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Thursday, April 27, 2017

The Community First Choice Option

Funding Tennessee’s Community Living Services


ADAPT in action
The Community First Choice (CFC) Option [part of the Affordable Care Act] will revolutionize the long term services and supports (LTSS) system for Tennessee.   Federal funding is available now and the final rules are published so Tennessee should immediately move forward with the creation of the Development and Implementation Council.


CFC would allow Tennessee to draw down an additional federal funds that could be up to $60 million annually in Medicaid resources to sustain the shifts in the long term services and supports system.


The Community First Choice Option is a community-based Medicaid state plan service which includes hands on assistance, safety monitoring, and cueing for assistance with activities of daily living, instrumental activities of daily living and health related functions for individuals based on functional need, not diagnosis or age.


The Affordable Care Act, Section 2401, added 1915(k) to the Social Security Act under Medicaid. Final rules available at 42 CFR 441 Part K or in the Federal Register at Vol. 77, No. 88 (77 FR 26828).

·       Supports choice, independence, and integration in accordance with the Olmstead decision

·       Person-centered and consumer-directed

·       Services must be provided in a home and community-based setting and CANNOT be provided in a nursing facility, institution for mental diseases (IMD), or intermediate care facility for people with development disabilities (ICF-MR)

·       Must be provided on a statewide basis

·       Eliminates HCBS waiting lists

·       States that implement CFC will receive an additional 6% in federal matching funds, with no sunset

·       States that are pursuing CFC (to date): AR, CA, CO, LA, MD, MN, NY, RI, WA



Must be Medicaid eligible

Must require an institutional level of care (hospital, nursing facility, ICF-MR, or IMD)


States must provide the following services.


·       Attendant services and supports to assist in accomplishing: activities of daily living (ADL), instrumental activities of daily living (IADL), and health-related tasks

·       Attendant services and supports include: hands-on assistance, safety monitoring, and cueing

·       Assistance with the learning skills necessary to accomplish ADL, IADL, and health-related tasks

·       Allows for the purchase of back-up systems (such as beepers or other electronic devices) to ensure continuity of services and supports.

·       The State must develop and offer a voluntary training to individuals on how to select, manage and dismiss attendants.




States can choose to provide the following services.


·       Transition costs, such as security deposits for rent or utilities, purchasing basic kitchen supplies, etc.

·       Services that increase independence or substitute for human assistance, such as assistance with learning how to use public transportation, for example.


CFC funding cannot be used to pay for the following services because either the service cannot be paid for by Medicaid or the service is available through alternative mechanisms, such as HCBS waivers.   However, similar services may be permissible under the context of “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.”

·       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


States can select one or more model for the delivery of CFC. Ideally, states will provide consumers with a robust system in order to increase choice. Services must be provided under a person-centered plan.


“Agency Provider Model” includes a range of approaches, with the individual having the ability to select, train, and dismiss their attendant, including:


Traditional agency managed services

Agency-with-Choice model where the agency operates solely as a fiscal intermediary

“Self-Directed Model with service budget” including:

·       Vouchers

·       Direct Cash Payments

·       Fiscal Agent


Emphasis on a person directed plan and planning process, which includes individuals chosen by the consumer

Consumers can select family members (except spouse or legal guardian) or any other individuals to provide services and supports


·       Consumers can train workers in specific areas of care needed by the individual and to perform the needed assistance in a manner that is consistent with the individual’s personal, cultural, and religious preferences

·       Consumers can establish additional staff qualifications based on their specific needs and preferences


Many decisions still have to be made. CFC sets the framework for a fully integrated, non-diagnosis-specific, community-based service system that provides individuals the civil right to live independently in the community and out of an institution. CFC is structured to allow states to work within their unique Medicaid system of state plan services, waivers, and managed care services.

The decisions for structure, implementation, and monitoring are the responsibility of the State’s CFC Development and Implementation Council, which must be comprised of mostly people disabilities, seniors, and their representatives – as required by CFC.  

It is imperative that Tennessee establish its Development and Implementation Council NOW! Every day delayed is money left on the table, and people’s rights ignored.    

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