Enacted into statute: October 1, 2011
Final Rule: May 7, 2012
Settings provisions applicable to 1915(k) published January 16, 2014.
1915(k) permits states to provide individuals meeting an institutional level of care the opportunity to receive necessary personal attendant services (PAS) and supports in a home and community-based setting. The CFC option expands Medicaid opportunities for the provision of home and community-based long-term services and supports (LTSS) and is an additional tool that states can use to facilitate community integration while receiving enhanced Federal match of six (6) additional percentage points for CFC services and supports.
Community income rules for medically needy population.
Information on SPA processing can be located at: https://www.medicaid.gov/resources-for-states/spa-and-1915-waiver-processing/index.html
State plan amendment submitted on pre-print.
Preprint and Technical Guide available at: https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/community-first-choice-cfc-1915-k/index.htm
One-time approval. Changes must be submitted to CMS and approved.
Annual reports on numbers of individuals served, expenditures and utilization and certain quality measures and additional information (42 CFR 441.580).
Administered by the Single State Medicaid Agency (SSMA) though may involve another state agency in operations and administration.
Required between providers and the SSMA.
State must cover all categorical eligibility groups and may elect to cover medically needy.
Individuals eligible for the CFC benefit are either:
- in an eligibility group entitled to nursing facility services under the State plan; or
- are not in an eligibility group entitled to nursing facility services but whose income is at or below 150 percent of the Federal poverty level.
States may NOT target 1915(k) benefit. Services must be provided on a statewide basis, in a manner that provides such services and supports in the most integrated setting appropriate to the individual’s needs, and 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 in order to lead an independent life.
Individuals must meet institutional level of care.
Individuals eligible for Medicaid under 42 CFR 435.217, must continue to meet the eligibility requirements for the 1915(c) waiver in order to maintain eligibility for Medicaid and CFC.
42 CFR §447.205 for payment methodology.
Must create a Development and Implementation Council that includes a majority of members with disabilities, elderly individuals, and their representatives. State must consult and collaborate with the Council when developing and implementing a State Plan amendment to provide HCBS attendant services.
MOE requirement for 1st fiscal year for services provided under §1115,
§1905(a), and §1915, of the Act.
Must establish & consult with a Development & Implementation Council with majority representation from consumers.
Cannot cover:
Certain assistive devices & assistive technology services; medical supplies & equipment, home modifications.
Room & board costs.
Special education and related services provided under IDEA that are education related only & vocational services provided under Rehab Act of 1973.
Increased FMAP
§1915(k)(2) of the Act provides that States offering this option to eligible individuals during a fiscal year quarter occurring on or after October 1, 2011 will be eligible for a 6 percentage point increase in the Federal medical assistance percentage (FMAP).
Not allowed.
May determine process for setting individual budgets for participant-directed services.
MUST COVER:
- Assistance w/ ADLs, IADLs, & health related tasks.
- Acquisition, maintenance & enhancement of skills necessary for individual to accomplish ADLs, IADLs, & health-related tasks.
- Back-up systems or mechanisms to ensure continuity of services & supports.
- Voluntary training on how to select, manage and dismiss staff.
MAY COVER
Permissible services and supports may include, but are not limited to, the following: (1) Expenditures for transition costs such as rent and utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies, and other necessities linked to an assessed need for an individual to transition from an institution to a home and community-based setting where the individual resides; (2) 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.
Settings where individuals receive support must comport with the settings requirements as set forth in 2014 final rule.
Provider qualification expectations for 1915(k) are set forth in 42 CFR 441.565. The State determines the provider qualifications for providers to provide CFC services under the agency provider model. Individuals receiving services under the agency provider model retain the right to establish additional staff qualifications based on the individual’s needs and preferences.
For the self-directed model with service budget, an individual has the option to permit family members, or any other individuals, to provide Community First Choice services and supports identified in the person centered service plan, provided they meet the qualifications to provide the services and supports established by the individual, including additional training.
In all instances, the individual may identify additional expectations for providers to ensure they meet the specific needs of the individual.
The state must make available financial management services to all individuals with a service budget. May be included as a service or an administrative activity.
Agency Provider Model: Services & supports provided by entities under contract or provider agreement. Participant has a significant role in the selection and dismissal of providers. Entity may provide services directly through their employees or arrange for the provision of services under the direction of the individual receiving services.
Self-Directed Model with Service Budget: Service plan and budget directed by the individual and based on functional needs assessment. FMS must be available. Direct cash or vouchers may also be used.
Other Service Delivery Model: States may propose other models.
Permitted as a covered service at the state’s election for 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.
Required (state may offer options that can be utilized voluntarily by providers to meet this requirement).
Can be coupled with a managed care authority for different payment arrangements.
Rate methodology must be approved as a part of the state plan.
N/A. State must submit CMS 179 including estimated FY impact on federal budget.
For the first full fiscal year in which the State Plan amendment is implemented, a State must maintain, or exceed, the level of expenditures for services provided under
§1115, §1905(a), and
§1915, of the Act, or otherwise to individuals with disabilities or elderly individuals attributable to the preceding fiscal year.
States must establish and maintain a comprehensive, continuous quality assurance system, described in the State plan amendment, which includes:
- A quality improvement strategy
- Methods to monitor health and welfare
- Individual outcomes measures
- Standards for service models, training, appeals and reconsiderations, etc.
Other items as required by the secretary
Individuals may be eligible for and receive services from multiple HCBS authorities simultaneously, so long as the person centered service plan ensures no duplication of services.
1915(k) may be operated concurrently with other authorities, for example 1915(a) or 1915(b).
Requirements at 42 CFR 441.550(c).
Individuals or entities providing case management (developing person-centered service plan) cannot be:
- Related by blood or marriage to the individual or a paid caregiver
- Financially responsible for the individual
- Empowered to make health-related decisions
- Individuals who would benefit financially from service provision
- Providers of State Plan HCBS
Providers of State Plan HCBS can provide case management only when:
- The state demonstrates that they are the only willing and qualified entity/entities in a geographic area;
- The state devises conflict of interest protections, including separation of assessment/planning and HCBS provider functions within entities; and;
Individuals are provided with a clear and accessible alternative dispute resolution process.
Must meet the requirements regarding the person centered plan and process at 42 CFR 441.540.
In addition to specific requirements regarding the process used to develop the plan, the regulations establish that the person-centered service plan must reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports.