Implementing the Community First Choice Option in New York
Lana Mutters, MPHPolicy Analyst
New York Association on Independent Living
Norain Siddiqui, MPHPolicy Analyst
Center for Disability Rights
History• Grassroots – ADAPT
• Community Choice Act (CCA)
• Affordable Care Act includes Community First Choice Option (March 2010)
• New York State – Selection of Option (March 2011)
• DOH CFC Workgroup (June 2012)
What is CFC?
Community-based Medicaid state plan service (1915[k] State Plan Amendment)
Includes hands-on assistance, safety monitoring, cueing, ADL, IADL
First program to provide services based on functional need, not diagnosis or age
Eligibility
• Must be Medicaid eligible• Must require an institutional level of care
(hospital, nursing facility, ICF-MR, or IMD)
Background and BasicsAffordable Care Act establishes Community First
Choice (CFC) under § 1915(k) of Social Security Act under Medicaid
CFC supports independence, integration, person-centered, consumer-directed in accordance with the Olmstead decision of 1999
As state plan amendment, entitlement
CANNOT include:• Nursing facilities
• Institutions for Mental Diseases (IMD)
• Intermediate Care Facilities for Mentally Retarded (ICF-MR)
• Any public/private facility that provides inpatient institutional treatment
• Any building on grounds of disability-specific housing complex
Services must be provided in community-based setting
Required Services• Attendant services and supports for
– activities of daily living (ADL) – instrumental activities of daily living (IADL)– health-related tasks
• Attendant services and supports include– hands-on assistance– safety monitoring– cueing
• Assistance with the learning skills necessary to accomplish ADL, IADL, and health-related tasks
• Purchase of back-up systems (beepers) to ensure continuity of services and supports
• NYS must develop/offer a voluntary training on how to select, manage, dismiss attendants
Permissible Services & Supports
• Transition costs – i.e. security deposits for rent/utilities– purchasing basic kitchen supplies, etc.
• Services that increase independence or substitute for human assistance– i.e. learning how to use public transportation
Excluded Services• Room and board
• Special education and related services provided
under IDEA and vocational rehab
• Assistive technologies (other than those used as
back-up systems)
• Medical supplies and equipment
• Home modifications
Models for Service Delivery• “Agency Provider Model” *
– range of approaches– individual has ability to select, train, dismiss attendant– Traditional agency managed services– Agency-with-Choice model where the agency operates solely as a
fiscal intermediary
• “Self-Directed Model with service budget”– Vouchers– Direct Cash Payments (similar to Cash & Counseling)– Fiscal Agent
* Chosen by New York in State Plan Amendment
How does CFC benefit New York?
• Supports Governor’s commitment to Olmstead
• Enhanced 6% FMAP with no sunset
• Addresses gaps in long term care system
• Streamlines system to reduce administrative redundancies
How is CFC different?• Cross-disability
• Home and/or community settings
• Includes transition costs from an institution to a home
• Maximizes consumer control and allows for a proxy chosen by individual
to direct care
• Supplemented with backup and emergency attendant services
• Voluntary training on how to self direct
• Availability of equipment or e-mods that substitute for human assistance
CFC will work for you• Applicable in multiple settings
• Flexible scheduling
• Person-centered
• Eliminates silos
• Self-direction
• Budgeting
New York’s State Plan Amendment • Submitted in December 2013, still awaiting CMS
approval
• “Agency with Choice” model
• NYAIL & CDR would like to see clarifications on:1. IADL “Care of others”2. Stakeholder feedback
Notable Issues• Definition of “community” and “setting”
– Dept. of Health and Human Services finalized definition in January 2014– Rules now in line with Olmstead
…settings do not include a nursingfacility, institution for mental diseases, or an intermediate care facility for individuals with intellectual disabilities…we have established that home and community-based settings must exhibit specific qualities to be eligible sites for delivery of home and community-based services.
Notable issues cont. • Nurse Practice Act
– NPA only allows licensed nurses to perform health-related tasks (i.e.
catheter, vent care, etc.)
– Must be amended to allow “advanced aide” to do these tasks, as
overseen by nurse
• Cost effective
• Aides already perform tasks in CDPAP
• Nurse shortage
– Contentious debate between NYS, NYSNA, disability rights groups
over patient safety, professional scope, civil rights
Nurse Practice Act cont. • If State fails to enact NPA exemption, entire SPA could be
dismissed by CMS
• CFC requires services to be delivered “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 requires to lead an independent life.”
Where are we now?
• Waiting for CMS to approve SPA • CFC in the budget process • Presented draft CFC language to Assembly • Pending CFC legislation
CFC in other statesCurrently Participating • California • Oregon • Maryland State Plan Amendment Withdrawn • Arizona • LouisianaPlan to Participate 2014 Fiscal Year • Montana • Texas• Arkansas• Wisconsin• Minnesota
Additional resourcesDOH CFC workgrouphttp://www.health.ny.gov/facilities/long_term_care/
Final regulationshttps://www.federalregister.gov/articles/2012/05/07/2012-10294/medicaid-program-community-first-choice-option
CMS final rules on HCBS http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html
Questions?Lana MuttersNew York Association on Independent Living(518) 465-4650 [email protected]
Norain Siddiqui Center For Disability Rights (518) [email protected]