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Maryland Department of Health and Mental Hygiene
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 PlanEmphasizes self direction Increases the State’s enhanced match on all CFC services by 6 %Allows Medicaid to set consistent policy and rates across programsRequires an institutional level of care
CFC will offer all mandatory and optional services allowablePersonal assistance servicesEmergency back-up systemsTransition services, Items that substitute for human assistance
Technology, accessibility adaptations, home delivered meals, etc.
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Old Service Structure
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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 standard
Waiver for Older Adults (WOA) Target group aged 50 and over Nursing Facility Level of Care standard
New Service Structure Services formerly offered through multiple programs are now
consolidated under CFCMaximizes the enhanced Federal match Resolves inconsistent rates and policies across programs
These 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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Service and System EnhancementsCFC adds emphasis on person-centered planning and self-
directionMaryland Department of Disabilities (MDOD) will be providing
self-direction training on hiring, firing, and managing providersCFC 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
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Enhancements for Participants• All participants have access to:
increased self-direction opportunities, a larger provider pool, and choice of supports planning providers
Waiver participants now have choice in case management (supports planning) providers and access to a larger provider pool
MAPC will move to an improved rate structure and increased self direction options
More people in the community will have access to waiver-like services
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Levels of CareThe new merged waiver will continue to use the nursing
facility level of careThe 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 services
MAPC 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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New Service Structure
MAPC CFCCO
WaiverPersonal 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 1. Items that sub *CFC Services will be available to all waiver
participants
Financial EligibilityParticipants 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 must
Be in an eligibility group under the State plan that includes nursing facility services; or
If 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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Medical EligibilityThe 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 waiversCommunity Options, New Directions, Community
Pathways, Autism, 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 Care
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Participation in Other Programs Waiver participants are eligible to receive CFC services, but
supports should be coordinated between programs to ensure adequate supports without duplication of services or allowing contraindicated services
Participants who receive bundled payments for some DDA, assisted living, or PACE services are not eligible to receive CFC services on the same day
Supports planners must obtain copies of supports plans from other programs, upload them into the LTSS, and account for them in the LTSS POS
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Community DefinitionTo be eligible for CFC, the participant must reside in a
community residence as defined by the new Federal regulation
CMS Toolkit on the community definition released on March 2014
Important eligibility requirement that 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, landlord-tenant or real property laws of the jurisdiction, and privacy and locks.
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Community DefinitionPeople in assisted living, group homes, and alternative living
units are not currently eligible for CFCDefinition will apply to most HCBS settings in the future
Unknown impact on day settingsRebecca VanAmburg is the State lead on implementation
Have until March 2015 to develop a transition plan for all programs to meet the definition
Up to 5 years to implement the plan, if approved by CMSWill be hosting stakeholder groups and gathering public input on
a transition plan
CFC Budget Process
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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 Service
Participant begins receiving services
Assigned a personal budget
How budget is determinedThe 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 budget
Other 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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Grouper Description Budget
Group 1 Physical Function – Low ADL $8,336
Group 2 Behavioral – Low ADL, High IADL $16,167
Group 3 Clin. Complex – Low to Medium ADL $22,504
Group 4 Physical Function – High ADL $30,314
Group 5 Extensive Services 1 – Medium to High ADL $34,545
Group 6 Extensive Services 2 – Medium to High ADL $43,558
Group 7 Extensive Services 3 – Medium to High ADL $76,360
Services within the flexible budget1. Personal Assistance2. Home-Delivered Meals3. “Other” Items that Substitute for Human Assistance
All other services are included in the Plan of Service in addition to the flexible budget
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Services in the Plan
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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 Planning Behavioral Health Consultation
Transition Services Senior Center Plus
Consumer Training Assisted Living
Personal Emergency Response Systems
Nurse Monitoring
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 standard
rate ($12.27)
Hours at standard
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
Exception ProcessIf 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 supporting documents to the LTSSMaryland tracking system
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Concerns about implementation Adequate, accurate information about denials and appeal
rights Process of negotiating exceptions requests before approval Requests for additional information about process and
outcomes How many people negotiated hours to avoid denials? How many people have had their hours cut? Has anyone gone back to a facility because of a reduction? How is DHMH processing exceptions? What are the criteria for
approval? What are the qualifications of the supports planners and review team
at DHMH?
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DHMH is committed to addressing all concerns and offering transparency 94% of plans with exceptions are approved 1% denial rate overall for the nearly 3,000 plans approved to
date Public meeting, led by advocates, to be held June 16th so all
concerns and issues can be heard by DHMH Data requests in progress
Number of people reinstitutionalizedNumber of people who have experienced a reduction in
hoursSpending on personal assistance services pre-and post
implementation
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Other Upcoming Change
Fair Labor Standards Act Domestic Service Final RuleFLSA Domestic Service Final Rule 29 CFR 552Published October 1, 2013, with an effective date of
January 1, 2015. Regulations concern domestic workers under the FLSA,
bringing minimum wage and overtime protection to workers who enable individuals with disabilities and the elderly to continue to live in their homes and participate in their communities.
Co-employersDOL definition: An employer of a personal
assistance provider other than the individual receiving services or their representative
Maryland is likely to be considered the co-employer Based on DOL’s example of Oregon’s program
Co-employers cannot claim exemptions of minimum wage and overtime
OvertimeWhen the State is the co-employer, overtime applies
across participantsCurrent 40 hour per week limit is per participant
If a provider works for John and Jane, they can work 40 hours for John and 40 hours for Jane (total of 80 hours)
New limit is for the providerExpands to include all participants the provider serves
The provider can only work 40 hours total for both John and Jane
Travel timeExisting regulations state that employees who travel to
more than one worksite for an employer during the workday must be paid for travel time between each worksite
Once the state I the co-employer, the provider will get paid for travel time between participantTime between shifts for John and Jane
Next StepsFurther Research
How are other States implementing the rule?How many of our providers serve more than 1 person per
day?How many providers work more than 40 hours because
they work for more than 1 participant?What is the budget impact?How do you calculate travel time?What budget pays for the travel time?
Future Stakeholder Meetings and Discussion
