The Community First Choice Option

Funding Tennessee’s Community Living Services

 

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.

OVERVIEW

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 BASICS

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

 

ELIGIBILITY

Must be Medicaid eligible

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

REQUIRED SERVICES

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.

 

 

PERMISSIBLE SERVICES and SUPPORTS

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.

EXCLUDED SERVICES

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

MODELS FOR SERVICE DELIVERY

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

CONSUMER RIGHTS

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

SO, WHAT WILL CFC LOOK LIKE IN TENNESSEE?

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.    

Mid-South ADAPT confronts Corker

Local ADAPT Chapter asks for support for Disability Rights

Today Mid-South ADAPT confronted Tennessee Sen. Bob Corker asking him to cosponsor the Disability Integration Act (S. 910). Standing on a chair in the Crave Coffee Shop in Arlington Tennessee, a Mid-South ADAPT member caught the Senator at a rare public meeting and requested the Senator support people with disabilities civil right to live in the community.

“Elderly Americans and people with disabilities demand choice in long-term care,” said the activist standing above the crowd on a chair. “Tennessee more than most states needs the Disability Integration Act to avoid expensive institutions and nursing homes.”

Corker spoke briefly at the coffee shop outside of Memphis and answered some questions from the crowd that packed the small venue. The Senator stopped promptly at 9:AM. Mid-South ADAPT handed Disability Integration Act information to Senator Corker and he said that he would look at the information.

The Disability Integration Act (DIA) is civil rights legislation, introduced by Senator Schumer to address the fundamental issue that people who need Long Term Services and Supports (LTSS) are forced into institutions and losing their basic civil rights. The legislation (S. 910) builds on the 25 years of work that ADAPT has done to end the institutional bias and provide seniors and people with disabilities home and community-based services (HCBS) as an alternative to institutionalization. It is the next step in our national advocacy after securing the Community First Choice (CFC) option.

The legislation, when enacted, establishes new federal law - similar in structure to the ADA - that requires states and insurance providers that pay for LTSS to change their policies, provide community-based services first, and offer HCBS to people currently in institutions. DIA operates alongside CFC, but these two laws work very differently. CFC is an option which states can choose. Even though CFC provides money for states to support independent living, many states have not chosen CFC. DIA requires states and insurance providers that pay for LTSS to make real and meaningful changes that support the right of people with disabilities to live in freedom like every other American.

The proposed legislation establishes new federal law - structured like the ADA - that says “No public entity or LTSS insurance provider shall deny an individual with an LTSS disability who is eligible for institutional placement, or otherwise discriminate against that individual in the provision of, community-based long-term services and supports that enable the individual to live in the community and lead an independent life.”

DIA makes it illegal for a state and insurance providers that pay for LTSS to fail to provide HCBS by using waiting lists, screening people out, capping services, paying workers too little for services, or the other excuses that have been used to keep people with disabilities from living in freedom. DIA requires each state to offer community-based services and supports to any individual who is eligible to go into an institution. It also requires states to take active steps to make sure that there is enough affordable, accessible, integrated housing.

The legislation requires states and LTSS insurance providers to complete a self-evaluation to evaluate current services, policies, and practices that do not or may not meet the requirements of the Act and to make the necessary changes in services, policies, and practices required to comply with the law.   Additionally, public entities are required to develop a transition plan using an extensive public participation process. Public entities that fail to comply with the law may face legal action for the Attorney General or may be sued directly. People who have been discriminated against may receive damages under the law.