Community First Choice Option (CFCO)

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Mark Kissinger, Director

Division of Long Term Care
Office of Health Insurance Programs
New York State Department of Health (DOH)

School of Public Health
June 27, 2016


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Partners and Sponsors

  • New York State Department of Health
  • University at Albany, School of Public Health, Center for Public Health Continuing Education

The planners, moderators, and presenters do not have any financial arrangements or affiliations with any commercial entities whose products, research, or services may be discussed in this activity.

No commercial funding has been accepted for this activity.

Continuing Education Credits

  • Credits available: CME, CNE, CHES, and Social Work
  • To obtain credits, participants must complete an evaluation and score 80 percent or above on the post-test.
  • A link to the evaluation and post-test will be available after the webinar.

Learning Objectives

  • Recognize the core elements of person-centered planning.
  • Identify eligibility requirements for CFCO.
  • Identify the two service delivery models under CFCO.
  • Identify in which settings CFCO services can be provided.

What is CFCO Option?
(Affordable Care Act, PL 111-148, Sec. 2401)

  • CFCO is an optional set of services under Medicaid that was authorized in the Affordable Care Act.
  • Allows states to expand and enhance state plan home/community-based attendant services and supports to individuals in need of long term care for help with everyday activities and health-related tasks that can be performed by an aide or direct care worker.
  • Focus is on person-centered, individually directed services that help the recipient maximize his or her independence and participation in the community.

Community First Choice Option - Why did NY elect to participate?

  • Provides additional FMAP (Federal Medical Assistance Percentage) to states to expand and enhance state plan home/community-based attendant services and supports to individuals in need of long term care for Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs) and health-related tasks.
  • Allows services to be focused on the person and remove the silos that more traditional programs have forced people into.
  • New York is the 6th State to have an approved state plan amendment taking up CFCO. (We join CA, OR, MT, MD, and TX.)


  • ADLs - Activities of Daily Living. Basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing and transferring.
  • IADLs - Instrumental Activities of Daily Living. Activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing and other essential items, performing necessary household chores, communicating by phone or other media, and traveling around and participating in the community.
  • Health-related tasks - Specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under state law to be performed by a direct care worker.

CFCO Services

  • These new State Plan Services must provide consumer controlled, personal assistance services and supports for ADLs, IADLs and health-related tasks, including supervision and cueing.
    • Prior to CFCO, supervision and cueing were available in NYS only through Medicaid-funded waiver programs.
  • Services must be provided across all Medicaid-eligible populations (DOH, OMH, and OPWDD).
  • Services and supports must be provided in the community.

Other Required Services and Supports

  • Backup mechanism to assure continuation of services. Some examples include:
    • A firm plan in place for a substitute aide when regular aide is absent.
    • Emergency Response System ready to go if necessary.
    • Natural supports that are aware of the role to assist the individual if an aide is not available.
  • Acquisition, maintenance or enhancement of an individual´s skills necessary to accomplish ADLS, IADLS and health-related tasks.
  • Voluntary training course for individuals on how to manage their direct care worker.
    • Training formats range from in person to web-based, making them more accessible across all populations.
    • Training is specific to the new State Plan Services allowable under CFCO.

Excluded Services

  • Room and board
  • Special education and related services provided under the IDEA, or vocational services provided under the Rehabilitation Act of 1973

Permissible Services and Supports

  • Transition expenses help an individual move from an institutional setting to a community-based setting.
  • Examples of transition expenses:
    • Rent and utility deposits
    • First month´s rent and utility expenses
    • Necessary household items to set up a home and make the transition smoother for the individual
  • Costs related to a need identified in the person-centered plan of services that increase an individual´s independence or substitute for human assistance
  • Examples include:
    • Utilizing the home-delivered meal service instead of paying for an aide to come and prepare meals
    • Computer software and hardware, such as voice recognition programs, screen readers, and screen enlargement applications, to help people with mobility and sensory impairments use computer technology

Current Services and Supports Covered Under the CFCO Umbrella

  • Assistive Technology
  • Community Habilitation
  • Community Transitional Services
  • Durable Medical Equipment/Medical Supplies
  • Environmental Modification
  • Home Delivered/Congregate Meals
  • Home Health Care
  • Homemaker/Housekeeper
  • Personal Care/Consumer Directed Personal Assistance Program
  • Personal Emergency Response
  • Transportation - Non-Emergency, Medical
  • Transportation - Non-Emergency, Social
  • Vehicle Modification

CFCO Services and Supports ARE State Plan Services

  • What do we mean by "State Plan Services"?
    • CFCO is now part of New York´s Medicaid State Plan, which means that CFCO services and supports are available to anyone who is eligible under Medicaid for which they have an assessed need.
    • With the addition of CFCO, the State is expanding access and availability by offering services and supports that have until now only been available through waivers.

Service Delivery Model Options under CFCO

There are two Service Delivery Model Options under CFCO:

  1. Agency Model
    • Based on the person-centered assessment of need
    • Services and supports are provided by personal care aides, personal attendants, home health aides, or direct service professionals employed by a traditional agency or provider
    • CFCO participants will still exercise as much control over the selection, management and, if necessary, dismissal of their direct care worker as they desire.
    • The Local Department of Social Services (LDSS), a managed care entity or a non-profit organization may contract with home care agencies or providers to deliver CFCO services.
  2. Agency with Choice Model:

    Also based on the person-centered assessment of need.
    • Will be utilized when the individual seeking CFCO services wants to directly hire his or her own direct care worker.
    • This direct care worker may be a parent of an adult child, another relative, a neighbor, a friend or an independent direct care worker. The direct care worker may not be a spouse or the parent of a minor child.
    • The individual will select, manage, train and, if necessary, dismiss his or her own direct care worker.
    • A fiscal intermediary will be used to keep track of the direct care worker´s hours, pay the direct care worker and deduct required amounts for taxes and insurance from the direct care worker´s check.
    • Fiscal intermediaries can be licensed home care services agencies, independent living centers, or other entities that pay direct care workers.
    • CFCO participants must have a choice of fiscal intermediaries.

Fee-for-Service Implementation

  • CFCO will be implemented in the Fee-for-Service environment in addition to the Managed Care environment.
  • Service planning will be person centered and follow the requirements of CFCO.
  • CFCO provides recipients the opportunity to participate in a process that assures that their preferences, needs and goals are recognized and addressed.
  • Implementation guidance documents are in development in the DOH.
  • These guidance documents will help local districts understand their roles and responsibilities with implementing CFCO, specifically how these services and supports will be accessed and authorized.

Managed Care/Managed Long Term Care Implementation

  • In the coming months, the scope of benefits for Managed Care Organizations (MCOs) will be amended to include these new State Plan Services allowable under CFCO.
  • MCOs will contract with service providers, and fiscal intermediaries to make these services available to plan enrollees.
  • The addition of these new State Plan Services to the plan benefit should not result in enrollees currently utilizing LTSS to change providers or experience a reduction in service.

Participant Eligibility

  • State Plan Services under CFCO are available to individuals who are:
    • Eligible for medical assistance under the State Plan;
    • Have an institutional level of care as determined by the functional assessment used by that population (UAS); and
    • Living in their own home or a family member´s home (not a congregate setting).
  • Individuals receiving services through CFCO will not be precluded from receiving other HCBS Long Term Care (LTC) services and supports through another Medicaid State Plan, waiver, grant or demonstration, as appropriate.
  • However, individuals will not be allowed to receive duplicative services in CFCO or any other available community-based services.

Determination for Level of Care

  • The State will ensure that a determination is made initially, and at least annually, that individuals require the Level of Care (LOC) provided in a hospital, a nursing facility, an intermediate care facility for Individuals with Intellectual Disabilities (ICF/IID), an institution providing psychiatric services for individuals under 21, or an institution for mental diseases for individuals 65 or over.
  • LOC for individuals between ages 21 and 65 needing psychiatric services is determined using hospital, ICF or nursing facility LOC criteria.
  • Various functional assessment tools in use across disability populations in New York State (NYS) will include a LOC outcome, either as part of the assessment or separately, and will also be used to inform a person-centered plan of care.
  • Different tools are utilized in order to accurately assess an individual´s specific needs based on the relevant institutional LOC being assessed (skilled nursing facility, hospital, intermediate care facility, institute for mental disease, etc.).

Assessment and Authorization

  • Eligibility for New York State´s Medicaid-supported home and community-based long term services and supports is determined by a number of federally approved assessments.
  • These assessment tools will assess individuals across dozens of critical domains such as: function, cognition, behavior, communication, informal supports, clinical, etc.
  • While the UAS-NY determines LOC, not all functional needs assessments in use do, so LOC will be determined separately.
  • All functional needs assessments will record the individual´s needs, strengths, preferences and goals for maximizing their independence and community integration through questions geared to elicit this information, which is essential to the person-centered planning process.
    • They will be completed face to face with each individual by a specifically trained assessor(s).
    • The service recipient will be able to request the participation of anyone he or she wants involved in the functional needs assessment and service planning process.

Person-Centered Service Plan

  • A person-centered plan of care, also known as the Service Plan (SP) will be developed for CFCO-eligible individuals based on a comprehensive functional assessment that, in part, identifies the individual´s needs and goals related to living independently in the community.
  • The agent of state government (i.e., local district for social services, regional developmental disability office or service coordinator or their delegate, etc.) or managed care entity must review the individual´s service needs at least annually, upon a significant change in the individual´s condition or if requested by the individual.

The person-centered SP will reflect the services and supports that are important for the individual to meet the needs identified through an assessment, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.

  • The plan must:
    • Reflect the individual´s freedom of choice to participate in community-based services and supports
    • Reflect the individual´s strengths and preferences
  • The plan must also:
    • Reflect clinical and support needs as identified through an assessment of functional need
    • Include individually identified goals and desired outcomes
    • Reflect the services and supports (paid and unpaid) that will assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports
    • Reflect risk factors and measures in place to minimize them, including individualized backup plans
  • In addition, the plan must:
    • Be understandable to the individual receiving services and supports, and the individuals important in supporting him or her
    • Identify the individual and/or entity responsible for monitoring the plan
    • Be finalized and agreed to in writing by the individual and signed by all individuals and staff responsible for writing the plan
    • Be distributed to the individual and other people involved in the plan
    • Prevent the provision of unnecessary or inappropriate care

Reassessment and Reauthorization

  • Individuals will be reassessed at least annually, or as needed when the individual´s support needs or circumstances change significantly.
  • Individuals will be informed that if they would like to be reassessed due to such changes, they need to notify their coordinator of the change and request a reassessment.

Conflict-Free Case Management

  • CFCO requires states to assure the assessment and service planning elements are provided in a conflict-free manner. The federal regulations require:
    • Individuals or entities conducting the assessment of functional need and person-centered service plan development process are not:
      1. Related by blood or marriage, or a paid caregiver of the individual.
      2. Financially responsible for the individual.
      3. Empowered to make financial or health-related decisions on behalf of the individual.
      4. Individuals who would benefit financially from the provision of assessed needs and services.

Scenario 1

  • Mary is an elderly woman who requires more than 120 days of home and community-based services and supports and is enrolled in a managed long term care plan.
  • She receives home health care (home health aide, nursing, physical therapy, and speech therapy) to address functional needs resulting from a stroke.
  • Mary also gets lunch and dinner from Meals on Wheels several days during the week when her adult child, with whom she lives, is at work.
  • Several days a week, Mary also attends an adult day health care program.
  • Mary will continue to receive all of the services she currently receives and her MLTC plan will receive a capitated monthly rate.
  • MLTC contracts will have to be amended and new rates negotiated in order to implement CFCO in a managed care environment.
  • Current MLTC participants will be able to receive the new State Plan Services, but will have to go outside their managed care provider and access them through Fee For Service until 2017.

Scenario 2

  • Tom is an elderly man suffering from the early stages of dementia.
  • He lives with his adult daughter.
  • Tom goes to a social day program that is not funded by Medicaid for five hours a day.
  • Tom still needs support before and after his day program until his daughter gets home from work.
  • Due to dementia, Tom needs to be reminded to turn off the stove and has begun to wander.
  • In order for Tom to access Medicaid-funded home and community based services and supports, like those provided through the CFCO, he needs to be eligible for Medicaid. Tom must go to the LDSS to obtain Medicaid.
  • Once Tom is approved for Medicaid, he must get assessed to determine his Level of Care and, if eligible, have a functional needs assessment to determine which CFCO services and supports would help him remain home in the community. He may also be found to need non-CFCO services and supports.
  • The local district will be able to help Tom access the services and supports he needs.
  • For instance, a supervision and cueing service may allow Tom to stay in the community as opposed to moving to a more restrictive institutional placement to address his needs.
  • Supervision and cueing used to be restricted to only Medicaid-funded waiver participants, but is now available through the State Plan under the CFCO umbrella. This is an example of expanded long term services and supports available under CFCO.


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