Community First Choice option

1. Community First Choice option Development and Implementation Council November 20, 2012

2. Community First Choice Option • Community First Choice Option (CFCO) is a section 2401 of the Affordable Care Act, which establishes a new State option to provide a broad range of personal attendant services and supports to eligible individuals based on functional needs. • CFCO provides a Six (6%) percentage point increase in Federal Medical Assistance Percentage (FMAP) permanently.

3. CFCO Services Required Services: • Home and community-based attendant services and supports to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, and/or cueing. Optional Services: • Transition costs such as rent and utility deposits, first month’s rent and utilities, purchasing bedding, basic kitchen supplies, and other necessities required for transition from an institution; • Provision of services that increase independence or substitute for human assistance to the extent that expenditures would have been made for the human assistance, such as non-medical transportation services or purchasing a microwave.

4. CFCO Services (Continued) Activities of Daily Living Instrumental Activities of Daily Living Basic ADLs consist of self-care tasks, including: • Personal hygiene and grooming • Dressing and undressing • Self feeding • Functional transfers (getting into and out of bed or wheelchair, getting onto or off toilet, etc.) • Bowel and bladder management • Ambulation (walking with or without use of an assistive device (walker, cane, or crutches) or using a wheelchair) Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community: • Housework • Taking medications as prescribed • Managing money • Shopping for groceries or clothing • Use of telephone or other form of communication • Using technology (as applicable) • Transportation within the community

5. Community First Choice Option Eligibility: To receive services under 1915(k), individuals • Must be eligible for medical assistance under the State’s Medicaid plan, • Must meet an institutional level of care, and • Must be in an eligibility group under the State plan that includes nursing facility services If the individual is in an eligibility group under the State plan that does not provide coverage of nursing facility services, the individual must have income that is at or below 150% of the federal poverty line ($16,755 for a household of one). Considerations for implementation

6. Community First Choice Option Who meets Institutional Level of Care need: • Individual who has been determined to require an institutional level of care to be eligible for nursing facility services under the State Plan • And for whom there has been a determination that, but for the provision of such services, the individuals would require the level of care provided in a • hospital, • a nursing facility, • ICFs/MR, • or an institution for mental diseases, the cost of which could be reimbursed under the State plan Institutional Level of Care

7. Community First Choice Option The State administering agency may permanently waive the annual recertification of Institutional Level of Care need eligibility requirement for an individual if: • It is determined that there is no reasonable expectation of improvement or significant change in the individual’s condition because of the severity of a chronic condition or the degree of impairment of functional capacity; and • The State administering agency, or designee, retains documentation of the reason for waiving the annual recertification requirement. Institutional Level of Care

8. Community First Choice Option States must provide consumer controlled home and community-based attendant services and supports to individuals • on a statewide basis, • in a manner that provides such services and supports in the most integrated settingappropriate to the individual’s needs, • 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 the individual requires to lead an independent life. States can establish benefit limits, and limit amount, duration, and scope of services in non-discriminatory manner Considerations for implementation

9. Community First Choice Option States are required to use a person-centered service plan that is based on an assessment of functional need: • Person-Centered Service Plan must be agreed to in writing by the individual, or his or her representative • Assessment will determine if the individual requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health-related tasks Assessment of Need Person-Centered Service Plan

10. Community First Choice Option • CFCO allows for the provision of services to be self-directedunder either an agency- provider model, a self-directed model with service budget, or other service delivery model defined by the State. • States may offer more than one service delivery model. Service Delivery Model

11. Community First Choice Option The services and supports must be provided by a qualified provider in a home and community-based setting Home and community-based setting excludes: • Hospitals • Nursing facilities • ICFs/MR • Settings located on or adjacent the campus of a public institution Qualified Providers Community-Based Setting

12. Community First Choice Option CMS Proposed Rule, May 3, 2012 Setting Requirements for Community First Choice Settings must exhibit the following qualities, in order to be eligible sites for delivery of home and community-based services: • The setting is integrated in, and facilitates the individual’s full access to, the greater community including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, like individuals without disabilities; • The setting is selected by the individual among all available alternatives and is identified in the person-centered service plan; • An individual’s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected; • Individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact are optimized and not regimented; and • Individual choice regarding services and supports, and who provides them, is facilitated. http://www.gpo.gov/fdsys/pkg/FR-2012-05-03/pdf/2012-10385.pdf Community-Based Setting (continued)

13. Community First Choice Option CMS Proposed Rule, May 3, 2012 Setting Requirements for Community First Choice In a provider-owned or controlled residential setting, the following additional conditions must be met. Any modification of the conditions, for example to address the safety needs of an individual with dementia, must be supported by specific assessed needs and documented in the person centered service plan: • The unit or room is a specific physical place that can be owned, rented or occupied under another legally enforceable agreement by the individual receiving services, and the individual has, at a minimum, the same responsibilities and protections from eviction that the tenants have under the landlord tenant laws of the State, county, city, or other designated entity. Community-Based Setting (continued)

14. Community First Choice Option Maintenance of Effort Requirement: During the first full twelve month period in which a CFC State plan amendment is implemented, the State must maintain or exceed the level of expendituresfor home and community- based attendant services provided under the State plan, waivers or demonstrations, for the preceding 12- month period. Maintenance of Effort Requirement

15. Community First Choice Option States must develop and have in place a process to implement an amendment in collaboration with a Development and Implementation Council established by the State that includes a majority of members with disabilities, elderly individuals, and their representatives State Plan Amendment Development and Implementation Council

16. Community First Choice Option • States must also establish and maintain a quality assurance system for community-based attendant services and supports that includes standards for agency-based and other delivery models for training, appeals for denials and reconsideration procedures of an individual plan, and other factors. • The quality assurance system must incorporate feedback from individuals and their representatives, disability organizations, providers, families of disabled or elderly individuals, and members of the community, and maximize consumer independence and control. • The quality assurance system must also monitor the health and well- being of each individual who receives section 1915(k) services and supports, including a process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports. Quality Assurance

17. Why CFCO in Arkansas • The program provides federal funding to expand choice options for persons with disabilities and access to long term services and supports in the most integrated setting. The program will expand access to lower cost community-based services that delay or avoid facility-based care by providing a broad range of options and enhanced community integration. • The CFC program provides additional resources and a mechanism to address the Alternative Community Services Waiver waiting list of over 2000 people with developmental disabilities and offers long- awaited services to those who need them. • Providing home and community based services under a single framework will streamline eligibility determination, assessment, intake processes into the long term care system and will be complimented by the development of ”No Wrong Door/Single Entry Point“ approach. • Reduce administrative burden on both state agency and providers through integration of programs and funding, and gaining efficiencies through standardization. • The CFC program promotes a strong emphasis on person-centered approach to services by making consumer directed service model a core component of the program.

18. Community First Choice Option State Balancing Incentive Payment Program (BIPP) • If implemented in conjunction with the State Balancing Incentive Payment Program (BIPP), CFCO provides the mechanism for rebalancing the Long-Term Care System, as it covers both transitional costs and Home and Community based Services (HCBS). BIPP

19. Community First Choice Option CFCO/BIPP Programs are an integral part of the Arkansas Health Care Payment Improvement Initiative (AHCPII) • The new programs provide framework and a mechanism for the AHCPII episode-based payment approach for community based services which will be reinforced by robust quality tracking and strong outcomes measures. • This effort directly aligns with the use of universal assessment for each population – ID/DD, aging, long term care, and behavioral health areas. The assessment will determine individual’s level of need and align it with the most appropriate level of services and most integrated setting of care. Payment Improvement Initiative

20. Community First Choice Option Considerations for implementation CFCO provides an opportunity to standardize system entry process: • DDS – InterRAI for Adults – launch in November 2012 • DDS - Children – Assessment Review Committee reviewing InterRAI tool • DAAS – InterRAI – launch in January 2013 Assessment Person- Centered Planning Community First Choice Option (Home and Community-Based Services)

21. Community First Choice Option CFCO/BIPP Programs are an integral part of the Arkansas Health Care Payment Improvement Initiative (AHCPII) • CFCO also complements implementation of innovative care coordination models such as Health Homes for those populations. Health Homes will provide seamless navigation of medical, behavioral, long term care, and other areas of services for those that have complex needs or require additional layers of support. • The expected outcomes of these reforms are enhanced personal choice, improved client experience and health outcomes, as well as cost reduction due to alignment of need with the appropriate level and setting of care, and reduction of unnecessary spending due to improved care coordination. Payment Improvement Initiative

22. Community First Choice Option CFCO may affect the following programs in Arkansas: • Personal Care Program • DDS Alternative Community Services (ACS) Waiver • Alternatives for Persons with Disabilities (APD) Waiver • ElderChoices (EC) Waiver • Living Choices Assisted Living (LCAL) Waiver • IndependentChoices • Developmental Day Treatment Clinic Services (DDTCS) • Money Follows the Person Affected Programs

23. Community First Choice Option • Transition existing state plan and waiver programs into CFCO • Align services across populations and CFCO service categories • Use this opportunity for service improvement, identifying and closing gaps in services Considerations for implementation

24. Community First Choice Option • CFCO does not include case management/care coordination component (would need to be established separately via TCM, Health Home, or another mechanism) Considerations for implementation Care Coordination Community First Choice Option (Direct Services)

25. Community First Choice Option Considerations for implementation CFCO provides an opportunity to standardize system entry process: Care Coordination Community First Choice Option (Direct Services) Universal Assessment Person Centered Planning

26. Estimated number of clients that will be served under CFCO

27. Community First Choice Option Main State Plan Amendment (SPA) Components: • Service Package and Service Definitions (January, February) • Service Delivery Model (March) • Payment Methodology, Qualifications of Providers of CFCO Services (April) • Quality Assurance and Improvement Plan (May) State Plan Amendment