Community First Choice Option (CFCO)

Medicaid Managed Care and Managed Long Term Care

CFCO Rate–Service Training

January 4, 2019



  • Today´s webinar is the first in a series to provide an overview of the services that encompass CFCO, their inclusion into the benefit packages for Managed Care and Managed Long–Term Care Plans, an update on new and existing rate codes, encounter reporting for CFCO and a additional information on the importance of Recipient Restriction Exemption/Exclusion codes in CFCO eligibility and identification
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Current CFCO Services

  • Current CFCO Services:
    • Consumer Directed Personal Assistance Services (CDPAS)
    • Home Health Aide
    • Homemaker/Housekeeper (Personal Care Level 1)
    • Personal Care Level 2
    • Personal Emergency Response System (PERS)
    • Non–Emergency Medical Transportation (NEMT)*
  • These services have been in benefit packages for both Managed Care and Managed Long–Term Care since their implementation as designated CFCO services on 4/1/18.
  • * The one exception is Non–Emergency Medical Transportation (NEMT). This benefit is carved out of Managed Care to Fee for Service (FFS) but remains a covered benefit for Managed Long–Term Care enrollees.
  • There was no change to the services or to the process of encounter reporting for all of the above
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Implementation of Additional CFCO Services

  • Implementation for July 1, 2019:
    • Assistive Technology (AT)
    • Environmental Modification (E–Mod)
    • Vehicle Modification (V–Mod)
    • Moving Assistance
    • Community Transitional Services (CTS)
    • Skill Acquisition Maintenance and Enhancement (SAME)
    • Home–Delivered/Congregate Meals
  • Readiness activities to implement these CFCO services (i.e., expand services beyond just certain 1915(c) Waivers to State Plan services) and to include them in the Managed Care benefit packages, has proven to be a complex undertaking for the State, providers, consumers, Managed Care Organizations (MCOs) and LDSS
  • However, these services will be added to the benefit packages for both Managed Care and Managed Long–Term Care effective 7/1/19.
  • Environmental Modifications (E–Mod) and Home Delivered /Congregate Meals are benefits already being provided for individuals in Managed Long–Term Care Plans.
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Pathways to Accessing CFCO Services

  • Next several slides will review:
    • CFCO eligibility criteria
    • Service definitions and service authorization
    • Billing and rate codes
  • Pathway depends on the person, including whether a person is enrolled in a Waiver, in Managed Care or in Fee–For–Service (FFS)
  • Recipient Restriction Exemption (RR/E) Codes will be used to identify the circumstance of the person, and whether they are eligible for CFCO services.
  • Comprehensive refresher trainings will be held for MCOs and LDSS on January 17 and 18, 2019
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CFCO Eligibility Criteria

  • An individual eligible to receive CFCO services must:
    • Be Medicaid eligible for community coverage with community–based long term care (with or without a spend down) or be Medicaid eligible for coverage of all care and services;
    • Have an assessed institutional level of care; and
    • Reside in his/her own home, or the home of a family member.
  • Individual´s Medicaid eligibility may not be dependent on:
    • Spousal impoverishment post–eligibility rules;
    • The Special Income Standard for Housing Expenses; or
    • Family of one budgeting for a child participating in a HCBS Waiver (State is seeking CMS approval to allow family of one children under the proposed consolidated Children´s 1915(c) Waiver to be eligible for CFCO services)
  • All services must be offered to all eligible individuals across the disability spectrum
    • Recipients may participate in Waiver Programs and receive other State plan services and supports as long as they are not duplicative
    • The CFCO services will be available in FFS and in the Managed Care Benefit packages (Mainstream, MLTC, MAP, PACE) on July 1, 2019
    NOTE: Individuals enrolled in current 1915(c) Waivers that may not meet CFCO eligibility criteria, but do meet the criteria of Waivers, will continue to access these services under the authority of the 1915(c) Waiver.
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All CFCO Services Must be Provided in a Home– or Community–Based Setting

  • All CFCO services must be provided in a home– or community–based setting
    • All CFCO services must be provided in settings that will comply with 42 CFR §441.530
    • Settings include the individual´s own home or a family member´s home that meets the settings criteria outlined in 42 § CFR 441.530
    • Does not include a nursing facility, hospital providing long–term care services, institution for mental disease, intermediate care facility for individuals with an intellectual disability or related condition, or setting with the characteristics of an institution
    • Does not include provider–owned or controlled residential settings

Guidance for OPWDD Providers

  • Training, education and technical support by the Department and OPWDD will be ongoing
    • Webinar schedules and technical guidance will be shared shortly
  • Managed Care Community of Practice is a project of the New York Alliance for Inclusion & Innovation that provides technical assistance and resources to the field of I/DD providers to prepare for the transition to managed care
    • Training, technical assistance, and education on managed care readiness, quality improvement and new reimbursement approaches associated with managed care
    • Developed in collaboration with OPWDD and DOH
    • Information available here

CFCO Services for 7/1/19

  • The following is a list of CFCO services, authorization guidelines, service limit amounts.
  • The service limit amounts for each of the following services may be exceed if there is a documented medical need and is authorized by your Plan´s medical director

Skill Acquisition, Maintenance and Enhancement (SAME)

  • Skill Acquisition, Maintenance and Enhancement (SAME) are services and supports related to an individual´s acquisition, maintenance and enhancement of skills necessary to perform Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs) and/or Health–Related Tasks
    • For OPWDD, SAME is known as Community Habilitation (CH)
  • Currently SAME/CH is provided by OPWDD providers that serve individuals who are predominantly not enrolled in an MCO
    • However, there are over 4,000 MCO members receiving SAME/CH services
  • This will require MCOs to contract with SAME/CH providers who are not familiar with the managed care contracting and billing processes

SAME and Community Transportation

  • The authorization for CFCO services includes community transportation only when it is part of the SAME service and will cover functional skills training or direct provision of transportation related to an individual´s assessed need for assistance with community transportation as detailed in the PCSP (i.e., teach a person to ride the bus so they can independently navigate the community or accompany the person to a community location when the person is not anticipated to acquire this skill)
  • OPWDD SAME rates include a component for transportation
  • The Department is developing a rate add–on for personal care rates when an aide´s transportation is included as part of the SAME service

SAME Service for Waiver Recipients in MCO´s

  • Managed Care Enrollees are eligible to receive SAME service in one of two ways:
  • Depending on the identified need, individuals enrolled in an OPWDD waiver or identified with an RRE code of 95 and enrolled in a Managed Care Plan may receive SAME services through a certified OPWDD Community Habilitation Provider. Or, if their needs are identified and can be met through the SAME service offered through LHCSA or CHHA assistance, that service may be used in place of the OPWDD certified providers
  • The same is true for Managed Care enrollees who are also enrolled in the Consolidated 1915c Children´s Waiver. Depending on their needs identified in their Person–Centered Plan of Care, these children may use the existing providers for Community Habilitation or through the SAME service offered through LHCSA or CHHA assistance. That service may be used in place of the Providers for Children´s Community Habilitation
  • NOTE: Waiver clients are not allowed to enroll in Managed Long–Term Care. SAME service for Managed Long–Term Care clients would be provided through the SAME service offered through LHCSA or CHHA assistance,
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Billing codes for SAME Service provided through a Licensed Home Health Care Agency (LHCSA)

  • To bill/report SAME services provided by a LHCSA, use the existing rate codes for personal care level II services or CDPAP Level II services.
  • In addition, during the course of ADL/IADL SAME services should an aide be required to accompany a patient for training in the use of public transportation, an add–on rate code is being developed to cover the cost of the aide´s transportation. The rate code would be billed by the LHCSA and must reflect personal care/CDPAP services on the same day. The add on rate code is:
    Companion Add–on Rate Codes for SAME
    Rate Code Description Effective Date HCPCS
    3171 ADL/IADL Skill Acquisition Svcs– CFCO Non DD As of 7/1/19 TBD

Environmental Modification (E–Mod):

July 1, 2019 Implementation

  • Definition: Expenditures relating to a need identified in an individual´s Person– Centered Service Plan that increases an individual´s independence or substitutes for human assistance, to the extent that expenditures would otherwise be made for the human assistance.
  • Service Limit: Contracts for environmental modifications may not exceed $15,000 without prior approval of DOH
    Rate Code for Environmental Modifications
    Rate Code Description Effective Date HCPCS Code

Assistive Technology:

July 1, 2019 Implementation

  • Definition: Assistive Technology (AT) is defined as an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or to improve the functional capabilities of the individual, and/or enhance an individual´s independence in performing activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health–related tasks. The use of the AT must increase a consumer´s independence or substitute for human assistance that would otherwise be authorized (e.g., personal care services). AT does not include items that are covered within the scope of durable medical equipment.
  • Service Limit: AT costs cannot exceed $15,000 per year without prior approval from the New York State Department of Health
    Rate Code for Assistive Technology
    Rate Code Description Effective Date HCPCS Code
    3186 ASSISTIVE TECHNOLOGY (AT) – CFCO 7/1/2019 T2028

Vehicle Modification (V–Mod)

July 1, 2019 Implementation

  • Definition: This service covers the cost of modifications to a vehicle if it is the primary means of transportation for the consumer. The vehicle may be owned by the consumer or by a family member or non–relative who provides primary, consistent and ongoing transportation for the consumer. Modifications are approved only when they are necessary to increase the consumer´s independence and inclusion in the community
  • Service Limit: Contracts for vehicle modifications may not exceed $15,000 without prior approval of DOH
    Rate Code for V Mods
    Rate Code Description Effective Date HCPCS Code

Community Transitional Services (CTS)

July 1, 2019 Implementation

  • Definition: Individually designed services intended to assist a member/recipient to transition from an institutional setting to an appropriate home and community–based setting.
  • Service Limit: Costs are limited to a one–time expense of up to $5,000
    Rate Code Description Effective Date HCPCS Code

Moving Assistance

July 1, 2019 Implementation

  • Definition: Individually designed service intended to transport the possessions and furnishings of a CFCO–eligible member/recipient who is moving from an institutional environment into a community–based setting. Moving assistance must be based on the assessed needs of the member/recipient and support his/her desires and goals as outlined in the Person–Centered Service Plan (PCSP). This service includes the cost of moving furniture and other belongings.
  • Service Limit: Moving Assistance is limited to a one–time expenditure of $5,000
    Rate Code Description Effective Date HCPCS Code
    3188 MOVING ASSISTANCE (HOURLY) –CFCO 7/1/2019 T2038

Home–Delivered/Congregate Meals

July 1, 2019 Implementation

  • Definition: Meals provided to an individual who cannot prepare or obtain nutritionally adequate meals for themselves, or when the provision of such meals will decrease the need for more costly supports to provide in–home meal preparation. This benefit may include up to two meals a day.
  • Authorization Guidelines: This service is reimbursed on a per meal basis
    Rates for Home Delivered and Congregate Meals
    Rate Code Description Effective Date HCPCS Code
    3183 HOME DELIVERED MEALS – CFCO 7/1/2019 S5170
    3184 CONGREGATE MEALS – CFCO 7/1/2019 S9977
    3185 HOME DELIVERED MEALS– (WKND)– CFCO 7/1/2019 S5170

Encounter Submission for CFCO Services

  • There will not be significant changes to the encounter submission for CFCO services as most of these services are already in the benefit package
  • Changes will only be applied to SAME services, changes are:
    • Need to add rate code
    • Need to add the Universal homecare billing codes and modifiers. Modifiers can be found here.
  • The MMCOR guide will be updated to reflect these changes and will be distributed to all plans by April 2019
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Contact Information

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