Community First Choice Option (CFCO)


January 29, 2019

CFCO: Administrative Directives (ADMs)

The Department has been in the process of finalizing the following ADMs:

4/1/18 ADM 4/1/19 ADM 7/1/19 ADM
  • Serves as an introduction to CFCO, lists eligibility criteria and provides details on services and supports available under the CFCO umbrella
  • Describes how the required CFCO services and supports are authorized, accessed, and delivered in FFS
  • Includes Person–Centered Planning Guidelines, Aide Training Program Manual, and RRE Work Instructions
  • Updates the policies and procedures regarding the approval and payment by Medicaid for Medicaid–eligible children for E– Mods, V–Mods and AT
  • Includes service authorization guidelines for these services
  • Describes how the seven remaining CFCO services and supports are authorized, accessed, and delivered in FFS
  • Attachments will include all service authorization guidelines, as well as rate codes

CFCO: Readiness Activities and Trainings

The Department has recently provided the following readiness activities/trainings:

CFCO Readiness Activity/Training Date
CFCO Webinar for MCOs and LDSS December 20, 2018
Feedback for April 1, 2018 ADM for CFCO Services January 2, 2019
Plans begin to contract with SAME/other CFCO providers January 2, 2019
Plans and LDSS begin to contract with providers Ongoing
Rate Code Overview Training for MCOs January 3, 2019
Rate Code Overview Training for LDSS January 8, 2019
Feedback for SAME and CTS/MA Service Authorization Guidelines January 11, 2019
CFCO RR/E Placement and Maintenance Refresher Training for LDSS January 17, 2019
CFCO RR/E Placement and Maintenance Refresher Training for MCOs January 18, 2019

CFCO: Upcoming Readiness Activities and Trainings

The following readiness activities and training sessions are upcoming:

CFCO Readiness Activity/Training Date
Open Q&A Webinar January 29, 2019
MMIS Utilization for LDSS February 1, 2019
Development and Implementation Council Meetings Quarterly, ongoing dialogue
July 1, 2019 ADM for CFCO Services February 2019
Additional Guidance on Congregate and Home–Delivered Meals February 2019


Q: What is the effective date of the Administrative Directive (ADM)?

A: The provisions in the April 1, 2018 CFCO ADM are effective February 1, 2019 and retroactive to April 1, 2018 where indicated.

Q: Does the case manager that works for the LDSS need to be trained in the Person Centered Planning Process, if they are the ones doing case management for CFCO under FFS? If so, where is this training available?

A: Yes, all case managers will need to receive training on the PC planning process. The Department is working together with PCG on a series of PCSP training. We will release training dates shortly.

Q: What guidance has NYSDOH provided to NYS OPWDD regarding the newly identified OPWDD cases referred by the districts? The district recently submitted a list of such cases to the DDRO and subsequently received a call from the state inquiring why the list was received.

A: On a case–by–case basis the family should be referred to the OPWD Front Door Contact Numbers. If there is a need for better coordination with the local DDRO Director´s Office, then LDSS leadership should contact the DDRO Directors Office

Q: How will the Person–Centered Planning be handled? Who is in charge of the meeting? Where is all the contact information found?

A: This will be handled by the authorizing entities (LDSS, MCO, DDRO, RRDC) and the individual. You will work together to ensure that all needs are met. If the individual is enrolled in a MCO, the MCO will lead the case management. For individuals enrolled in a Health Home, the Health Home is responsible for the development of the Person–Centered Service Plan. Similarly, if the individual is enrolled in a waiver, the waiver program will take the lead on case management. If the individual is not enrolled in either an MCO or a waiver, the LDSS will take the lead on case management. Contact information for MCOs and DOH waivers can be found on the DOH website. For DDROs, please visit the Front Door Page.

Q: What assessment tool are you referring to in the ADM?

A: Level of Care and Person–Centered Service Planning are dependent upon a variety of state approved assessments including the Uniform Assessment Systems for New York (UAS–NY) and the Child and Adolescent Needs and Strengths for New York (CANS–NY).

Q: Are CFCO services available to client´s receiving Hospice?

A: NYSDOH defines Hospice as a coordinated and supportive program for terminally ill persons and their families. Care focuses on easing symptoms rather than treating disease. The patient and his or her family receive physical, psychological, social and spiritual support and care. The core services are nursing and physician services provided by a specially–trained team of doctors, nurses, social workers and other specialists, medical social services, nutrition counseling, physical therapy, occupational therapy, speech therapy, and spiritual and bereavement counseling. These services would not be considered CFCO services. Hospice can also provide home health aide and homemaker services, medical supplies and appliances.

CFCO services may supplement hospice services as long as there is no duplication of the service provided to the same individual. The care manager is responsible to provide sufficient justification for the need for the CFCO service in the plan of care and to define the circumstances in which the service is provided so that a duplication of services does not occur. Services should be offered in the setting least restrictive for desired outcomes, including the most integrated home and community–based setting. CFCO services may not be provided in a residential hospice setting.

Q: Please supply a current matrix of all CFCO services within the OPWDD, CAH, TBI and NHTD waivers; and identify those CFCO services which an individual may seek from districts apart from the waivers.

A: This matrix is provided in the December 20, 2018, CFCO webinar slidesthat are available on the Department´s CFCO website.

Q: Non–Emergency Medical Transportation is being managed by who?

A: The LDSS will assess for and authorize the NEMT service for FFS recipients. The LDSS will continue to work with our NYS transportation manager, Medical Answering Services (MAS), for service provision.

Q: Please note that Personal Care services under CFCO or the State Plan do not include safety monitoring as an independent or "stand–alone" service in the absence of providing assistance with an ADL/IADL/tasks. Can you clarify this statement?

A: The individual in receipt of Personal Care must have an assessed need for assistance with ADL/ADL/health–related tasks. The need for safety monitoring alone cannot constitute a service authorization for Personal Care. Supervision and/or cueing is a means of providing assistance with the needed ADL/IADL/health–related task in addition to providing partial or total hand–on assistance.

Q: An individual who is not able to self–direct will not be able to select an adult to direct for them. Will the LDSS be responsible to determine who is capable of selecting an adult to direct? Are there limitations on who can direct?

A: As in CDPAP, currently, an individual who is not able to self–direct may be able to select an adult to direct for them, and it is important that the opportunity to do so is presented to the individual.

The LDSS is not responsible for selecting an adult to direct the care; this is solely up to the individual. If the individual does not have an adult to direct his/her care, that individual will receive services via the Traditional Agency model.

Q: If the Regional Resource Development Center (RRDC) approves Personal Care under the agency of choice model, would it be appropriate for the LDSS to also approve CDPAP for skilled needs, (similar to HCSS and CDPAP) or would the personal care and skilled needs be provided only under CDPAP?

A: PCA and CDPAP are not waiver services, they remain state plan services and, as such, the LDSS approves the services. All state plan services provided to a waiver participant are included in the waiver participant´s plan of care. Home and Community Support Services (HCSS) is a waiver service and is authorized by the RRDC upon approval of the service plan.

Q: Will the LOC, with the agency of choice model be only PCA–1/PCA–2?

A: PCA level 1 and 2 will be authorized as it is currently for individuals in FFS.

Q: What are the differences between the Agency of Choice model and CDPAP?

A: There are no significant differences in these self–directed service delivery models.

The main difference currently is that consumers must be eligible for CFCO services to utilize the Agency of Choice model. Please note that if consumers are not eligible for CFCO, but still have a personal care need, and capable to self–direct their care, and are appropriate for the CDPAP program, they are still eligible to receive CDPAP outside of the CFCO benefit.

Q: Is the LDSS responsible for reviewing the training info with the client?

A: The LDSS is not responsible for a thorough review of the training material. However, similar with providing information on the CDPAP, the nurse assessor will provide the training manual to consumers.

Q: What about an Adult Day Care Center? Is this a compliant setting?

A: No, that is not a compliant setting.

Q: "Provider–owned or controlled residential settings." The assumption is that these are ALPs and Adult Homes. Is this correct? Would an apartment in a commercial building or NYCHA Housing or subsidized Senior Housing be eligible?

A: Under the Federal Regulation, there are additional standards that apply to provider owned and controlled settings. Currently, individuals living in these settings are not eligible for CFCO. Individuals living in an apartment that receive a rental subsidy are eligible as long as they have a lease, control their environment, and have unrestricted access to their living space.

Q: Please supply state model provider agreements for CFCO services beyond those districts currently authorize (PCS, CDPAP, Personal Emergency Response), along with a state model agreement for contracting the CFCO functional assessment, care plan development and oversight, etc.

A: We are currently in the process of creating a model contract for CFCO services. This model contract will not be mandatory.

Q: "All CFCO services must be provided within the scope of practice of the person providing the service and only by providers who have a valid Medicaid Management Information System (MMIS) number under the Medicaid program." How is the LDSS looking up these MMIS numbers?

A: Please utilize eMedNY for this information.

Q: Why can´t the State contract with providers and the LDSS use those contracts?

A: The State is looking into options like this to make it easier for LDSSs to help address provider capacity issues and streamline work for the LDSS. These options will likely not be available for the July 1, 2019 launch.

Q: Will districts be required to contract with each CFCO service provider, or will there be a CFCO clearinghouse established by the State with which to contract?

A: The State is looking into options like this to make it easier for LDSSs to help address provider capacity issues and streamline work for the LDSS. These options will likely not be available for the July 1, 2019 launch.

Q: "The LDSS will ensure that there is separation between the function of assessor, or care manager/case coordinator, and the other functions the same person performs at the LDSS or agency/provider." The LDSS would only be able to ensure separation of functions for FFS cases.

A: Yes, the LDSS is only responsible for this assurance in FFS cases.

Q: "Federal regulations provide an exception to item (v) when the LDSS can document diligent effort to identify that the only willing and qualified entity/entities to perform functional needs assessment and/or develop PCSPs in a geographic area, such as in rural areas, are also providers of HCBS." Please define diligent effort.

A: Diligent effort can be described as repeated, ongoing, varied attempts.

Q:"Medicaid Eligibility Determination." How will the LDSS tract this? Who is responsible? The Home Care units do not determine eligibility. Some type of automatic system notice needs to be sent to the Home Care unit notifying them of the determination.

A:The LDSS will be able to look at the Medicaid coverage code to determine CFCO Medicaid eligibility.

Q: MLTC Plans are determining CFCO eligibility for their consumers, but the Plans would not know if these special Medicaid eligibility standards have been applied to their consumers by the LDSS. The application of these special eligibility standards can change.

A: The Department will work with MCOs to ensure appropriate information is transmitted regarding their enrollees´ CFCO Medicaid eligibility.

Q: HRA–LDSS conducts LOC only upon the receipt of Doctor´s orders/Medical Request for Home Care (M11–q) from a client. For clients not seeking home care but seeking non–home care CFCO services, does the LDSS make a direct referral to the CFEEC? (LDSS CFCO RRE Work Instruction_Draft_v0.6c 12–4–18 page 7) What is the process? How does the LDSS receive the results of the CFEEC? What would be the annual review process for non–home care recipients? HRA–LDSS does not maintain case records for non–home care Medicaid clients.

A: Yes, the LDSS will refer the individual to the Conflict Free Evaluation and Enrollment Center (CFEEC) for a Level of Care (LOC) determination. A CFEEC evaluation will occur. If the individual is not sent to a MCO for enrollment, the CFEEC representative will contact the LDSS with the individual on the phone and warm transfer the individual to the LDSS for service authorization.

Q: "The LDSS must identify whether or not an individual seeking CFCO services is participating with any other State programs "(e.g., MMC, MLTC, NHTD/TBI, OMH, OPWDD, etc.)." The Home Care units need training reading these screens; they are not eligible staff."

A: The Department will provide this training.

Q: A process and forms are needed to direct a consumer to the most appropriate service authorization pathway. Is there an opportunity for an appeal or Fair Hearing if a client disagrees? What if there is a disagreement between "programs" as to who would be responsible for the CFCO services?

A: All consumers maintain their Fair Hearing rights regardless of the authorizing entity. If there is a disagreement, the authorizing entity is ultimately responsible for the CFCO service authorization.

Q: How often does the residential determination need to be made? What discontinuation notification does the CFCO client receive upon entry to ALP, NH or Adult Home? Who is responsible for notifying the client MCO, MLTC, OPWDD, or LDSS?

A: Upon re–assessment, every six months, the residential determination will be made. A Notice of Decision with Fair Hearing Rights will be sent to the individual by the authorizing entity if services change or eligibility relapses. If the LDSS has been authorizing services, the LDSS is responsible for the notice.

Q: "After the LDSS has determined that an individual seeking Personal Care Services meets all three CFCO eligibility criteria, the LDSS will provide the individual with the Department´s Physician´s Order for Personal Care/Consumer Directed Personal Assistance Services DOH–4359." This is still confusing; the LDSS needs the MD order to do the assessment. You can´t have an assessed institutional level of care before this is done. It appears two qualifiers need to be met at this point.

A: The CFEEC will determine LOC. A MD order is not necessary for a CFEEC. The functional needs assessment will be completed by the county after the CFEEC evaluation is completed, and after the MD order is received.

Q: HRA uses the M11–q. and not the DOH–4359

A: We will add that form as eligible to use in the April 1, 2018 CFCO ADM.

Q: Please identify the types and names of entities which districts may contract with to conduct the CFCO functional needs assessment, Level of Care determination, and care managers to develop and oversee the Person–Centered Plan of Care.

A: A registered nurse, either employed by the LDSS or an approved provider agency, or directly contracted by the LDSS or the State, will conduct the functional needs assessment (i.e., the UAS–NY). The CFEEC will provide the Level of Care (LOC) determination. The LDSS will be responsible for developing and overseeing the Plan of care if they are authorizing the FFS services. The Department will provide training on person–centered planning to the counties. The Person–Centered Planning Guidelines are currently available on the Department´s CFCO website.

Q: Will there be a separate training on Person Center Planning and the use of the new Person–Centered Service Plan Template?

A: Yes, the Department will provide training on the Person–Centered Planning process. The training date will be announced shortly. Please note that the use of the Person–Centered Service Plan Template is not mandatory; it was provided as an additional resource for the LDSSs.

Q: Please develop and provide training for local districts and contracted staff on CFCO Person–Centered Service Planning.

A: The Department will provide this training and dates will be announced soon.

Q: The LDSS currently develops a Person–Centered POC for home care recipients. Can the existing POC be used with appropriate revisions? For CFCO clients not in recipient of LDSS Home Care or Managed Care, who will conduct a FNA and then PCPOC?

A: Yes, the POC can be modified to include the required elements as outlined in the Guidelines.

If the individual is enrolled in a waiver program, the waiver program is responsible for assessment, person–centered planning, and service authorization.

Q: "The individual´s service needs must be reviewed every six months, upon a significant change in condition, or if requested by the individual." How often can an individual request such an assessment? What is the definition of "significant?"

A: The individual can make reasonable requests within the 6–month period. There is no firm number for the maximum number of requests. If the county receives an unusually high amount of such requests, please refer the consumer to the County´s DOH liaison. For the purposes of this ADM, "significant" means anything that alters the day to day functioning where current service authorizations must be altered.

Q: "For individuals enrolled in a 1915(c) waiver or a managed care plan, their respective care manager will oversee the PCSP process and develop the POC. The LDSS will consult and collaborate where appropriate." The LDSS does not have authority over the Managed Care plans. What is meant by consult and collaborate?

A: If an individual is enrolled in a Managed Care plan and receiving services FFS, both authorizing entities must collaborate on the person–centered service planning process to ensure that all assessed needs are met and there are no duplicative services.

Q: What abilities will the counties have to provide services that the MCO would not?

A: The Managed Care Organization (MCO) can only provide services that are included in the Managed Care benefit. Not all CFCO services are included in this benefit. Please see the answer to question 40 for more information.

Q: "The LDSS authorization/denial of CFCO services should be limited to only those CFCO services that are not in the individual´s MCO or waiver benefit package." Can you give more information and explanation about this statement?

A: All CFCO services are not available in the Managed Care benefit. For example, Non– Emergency Medical Transportation (NEMT) is not included in the Mainstream Managed Care benefit package, so those enrollees will come to the district for NEMT. The district will assess and authorize for this service. Similarly, all CFCO services are not available in all waiver programs. For example, personal care is not available in the TBI/NHTD waiver program, so those waiver recipients will come to the district for Personal Care. The district will assess and authorize for this service.

Q: Written guidance with Fairing Rights and forms will be needed for each of the non–home care CFCO services. This is assuming the current Personal Care CNS notices can be used for the CFCO home care services.

A: The Fair Hearing Rights and notification processes have not changed.

Q: Is the State developing the actual notice for CFCO services?

A: This depends on the service in question. Notices for Personal Care and current State Plan services will not need to be changed. For the new services, with various service authorization requirements and utilization limits, a new notice is needed to guide the decision, depending on who is receiving the notice. The Department will provide updated notices for those services implemented on July 1, 2019.

Q: The LDSS can only provide reassessment and reauthorization for clients in receipt of FFS personal care and CDPAP services.

A: The LDSS can provide reassessment and reauthorization for clients in receipt of FFS CFCO services as they are all State Plan services.

Q: HRA has approval for 12–month reassessments. HRA recommends that the waiver be applicable for CFCO services as well.

A: The Department will circle back on this question. We understand the need and look towards allowing this exception.

Q: "Among the items that must be reviewed are the individual´s ability to meet desired goals and outcomes based on the frequency, amount, duration of services authorized, and provided." Desired goals or established goals?

A: The intent here is to review the goals that were agreed upon during the person– centered planning and are documented in the Plan of Care.

Q: Can current home care forms be revised to accommodate the corresponding CFCO services?

A: Yes. Please submit the revised notices to the Department for review and approval.

Q: "The LDSS will furnish all information necessary for the Department to assure adequate capacity and access for the participating population and to demonstrate administrative arrangements satisfactory to the Department." We have NOT had adequate capacity for the past 20 years. We have unfilled cases. How are we going to address this?

A: The Department is working on various workforce initiatives to address the shortage that exists in some parts of the State.

Q: "Before authorizing CFCO services, LDSSs shall make maximum use of home health and/or nursing services provided under Medicare or other third–party insurance whenever eligibility under those programs can be established." HRA does not authorize or monitor these services.

A: This is a standard clause for maximization of Medicare and other third–party insurance.

Medicaid is always the payer of last resort.

Q: "Payments made for CFCO services cannot be duplicative of other authorized services." This needs to be monitored and controlled by eMedNY.

A: There are controls in place at eMedNY. The LDSS must monitor for duplication of services as well.

Q: "No payment to the provider will be made for authorized services unless the provider´s claim is supported by documentation of the time spent in provision of services for each individual." Who is responsible to keep the supporting documentation?

A: The LDSS would have this supporting documentation as part of the service authorization. If the LDSS does not have the information, there must be assurances in place with the appropriate providers to keep the supporting documentation (time sheets, invoice, etc.).

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