n
Goods and Services - Services or supports for a need identified in the individual's person-centered plan of services that increase an individual's independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance. Include a service description including provider type and any limitations for each services provided.
Name of Service:
Description, Provider Type and and Limitations:
√
Each individual receiving Community First Choice services and supports must reside in a home or community-based setting and receive CFC services in community settings that meet the requirements of 42 CFR 441.530
Setting Types (check all that apply):
CFC services are only provided in private residences and are not provided in provider - owned or controlled settings.
CFC services may be provided in private residences and in provider owned or controlled settings.
The CFC benefit includes settings that have been determined home and community-based through the heightened scrutiny process.
Provider –owned or controlled settings:
Please identify all residential setting types in which an individual may receive services under the CFC benefit.
Please identify all non-residential setting types in which a person may receive services under the CFC benefit.
Setting Assurances – The state assures the following:
CFC services will be furnished to individuals who reside in a home or community setting, which does not include a nursing facility, institution for mental diseases, an intermediate care facility for individuals with intellectual disabilities, or a hospital providing long-term care services.
Any permissible modifications of rights within a provider owned and controlled setting is incorporated into an individual’s person-centered service plan and meets the requirements of 42 CFR 530(a)(vi)(F).
Additional state assurances:
Community First Choice Support System, Assessment and Service Plan
Support System
The support system is provided in accordance with the requirements of §441.555.
Provide a description of how the support system is implemented and identify the entity or entities responsible for performing support activities:
Specify any tools or instruments used as part of the risk management system to identify and mitigate potential risks to the individual receiving CFC services:
Provide a description of the conflict of interest standards that apply to all individuals and entities, public or private to ensure that a single entity doesn’t provide the assessments of functional need and/or the person-centered service plan development process along with direct CFC service provision to the same individual:
y/n
Assessment of Need
Describe the assessment process or processes the state will use to obtain information concerning the individual's needs, strengths, preferences and goals.
The
state will allow the use of telemedicine or other information
technology medium in lieu of a face-to-face assessment in accordance
with §441.535. The individual is provided with the opportunity
for an in-person assessment in lieu of one performed via
telemedicine. Include a description about how an individual receives
appropriate support including access to on-site support staff during
the assessment:
The
state will claim costs associated with CFC assessment activities as:
A Medicaid Service
An Administrative Activity
Indicate who is responsible for completing the assessment prior to developing the Community First Choice person-centered service plan. Also specify their qualifications:
Social Worker (specify qualifications)
Registered Nurse, licensed to practice in the state, acting within scope of practice under state law.
Licensed Practical Nurse or Vocational Nurse, acting within scope of practice under state law
Licensed Physician (M.D. or O.D.), acting within scope of practice under state law
Case Manager (specify qualifications)
Other (specify what type of individual and their qualifications)
The reassessment process is conducted every:
12 months
Other (must be in increments of time less than 12 months)
Describe the reassessment process the state will use when there is a significant change in the individual's needs or the individual requests a reassessment. Indicate if this process is conducted in the same manner and by the same entity as the initial assessment process or if different procedures are followed:
Person-Centered Service Plan
The Community First Choice service plan must be developed using a person-centered and person- directed planning process. This process is driven by the individual and includes people chosen by the individual to participate.
The
State will claim costs associated with CFC person-centered planning
process as:
A Medicaid Service
An Administrative Activity
Indicate who is responsible for completing the Community First Choice person-centered service plan.
Case Manager. Specify qualifications:
Social Worker. Specify qualifications:
Registered Nurse, licensed to practice in the state, acting within scope of practice under state law.
Licensed Practical Nurse or Vocational Nurse, acting within scope of practice under state law
Licensed Physician (M.D. or O.D.), acting within scope of practice under state law
Other. Specify provider type and qualifications:
Person-Centered Service Plan Development Process: Use the section below to describe the process that is used to develop the person-centered service plan.
Specify the supports and information that are made available to the individual (and/or family or authorized representative, as appropriate) to direct and be actively engaged in the person-centered service plan development process and the individual’s authority to determine who is included in the process:
Indicate who develops the person-centered service plan. Identify what individuals, other than the individual receiving services or their authorized representative, are expected to participate in the person-centered service plan development process. Please explain how the state assures that the individual has the opportunity to include participants of their choice:
Describe the timing of the person-centered service plan development to assure the individual has access to services as quickly as possible; describe how and when it is updated, including mechanisms to address changing circumstances and needs or at the request of the individual:
Describe the state's expectations regarding the scheduling and location of meetings to accommodate individuals receiving services and how cultural considerations of the individual are reflected in the development of the person-centered service plan:
Describe how the service plan development process ensures that the person-centered service plan addresses the individual's goals, needs (including health care needs), and preferences and offers choices regarding the services and supports they receive and from whom. Please include a description of how the state records in the person-centered service plan the alternative home and community based settings that were considered by the individual:
Describe the strategies used for resolving conflict or disagreements within the process:
Please describe how the person-centered service plan development process provides for the assignment of responsibilities for the development of the plan and to implement and monitor the plan.
The state assures that assessment and service planning will be conducted according to 441.540(B) 1-12.
The
person-centered service plan is reviewed and updated every:
3 months
6 months
12 months
Other (must be less than 12 months
AND
When an individual's circumstances or needs change significantly or at the individuals request.
Describe the person-centered service plan review process the state will use. In the description please indicate if this process is conducted in the same manner and by the same entity as the initial service plan review process or if different procedures are followed:
Community First Choice Service Delivery Systems
Identify the service delivery system(s) that will be used for individuals receiving Community First Choice services:
Traditional State-Managed Fee-for-Service (4.19(b) page is required)
Managed Care Organization
Other
Describe:
Quality Assurance System
Please describe the state's quality improvement strategy:
Describe the methods the state will use to continuously monitor the health and welfare of each individual who receives home and community-based attendant services and supports, including a process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports:
Describe how the state measures individual outcomes associated with the receipt of home and community-based attendant services and supports as set forth in the person centered service plan, particularly for the health and welfare of individuals receiving such services and supports. These measures must be reported to CMS upon request.
Describe
the standards for all service delivery models for training, appeals
for denials and
reconsideration procedures for an individual’s
person-centered service plan:
Describe the methods used to monitor provider qualifications:
Describe the methods for assuring that individuals are given a choice between institutional and community based services:
Describe the methods for assuring that individuals are given a choice of services, supports and providers:
Describe the methods for monitoring that the services and supports provided to each individual are appropriate:
Describe the state process for ongoing monitoring of compliance with the home and community-based setting requirements, including systemic oversight and individual outcomes.
Choice and Control
Describe the quality assurance system's methods to (1) maximize consumer independence and control, (2) provide information about the provisions of quality improvement to each individual receiving CFC services and supports:
Stakeholder Feedback
Describe how the state will elicit feedback from key stakeholders to improve the quality of the community-based attendant services and supports benefit:
Identify the stakeholders from whom the state will elicit feedback:
The state will elicit feedback from the following stakeholders: (1) Individuals receiving CFC services and if applicable, their representatives, (2) disability organizations, (3) providers, (4)
families of elderly individuals or individuals with disabilities, (5) and members of the community
Other
Describe:
The state assures there are necessary safeguards in place to protect the health and welfare of individuals provided services under this state Plan Option, and to assure financial accountability for funds expended for CFCO services.
With respect to expenditures during the first full year in which the state plan amendment is implemented, the state will maintain or exceed the level of state expenditures for home and community-based attendant services and supports provided under section 1905(a), section 1915, section 1115, or otherwise to individuals with disabilities or elderly individuals attributable to the preceding year.
The state assures the collection and reporting of information, including data regarding how the state provides home and community-based attendant services and supports and other home and community-based services, the cost of such services and supports, and how the state provides individuals with disabilities who otherwise qualify for institutional care under the state plan or under a waiver the choice to instead receive home and community-based services in lieu of institutional care, and the impact of CFC on the physical and emotional health of individuals.
The
state shall provide the Secretary with the following information
regarding the provision of home and community-based attendant
services and supports under this subsection for each fiscal year for
which such services and supports are provided:
The number of individuals who are estimated to receive home and community-based attendant services and supports under this option during the fiscal year.
The number of individuals that received such services and supports during the preceding fiscal year.
The specific number of individuals served by type of disability, age, gender, education level, and employment status.
Whether the specific individuals have been previously served under any other home and community based services program under the state plan or under a waiver.
The state assures that home and community-based attendant services and supports are provided in accordance with the requirements of the Fair Labor Standards Act of 1938 and applicable Federal and state laws.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lindsey Wilde |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |
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