Maryland Department of Health and Mental Hygiene

CFC Training CFC Overview Services Eligibility Enrollment Process 2

Community First Choice (CFC) Affordable Care Act (ACA) program expanding options for community- based long-term services and supports. Allows waiver-like services to be provided in the State Plan Emphasizes self direction Increases the State’s enhanced match on all CFC services by 6 % Allows Medicaid to set consistent policy and rates across programs Requires an institutional level of care CFC will offer all mandatory and optional services allowable Personal assistance services Emergency back-up systems Transition services, Items that substitute for human assistance Technology, accessibility adaptations, home delivered meals, etc. 3

Former Service Structure 4 Maryland operated 3 Medicaid programs that offered personal assistance services: Medical Assistance Personal Care (MAPC) State plan program that offers personal care and nurse case monitoring Uses the 302 assessment and has a 1 ADL medical necessity standard Living at Home (LAH) Waiver Target group ages with disabilities Nursing Facility Level of Care standard Waiver for Older Adults (WOA) Target group aged 50 and over Nursing Facility Level of Care standard

Former Service Structure MAPCLAHWOA Personal Assistance Services Case Management/Nurse Case Monitoring Consumer Training Personal Emergency Back-up Systems Transition Services Home Delivered Meals Assistive Technology Accessibility Adaptations Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus 5

New Service Structure Services formerly offered through multiple programs are now consolidated under CFC Maximizes the enhanced Federal match Resolves inconsistent rates and policies across programs These two 1915(c) waiver programs merged into a single waiver Reduces duplicate applications Offers a full menu of services to waiver participants Simplifies administration 6

HCBO Waiver: Community Options Provides community services and supports that enable older adults and individuals with physical disabilities to live in their own homes Services provided under CFC are available to participants of this waiver Extra services exclusively attached to this waiver are medical day care, nutritionist/dietician, family training, behavioral consultation, assisted living and senior center plus 7

New Service Structure MAPCCFCWaiver Personal Assistance Services Case Management/Supports Planning Nurse Monitoring Personal Emergency Back-up Systems Transition Services Consumer Training Home Delivered Meals 1 Assistive Technology 1 Accessibility Adaptations 1 Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus 1.Items that sub *CFC Services available to all waiver participants

Levels of Care The new merged waiver will continue to use the nursing facility level of care The CFC program will be available to individuals who meet any institutional level of care. Includes nursing facility, chronic hospitals, ICF/IID, and psychiatric hospitals MAPC uses a standard that is lower than NF LOC; one ADL We estimate that approximately 80% of the MAPC participants meet nursing facility LOC and will be eligible to receive CFC services MAPC and NF Levels of Care will be determined with a core standardized assessment instrument, the interRAI-Home Care, completed by local health department clinicians Levels of care will be reviewed annually 9

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CFC Service Package Personal Assistance Nurse Monitoring Supports Planning Items or Services that Substitute for Human Assistance Environmental Assessments and /or Modifications Technology Home Delivered Meals Consumer Training Personal Emergency Response System Transition Services 11

Service and System Enhancements CFC adds emphasis on person-centered planning and self- direction Maryland Department of Disabilities (MDOD) will be providing self-direction training on hiring, firing, and managing providers CFC offers the participant some flexibility in choosing provider rates for personal assistance services Budgets will be set based on the assessment of need and approved by the Department Participants will be able to act as their own supports planner and request changes to their plans and rates via the LTSSMaryland tracking system portal 12

Enhancements for Participants All participants have access to: increased self-direction opportunities, a larger provider pool, and choice of supports planning providers Waiver participants now have choice in case management (supports planning) providers and access to a larger provider pool MAPC will move to an improved rate structure and increased self direction options after July 1 st More people in the community will have access to waiver-like services 13

Personal Assistance Assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living, health related tasks through hands on assistance, supervision, and/or cueing, will be provided under the Personal Assistance Services. Participants will be able to choose between receiving Personal Assistance Services through an agency or an independent model. Proposal to create a shared Personal Assistance Service for participants that share a home. 14

Nurse Monitoring Nurse Monitors provide quality oversight by assessing the participant and monitoring the provision of personal assistance services The participant can determine the frequency of nurse monitoring in a self directed model, but there is a minimum of two times a year. The Nurse Monitor recommends the frequency of services, based on clinical judgment and whether there are delegated nursing tasks. Supports Planner adds Nurse Monitoring to the POS. 15

Nurse Monitoring Nurse Monitors are required to contact the participant for the purpose of evaluating participant status at a minimum of every 6 months, with at least one in-person home or workplace visit every 12 months. More frequent nurse monitoring can be approved if needed, as recommended by the nurse monitor. Nurse monitoring visits can be conducted on the same day as the InterRAI. 16

Supports Planning Supports planning providers will engage participants in a person-centered planning process that identifies the goals, strengths, risks, and preferences of the participant. The Supports Planner will: Appropriately counsel an individual before enrollment; and Provide the necessary information, training, and assistance to ensure that an individual has the required knowledge and ability to manage their services and budgets. 17

Supports Planning Responsibilities Coordinate community services and supports from various programs and payment sources to aid applicants and participants in developing a comprehensive plan for community living. Support applicants in locating and accessing housing options, identifying housing barriers such as past credit, eviction, and criminal histories, and in resolving the identified barriers. Assist the applicant in developing a comprehensive POS that coordinates the transition from an institution, and maintains community supports throughout the individual’s participation in services. 18

Items that increase independence or substitute for human assistance The following will be services permissible under CFC in the category of items that substitute for human assistance: Home delivered meals Accessibility Adaptations Environmental Assessments Technology Each of these services are covered as items that substitute for human assistance, but have their own enrolled provider pool “Other” items that substitute may also be covered to the extent that they meet the service definition Only “Other” items that substitute for human assistance are paid through the fiscal intermediary 19

Consumer Training The topics covered by consumer training may include, but are not limited to money management and budgeting, independent living and meal planning. These activities are to be targeted to the individualized needs of the participant receiving the training; and sensitive of the educational background, culture, and general environment of the participant receiving the training. Consumer training will be provided by an approved Medicaid provider. 20

Consumer vs. Self Direction Training Consumer TrainingSelf Direction Training Provided by MA ProvidersProvided by MDOD CFC Service (6% enhanced match)CFC Administrative Activity (no enhanced match) Trains consumer on the acquisition, maintenance and enhancement of skills necessary for individuals to perform ADLs, IADLs, and Health Related Tasks Trains consumer on hiring, firing, evaluating and managing Personal Assistance providers 21

Personal Emergency Response System A personal emergency response system (PERS) is an electronic device, piece of equipment or system which, upon activation, enables a participant to secure help in an emergency, 24 hours per day, seven days per week. There are a variety of devices and systems available to meet individual needs and preferences of CFC participants choosing this service. This service may include any or all of the following components: purchase/installation and monthly maintenance/monitoring of a PERS device. 22

Transition Assistance Expenditures essential for transition and linked to an assessed need for an individual to transition from an institution to a community-based home setting. Such as security and utility deposits, bedding, basic kitchen supplies, and other necessities. Items must be essential to a successful transition and may be secured up to 60 days post-transition. Fiscal Intermediary only pays for items on an approved plan of service. Excludes recreational and non-essential items such as home décor, TVs, internet access, and gaming systems. 23

CFC and Waiver Eligibility

Community First Choice 25 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

Financial Eligibility Participants must already be in a waiver and meet the financial qualifications of that waiver, OR Participants must be eligible for Medicaid under the State Plan AND Participants must Be in an eligibility group under the State plan that includes nursing facility services; or If in an eligibility group under the State plan that does not include such nursing facility services, have an income that is at or below 150 percent of the Federal poverty level (FPL) 26

Community First Choice 27 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

Medical Eligibility The individual must meet the institutional level of care Individuals participating in any of the waiver programs meet an institutional level of care, as this is a requirement for all waivers Community Options, New Directions, Community Pathways, Autism, Traumatic Brain Injury, Medical Day Care, Model Medical needs will be assessed by the Local Health Department using the interRAI UCA (currently Delmarva) will verify Nursing Facility and MAPC levels of Care 28

Participation in Other Programs Waiver participants are eligible to receive CFC services, supports will be coordinated between programs to ensure adequate supports without duplication of services or allowing contraindicated services Participants who receive bundled payments for some TBI, DDA, assisted living or PACE services are not eligible to receive CFC services on the same day 29

Other Eligibility Requirements To be eligible for CFC, the participant must reside in a community residence. This means that the participant has: access to the community and community services, control over choice of roommates, choice of if and when to receive visitors, access to food at any time, and privacy and locks The residence must be physically accessible to the participant. Any restrictions on the activities of the participant cannot be for the convenience of the caregiver. The living arrangement must be subject to the normal landlord-tenant or real property laws of the jurisdiction. 30

Waiver Eligibility Technical: Must be at least 18 years old Medical: Must meet a nursing facility level of care Financial: Eligibility is based on both income and assets. The monthly income limit in based on 300% of SSI. In 2014, the income standard is $2,163. Assets may not exceed $2,000 or $2,500 depending on eligibility category. The income standard changes annually in January.

CFC and Waiver Enrollment

Applicants can enroll into CFC from… An institution The community 33

34 Enrollment in CFC from Nursing Facility Applicant in Nursing Facility receives options counseling Applicant has community MA No community MA Options Counselor refers to LHD for assessment* and provides Supports Planning selection packet to applicant** Options Counselor helps complete MA application. Contact is made with Supports Planning provider Supports Planner meets with participant to create Plan of Service*** Plan of Service approved by DHMH Supports Planner coordinates transition Supports Planner meets with participant at least once every 90 days (can be waived by participant) *LHD has 15 calendar days to complete assessment and Recommended Plan of Care **Applicant has 21 calendar days to select a Supports Planner before auto assignment ***Supports Planner has 20 days to submit the POS

Enrollment into Waiver from a Nursing Facility 35 Applicant in Nursing Facility receives options counseling Has Long Term Care MA Has Community MA Wavier Application Assistance Contact made with Supports Planning Provider Supports Planner meets with participant to create Plan of Service*** Plan of Service approved by DHMH Supports Planner meets with participant at least once every 90 days (can be waived by participant) *LHD has 15 calendar days to complete assessment and Recommended Plan of Care **Applicant has 21 calendar days to select a Supports Planner before auto assignment ***Supports Planner has 20 days to submit the POS DEWS LHD for assessment Provides Supports Planning selection packet to applicant Supports Planner coordinates transition Apply for CFC

36 Enrollment in CFC from the Community Contact DHMH Applicant contacts MAP site, referred to DHMH Community MA status verified by DHMH No Community MA Has Community MA Contact made with Supports Planning Provider Supports Planner meets with participant to create Plan of Service*** Supports Planner meets with participant at least once every 90 days (can be waived by participant) Applicant in Community Refer to Local DSS Plan of Service approved by DHMH Add to LTSS Referral to LHD for assessment* Mail out Supports Planning selection packet** *LHD has 15 calendar days to complete assessment and Recommended Plan of Care **Applicant has 21 calendar days to select a Supports Planner before auto assignment ***Supports Planner has 20 days to submit the POS

Community First Choice 37 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

Assessment by the LHD After a person applies, they are referred to the local health department for an assessment LTSS programs use the interRAI Home Care (HC) assessment, the core standardized assessment adopted by the Department Informs and guides comprehensive care and service planning in community-based settings Developed through years of research and is tested as reliable and valid instrument to measure level of need Generates Clinical Assessment Protocols and Resource Utilization Groups as indicators of need and areas of support Is used to determine Nursing Facility level of care 38

Community First Choice 39 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

Supports Planner Provider Selection Applicants will be provided with information about all Supports Planning agencies by the Options Counselor or via a mailing form the Department The applicant may contact the agency of choice The Agency of Choice will enter the selection into LTSS If no selection is made within 21 days, an agency will be auto- assigned A participant can choose to change their auto-assigned supports planning provider agency at any time Once the initial selection has been made by the applicant, another agency may not be chosen for 45 days

Community First Choice 42 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

How budget is determined The interRAI assessment has existing algorithms statistically validated in this instrument to assign one of 23 Resource Utilization Groups (RUGs) to participants Using RUGs-based acuity, the Department assigns participants to groups with a given budget for each group based on a scale of needs Participants will use this budget for certain services and are then empowered to determine their personal assistance hours and schedules within their budget Other services will be provided as needed and accounted for outside of the flexible budget 43

Budgets by Group 44 RUGGrouper DescriptionBudget Group 1PA1Physical Function – Low ADL$8,336 BA1Behavioral – Low ADL$8,336 CA1Clin. Complex – Low ADL$8,336 IA1Cognitive Impairment – Low ADL$8,336 PA2Physical Function – Low ADL, Low to High IADL$8,336 RA1Rehabilitation - Low ADL$8,336 Group 2BA2Behavioral – Low ADL, High IADL$16,167 CA2Clin. Complex – Low ADL, High IADL$16,167 IA2Cognitive Impairment – Low ADL, Low to High IADL$16,167 PB0Physical Function – Low to Medium ADL$16,167 Group 3CB0Clin. Complex – Low to Medium ADL$22,504 RA2Rehabilitation Low – Low ADL, High IADL$22,504 PC0Physical Function – Medium to High ADL$22,504 SSASpecial Care – Low to High ADL$22,504 IB0Cognitive Impairment – Medium ADL$22,504 BB0Behavioral – Medium ADL$22,504 Group 4PD0Physical Function – High ADL$30,314 CC0Clin. Complex – High ADL$30,314 Group 5SE1Extensive Services 1 – Medium to High ADL$34,545 RB0Rehabilitation High – High ADL$34,545 SSBSpecial Care – Very High ADL$34,545 Group 6SE2Extensive Services 2 – Medium to High ADL$43,558 Group 7SE3Extensive Services 3 – Medium to High ADL$76,360 RUGGrouper DescriptionBudget Group 1PA1Physical Function – Low ADL$8,336 BA1Behavioral – Low ADL$8,336 CA1Clin. Complex – Low ADL$8,336 IA1Cognitive Impairment – Low ADL$8,336 PA2Physical Function – Low ADL, Low to High IADL$8,336 RA1Rehabilitation - Low ADL$8,336 Group 2BA2Behavioral – Low ADL, High IADL$16,167 CA2Clin. Complex – Low ADL, High IADL$16,167 IA2 Cognitive Impairment – Low ADL, Low to High IADL$16,167 PB0Physical Function – Low to Medium ADL$16,167 Group 3CB0Clin. Complex – Low to Medium ADL$22,504 RA2Rehabilitation Low – Low ADL, High IADL$22,504 PC0Physical Function – Medium to High ADL$22,504 SSASpecial Care – Low to High ADL$22,504 IB0Cognitive Impairment – Medium ADL$22,504 BB0Behavioral – Medium ADL$22,504 Group 4PD0Physical Function – High ADL$30,314 CC0Clin. Complex – High ADL$30,314 Group 5SE1Extensive Services 1 – Medium to High ADL$34,545 RB0Rehabilitation High – High ADL$34,545 SSBSpecial Care – Very High ADL$34,545 Group 6SE2Extensive Services 2 – Medium to High ADL$43,558 Group 7SE3Extensive Services 3 – Medium to High ADL$76,360

Services within the flexible budget 1. Personal Assistance 2. Home-Delivered Meals 3. “Other” Items that Substitute for Human Assistance All other services are included in the Plan of Service in addition to the flexible budget 45

Services in the Plan 46 CFC Services Allowable Under Flexible Budget Other CFC Services based on the Individual Participant’s Assessed NeedsWaiver Services Personal AssistanceTechnology Dietitian and Nutrition Services Home-Delivered Meals Environmental Accessibility Adaptations Family Training Other items that Substitute for Human Assistance Environmental AssessmentsMedical Day Care Supports Planning Behavioral Health Consultation Transition ServicesSenior Center Plus Consumer Training Assisted Living Personal Emergency Response Systems Nurse Monitoring

Exception Process If a person cannot be supported in the community within the recommended flexible budget, an exceptions process exists to request additional funds, beyond those assigned through the interRAI and the RUGs referenced. The exceptions process is also used to request items of services not recommended by the clinician in the recommended plan of care The supports planner is responsible for explaining this process to the participant, completing the exceptions form, acquiring any additional documentation needed to support the exception request, and uploading all documents to the LTSSMaryland tracking system 47

Community First Choice 49 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

Supports planner will engage in a person-centered planning process with the participant. Review the interRAI assessment and Recommended POC. Determine the desired level of self-direction. Identify strengths, goals, and risks. Develop a plan that includes Medicaid and non-Medicaid services and supports. Identify back up providers for emergencies. The supports planner has 20 days to submit the POS. The requested POS will be reviewed by the Department to assure health and safety standards are met. 50 Plan of Service Development

Community First Choice 51 Eligible for Medicaid (through a waiver or state plan) Assessed by Local Health Department Applicant selects Supports Planner Develops Plan of Service Department (DHMH) approves Plan of Service Participant begins receiving services Assigned a personal budget

Ongoing Supports After enrollment, the participant receives services and supports according to their plan of service Supports planners must contact the participant monthly and conduct quarterly visits, unless waived by the participant The nurse monitor will visits at a frequency they determine based on their assessment of the clinical needs and presence of any delegated nursing tasks Nurse monitoring may only be waived down to twice per year The supports planner is responsible for monitoring service provision, health and welfare, and for initiating changes to the level of support as needed 52

Contact Us 53 DHMH: Jennifer Miles, MFP Housing Director Michelle Haile, Health Policy Analyst MFP Housing Specialist MDOD: John Brennan, Chief of Staff Maryland Department of Disabilities